Risk Factors for Complications in Patients Undergoing Temporal Bone Resection and Neck Dissection: Insights From a National Database

BACKGROUND

Temporal bone resection (TBR) with or without neck dissection (ND) is performed for otologic malignancies with occult or clinical cervical lymph node metastases. To date, characterization of post-operative complications in single institution case series may be non-representative of real-world outcomes. Here, we used data from the National Inpatient Sample (NIS) to comprehensively assess the complications encountered, their frequencies, and to identify underlying risk factors to improve future outcomes.

METHODS

The population was patients undergoing TBR and ND derived from the NIS between the years of 2017 and 2019. We utilized ICD-10 diagnosis codes to identify patients with post-operative complications, those discharged to non-home facilities (DNHF), and those with increased length of stay (LOS). Multivariable regression was performed to identify significant variables related to the above outcomes.

RESULTS

Ninety of 277 patients that underwent LTBR with ND had postoperative complications. Wound complications were the most frequent complication, occurring in 11 (4%) of patients, followed by CSF leak (n = 6; 2.2%), with acute respiratory failure being the most common medical complication (n = 4; 1.4%). Sixteen percent (45/277) were discharged to a facility besides home. Dementia (OR = 7.96; CI95 3.62-17.48), anemia (OR = 2.39; CI95 1.15-4.99), congestive heart failure (OR = 5.31; CI95 1.82-15.45), COPD (OR = 3.70; CI95 1.35-10.16), and history of prior stroke (OR = 8.50; CI95 1.55-46.68) increased the odds of DNHF. When evaluating LOS (median = 5 days, IQR = 1, 9), anemia (OR = 5.49; CI95 2.86-10.52), and Medicaid insurance (OR = 3.07; CI95 1.06-10.52) were found to increase the LOS.

CONCLUSIONS

The vast majority of patients undergoing LTBR with ND have no complications and are discharged within a week. Liver disease is a risk factor for medical complications and increased charges. Patients with dementia or a prior stroke are at risk for DNHF, and those with prior anemia are at risk for a wound complication.

LAY SUMMARY

This study identified factors related to worse post-operative outcomes in patients undergoing temporal bone resection and neck dissection. Although safe for most patients, an existing diagnosis of liver disease, stroke, dementia, and anemia specifically are at risk for developing negative outcomes.

LEVEL OF EVIDENCE

3.

Early, precise, and safe clinical evaluation of the pharmacodynamic effects of novel agents in the intact human tumor microenvironment

Introduction: Drug development is systemically inefficient. Research and development costs for novel therapeutics average hundreds of millions to billions of dollars, with the overall likelihood of approval estimated to be as low as 6.7% for oncology drugs. Over half of these failures are due to a lack of drug efficacy. This pervasive and repeated low rate of success exemplifies how preclinical models fail to adequately replicate the complexity and heterogeneity of human cancer. Therefore, new methods of evaluation, early in the development trajectory, are essential both to rule-in and rule-out novel agents with more rigor and speed, but also to spare clinical trial patients from the potentially toxic sequelae (high risk) of testing investigational agents that have a low likelihood of producing a response (low benefit). Methods: The clinical in vivo oncology (CIVO®) platform was designed to change this drug development paradigm. CIVO precisely delivers microdose quantities of up to 8 drugs or combinations directly into patient tumors 4-96 h prior to planned surgical resection. Resected tissue is then analyzed for responses at each site of intratumoral drug exposure. Results: To date, CIVO has been used safely in 6 clinical trials, including 68 subjects, with 5 investigational and 17 approved agents. Resected tissues were analyzed initially using immunohistochemistry and in situ hybridization assays (115 biomarkers). As technology advanced, the platform was paired with spatial biology analysis platforms, to successfully track anti-neoplastic and immune-modulating activity of the injected agents in the intact tumor microenvironment. Discussion: Herein we provide a report of the use of CIVO technology in patients, a depiction of the robust analysis methods enabled by this platform, and a description of the operational and regulatory mechanisms used to deploy this approach in synergistic partnership with pharmaceutical partners. We further detail how use of the CIVO platform is a clinically safe and scientifically precise alternative or complement to preclinical efficacy modeling, with outputs that inform, streamline, and de-risk drug development.

ctDNA as an Adjunct to Posttreatment PET for Head and Neck Cancer Recurrence Risk Assessment

OBJECTIVE

Circulating tumor DNA (ctDNA) detection is an emerging technique that identifies minimal residual disease in patients with solid tumors. ctDNA can act as an adjunct method to help overcome the limitations of positron emission tomography (PET) and select patients who are at high risk for recurrence.

STUDY DESIGN

Retrospective Single Institutional Study.

SETTING

University Hospital Setting.

