Systemic chemotherapy for squamous cell head and neck cancer

Efficacy and Safety of Intro-Arterial Chemotherapy Combined with Radiotherapy on Head and Neck Cancer: A Systematic Review and Meta-Analysis

Objectives: Intro-arterial chemotherapy combined with radiotherapy (IACRT) for the treatment of head and neck cancer (HNC) underwent a revival in recent years. Although many clinical trials have reported favorable outcomes, the effect of IACRT for HNC is still controversial. Therefore, this study was designed to evaluate the efficacy and safety of IACRT for HNC.

Methods: The relevant articles published before August 2019 were searched from PubMed, Embase, Cochrane Library, Web of Science and PMC databases. Data were extracted and the combined complete response (CR), overall survival (OS) and toxicity incidence with 95% credible interval (CI) were examined from eligible studies.

Results: Thirty-four studies comprising 1890 patients were included. IACRT achieved high CR (0.81, 95% CI: 0.76-0.86, P < 0.001), 3-year OS (0.75, 95% CI: 0.68-0.82, P < 0.001) and 5-year OS (0.68, 95% CI: 0.61-0.75, P < 0.001). The 3-year OS rate of stage III cancer (0.75, 95% CI: 0.53-0.97, P< 0.001) was higher than stage IV (0.52, 95% CI: 0.37-0.66, P = 0.025). Meanwhile, the 5-year OS of T3 cancer (0.87, 95% CI: 0.73-1.01, P = 0.028) was higher than T4 (0.53, 95% CI: 0.42-0.63, P = 0.286). Additionally, oral diseases, mucositis, leukopenia and dermatitis were the major toxicities of IACRT, which were all reversible.

Conclusion: IACRT is an efficient and safe modality for HNC, which could achieve favorable cancer response and higher survival rate with acceptable toxicities, even for advanced HNC.

Physical and adhesive properties of dental enamel after radiotherapy and bonding of metal and ceramic brackets

INTRODUCTION

The increasing success rates for cancer patients treated with radiotherapy and the frequent occurrence of tooth loss during treatment have led to an increased demand for orthodontic treatment after radiotherapy. The aim of this study was to evaluate tooth enamel of irradiated teeth after the bonding and debonding of metal and ceramic brackets.

METHODS

Ten permanent molars were cut into enamel fragments measuring 1 mm(2) and divided into an irradiated group (total dose of 60 Gy) and a nonirradiated group. The fragments were subjected to microshear testing to evaluate whether radiotherapy altered the strength of the enamel. Furthermore, 90 prepared premolars were divided into 6 groups and subgroups (n = 15): group 1, nonirradiated and nonaged; group 2, nonirradiated and aged (thermal cycled); group 3, irradiated and aged; each group was divided into 2 subgroups: metallic and ceramic brackets. After thermal cycling and radiotherapy, the brackets were bonded onto the specimens with Transbond XT (3M Unitek, Monrovia, Calif). After 24 hours, the specimens were subjected to the shear tests. Images of the enamel surfaces were classified using the adhesive remnant index. The composite resin-enamel interface was also evaluated.

RESULTS

Enamel fragments subjected to radiation had lower strength than did the nonirradiated samples (P <0.05). The groups and subgroups submitted to radiation and bonded ceramic brackets had the lowest strength values. Groups 1 and 2 with metallic brackets had less adhesive on the surface, whereas groups 1 and 2 with ceramic brackets and group 3 with both metallic and ceramic brackets had more adhesive on the surfaces. On the images of the composite resin-enamel interface, resin tags were more extensive on irradiated tooth enamel.

CONCLUSIONS

Radiation decreased tooth enamel strength, and the specimens treated with radiotherapy had higher frequencies of adhesive failure between the bracket and the composite resin as well as more extensive tags.

