Treatment results for hypopharyngeal cancer by different treatment strategies and its secondary primary--an experience in Taiwan

Survival analyses of different treatment modalities and clinical stage for hypopharyngeal carcinoma

Objective

We investigated the effects of different treatment modalities and clinical stage for hypopharyngeal carcinoma (HPC) patients.

Methods

Between February 2004 and December 2012, 167 HPC patients were reviewed. We calculated overall survival (OS), progression-free survival (PFS), local failure-free survival (LFFS), regional failure-free survival (RFFS), and distant metastasis failure-free survival (DMFFS) using the Kaplan-Meier method and compared various survival outcomes between definitive chemoradiotherapy (CRT) and surgery-based therapy (SBT).

Results

There were no significant differences in baseline characteristics between SBT (n = 102) and definitive CRT (n = 65) groups. The 5-year rates of OS (59.7% vs. 24.0%, p < 0.0001) and PFS (49.9% vs. 22.6%, p = 0.0002) were significantly better in patients who received SBT than in those who received definitive CRT. The SBT group also obtained better LFFS (p < 0.0001), RFFS (p = 0.0479), and DMFFS (p = 0.0110). We did similar analyses by different T-classification (T1-2, T3, and T4) and found that SBT had better OS (p < 0.0001 and p = 0.0020), PFS (p < 0.0001 and p = 0.0513), LFFS (p = 0.0002 and p = 0.0075), RFFS (p = 0.1949 and p = 0.0826), and DMFFS (p = 0.0248 and p = 0.0436) in the T4 and T1-2 subgroups but similar OS (p = 0.9598), PFS (p = 0.5052), RFFS (p = 0.9648), and DMFFS (p = 0.8239) in T3 patients. Analyses by different overall stages revealed no differences between definitive CRT and SBT for stage III patients but significantly better results for stage IV patients who received SBT.

Conclusions

SBT can obtain significant survival benefits when compared with definitive CRT for the whole cohort of patients. Definitive CRT has similar survival outcomes compared with SBT only for T3 tumors or overall stage III disease.

Antitumor effects of valdecoxib on hypopharyngeal squamous carcinoma cells

The antitumoral effects of valdecoxib (Val), an United States Food and Drug Administration-approved anti-inflammatory drug that was withdrawn due to the side effects of increased risk of cardiovascular adverse events, were investigated in hypopharyngeal squamous cell carcinoma cells by performing a cell viability assay, transwell assay, immunofluorescence imaging, and Western blotting. Val markedly inhibited cell viability with an IC50 of 67.3 μM after 48 h of treatment, and also downregulated cell cycle proteins such as Cdks and their regulatory cyclin units. Cell migration and invasion were severely suppressed by inhibiting integrin α4/FAK expression. In addition, Val activated the cell cycle checkpoint CHK2 in response to excessive DNA damage, which led to the activation of caspase-3/9 and induced caspase-dependent apoptosis. Furthermore, the signaling cascades of the PI3K/AKT/mTOR and mitogen-activated protein kinase pathways were significantly inhibited by Val treatment. Taken together, our results indicate that Val can be used for the treatment of hypopharyngeal squamous cell carcinoma.

A nomogram for prediction of distant metastasis in patients with hypopharyngeal squamous cell carcinoma: a study based on the SEER database

BACKGROUND

The prognosis of hypopharyngeal squamous cell carcinoma (HPSCC) is poor due to its high incidence of local invasion and distant metastasis (DM). This study aims to explore the DM risk factors of HPSCC and establish a clinical prediction model.

METHODS

We downloaded patient data from the Public Surveillance, Epidemiology, and End Results (SEER) database between 2004 and 2018. Univariate and multivariate logistic regression analyses were performed to screen the clinical risk factors for DM of HPSCC. A new nomogram prediction model was then established based on the selected clinical risk factors. We further validated the model's accuracy based on the concordance index (C-index), the area under the receiver operating characteristic (AUC) curve, and the calibration plot. The decision curve analysis (DCA) to test the potential clinical value of the new model was also applied.

RESULTS

A total of 3502 patients were enrolled; the patients with HPSCC were randomly assigned to a training set (n=2463) and a validation set (n=1039). Multivariate Logistic model analysis suggested that sex, T stage, N stage, and the total number of tumors were influence factors for DM of HPSCC. We established and validated a novel nomogram prediction model based on the multivariate logistic model with these influence factors. The C-index was 0.943 and 0.849 in the training and validation sets respectively. The AUC of the training set was 0.705 (95% CI: 0.669-0.741), and the validation set was 0.667 (95% CI: 0.609-0.725). The calibration plot shows that the actual observation value was similar to the predicted value, meaning the model has an excellent discrimination ability. DCA of the nomogram in the training and validation sets suggested that our nomogram has potential application value.

CONCLUSIONS

We found that sex, T stage, N stage, and the total number of tumors are independent risk factors for DM of HPSCC. We developed a novel prediction model to predict DM in patients with HPSCC. This nomogram can identify patients with a high risk of DM and has a high clinical application value.

Impact of invasion into cervical esophagus for patients with hypopharyngeal squamous cell carcinoma

OBJECTIVES

The invasion into cervical esophagus (ICE) sometimes could be encountered in patients with hypopharyngeal squamous cell carcinoma (HypoSCC). However, the incidence, predictive factors, and prognostic impact of ICE on the patients with HypoSCC remain unclear.

