Induction TPF followed by concomitant treatment versus concomitant treatment alone in locally advanced head and neck cancer. A phase II-III trial

Background

Platinum-based chemoradiation (CCRT) is the standard treatment for Locally Advanced Head and Neck Squamous-Cell Carcinoma (LAHNSCC). Cetuximab/RT (CET/RT) is an alternative treatment option to CCRT. The efficacy of induction chemotherapy (IC) followed by chemoradiation compared to chemoradiation alone has not been demonstrated in randomized clinical trials. The goals of this phase II-III trial were to assess: (i) the overall survival (OS) of IC versus no-induction (no-IC) and (ii) the Grade 3-4 in-field mucosal toxicity of CCRT versus CET/RT. The present paper focuses on the analysis of efficacy.

Materials and methods

Patients with LAHNSCC were randomized to receive concomitant treatment alone [CCRT (Arm A1) or CET/RT (Arm A2)], or three cycles of induction docetaxel/cisplatin/5 fluorouracil (TPF) followed by CCRT (Arm B1) or followed by CET/RT (Arm B2). The superiority hypothesis of OS comparison of IC versus no-IC (Arms B1 + B2 versus A1 + A2) required 204 deaths to detect an absolute 3-year OS difference of 12% (HR 0.675, with 80% power at two-sided 5% significance level).

Results

414 out of 421 patients were finally analyzed: 206 in the IC and 208 in the no-IC arm. Six patients were excluded because of major violation and one because of metastatic disease at diagnosis. With a median follow-up of 44.8 months, OS was significantly higher in the IC arm (HR 0.74; 95% CI 0.56-0.97; P = 0.031). Complete Responses (P = 0.0028), Progression Free Survival (P = 0.013) and the Loco-regional Control (P = 0.036) were also significantly higher in the IC arm. Compliance to concomitant treatments was not affected by induction TPF.

Conclusions

IC followed by concomitant treatment improved the outcome of patients with LAHNSCC without compromising compliance to the concomitant treatments. The degree of the benefit of IC could be different according to the type of the subsequent concomitant strategy.

Clinical Trial Number

NCT01086826, www.clinicaltrials.gov.

Cytokines and Thyroid Autoimmunity

Cytokines may play important roles in the development and perpetuation of autoimmunity. In this paper are briefly reviewed selected data on the relationship between cytokines and thyroid autoimmune diseases (AITD), which represent a typical example of organ-specific autoimmune endocrinopathy. The availability of high efficiency T-cell cloning techniques recently allowed the phenotipic and functional characterization of T lymphocytes derived from thyroid infiltrates of patients with Graves' disease and Hashimoto's thyroiditis. A high prevalence of T cell clones with cytolytic potential and displaying increased γ-interferon production was observed in both diseases; in contrast, high tumor necrosis factor-α secretion was a peculiar characteristic of T-cell clones derived only from Hashimoto's infiltrates. The production of IL-4 by CD4 + T cell clones from AITD infiltrates was remarkably low, suggesting a quite homogeneous populations of Thl-type «inflammatory» T cells. This pattern of cytokine production by thyroid infiltrates may be important not only in triggering and/or maintaining thyroid autoimmune reaction, but could also modulate the expression of AITD by exerting direct functional effects on thyroid epithelial cells, as suggested by recent in vitro studies.

Evidence of presymptomatic cognitive decline in Huntington's disease

Asymptomatic persons at risk for Huntington's disease (HD) (N = 28) were assessed with neuropsychological, psychiatric, and neurologic tests while undergoing genetic linkage studies to determine their probability of carrying the HD gene. Those participants who were subsequently identified as probable gene carriers did not differ on neurologic or psychiatric examination from those subsequently identified as probable noncarriers. Neuropsychological data are presented for a subset of participants free of other conditions (such as alcoholism) putting them at risk for cognitive deficits. Among these subjects, probable gene carriers were inferior to probable noncarriers on the neuropsychological battery as a whole and on several individual tests involving learning and memory. The results suggest the presence of cognitive decline prior to identifiable motor impairments in HD.