Safe and effective treatment of spontaneous neoplasms with interleukin 12 electro-chemo-gene therapy

Electroporation improves the anti-tumour efficacy of chemotherapeutic and gene therapies. Combining electroporation-mediated chemotherapeutics with interleukin 12 (IL-12) plasmid DNA produces a strong yet safe anti-tumour effect for treating primary and refractory tumours. A previously published report demonstrated the efficacy of a single cycle of IL-12 plasmid DNA and bleomycin in canines, and, similarly, this study further demonstrates the safety and efficacy of repeated cycles of chemotherapy plus IL-12 gene therapy for long-term management of aggressive tumours. Thirteen canine patients were enrolled in this study and received multiple cycles of electro-chemo-gene therapy (ECGT) with IL-12 pDNA and either bleomycin or gemcitabine. ECGT treatments are very effective for inducing tumour regression via an antitumour immune response in all tested histotypes except for sarcomas, and these treatments can quickly eradicate or debulk large squamous cell carcinomas. The versatility of ECGT allows for response-based modifications which can overcome treatment resistance for affecting refractory lesions. Importantly, not a single severe adverse event was noted even in animals receiving the highest doses of chemotherapeutics and IL12 pDNA over multiple treatment cycles. This report highlights the safety, efficacy and versatility of this treatment strategy. The data reveal the importance of inducing a strong anti-tumour response for successfully affecting not only the treated tumours, but also non-treated metastatic tumours. ECGT with IL12 pDNA plus chemotherapy is an effective strategy for treating multiple types of spontaneous cancers including large, refractory and multiple tumour burdens.

Concomitant chemoradiation versus radical radiotherapy in advanced squamous cell carcinoma of oropharynx and nasopharynx using weekly cisplatin: a phase II randomized trial

BACKGROUND

To know the effectiveness and tolerance of weekly cisplatin added to radiotherapy (RT) in advanced carcinoma of oropharynx and nasopharynx.

PATIENTS AND METHODS

Stage II-IV cancer patients were randomly assigned to either radical RT, 70 Gy/35 fractions over 7 weeks (RT arm), or chemoradiotherapy (CRT), cisplatin 40 mg/m² weekly for seven doses plus RT. Primary end points were (i) the responses, (ii) toxicity profile, and (iii) overall survival (OS) in two groups. Study period was from June 2003 to July 2005.

RESULTS

One hundred and fifty-three patients were randomly allocated to the study, 76 in RT arm and 77 in CRT arm. Seventy-one in each arm completed the planned treatment; complete response (CR): 67.1% versus 80.5% in RT and CRT arms (P = 0.04). Grade III and IV toxicity were 16% and 40% in RT and CRT arms, respectively (P = 0.01). There were frequent treatment interruptions (9.3% versus 28.9%; P = 0.003) and hospitalization (20% versus 40.8%) in the CRT group. OS was superior in the CRT arm (P = 0.02): 27 months [95% confidence interval (CI) 15.2-36.8] for RT versus not reached for CRT. Three-year OS was 42% for RT and 62% for CRT group. CRT and CR were independent prognostic factors.

CONCLUSION

This trial on Indian head and neck squamous cell carcinoma patients confirms that the use of weekly cisplatin is safe and CRT is superior to RT alone resulting in higher OS.

Impact of the prophylactic gastrostomy for unresectable squamous cell head and neck carcinomas treated with radio-chemotherapy on quality of life: Prospective randomized trial

BACKGROUND AND PURPOSE

Concomitant radio-chemotherapy is the gold standard treatment for unresectable head and neck carcinomas. Placement of prophylactic gastrostomy has been proposed to provide adequate nutrition during the therapeutic sequence. The objectives of this study were to assess the impact of prophylactic gastrostomy on the 6-month quality of life, and to determine the factors related to this quality of life.

MATERIALS AND METHODS

Design. randomized, controlled, open study ("systematic percutaneous gastrostomy" versus "no systematic gastrostomy"). Patients. squamous cell head and neck carcinoma (stages III and IV, UICC 1997). Setting. oncological departments of French university teaching hospitals. Treatment. optimal concomitant radio-chemotherapy. Evaluations. T0 baseline evaluation, T1 during the treatment, T2 end of the treatment, and T3 6-month post-inclusion. Primary endpoint. 6-month quality of life (Qol) assessed using SF36, EORTC QLQ-C30, EORTC QLQ H&N35 questionnaires.