MATERIALS AND METHODS

Patient diagnosis with HypoSCC at the National Taiwan University Hospital between January 2007 and December 2018 were reviewed. All patients were classified into two groups: with and without ICE. The curative treatment included upfront laryngectomy or pharyngo-laryngo-esophagectomy (PLE) with adjuvant chemoradiation, or definite organ-sparing chemoradiation.

RESULTS

We analyzed 527 HypoSCC patients, 71 (13.47%) with and 456 (86.53%) without ICE. ICE presented more frequently in females (odds ratio (OR) = 3.01, p = 0.03) and posterior pharyngeal wall (OR = 2.34, p = 0.04). The 5-year disease-free survival of patients with and without ICE were 21.7% and 54.1%, respectively (p < 0.0001) and the 5-year overall survival were 13.1% and 53.8%, respectively (p < 0.0001). Among patients with ICE, the disease-free and overall survival of patients with upfront PLE were worse than the patients without upfront PLE (p = 0.21 and p = 0.27, respectively). After multivariant cox analysis, ICE was an independent risk factor for disease-free survival (p < 0.001) and overall survival (p < 0.001).

CONCLUSION

ICE was occasionally present (13.47%) in HypoSCC patients. Unfortunately, the presence of ICE had a significant impact on disease-free and overall survival. For the HypoSCC patients with ICE, organ-sparing chemoradiation should be considered first as upfront PLE had no additional benefit.

Survival and swallowing function outcome impact factors analysis of surgery-oriented comprehensive treatment for hypopharyngeal cancer in a series of 122 patients

OBJECTIVE

Under current standards of treating highly aggressive hypopharyngeal cancer (HPC), oncological control and functional outcome are still unsatisfactory worldwide. This study explored the surgery-oriented comprehensive treatment approach based on 15 years of practice.

METHODS

A retrospective cohort of HPC patients treated by the senior author at Chinese PLA General Hospital between Nov 2005 and Aug 2012 and Capital Medical University Beijing Friendship Hospital between May 2014 and Nov 2019 was studied. Oncological control, swallowing function, and quality of life (QoL) were assessed.

RESULTS

In total, 122 patients were included in this study, with 11 (9.0%) cases in the early stage and 111 (91.0%) cases in the advanced stage. Five-year overall survival (OS) and disease-free survival (DFS) were 40.0% and 36.1%, respectively. The swallowing outcome was satisfactory in 90 (73.8%) patients. Tracheostomy-free survival was achieved in 55 (45.1%) patients. Multivariate cox regression analysis showed that the size of the surgical defect, local-regional recurrence, and distant metastasis were independent impact factors for OS and DFS (P < .05). Multivariate analysis showed that the logistic regression coefficients (standard error) of pharyngo-cutaneous fistula and local-regional recurrence on swallowing function were 1.274 (.532) and 1.283 (.496), respectively (P < .05). In addition, the logistic regression coefficients (standard error) of the clinical stage, local-regional recurrence, decannulation, and feeding tube on QoL were -7.803 (3.593), -7.699 (3.151), 13.853 (3.494), and -20.243 (3.696), respectively (P < .05).

CONCLUSIONS

Surgery-oriented comprehensive treatment can give rise to good swallowing function without jeopardizing oncological control. The size of the surgical defect, local-regional recurrence, and distant metastasis were independent factors impacting OS and DFS. Pharyngo-cutaneous fistula and local-regional recurrence were independent factors impacting swallowing function. Clinical stage, local-regional recurrence, decannulation, and feeding tube were independent factors impacting QoL.

Surgical approach of laryngofissure combined with epiglottis valley in treating locally-advanced pyriform sinus carcinoma

OBJECTIVES

To evaluate feasibility and efficacy of surgical approach of laryngofissure combined with epiglottis valley in treating locally-advanced pyriform sinus carcinoma.

METHODS

Clinical data of 216 patients with T3 and T4a pyriform sinus carcinoma, who came from the Department of Otorhinolaryngology Head and Neck Surgery, Xiangya Hospital, Central South University between January 2013 and December 2019, were retrospectively analyzed. Three different types of surgery were used in these patients. Seventy-three patients were performed by approach of laryngofissure combined with epiglottis valley for partial laryngopharyngectomy (Group I); 75 patients were performed by approach of lateral pharynx for piriform fossa resection (Group II); 68 patients were performed by total laryngopharyngectomy (Group III). All patients were treated with radiotherapy and followed up regularly after operation. Kaplan-Meier regression model was used to analyze the overall survival rate. EAT-10 swallowing scale was utilized to evaluate the postoperative swallowing function, while the rate of tracheal tube extubation and the incidence of postoperative complications in each group were compared.

RESULTS

There were 76.7% patients with T3 stage in Group I, 100% patients with T3 stage in Group II, and 64.7% patients with T4a stage in Group III. There was significant difference between them (P<0.01). Clinical stage IV patients in the Group I, Group II, and Group III were 74.0%, 54.7%, and 89.7%, respectively, with significant difference (P<0.01). The 3-year overall survival (OS) rate in Group I, Group II, and Group III were 69.9%, 53.3%, and 58.8%, respectively. Patients in the Group I had a better survival outcome than that in the Group II (P<0.05). The median score of EAT-10 swallowing scale was 12.0 in the Group I, 8.0 in Group II, and 5.0 in Group III, with significant difference (P<0.01). There was no significant difference in the rate of tracheal tube extubation and the incidence of complication among the 3 groups (both P>0.05).