METHODS

Twenty-nine patients who underwent definitive treatment for squamous cell carcinoma of the head and neck (HNSCC) from 8/2021 to 01/2023 had ctDNA levels analyzed at 1 to 3, 6, 9, and 12 months after definitive treatment. A personalized, tumor-informed, multiplex polymerase chain reaction (PCR) next-generation sequencing (NGS) assay was used to detect the ctDNA levels. The primary outcome was recurrence-free probability (RFP), and the secondary outcomes were overall survival (OS), sensitivity, specificity, and the test's negative (NPV) and positive predictive values (PPV).

RESULTS

The median age of patients was 65 years (interquartile range: 56-69), with majority being males (n = 22, 76%). The primary sites were larynx (n = 12), oropharynx (n = 10), and oral cavity (n = 6). Posttreatment ctDNA was detected in 7 patients, all of whom had disease recurrence. ctDNA detection after definitive treatment was associated with a higher risk of disease recurrence (hazard ratio: 9.94, 95% confidence interval: 1.56-63.3, P = .015). ctDNA identified recurrence with 100% specificity and 78% sensitivity. The NPV and PPV were 91% and 100%. PET had 78% sensitivity but only 68% specificity with 86% NPV, and 54% PPV.

CONCLUSION

Based on our data, ctDNA can be an excellent adjunct test for posttreatment PET and can help guide physicians in cases where PET results are inconclusive and difficult to interpret.

Sexual history of patients with human papillomavirus positive and negative oropharyngeal cancer: A systematic review and meta-analysis

BACKGROUND

Increased sexual activity is associated with higher human papillomavirus (HPV) rates; however, there is a lack of analysis comparing the sexual history of patients with HPV positive and HPV negative oropharyngeal cancer (OPC).

METHODS

In this meta-analysis, PubMed, Scopus, and CINAHL were searched for articles that included patients with OPC and reported information regarding HPV status and either history of oral sex, number of sexual partners, or sexually transmitted infections (STI).

RESULTS

A total of 11 studies were included with 3296 patients with OPC. Patients with HPV positive OPC were more likely than patients with HPV negative OPC to report a history of oral sex (92%, 95% CI: 87.0-97.0 vs. 74.5%, 95% CI: 50.6-98.4, p < 0.0001), higher mean number of sexual partners (18.4 partners, 95% CI: 1.5-35.4 vs. 7.2 partners, 95% CI: 1.0-13.4, p < 0.0001), and more frequent history of STI (23.7%, 95% CI: 18.4-29.0 vs. 8.8%, 95% CI: 4.7-12.8, p = 0.0001).

CONCLUSIONS

Compared to patients with HPV negative OPC, our analysis shows a larger proportion of patients with HPV positive OPC had participated in oral sex, had a higher number of sexual partners, and had a higher proportion of STI history.

Impact of Dementia on the Postoperative Outcomes in Patients Undergoing Surgery for Head and Neck Cancers: A National Study

BACKGROUND

Dementia, a growing concern among the elderly, has an increased poor postoperative outcome that goes unrecognized by many. Our study aims to establish if dementia plays a role in the outcomes of head and neck cancer patients that undergo resections.

METHODS

We queried the National Inpatient Sample (NIS) database from 2016 to 2019 with a primary diagnosis of head and neck cancer who underwent surgical resection. Outcomes analyzed include postoperative delirium, ICU stay, complications, length of stay, and non-routine discharge.

RESULTS

A total of 77095 patients were included, of which 1140 patients had dementia. The mean age of the patients with dementia was 77.5 years (±9.1) versus 63.2 years (±12.1) with no dementia. Dementia patients had a higher non-home discharge rate (77.2% vs 46.8%, p = <0.001), extended length of stay (10.9 days ±14.7 vs 7.9 days ±8.8), postoperative delirium (15.4% vs 1.5%, p = <0.001), and longer ICU stay (8.3% vs 5.8%) as compared with patients with no dementia. A higher number of patients with Dementia were placed in long-term facilities (53.5% vs 14.6%) postoperatively. More dementia patients (7.9% vs 0.9%) were transferred in from another health care facility for surgery. Dementia was associated with higher odds of delirium (OR, 6.36; 95% CI, 5.2-7.77), non-routine discharge (OR, 2.05; 95% CI, 1.76-2.3), ventilation (OR, 0.8; 95% CI, 0.6-1.05), and length of stay (estimate 3.01, 95% CI, 1.84-4.184).

CONCLUSION

Preoperative dementia significantly impacts postoperative delirium, non-home discharge, and extended length of stay in head and neck cancer patients undergoing surgery.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:1258-1264, 2024.