RESULTS

The Qol changes from baseline included a decline (T1 and T2) followed by an improvement (T3). Qol at 6 months was significantly higher in the group receiving systematic prophylactic gastrostomy (p=10(-3)). Higher initial BMI and lower initial Karnofsky index were significant factors related to a higher 6-month Qol.

CONCLUSIONS

The study results suggest that prophylactic gastrostomy improves post-treatment quality of life for unresectable head and neck cancer patients, after adjusting for other potential predictive quality of life factors.

Oral health status of 207 head and neck cancer patients before, during and after radiotherapy

The aim of this retrospective study was to describe the oral health status of patients before, during, and after radiotherapy (RT) for the treatment of head and neck cancer (HNC). Before RT, the following data was collected: presence of unrecoverable teeth, residual roots, unerupted teeth, use of dentures, periodontal alterations, caries, candidiasis, and xerostomia. Mucositis, candidiasis, and xerostomia were evaluated during RT. Patients continued to be followed after RT for evaluation of mucositis, candidiasis, xerostomia, radiation caries, and osteoradionecrosis. For statistical analysis, 95% confidence intervals (CI) were determined using sample size, population, and percentages. Before RT, 120 (57.9%) patients presented with alterations in the oral cavity namely, 85 (41.0%) with periodontal disease, 44 (21.2%) with residual roots, 25 (12.0%) with caries, 15 (7.2%) with candidiasis, and 12 (5.8%) had an unerupted tooth present. Xerostomia was a complaint of 19 patients (9.1%). Restorations were indicated for 33 patients (15.9%), whereas extraction was indicated for 104 (50.2%) patients. During RT, mucositis was found in 80 (61.7%) patients, candidiasis in 60 (45.8%), and xerostomia was a complaint of 82 patients (62.6%). After RT, mucositis persisted in 21 patients (19.2%), candidiasis was identified in 23 patients (21.1%), and xerostomia was reported by 58 patients (53.2%). Radiation caries developed in 12 patients (11.0%), whereas six patients (5.5%) developed osteoradionecrosis. The demographic profile herein presented will be useful as baseline data to provide additional epidemiological information and to determine future measures for prevention and treatment of RT-induced complications and sequelae.

Salvage surgery with free flap reconstruction: factors affecting outcome after treatment of recurrent head and neck squamous carcinoma

OBJECTIVE

To determine factors predicting the outcome after salvage surgery with microvascular flap reconstruction for recurrent squamous cell cancer (SCC) of the head and neck.

STUDY DESIGN

This is a retrospective analysis of patients treated at an academic medical center.

METHODS

One hundred six patients underwent salvage surgery and microvascular flap reconstruction after prior unsuccessful cancer treatment using surgery, radiation, or chemotherapy. All patients had a follow-up interval after salvage surgery of at least 24 months unless cancer rerecurrence occurred within 24 months after salvage surgery. Factors including age, sex, comorbidity level, tobacco use, alcohol use, disease-free interval since prior therapy, prior radiation, prior chemotherapy, prior surgery, recurrent tumor T class, recurrent tumor N class, recurrent cancer stage, and tumor location were examined to determine their association with cancer rerecurrence after salvage surgery. Successful treatment was defined as patients who remained free from cancer rerecurrence for a minimum 2 year period after salvage surgery.

RESULTS

Advanced recurrent T class (P = .02) was significantly associated with cancer recurrence. Recurrent cancer stage and patient smoking status approached statistical significance (P = .06).

CONCLUSION

Patients with recurrent T1 and T2 class are the best candidates for salvage surgery and microvascular flap reconstruction for treatment of recurrent SCC of the head and neck. Patients with T3 and T4 class recurrent cancers and patients who continue to smoke after initial diagnosis and treatment of head and neck SCC are poor candidates to undergo salvage surgery.