CONCLUSIONS

Surgical approach of laryngofissure combined with epiglottis valley in the treating locally-advanced piriform sinus carcinoma presents favorable outcome in terms of survival rate and laryngeal function preservation, which deserves to be promoted.

Management of Advanced-stage Hypopharyngeal Carcinoma: 25-Year Experience from a Tertiary Care Medical Center

Introduction

Due to conflicting data in the literature, there is a continuing debate on whether advanced hypopharyngeal carcinoma patients should be treated with definitive surgery or chemoradiotherapy. The purpose of this study is to evaluate the management and outcomes of advanced hypopharyngeal carcinoma in a tertiary care institution over the last 25 years.

Methods

An Institutional Review Board (IRB)-approved and HIPPA-compliant retrospective analysis was performed of patients with advanced-stage squamous cell carcinoma of the hypopharynx treated at our institution between January 1994 and December 2018. Data regarding demographics, stage, treatment, and follow-up were collected. Outcomes including median survival and overall survival were calculated using the Kaplan Meier method. All analyses were performed using SPSS v. 24. 

Results

This study included a total of 103 advanced stage hypopharyngeal cancer patients. The median age for this cohort is 61 years (range: 41-88, SD 9.3). Of the total 103 eligible patients treated, 92 (89.3%) were male and 11 (10.7%) female; 61 (59.2%) were African Americans, 39 (37.9%) were Caucasians and three (2.9%) were other races. Seventeen patients (16.5%) had stage III disease, whereas 86 (83.5%) patients were diagnosed with Stage IV A or B disease. Seventy-two patients (69.9%) were treated with definitive chemoradiotherapy (ChemoRT group), and 31 patients (30.1%) underwent primary surgery with or without adjuvant treatments (Surgery group). The two treatment groups were similar in terms of age, gender, ethnicity, alcohol status, N staging, and subsites but were significantly different for smoking status (p = 0.035) and T staging (p = 0.024). The median follow-up was 17 months. The median survival of the overall cohort was 26 months, and five-year overall survival was 25.5%. The median survival was found to be significantly better for the surgery group as compared to the definitive chemoradiotherapy group (43 months vs 16 months, p = 0.049). The five-year overall survival (OS; 41.5% vs 18.5%, p = 0.049) and disease-free survival (DFS; 75.3% vs 56%; p = 0.029) were significantly better for patients in the surgery group compared to the chemoradiotherapy group. On multivariate Cox-regression analysis, lymph nodal status (HR = 1.27, CI: 1.00-1.62, p = 0.047) and chemoradiation treatment (HR = 1.82, CI: 1.00-3.29, p = 0.048) were associated with higher risk of mortality. 

Conclusion

In our single institutional experience of advanced hypopharyngeal carcinoma management, the five-year overall survival rate was found to be 25.5 % and was the poorest among head and neck cancers. The patients with advanced hypopharyngeal cancer treated with surgery followed by adjuvant radiation or chemoradiation have significantly improved overall survival compared to those treated with definitive chemoradiotherapy. Further research warranted for early detection and better treatment to improve the cure rate in hypopharyngeal carcinoma patients. 

The Role of Pretreatment Serum Neutrophil-to-Lymphocyte Ratio in Hypopharyngeal Cancer Treated with Definitive Chemoradiotherapy: A Pilot Study

Serum neutrophil-to-lymphocytes ratio (NLR) is a potential predictive and prognostic marker in head and neck cancers. This study aimed to determine the role of pretreatment serum NLR in patients with hypopharyngeal cancer (HPC) treated with definitive chemoradiotherapy. We retrospectively investigated the correlation between clinicopathological parameters and NLR status and analysed its impact on therapeutic response and survival. A total of 120 patients treated at a single institution between 2009 and 2015 were included. The median follow-up time was 24.1 months. High NLR (NLR ≥ 4) was associated with advanced T classification (p = 0.01*) and advanced stage (p = 0.02*) based on chi-square test. We also found that high pretreatment NLR was correlated with poor treatment response (HR = 2.42, 95% CI: 1.08–5.44, p = 0.03*). Pretreatment NLR was also an independent prognostic factor for progression-free survival (HR = 1.71, 95% CI: 1.01–2.90, p = 0.046*) and overall survival (HR = 1.99, 95% CI: 1.21–3.28, p = 0.01*) while correcting for known prognostic factors. Overall, these findings support that NLR is a potential biomarker for host response to tumour aggressiveness, therapeutic response to chemoradiotherapy and survival in HPC patients. This study is limited by its retrospective nature and further validation is warranted.

Options of medical treatment and laryngeal function preservation in elderly patients with medial wall pyriform sinus cancer

Objective

To retrospectively investigate the clinical efficacy and larynx preservation of two different treatments: radiotherapy followed by surgery (R+S) and surgery followed by radiotherapy (S+R), in elderly patients with medial wall pyriform sinus cancer.

Materials and methods

Medical records from 48 patients over 70 years old with medial wall pyriform sinus cancer who underwent different treatments between 2001 and 2010 were analyzed. Twenty-one patients underwent radiotherapy first followed by surgery (R+S), and the other 27 patients underwent surgery first followed by radiotherapy (S+R). A Kaplan–Meier method was used to calculate the survival rate.