Inducible Keratinocyte Specific FGFR2 Deficiency Inhibits UVB-Induced Signaling, Proliferation, Inflammation, and Skin Carcinogenesis

A potential role for fibroblast growth factor receptor 2 (FGFR2) in cutaneous squamous cell carcinoma (cSCC) has been reported. To demonstrate the specific role of FGFR2 in UVB-induced skin carcinogenesis and development of cSCC, we generated a keratinocyte specific, tamoxifen inducible mouse model of FGFR2 deficiency. In this mouse model, topical application of 4-hydroxy tamoxifen led to the induction of Cre recombinase to delete FGFR2 in epidermal keratinocytes of both male and female transgenic mice. Analysis of epidermal protein lysates isolated from FGFR2 deficient mice exposed to UVB showed significant reductions of phospho-FGFR (pFGFR; Y653/654) and phospho-fibroblast growth factor receptor substrate 2α as well as downstream effectors of mTORC1 signaling. Phosphorylation of signal transducer and activators of transcription 1/3 was significantly reduced as well as levels of IRF-1, DUSP6, early growth response 1, and PD-L1 compared to the control groups. Keratinocyte-specific ablation of FGFR2 also significantly inhibited epidermal hyperproliferation, hyperplasia, and inflammation after exposure to UVB. Finally, keratinocyte-specific deletion of FGFR2 significantly inhibited UVB-induced cSCC formation. Collectively, the current data demonstrate an important role of FGFR2 in UVB-induced oncogenic signaling as well as development of cSCC. In addition, the current preclinical findings suggest that inhibition of FGFR2 signaling may provide a previously unreported strategy to prevent and/or treat UVB-induced cSCC.

Editorial: Special Issue on the Epidemiology of Human Papilloma Virus-Associated Oropharyngeal Squamous Cell Carcinoma

In this Special Issue of Cancers, the role of oncogenic human papilloma virus (HPV) with oropharyngeal squamous cell carcinoma is explored […].

Current management of xerostomia in head and neck cancer patients

Radiotherapy (RT) continues to play a key role in the management of head and neck cancer (HNC). Xerostomia remains a principal detriment to the quality of life (QoL) for 80 % of surviving patients receiving head and neck radiation. Radiation-induced injury to the salivary glands is dose-dependent, and thus efforts have been focused on decreasing radiation to the salivary glands. Decreased saliva production reduces both short-term and long-term quality of life in head and neck survivors by impacting on taste and contributing to dysphagia. Several radioprotective agents to the salivary gland have been investigated. Although not widely practiced, surgical transfer of the submandibular gland prior to RT is the mainstay of surgical options in preventing xerostomia. This review focuses on the strategies to improve xerostomia following radiation therapy in head and neck cancers.

Abstract 4448: Chemokine (C-X-C motif) ligand 17 promotes cutaneous squamous cell carcinoma via modulating tumor-immune evasion

Cutaneous squamous cell carcinoma (cSCC) is a keratinocyte-derived invasive and metastatic tumor of the skin. It is the second-most commonly diagnosed form of skin cancer, striking 200,000 Americans annually. Further, organ transplant patients are at significantly increased risk of cSCC compared to the general population. Excision of cSCC of the head and neck area results in significant facial disfigurement. An increased understanding of the mechanisms involved in the pathogenesis of cSCC could identify means to prevent, inhibit, and reverse this process. Chemokine (C-X-C motif) ligand 17 (CXCL17) is the latest chemokine family member, and an increased CXCL17 protein expression was observed in both mouse and human cSCC cell lines. Further, deletion of CXCL17 was associated with significant inhibition of tumor cell-intrinsic properties such as proliferation, migration, and motility. CXCL17 is identified as a potent chemoattractant for macrophages, dendritic cells and myeloid-derived suppressive cells. Accordingly, utilizing a syngeneic, tumor-cell xenograft cSCC mouse model, we evaluated the effect of CXCL17 deletion on cSCC tumor-immune evasion and elucidated the underlying mechanism. Deletion of CXCL17 was associated with a significant reduction in tumor volume compared to the wild-type counterparts. Further, CXCL17 deleted cSCC tumor cell xenografts exhibited a significant increase in CD8+, cytotoxic T cells in the tumor microenvironment, suggesting an important role of CXCL17 in mediating tumor-immune evasion. Interestingly, treatment with CXCL17 induced macrophage M2 polarization and promoted macrophage efferocytosis via modulating efferocytotic machinery proteins such as MERTK, TIM4, GAS6 and AXL. Our studies have established substantial evidence for the role of CXCL17 in modulating tumor-cell extrinsic properties to affect the progression of cSCC.

Citation Format: Alok R. Khandelwal, Rema Anisha Kandula, Emily Daniel, Md Maksudul Alam, Henry Craighead, Tara Moore-Medlin, Cherie-Ann O. Nathan. Chemokine (C-X-C motif) ligand 17 promotes cutaneous squamous cell carcinoma via modulating tumor-immune evasion. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4448.