Factors associated with slow progression in Huntington's disease

The rate of disease progression was assessed for 42 persons affected by Huntington's disease who had been neurologically examined at least six times and followed up for at least 3 years. Disease progression was assessed by a disability rating scale administered at each examination. Slow progression was associated with older age at onset of disease and with heavier weight (body mass index) at the first examination. Men tended to have a slower disease progression than did women, and this was particularly evident among men inheriting Huntington's disease from affected mothers. Neither the butyrophenone haloperidol nor the tricyclic antidepressant imipramine were related to rate of progression. Assessments of depression, hostility, and tobacco use were also unrelated to rate of progression. Clinical trials in Huntington's disease should consider these factors when designing therapeutic studies.

Purified protein derivative of Mycobacterium tuberculosis and excretory-secretory antigen(s) of Toxocara canis expand in vitro human T cells with stable and opposite (type 1 T helper or type 2 T helper) profile of cytokine production

A large series of T cell clones (TCC) specific for purified protein derivative (PPD) of Mycobacterium tuberculosis (total 60) or Toxocara canis excretory/secretory (TES) antigen (total 69) were established from the peripheral blood of two healthy individuals and analyzed for their profile of cytokine production in response to stimulation with either the specific antigen or the polyclonal activator phorbol myristate acetate plus anti-CD3 antibody. Under both these experimental conditions, the great majority of PPD-specific TCC secreted IL-2 and IFN-gamma but not, or limited amounts of, IL-4 and IL-5. In contrast, most TES-specific TCC secreted IL-4 and IL-5 but not, or limited amounts of, IL-2 and IFN-gamma. PPD-specific TCC that failed to secrete IL-4 and IL-5, and TES-specific TCC that failed to secrete IL-2 and IFN-gamma, were found to lack transcripts for IL-4 and IL-5, or for IL-2 and IFN-gamma, respectively. During the course of the study, over a 6-mo period, the functional phenotype of both TES- and PPD-specific TCC was repeatedly assessed and remained constant. These data demonstrate that T cells with stable Th1 or Th2 functional pattern exist not only in mice but also in humans and suggest that in the course of natural immunization certain infectious agents preferentially expand T cell subsets with stable and definite profile of cytokine production.

The autoimmune infiltrate of Basedow's disease: analysis of clonal level and comparison with Hashimoto's thyroiditis

The availability of high efficiency T-cell cloning techniques recently allowed the identification and characterization of clones derived from the thyroid infiltrate of patients with autoimmune thyroid diseases. Phenotypical and functional analysis of T-cell clones obtained from thyroid infiltrates of patients with Hashimoto's thyroiditis show that most of them are progenies of CD8+ cytolytic T cells with natural killer activity. This phenomenon, of potential importance in tissue damage, is markedly less pronounced in Basedow's disease glands. In both Hashimoto's thyroiditis and Basedow's disease only a minority of clones appear to be specific for autologous thyroid cells and most of them are potent interferon-gamma producers, while increased secretion of tumor necrosis factor-alpha is observed only in Hashimoto's thyroiditis. In contrast with normal lymphoid tissue, only very few T cell clones derived from both BD and HT infiltrates were able to produce detectable amounts of IL-4, suggesting that most of the thyroid-infiltrating T cells represent quite homogeneous populations of Th1-type "inflammatory" T cells. This peculiar potential of lymphokine secretion could play a role in the expression and/or maintenance of thyroid autoimmunity and thyroid functional damage.

Attitudes toward presymptomatic testing in Huntington disease

One hundred thirty-one individuals at 50% risk of inheriting Huntington disease (HD) responded to a survey to study their attitudes toward taking a genetic test based on the identification of a genetically linked DNA polymorphism. Ninety-six percent of the respondents believe that presymptomatic testing should be available, and 66% say they will use it themselves. Fewer married individuals, in comparison to those single, separated, and divorced, intend to take the test. Many respondents (40%) said their primary reason for wanting to be tested is to end the uncertainty in their lives. Results suggest that there will be self-selection in test use, with many individuals who believe they will be depressed or possibly suicidal with a positive test result deciding not to be tested or unsure about testing. However, 15% of those who want to be tested acknowledge that they may be at risk for suicide if they are probable gene carriers. Only 12% of all respondents say they will be likely to use prenatal testing, suggesting that initial demand may be low in New England. Implementation of presymptomatic testing challenges health care providers to develop strategies to care for otherwise healthy persons who will be given a diagnosis years before the onset of illness.