Results

Overall 3-year and 5-year survival rates were 60.4% and 35.4%, respectively. The 5-year survival rates in R+S group and S+R group were 38.1% and 33.3%, respectively, without a statistically significant difference between the two groups (P>0.05). Also, comparisons of the decannulation rates (64.3% for R+S group vs 50.0% for S+R group) and postoperative complication rates (42.9% for R+S group vs 37.0% for S+R group) between the two groups of patients did not show obvious differences. However, the laryngeal preservation rates in R+S group and S+R group were 66.7% and 37.0%, respectively, with significantly statistical difference between the two groups (P<0.05).

Conclusion

Based on the data analysis of 48 patients, the survival rates of elderly patients who underwent R+S or S+R were comparable, but R+S treatment could improve the laryngeal preservation rate of patients. Further study on large-scale sample pool should be performed to confirm this conclusion.

To do or not to do: salvage management for hypopharyngeal cancer after chemoradiation therapy

PURPOSES

The management of recurrent hypopharyngeal cancer after primary curative-intent radiation or chemoradiation therapy is inconclusive. The benefit of salvage surgery may be reduced by its high complication rate. The improvement of medical care modalities may change the survival after management for loco-reginal recurrences. The present study aims to determine the role of salvage surgery.

METHODS

From December 2007 to November 2013, 46 patients with recurrent hypopharyngeal squamous cell carcinoma (HPSCC) after radiation or chemoradiation therapy and without double cancers were recruited. Two year loco-regional failure and overall survival were analyzed and compared between failure patterns.

RESULTS

Five-year survival was 24% in patients after loco-regional recurrences. Those who received salvage surgery for loco-regional recurrences had significantly better survival (P < 0.001). Among patients with salvage surgery, 2-year overall survival was significantly higher in recurrent (n = 11) than persistent (n = 24) disease (90 vs 38%, P = 0.006).

CONCLUSIONS

Salvage surgery provides better oncologic outcomes in patients with HPSCC, especially for patients with recurrences after 6 months since completion of primary radiation or chemoradiation. The present data of outcomes can be provided for pretreatment consultation for loco-regional recurrent hypopharyngeal cancers.

Management of advanced hypopharyngeal carcinoma: systematic review of survival following surgical and non-surgical treatments

BACKGROUND

Advanced hypopharyngeal carcinoma has a dismal prognosis. The optimal treatment for these patients remains under debate. This systematic review aimed to compare survival following surgical and non-surgical treatments.

METHODS

A systematic review was conducted of randomised studies, with a descriptive analysis of retrospective observational studies.

RESULTS

Two randomised trials and 11 observational studies were included in the review. A meta-analysis of randomised trials reported a hazard ratio of 0.89 for overall survival in favour of surgical treatment (p = 0.44). Neither treatment was favoured in terms of overall survival. Observational studies did not report a survival advantage with either treatment. The five-year larynx preservation rates for non-surgically treated patients were between 38 and 58 percent.

CONCLUSION

Chemoradiotherapy offers similar survivorship compared to surgery in advanced disease, while also making larynx preservation feasible. It can be used as a treatment in all patients as an alternative to surgery.

Thirty-five years of single surgeon experience in the reconstruction of esophagus and voice with free ileocolon flap following total pharyngolaryngectomy

BACKGROUND

Several surgical options exist for the reconstruction of total pharyngolaryngectomy defect. The purpose of this report is to present our experience with ileocolon flap for simultaneous reconstruction of both esophagus and voice.

METHODS

Demographic data, clinical information, and outcomes of 205 patients who underwent the ileocolon flap procedure over the last 35 years were examined. Preoperative evaluation, intraoperative details, and postoperative management were analyzed. The types of additional procedures performed to improve outcomes were explored.

RESULTS

Of the 205 patients, 191 had a free ileocolon flap and the remaining 14 a pedicled flap. Ninety-seven percent of the flaps were successful with a fistula rate of 5.4%. Seven patients required reexploration and six flaps failed. Seventy-eight percent of the patients reported their swallowing function to be very good to excellent. Speech function was rated as good in 64% of patients and moderate in 21%. Three patients develop bowel obstruction, two of which required enterolysis. Five patients had postoperative diarrhea that responded to conservative measures.

CONCLUSION

Reconstruction of pharyngoesophageal defects with ileocolon flap permits resumption of swallowing and production of speech without the need for voice prosthesis and with minimal complications.

The survival rate and larynx preservation in elderly cancer patients who received surgical operation: A retrospective cohort study

BACKGROUND

To investigate the efficiency of surgical operation for patients over 70 years with hypopharyngeal cancer.

MATERIALS AND METHODS

A retrospective analysis of the medical records from 68 patients over 70 years-old with hypopharyngeal cancer who underwent different therapeutic regimen between 2000 and 2009 was conducted. 36 of 68 patients underwent larynx preservation. All patients were treated with surgical operation and adjuvant radiotherapy. A Kaplan-Meier method was employed to calculate the survival rate.

RESULTS

Overall 3 year-and 5 year-survival rates were 48.6% and 29.4% respectively. For patients who underwent larynx preservation, 5 year-survival rate was 30.5%, which was decreased compared to 3 year-survival rate (46.9%) However, 3 year- and 5 year-survival rates in patients without larynx preservation were 46.9% and 28.1% respectively, suggesting that no statistically significant difference of survival rates was found between patients with or without larynx preservation (P > 0.05). A majority of patients who receive larynx preservation exhibited normal breathing and eating abilities and could present an intelligible speech. 16 of 36 patients who preserved larynx and 14 of 32 patients who underwent laryngectomy showed postoperative complication. No significant difference was observed in these two treatments, indicating larynx preservation is not a factor for inducing complication.