A Randomized Multi-institutional Phase II Trial of Everolimus as Adjuvant Therapy in Patients with Locally Advanced Squamous Cell Cancer of the Head and Neck

PURPOSE

Investigate whether adjuvant everolimus, an mTOR inhibitor, improves progression-free survival (PFS) in advanced-stage head and neck squamous cell carcinoma (HNSCC) and provide outcomes related to correlative biological factors associated with disease control.

PATIENTS AND METHODS

This was a prospective, randomized, double-blind phase II trial of patients with advanced-stage HNSCC from 13 institutions who were confirmed disease-free post-definitive therapy and enrolled between December 2010 and March 2015. Patients received adjuvant everolimus or placebo daily (10 mg, oral) for a maximum of 1 year. p16 IHC as a surrogate marker for human papillomavirus infection and whole-exome sequencing were performed. Cox proportional hazard models estimated hazard rates. Log-rank tests evaluated differences in survival. The primary endpoint was PFS. Secondary endpoints and objectives included overall survival (OS) and toxicity assessment.

RESULTS

52 patients [median (range) age, 58 (37-76) years; 43 men (83%), 9 women (17%)] were randomized to placebo (n = 24) or everolimus (n = 28). PFS favored everolimus, but was not significant [log-rank P = 0.093; HR = 0.44; 95% confidence interval (CI), 0.17-1.17]. There was no difference in OS (P = 0.29; HR = 0.57; 95% CI, 0.20-16.2). Everolimus resulted in significant improvement in PFS for p16-negative patients (n = 31; P = 0.031; HR = 0.26; 95% CI, 0.07-0.97), although subgroup analysis showed no difference for p16-positive patients (n = 21; P = 0.93). Further, PFS was significantly higher in TP53-mutated (TP53mut) patients treated with everolimus compared with placebo (log-rank P = 0.027; HR = 0.24; 95% CI, 0.06-0.95). No treatment difference was seen in patients with TP53 wild-type tumors (P = 0.79).

CONCLUSIONS

p16-negative and TP53mut patients may benefit from adjuvant treatment with everolimus.

Transoral Robotic Surgery for Oropharyngeal Squamous Cell Carcinoma of the Tonsil versus Base of Tongue: A Systematic Review and Meta-Analysis

Simple Summary

Transoral Robotic Surgery (TORS) has become widely adopted for the surgical removal of oropharyngeal squamous cell carcinoma (OPSCC). However, it is currently unknown if TORS has equal efficacy and outcomes in patients with tonsillar or base of tongue (BOT) OPSCC. Therefore, we performed a systematic review, including articles describing the surgical management of OPSCC with TORS that compared margin status, complications, and recurrence between tonsil and BOT. BOT OPSCC had a higher rate of positive margins compared to tonsillar OPSCC. However, no differences were seen in the recurrence or postoperative hemorrhage rates of BOT and tonsillar OPSCC. While a higher rate of positive margins was seen in BOT OPSCC when compared to tonsillar OPSCC, this did not translate to a higher recurrence rate in the BOT group. Future research on which subset of patients with BOT is more likely to have positive margins is warranted to improve the utility of TORS further.

Abstract

Transoral Robotic Surgery (TORS) has become widely adopted for the surgical removal of oropharyngeal squamous cell carcinoma (OPSCC), with the most common locations being in the tonsil and base of tongue (BOT). However, it is currently unknown if TORS has equal efficacy and outcomes in patients with tonsillar or BOT OPSCC. Therefore, the aim of this study was to compare the margin status and recurrence rates of tonsillar and BOT OPSCC after TORS. Per PRISMA guidelines, PubMed, Scopus, and CINAHL were systematically searched from inception to 2/28/2022. Articles including the surgical management of OPSCC with TORS that compared margin status, complications, and recurrence between tonsil and BOT were included. Meta-analyses of proportions and odds ratios were performed. A total of 28 studies were included, comprising 1769 patients with tonsillar OPSCC and 1139 patients with BOT OPSCC. HPV positivity was seen in 92.3% of tumors. BOT OPSCC had a higher rate of positive margins compared to tonsillar OPSCC (28.1% [95%CI 15.1–43.3] vs. 7.5% [95%CI 3.3–13.3]). No differences were seen in recurrence between BOT and tonsillar OPSCC (OR 1.1 [95%CI 0.8–1.5], p = 0.480). In addition, no differences in postoperative hemorrhage were seen between tonsillar and BOT OPSCC (10.7% [95%CI 6.1–16.5] vs. 8.8% [95% CI 1.5–21.3]). While a higher rate of positive margins was seen in BOT OPSCC when compared to tonsil OPSCC, this did not translate to a higher recurrence rate in the BOT group. Future research on which subset of patients with BOT is more likely to have positive margins is warranted to improve the utility of TORS further.