Standard, and novel cytotoxic and molecular-targeted, therapies for HNSCC: an evidence-based review

(1) Head and neck squamous cell carcinoma is the sixth most frequently occurring cancer worldwide.(2) Chemotherapy has shown some success as part of multimodal treatment schedules for locally advanced, nonmetastatic head and neck squamous cell carcinoma, and too a much lesser extent for metastatic head and neck squamous cell carcinoma.(3) A recent meta-analysis of 32 studies involving >10,000 patients concluded that chemotherapy added to radiotherapy produces a large survival advantage relative to radiotherapy alone.(4) Concurrent or alternate chemoradiotherapy, with a schedule based on cisplatin, has an established place in the management of locally advanced nonmetastatic head and neck squamous cell carcinoma.

Candida oral colonization and infection in Brazilian patients undergoing head and neck radiotherapy: a pilot study

OBJECTIVE

The aim of this study was to verify the profile of Candida species responsible for colonizing and infecting the oral cavity of Brazilian patients undergoing radiotherapy (RT).

STUDY DESIGN

Saliva samples were collected from 21 patients before, during, and immediately after RT. Each sample was distributed in agar Sabouraud dextrose/chlorophenicol and incubated at 37 degrees C for 18 hours. Emerging colonies were identified biochemically and through the germinative tube test. Patients were examined weekly to identify clinical candidiasis.

RESULTS

Candida colonization continuously increased during RT. Infection occurred in 52% of the patients, and baseline colonization was higher in infected patients. A shift toward non-albicans species was observed in both infected and noninfected patients.

CONCLUSIONS

RT leads to increased colonization and infection by Candida. The shift toward non-albicans species was unrelated to antifungal therapy. There may be epidemiological differences between infected and noninfected patients.

A phase II clinical and pharmacodynamic study of E7070 in patients with metastatic, recurrent, or refractory squamous cell carcinoma of the head and neck: modulation of retinoblastoma protein phosphorylation by a novel chloroindolyl sulfonamide cell cycle inhibitor

PURPOSE

E7070 is a synthetic sulfonamide cell cycle inhibitor that induces hypophosphorylation of the retinoblastoma (Rb) protein and G(1) arrest in vitro. This Phase II study was conducted to explore the efficacy, safety, and pharmacodynamics of E7070 in squamous cell carcinoma of the head and neck (SCCHN).

EXPERIMENTAL DESIGN

Patients with metastatic, recurrent, or refractory SCCHN, treated with no more than one prior therapy for recurrent disease, received E7070 at 700 mg/m(2) over 1 h every 3 weeks. Pre- and posttreatment tumor fine needle aspirates were subjected to immunohistochemistry with a panel of phospho-specific anti-Rb antibodies. End points included progression-free survival, response rate and duration, overall survival, toxicity profile, and inhibition of Rb phosphorylation.

RESULTS

Because none of the first 15 patients achieved progression-free survival > 4 months, the early stopping rule was invoked. Eleven patients had oropharyngeal cancer and 12 were male. Median age was 59 years (range, 49-73 years). Thirty-nine cycles of E7070 were delivered (median, 2.6 cycles/patient; range, 1-5 cycles). Six patients had stable disease after 2 cycles and 2 patients each subsequently received 1, 2, and 3 additional cycles, respectively, before experiencing progression. Immunohistochemistry of tumor cell aspirates from 3 patients demonstrated reduced Rb phosphorylation posttreatment.

CONCLUSIONS

At this dose and schedule, E7070 is unlikely to be superior over single-agent chemotherapy in SCCHN. However, the data suggest that cdk activity can be inhibited in tumor cells, resulting in posttreatment modulation of Rb phosphorylation. In the absence of cytotoxicity, more frequent administration of E7070 may be required to sustain Rb hypophosphorylation and cytostatic growth arrest.