CONCLUSION

This study provides evidence that the quality of life for elderly patients with hypopharyngeal cancer can be improved by optimizing the therapeutic regimen based on the physical condition of each patient.

The effect and mechanism of action of metformin on in vitro FaDu cell proliferation

Objective

To investigate the effect and mechanism of action of metformin on proliferation of a human hypopharyngeal carcinoma cell line (FaDu).

Methods

FaDu cells were treated with metformin (25–125 mmol/l). Cell proliferation was evaluated via CCK-8 assay. Real-time quantitative reverse transcription–polymerase chain reaction was used to evaluate microRNA (miR)-21-5p and PDCD4 (programmed cell death 4) expression. PDCD4 protein was quantified by Western blot.

Results

Metformin significantly inhibited FaDu cell proliferation in a dose- (25–100 mmol/l) and time-dependent manner (12 h–36 h), significantly downregulated miR-21-5p, and upregulated PDCD4 mRNA and protein expression.

Conclusions

Metformin significantly inhibited FaDu cell proliferation, possibly via downregulation of miR-21-5p and upregulation of PDCD4.

Glasgow prognostic score and neutrophil-lymphocyte ratio are good prognostic indicators after radical neck dissection for advanced squamous cell carcinoma in the hypopharynx

PURPOSE

Locally advanced carcinomas arising in the hypopharynx have been traditionally treated by resection of the hypopharynx, larynx, and cervical esophagus. However, the prognosis of these patients is still low. In the present study, we retrospectively analyzed the long-term survival of patients with locally advanced hypopharyngeal squamous cell carcinoma (HSCC) reconstructed by jejunal graft.

METHODS

Between 2004 and 2014, 68 patients with HSCC were treated at Tottori University Hospital. Nine patients with synchronous esophageal cancer were excluded. We analyzed the overall survival of 59 patients with clinical stage III and IV HSCC who underwent pharyngo-laryngo-cervical esophagectomy with definitive tracheostomy followed by free jejunal graft reconstruction. Additionally, prognostic significances of preoperative patients' Glasgow prognostic score (GPS), neutrophil-lymphocyte ratio (NLR), and prognostic nutritional index were analyzed.

RESULTS

Postoperative complications occurred in 18.6 % of 59 patients. There were no cases of graft loss, and no patient died from complications. Preoperative poor performance status of patients was a risk factor for postoperative complications. The 5-year overall survival rate of the 59 patients was 46.1 %, and the median survival time was 28 months. In univariate and multivariate survival analyses, high GPS (1 or 2), and high NLR (≥5) were recognized as independent poor prognostic markers for patients with HSCCs.

CONCLUSIONS

Pharyngo-laryngo-cervical esophagectomy followed by free jejunal reconstruction was performed safely. Additional treatment, such as chemoradiotherapy, should be introduced for patients with high preoperative GPS or NLR after curative operation.

Chloroquine-enhanced efficacy of cisplatin in the treatment of hypopharyngeal carcinoma in xenograft mice

Hypopharyngeal squamous cell carcinoma (HSCC) has the worst prognosis among head and neck cancers. Cisplatin (DDP)-based chemotherapy is an important part of multimodal treatments. However, resistance to DDP severely impairs the effectiveness of chemotherapy for HSCC. Chloroquine (CQ) has been reported to enhance the effectiveness of chemotherapy and radiotherapy in liver, pancreas, breast, prostate and colon tumors, but it is unclear whether CQ could increase the efficacy of DDP for treating HSCC. We inoculated BALB/c nude mice with a subcutaneous injection of human hypopharyngeal FaDu cells to generate our animal model. Mice were randomly divided into 4 groups and treated with vehicle control, CQ (60 mg/kg/day), DDP (5 mg/kg/6 days), or a combination of DDP and CQ. Tumor growth and survival of the mice were monitored. We found that CQ inhibited autophagy and increased DDP-induced apoptosis in the xenograft mouse model. CQ enhanced the efficacy of DDP, resulting in decreased tumor growth and prolonged survival of the mice. To test whether blocking autophagy enhanced the efficacy of DDP, FaDu cells were infected with lentiviral shRNA to Beclin-1 and inoculated into the flanks of nude mice. Inhibition of autophagy markedly enhanced the DDP-induced antitumor effect. Our study suggests that the addition of CQ to DDP-based chemotherapy could be a potential therapeutic strategy for treating HSCC, and the inhibition of autophagy may contribute to chemotherapy sensitization in HSCC.

Association between genetic polymorphisms in DNA mismatch repair-related genes with risk and prognosis of head and neck squamous cell carcinoma