Abstract 231: Targeting CXCL17 (C-X-C Motif Chemokine Ligand 17) inhibits cutaneous squamous cell carcinoma via modulating angiogenesis

Cutaneous squamous cell cancer (cSCC) is one of the most rapidly increasing cancers in the USA, striking 200,000 Americans annually, and is associated with significant morbidity & mortality. Exposure to Solar UVB (ultraviolet B) radiation is the primary etiologic factor for skin cancer. Sunscreens provide limited protection against UVB-induced skin cancer, and there is no effective adjuvant therapy for aggressive cSCC. Therefore, new mechanism-based approaches are needed for both prevention of cSCC and as adjuvant treatment for patients at high risk for recurrence and metastasis. Moreover, excision of cSCC of the Head & Neck results in significant facial disfigurement, and thus, chemoprevention for patients with condemned skin is critical. Chemokine (C-X-C motif) ligand 17 (CXCL17) is the latest chemokine family member, and recent studies have identified both a causative and protective role of CXCL17 in tumorigenesis. The role of CXCL17 in the development and progression of cSCC is not yet elucidated. In our ongoing studies, CXCL17 protein expression was significantly overexpressed in cSCC cell lines (SCC12A, SCC118, SCC7, SCC59) compared to normal human epidermal keratinocytes. Deletion of CXCL17 significantly inhibited cSCC cell proliferation, migration, and motility, suggesting an essential role in tumor growth, invasion, and metastasis. Tumor-specific overexpression of CXCL17 was detected in human cSCC that further bolsters our in vitro findings, indicating a causative role for CXCL17 in skin tumorigenesis. Further, deletion of CXCL17 in cSCC cell lines was associated with marked downregulation of the AKT/mTOR/STAT3 cell signaling pathways. To translate our in vivo data in an in vivo animal model, the effect of CXCL17 deletion on cSCC tumor cell xenograft growth was evaluated. Deletion of CXCL17 in both non-metastatic and metastatic cSCC cells significantly decreased tumor growth. Moreover, the reduction in tumor growth was associated with a significant downregulation in tumor angiogenesis measured using IHC for CD31. Finally, using a retrospective chart review for patients at Louisiana State University Health Sciences Center Shreveport (LSUHSC-S) and Overton Brooks Veterans Affairs Medical Center, we investigated the correlation of CXCL17 staining in human cSCC tumor samples and clinicopathological factors associated with metastatic cSCC. Among 44 subjects included in the analysis, the Histo-score of cytoplasmic CXCL17 expression was significantly higher in the metastatic cSCC group compared to non-metastatic tumor samples. Interestingly, the CXCL17 staining score correlated with the perineural invasion, suggesting CXCL17 as a biomarker of aggressiveness. Our studies have established a causative role for CXCL17 in cSCC and a novel target in the treatment of cSCC

Citation Format: Alok R. Khandelwal, Rema Anisha Kandula, Md Maksudul Alam, Janmaris Marin Fermin, Tara Moore-Medlin, John DiGiovanni, Cherie-Ann O. Nathan. Targeting CXCL17 (C-X-C Motif Chemokine Ligand 17) inhibits cutaneous squamous cell carcinoma via modulating angiogenesis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 231.

Abstract CT216: A phase 0 master protocol utilizing a novel intratumoral microdosing approach for simultaneously evaluating multiple drugs and drug combinations in patients with solid tumors

Purpose/Objectives: Tumor responses to cancer treatments are highly context-specific and often involve complex interactions between the anti-cancer therapy, genetically diverse tumor cells, and a heterogeneous tumor microenvironment (TME). All preclinical models fall short in capturing this complexity. CIVO (Comparative In Vivo Oncology) is an intratumoral microdose injection research tool intended to bridge the translational gap between preclinical and clinical studies by enabling in situ assessment of up to 8 oncology drugs or drug combinations simultaneously within a patient’s tumor. The CIVO Phase 0 model was established under FDA’s exploratory IND guidelines for microdosing. A Master Protocol was then developed, enabling ongoing evaluation of multiple investigational drugs and combinations without a need for stand-alone new protocols. Each investigational drug or combination is specified as a substudy of the Master Protocol, thus reducing administrative burden to clinical site staff and creating an infrastructure to ensure quality data and oversight of patient safety. This is a multi-center, open-label Phase 0 Master Protocol designed to study the localized pharmacodynamics (PD) of anti-cancer therapies within the TME when administered intratumorally in microdose quantities via the CIVO device. The safety of intratumoral microdose administration via the CIVO device will also be evaluated.

Materials/Methods: Approximately 12 subjects are expected to be enrolled per substudy. All substudies will evaluate subjects ≥18 years with a diagnosis of solid tumors with scheduled surgical intervention. Eligible subjects have at least one lesion (primary or recurrent tumor or effaced metastatic lymph node) ≥2 cm in the shortest diameter that is surface accessible for CIVO injection. Each substudy will define the tumor type and specific eligibility criteria for enrollment. The study visits consist of screening, CIVO injection, surgical intervention, and two follow-up visits. All patients will be injected by the CIVO device containing microdose quantities of drugs specified in respective substudies. The CIVO device can be configured with 3, 5, or 8 needles and the device configuration will be assigned on a per-patient basis, dependent upon lesion size. Following surgical resection, the injected portion of the tumor will undergo central PD biomarker analysis. At the time of submission, the study is open for enrollment with 1 substudy enrolling Head and Neck Squamous Cell Carcinoma (HNSCC) patients and 1 substudy enrolling HNSCC or soft tissue sarcoma patients. The Master Protocol was established to efficiently add substudies and accommodate evaluation of a wider repertoire of new agents in order to continually inform and de-risk drug development via the CIVO platform.

Clinical trial information: NCT04541108.

Citation Format: Karthik Rajasekaran, Jason G. Newman, Robert G. Maki, Thomas J. Ow, Vikas Mehta, Kenneth R. Gundle, Daniel R. Clayburgh, Ryan J. Li, Mercedes Porosnicu, Cherie-Ann O. Nathan, Alice Tang, Beryl A. Hatton, Kimberly H. Sottero, Gloria Kung, Marc O. Grenley, Kirsten Anderson, Richard A. Klinghoffer. A phase 0 master protocol utilizing a novel intratumoral microdosing approach for simultaneously evaluating multiple drugs and drug combinations in patients with solid tumors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr CT216.

Abstract 3209: Everolimus inhibits angiogenesis and lymphangiogenesis to affect tumor growth in TP53 mutant HNSCC

Head and neck squamous cell carcinoma (HNSCC) constitutes the eighth most common cancer globally, with the eighth highest mortality rate amongst all cancer types. TP53 is the most frequently mutated gene in HPV -negative HNSCC. HPV-negative HNSCC harboring p53 mutations have the worst clinical outcomes with 50-60% local regional and distant recurrences causing increased morbidity and mortality. TP53 mutations are associated with shorter recurrence-free and overall survival. Angiogenesis and lymphangiogenesis play a causal role in tumor recurrence and lymph node metastasis. Therefore, inhibiting tumor angiogenesis and lymphangiogenesis is important in to preventing tumor recurrence and metastasis of TP53 mutant HNSCC. Previous studies demonstrated that mTOR activates STAT3 to upregulate HIF-1α and its target proteins, VEGF-A and VEGF-C, key molecules involved in angiogenesis and lymphangiogenesis, respectively. Further, mTOR inhibitors suppress autocrine and paracrine growth stimulation of tumor and lymphatic endothelial cells by impairing the VEGF-C/VEGF-3 axis and releasing soluble VEGFR-2. Accordingly, our objective was to investigate the effect of an mTOR inhibitor, everolimus, on angiogenesis and lymphangiogenesis of HPV-negative TP53 mutant HNSCC. Everolimus treatment of HPV-negative HNSCC cell lines harboring a variety of TP53 mutations, significantly downregulated protein and mRNA levels of VEGF-A and VEGF-C. Moreover, everolimus downregulated HIF-1α protein levels suggesting a HIF-1alpha-dependent VEGF modulation. Interestingly, treatment of human microvascular and lymphatic endothelial cells (HMEC-1 and HMEC-1A, respectively) with everolimus was also associated with a significant reduction in cell proliferation, in vitro tube formation, and migration. Protein and mRNA levels of HIF-1α, VEGF-A, and VEGF-C were downregulated by everolimus treatment in both HMEC-1 and HMEC-1A cell lines. Taken together, our data suggest that everolimus prevents angiogenesis and lymphangiogenesis through the inhibition of HIF-1α, indicating a promising role for mTOR inhibitors in treating HPV-negative TP53 mutant HNSCC patients at high risk for recurrence.

Citation Format: Md Maksudul Alam, Janmaris Marin Fermin, Mark Knackstedt, Mackenzie J. Noonan, Emily K. Daniel, Tara Moore-Medlin, Xiaohua Rong, Alok R. Khandelwal, Cherie-Ann O. Nathan. Everolimus inhibits angiogenesis and lymphangiogenesis to affect tumor growth in TP53 mutant HNSCC [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3209.