We examined the influence of MLH1 c.-93G>A, MSH2 c.211 + 9C>G, MSH3 c.3133G>A and EXO1 c.1765G>A polymorphisms, involved in DNA mismatch repair (MMR), on head and neck (HN) squamous cell carcinoma (SCC) risk and prognosis. Aiming to identify genotypes, DNA from 450 HNSCC patients and 450 controls was analyzed by PCR-RFLP or real time PCR. MSH2 GG plus MSH3 GG (31.7% vs. 18.7%, p = 0.003) genotypes were higher in laryngeal SCC (LSCC) patients than in controls. Carriers of the respective combined genotype were under a 3.69 (95% CI: 1.54-8.81)-fold increased risk of LSCC. Interactions of tobacco and tobacco plus all the above-mentioned polymorphisms on HNSCC and LSCC risk were also evident in study (p = 0.001). At 60 months of follow-up, relapse-free survival (RFS) was shorter in patients with EXO1 GG genotype (54.8% vs. 61.1%, p = 0.03) and overall survival (OS) was shorter in patients with MSH3 GG genotype (42.8% vs. 52.5%, p = 0.02) compared to those with other genotypes, respectively. After multivariate Cox analysis, patients with EXO1 GG and MSH3 GG genotypes had worst RFS (HR: 1.50, 95% CI: 1.03-2.20, p = 0.03) and OS (HR: 1.59, 95% CI: 1.19-2.13, P = 0.002) than those with the remaining genotypes, respectively. Our data present, for the first time, evidence that inherited MLH1 c.-93G>A, MSH2 c.211 + 9C>G, MSH3 c.3133G>A, and EXO1 c.1765G>A abnormalities of DNA MMR pathway are important determinants of HNSCC, particularly among smokers, and predictors of patient outcomes.

Contemporary therapeutic management of locally advanced hypopharyngeal cancer: oncologic and functional outcomes - a report on 100 cases

CONCLUSION

A significant proportion of patients with locally advanced hypopharyngeal cancer could not be managed by larynx-sparing therapy. T4 stage is one of the main predictive factors of oncologic and functional outcomes.

OBJECTIVES

To analyze the therapeutic management of patients with locally advanced hypopharyngeal cancer in clinical practice and to report oncologic and functional outcomes.

METHODS

This was a retrospective study of all patients treated for a locally advanced hypopharyngeal squamous cell carcinoma between 2001 and 2012 at our institution.

RESULTS

A total of 100 patients were included in this study. Induction chemotherapy (CT) followed by radiotherapy (RT) ± CT, primary RT + CT, and primary total pharyngolaryngectomy (TPL) comprised the initial therapeutic management for 54, 24, and 20 patients, respectively. Two patients received only supportive care. Overall survival (OS) and cause-specific survival (SS) were 50% and 60% at 3 years, respectively. In the group of patients referred for induction CT, the 3-year OS and SS were 58% and 70%, respectively. In multivariate analysis, T stage (p = 0.05) and ASA score (p = 0.02) were significant predictive factors of OS. T4 tumor stage had a pejorative impact on swallowing function after therapy (p = 0.006). The rate of patients alive, disease-free, and with a functional larynx at 2 years was 23%.

Interactions between clinical factors, p16, and cyclin-D1 expression and survival outcomes in oropharyngeal and hypopharyngeal squamous cell carcinoma

BACKGROUND

P16 and cyclin-D1 are cell cycle proteins commonly dysregulated in head and neck carcinoma. We assessed their expression, clinicopathological variables, and overall survival (OS) in oropharyngeal and hypopharyngeal squamous cell carcinoma (SCC).

METHODS

Clinical characteristics and p16 and cyclin-D1 expression were evaluated in 101 patients with oropharyngeal SCC and 75 patients with hypopharyngeal SCC. Associations with OS were assessed using Cox regression and Kaplan-Meier analysis.

RESULTS

Compared to oropharyngeal SCC, patients with hypopharyngeal SCC were older, men, ever-smokers with higher mean Charlson Comorbidity Index (CCI), lower p16 expression, and poorer median OS (24.8 vs 62.3 months; p < .01). In oropharyngeal SCC, CCI (p < .001), cyclin-D1 (hazard ratio [HR] = 3.55; p = .007), current smoking (HR = 5.72; p = .004), and former smoking (HR = 4.12; p = .035) were independently associated with OS. In hypopharyngeal SCC, only nodal and Eastern Cooperative Oncology Group status were associated with OS.

CONCLUSION

In oropharyngeal SCC, cyclin-D1 expression is correlated with survival, whereas smoking status and CCI may allow further stratification of outcome.

Pyriform sinus squamous cell carcinoma: oncological outcomes in good responders of induction chemotherapy-based larynx preservation protocols

Induction chemotherapy-based larynx preservation protocols use chemotherapy to select exclusively patients with 'chemosensitive' tumors for a nonsurgical treatment with radiation therapy. This study on pyriform sinus squamous cell carcinoma (SCC) is interested in the oncological outcome of treatment based on radiation therapy when offered to patients with tumors responding to induction chemotherapy. This was a retrospective cohort study. The cohort included good responders to induction chemotherapy, subsequently treated with definite radiation therapy (with or without concomitant chemotherapy) for pyriform sinus SCC, in a tertiary referral cancer center. The primary endpoints were overall, laryngectomy-free and disease-free survival and the secondary endpoints were analysis of treatment failures and possibilities of salvage treatment. Forty-two patients fulfilled the inclusion criteria and were retained for analysis; 7% were stage II (3/42), 48% stage III (20/42) and 45% stage IV (19/42). At 1, 3 and 5 years, the overall survival was 95% (40/42), 74% (31/42), and 60% (SE ≈ 0.08), respectively. For the same intervals, the laryngectomy-free survival was 90% (38/42), 69% (29/42) and 50% (SE ≈ 0.08), respectively. The estimated 5-year disease-free survival was also 50%. Disease-free survival was significantly better for N0 patients. There was a 28% recurrence rate, mainly in the primary tumor site (9/11), with or without simultaneous nodal recurrence. Interestingly, more than one-third of all oncologic failures occurred beyond the first 3 years of follow-up. Salvage treatment was not possible or definitely inefficient in at least 2/3 of all recurrences. In candidates for larynx preservation for a pyriform sinus SCC, good response to induction chemotherapy followed by definite radiation therapy seems to be associated with a more favorable prognosis. Nevertheless, in case of locoregional recurrence the possibilities for efficient salvage treatment are limited.