Inhibition of Fibroblast Growth Factor Receptor Attenuates Ultraviolet B-Induced Skin Carcinogenesis

Altered FGFR signaling has been shown to play a role in a number of cancers. However, the role of FGFR signaling in the development and progression of ultraviolet B-induced (UVB) induced cutaneous squamous cell carcinoma (cSCC) remains unclear. In the current study, the effect of UVB radiation on FGFR activation and its downstream signaling in mouse skin epidermis was examined. In addition, the impact of FGFR inhibition on UVB-induced signaling and skin carcinogenesis was also investigated. Exposure of mouse dorsal skin to UVB significantly increased phosphorylation of FGFRs in the epidermis as well as activation of downstream signaling pathways, including AKT/mTOR, STATs and MAPK. Topical application of the pan-FGFR inhibitor AZD4547 to mouse skin prior to exposure to UVB significantly inhibited FGFR phosphorylation as well as mTORC1, STAT3 and MAPK activation (i.e., phosphorylation). Moreover, AZD4547 pretreatment significantly inhibited UVB-induced epidermal hyperplasia and hyperproliferation and reduced infiltration of mast cells and macrophages into the dermis. AZD4547 treatment also significantly inhibited mRNA expression of inflammatory genes in the epidermis. Finally, mice treated topically with AZD4547 prior to UVB exposure showed decreased cSCC incidence and increased survival rate. Collectively, the current data supports the hypothesis that inhibition of FGFR in epidermis may provide a new strategy to prevent and/or treat UVB-induced cSCC.

Substernal goitre presenting with upper and lower extremity oedema

Substernal goitre is characterised by compressive symptoms of the airway and oesophagus. Chronic, progressive symptoms usually result in surgical removal. We report a rare presentation of substernal goitre in a male in his early 70s who suffered from severe bilateral lower extremity (LE) lymphoedema, resulting in immobility and nursing home placement, and left upper extremity lymphoedema. Our initial assessment led to a filariasis work-up, which was negative, due to the patient's prior 2-year residence in India and service overseas. Chest CT scan revealed an incidental substernal goitre extending posterior to the left innominate vein and aortic arch to the level of the left mainstem bronchus. The patient underwent a left hemithyroidectomy via cervical excision and sternotomy and had an uneventful recovery with resolution of lymphoedema and mobility. Despite extensive literature regarding clinical presentations of substernal goitre, severe lymphoedema of the LE is not a well-established association.

Concerns and Needs of Patients With Head and Neck Cancer in the COVID-19 Era

Objective

To evaluate the concerns and needs of patients and survivors of head and neck cancer (HNC) in the COVID-19 era.

Study Design

Prospective cross-sectional survey.

Setting

Contact lists of 5 North American HNC advocacy groups.

Methods

A 14-question survey was distributed to the contact lists of 5 HNC advocacy groups evaluating patient and survivor needs and concerns related to their cancer care and COVID-19.

Results

There were 171 respondents, with 75% in the posttreatment period. The most common concern was contraction of COVID-19 (49%). More patients in active treatment preferred in-person visits than those in the early (≤5 years) and late (>5) survivorship period (72% vs 61% vs 40%, P < .001). A higher percentage of late survivors preferred virtual visits (38% vs 28%, P = .001). In total, 91 (53.2%) respondents sought emotional support outside of immediate family and friends. This included cancer support groups (36.2%), the medical team (29.7%), and other sources outside of these (34.1%), including faith-based organizations and online communities. A higher proportion of women than men (62% vs 41%, P = .001) were seeking emotional support outside of immediate family and friends.

Conclusions

During the early stages of the COVID-19 pandemic, patients with HNC who were actively undergoing treatment had increased need for support resources and preferred in-person provider visits. Alternatively, a higher percentage of patients >5 years from treatment preferred virtual visits. Emotional support outside of family and friends was sought out by a majority of respondents. Further research is needed to determine what support and educational resources are needed to best aid these various populations.

Rapalogs induce non-apoptotic, autophagy-dependent cell death in HPV-negative TP53 mutant head and neck squamous cell carcinoma