Effect of number and ratio of positive lymph nodes in hypopharyngeal cancer

BACKGROUND

The number and ratio of positive lymph nodes are important prognostic factors in gastric cancer, but there is little data reported in hypopharyngeal cancer.

METHODS

Medical data from 81 patients with hypopharyngeal cancer undergoing radical hypopharyngectomy and cervical lymph node dissection were reviewed.

RESULTS

The median survival time was 84, 54, 30, and 13 months in patients with N0, N1, N2, and N3, respectively, and 84, 51, and 17 months with positive lymph node ratios (N ratio) 0, <10%, and >10%, respectively. Of the 24 N1 patients, the 20 patients that had an N ratio <10% had a better prognosis than the 4 patients with an N ratio >10%. Similar data was seen for the N2 patients. Tumor (T) classification, adjuvant therapy, and N ratio were independent prognostic factors in multivariate analysis.

CONCLUSION

The positive lymph node ratio is complementary to the current N classification system.

Dynamic contrast-enhanced MR imaging predicts local control in oropharyngeal or hypopharyngeal squamous cell carcinoma treated with chemoradiotherapy

The role of pretreatment dynamic contrast-enhanced perfusion MR imaging (DCE-PWI) and diffusion-weighted MR imaging (DWI) in predicting the treatment response of oropharyngeal or hypopharyngeal squamous cell carcinoma (OHSCC) to chemoradiation remains unclear. We prospectively investigated the ability of pharmacokinetic parameters derived from pretreatment DCE-PWI and DWI to predict the local control of OHSCC patients treated with chemoradiation. Between August, 2010 and March, 2012, patients with untreated OHSCC scheduled for chemoradiation were eligible for this prospective study. DCE-PWI and DWI were performed in addition to conventional MRI. The relationship of local control with the following clinical and imaging variables was analyzed: the hemoglobin level, T-stage, tumor location, gross tumor volume, maximum standardized uptake value, metabolic tumor volume and total lesion glycolysis on FDG PET/CT, transfer constant (K^trans), volume of blood plasma and volume of extracellular extravascular space on DCE-PWI, and apparent diffusion coefficient on DWI of the primary tumor. The patients were also divided into a local control group and a local failure group, and their clinical and imaging parameters were compared. There were 58 patients (29 with oropharynx squamous cell carcinoma [SCC] and 29 with hypopharynx SCC) with successful pretreatment DCE-PWI and DWI available for analysis. After a median follow-up of 18.2 months, 17 (29.3%) participants had local failure, whereas the remaining 41 patients achieved local control. Univariate analysis revealed that only the K^trans value was significantly associated with local control (P = 0.03). When the local control and local failure groups were compared, significant differences were observed in K^trans and the tumor location (P = 0.01 and P = 0.04, respectively). In the multivariable analysis, only K^trans was statistically significant (P = 0.04). Our results suggest that pretreatment K^trans may help predict the local control in OHSCC patients treated with chemoradiation.

Hypopharyngeal cancers requiring reconstruction: a single institute experience

The main objective of this retrospective analysis was to understand the length of stay in hospital, the complication rates and the perioperative mortality after various forms of hypopharyngeal reconstructions. This is a retrospective analysis of hypopharyngeal cancer patients who underwent surgery at the Tata Memorial Hospital, during 2005-2010. Of the total 393 patients, 103 required some form of pharyngeal reconstruction. The mean age of this population was 56 with a male to female ratio of 4:1. The mean hospital stay for all patients was 22 days (mean: 22, median: 15) and 17 % were readmitted for various reasons in the first 30 days after the initial discharge from hospital. The overall perioperative mortality was 10 % (10/103) and majority of these patients (6/10) had GPU as part of treatment. Gastric pull up has a high morbidity especially in patients with low albumin levels and should be used judiciously when needed. A comprehensive analysis of clinical and radiological data is helpful for choosing an ideal reconstruction after hypopharyngeal cancer excision.

Outcomes of anterolateral thigh flap reconstruction for salvage laryngopharyngectomy for hypopharyngeal cancer after concurrent chemoradiotherapy

OBJECTIVE

To evaluate the functional and oncological outcomes of anterolateral thigh flap reconstruction for salvage laryngopharyngectomy after concurrent chemoradiotherapy for patients with hypopharyngeal carcinoma.

MATERIALS/METHODS

A retrospective review was conducted on patients who underwent pharyngoesophageal reconstruction using anterolateral thigh flap after salvage laryngopharyngectomy for recurrent hypopharyngeal carcinoma between June 2003 and May 2010 at Chang Gung Memorial Hospital. The perioperative morbidity, mortality, functional outcomes, and oncological outcomes were evaluated.

RESULTS

33 patients were entered into the study. The mean follow-up time was 19.5±12.3 months. Recurrent pathological TNM stages included 3 (9.1%), 2 (6.1%), and 28 (84.8%) patients with stage II, III, and IV disease, respectively. Mean ICU stay was 10.3 days and the mean hospital stay was 39.9 days. Peri-operative mortality occurred in one patient (3%). 16 patients (48.5%) developed recipient site complications. Among them, 14 patients (42.4%) developed fistulas and 9 patients (27.3%) developed strictures. Except for 4 patients (12.1%), all achieved varying degree of oral intake with 29 patients (60.6%) being completely independent from tube feeding. The mean interval to start oral intake was 15.1 days. The 5-year overall survival and disease-free survival rates were 51.8% and 53.7%, respectively. The pN status is an independent predictor of overall survival and disease-free survival (P = 0.027 and 0.038, respectively).

CONCLUSION

Pharyngoesophageal reconstruction after salvage laryngopharyngectomy remains challenging even in the experienced hands. Reconstructive microsurgeons who are prepared to take on these cases should be equally well prepared to manage the potential postoperative complications.

Treatment of hypopharyngeal carcinoma with primary chemoradiotherapy: functional morbidity

PURPOSE OF REVIEW

This review aims at unravelling the medical literature which has reported on the treatment of 'larynx preserving' chemoradiotherapy strategies and separating the treatment sites, larynx and hypopharynx, from each other and reporting on the adverse effects and functional outcomes of patients with hypopharyngeal cancer.

RECENT FINDINGS

The literature reports on the treatment of advanced laryngeal and hypopharyngeal cancer with chemoradiotherapy together as a 'common cancer site'. Although the chemotherapeutic drugs affect the tumour and the normal tissues similarly in both the larynx and hypopharynx, their effects on the patient groups are different, mainly affecting swallow, airway protection mechanisms and voice/speech to a greater or lesser extent. Pretreatment symptoms and function should be documented subjectively and objectively prior to commencing nonsurgical treatment. Hypopharyngeal cancer should be reported separately, and preferably stratified into the three subsites, according to the T stage of disease rather than TNM stage. Equipment for such testing and the process for such documentation are available in most clinical areas, worldwide.

SUMMARY

Future analysis relies on the conscientious monitoring of adverse effects of all treatment modalities and an assessment of function as well as quality of life impact on the patient. Thus, the specialty can make informed decisions on the most appropriate and most suitable mode of treatment for individual patients based upon their tumour, their preoperative organ function, their likely future organ function and the likelihood of cure.

NBI flexible laryngoscopy targeted tissue sampling in head and neck cancer patients with difficult airways

Direct suspension laryngoscopic biopsy of neoplasms in larynx, oropharynx, and hypopharynx was an arduous procedure in patients with a history of head and neck cancer and difficult airways. This preliminary study was aimed to report the efficacy and safety of a narrow band imaging-guided biopsy of this category by flexible laryngoscopy. This is a retrospective chart review study conducted in setting of tertiary referral centre. Nineteen consecutive head and neck cancer patients with difficulty in general anesthesia and rigid endoscopic approach due to trismus, craniofacial deformities, and/or limited neck extension after cancer therapy were referred for endoscopic biopsy of their suspicious lesions in larynx, hypopharynx, or parts of oropharynx. Following topical anesthesia, a flexible laryngoscope was introduced through the nose into the pharynx. Under narrow band imaging magnified view, the specified tumor foci were biopsied in an office-based setting. All of the lesions were reached and biopsied to obtain sufficient tissue samples. The procedure took <20 min in every case. Twelve of the 19 pathologic examinations disclosed the malignancies at the first biopsy, and another underwent a second biopsy to prove cancer recurrence. The other six patients with benign lesions received further follow-up for at least 6 months and showed no recurrence. There were no complications associated with the technique. This study introduced that flexible laryngoscopy with narrow band imaging has the advantages of nimbleness, precision, and minimal morbidity. This combined technique may be a safe and promising method for tissue sampling of suspicious recurrence in head and neck cancer patients with difficult airways.

Low dose of gamma irradiation enhanced boronophenylalanine uptake in head and neck carcinoma cells for boron neutron capture therapy

This study attempted to increase the boron uptake of human head and neck carcinoma SAS cells for BNCT by using a gamma dose of 0.1 Gy for combined treatment. Intracellular boron concentrations in 25 μgB/mL medium of BPA treated and BPA combined gamma-irradiation treated SAS cells were 73.8±1.73 and 95.15±1.36 ppm, respectively. After neutron irradiation, the G2/M-phase cell populations of untreated, BPA treated and BPA combined gamma-irradiation treated SAS cells were 19.31±1.71%, 52.47±2.25% and 59.19±2.63%, respectively. Experimental results indicate that the low dose gamma radiation with combination BPA treatment has the highest killing rate after neutron irradiation. Capable of significantly increasing the G2/M arrest after neutron irradiation, the combined treatment of a low dose of gamma irradiation with 25 μg B/mL medium of BPA also provided a higher killing effect for BNCT.

Advanced hypopharyngeal cancer with amyotrophic lateral sclerosis

We present a case of advanced hypopharyngeal cancer occurring in a patient with amyotrophic lateral sclerosis (ALS). A 58-year-old man diagnosed with ALS 2 years previously noticed a mass in his neck and dysphagia. We diagnosed him as having hypopharyngeal squamous cell carcinoma with the left cervical lymph node metastases (T3N2bM0) and treated with concurrent chemoradiotherapy. During and after the treatment, his neurological symptoms showed no worse signs. The patient has been cancer-free for 13 months after concurrent chemoradiotherapy. The influence of ALS on the patients' quality of life (QOL) and/or prognosis had to be taken into consideration when determining an appropriate treatment for the hypopharyngeal cancer. To the best of our knowledge, this may be the first case with ALS who was treated for hypopharyngeal cancer.