TP53 is the most frequently mutated gene in head and neck squamous cell carcinoma (HNSCC). Patients with HPV-negative TP53 mutant HNSCC have the worst prognosis, necessitating additional agents for treatment. Since mutant p53 causes sustained activation of the PI3K/AKT/mTOR signaling pathway, we investigated the effect of rapalogs RAD001 and CCI-779 on HPV-negative mutTP53 HNSCC cell lines and xenografts. Rapalogs significantly reduced cell viability and colony formation. Interestingly, rapalogs-induced autophagy with no effect on apoptosis. Pretreatment with autophagy inhibitors, 3-methyladenine (3-MA) and ULK-101 rescued the cell viability by inhibiting rapalog-induced autophagy, suggesting that both RAD001 and CCI-779 induce non-apoptotic autophagy-dependent cell death (ADCD). Moreover, rapalogs upregulated the levels of ULK1 and pULK1 S555 with concomitant downregulation of the mTORC1 pathway. However, pretreatment of cells with rapalogs prevented the ULK-101-mediated inhibition of ULK1 to sustained autophagy, suggesting that rapalogs induce ADCD through the activation of ULK1. To further translate our in vitro studies, we investigated the effect of RAD001 in HPV-negative mutTP53 (HN31 and FaDu) tumor cell xenograft model in nude mice. Mice treated with RAD001 exhibited a significant tumor volume reduction without induction of apoptosis, and with a concomitant increase in autophagy. Further, treatment with RAD001 was associated with a considerable increase in pULK1 S555 and ULK1 levels through the inhibition of mTORC1. 3-MA reversed the effect of RAD001 on FaDu tumor growth suggesting that RAD001 promotes ACDC in HPV-negative mutTP53 xenograft. This is the first report demonstrating that rapalogs promote non-apoptotic ADCD in HPV-negative mutTP53 HNSCC via the ULK1 pathway. Further studies are required to establish the promising role of rapalogs in preventing the regrowth of HPV-negative mutTP53 HNSCC.

Impact of smoking on stage-specific survival in human papilloma virus-associated oropharyngeal squamous cell carcinoma

BACKGROUND

The American Joint Committee on Cancer (AJCC) released a new staging system for human papilloma virus (HPV) positive oropharyngeal cancer (OPC) in their eighth edition. The role of smoking in HPV positive oropharyngeal cancer remains controversial and is not factored into the updated staging system.

METHODS

Single institutional, retrospective chart review of patients with HPV positive OPC from 2009 to 2017 was completed. Dichotomized smoking data were collected into 0-9 and ≥10 pack-year histories. Kaplan-Meier survival curves compared overall survival (OS) for smokers and nonsmokers.

RESULTS

Five-year OS was not statistically different in stage I or stage II HPV positive OPC comparing nonsmokers versus smokers, but worse in stage III smokers (38% vs. 76%, p < 0.05).

CONCLUSION

Greater than 10 pack-year smoking status may negatively affect survival in late stage HPV positive OPC but not in early stage disease. HPV positive smokers may require additional risk stratification.

Abstract 3859: CXCL17 modulates macrophage polarization and immune cell infiltrate in cutaneous squamous cell carcinoma

Cutaneous squamous cell carcinoma (cSCC), a keratinocyte-derived invasive and metastatic tumor of the skin, is the second most common form of skin cancer. Exposure to UltraViolet B (UVB) radiation represent a unique risk factors for cSCC development, and the immune system plays a key role in modulating the response. Immunosuppressed patients are at a considerably increased risk for cSCC-induced morbidity and mortality due to its enhanced recurrence and metastatic potential. Novel mechanism-based therapeutics are needed to prevent UVB-induced cSCC. Chemokines are a group of small chemotactic cytokines that can exert extensive and complex effects on cancer via interaction with their receptors. Chemokine (C-X-C motif) ligand 17 (CXCL17) is the latest member of the chemokine family, and recent studies have identified both a causative and suppressive role of CXCL17 and its cognate receptor GPR35 in tumorigenesis. The purpose of the study was to investigate the role of CXCL17 in modulating tumor immune cell infiltrate with primary focus on macrophages. Further, the effect of CXCL17 on macrophage polarization and function was also assessed. Treatment of RAW 264.7 and bone marrow-derived macrophages (BDMC) with CXCL17 increased chemotaxis and polarized the cells towards an M2 phenotype with significant increase in transcriptional levels of Arginase, Fizz and Ym2. Interestingly, CXCL17 also increased transcript level of TNF-alpha in both RAW and BDMC's suggesting a “mixed” M1/M2 phenotype population that may potentially maintain a certain degree of flexibility and adaptability in facilitating tumor survival and resistance to biologic therapies. This “mixed” phenotype is also expected to promote a variety of pro-tumor functions. To further translate our in vitro studies in an in vivo mouse syngeneic cSCC model, SCCB cells were deleted for CXCL17 and injected into the flank of FVB mice. Tumors were collected and subjected to flow cytometry analysis for tumor cell infiltrate. Deletion of CXCL17 significantly decreased macrophage infiltration at the tumor site. Further, decrease in CXCL17 was associated with a reduction in immunosuppressive cells such as Tregs and MDSC suggesting a role for CXCL17 in tumor immune evasion. Our studies underscore the importance of CXCL17 signaling in cSCC and provide a novel target for the treatment of non-melanoma skin cancer.

Citation Format: Alok R. Khandelwal, Ameesha A. Paralikar, Rafay Q. Soleja, Zachary B. Temple, Madison M. Robert, Maksudul Alam, Cherie-Ann O. Nathan. CXCL17 modulates macrophage polarization and immune cell infiltrate in cutaneous squamous cell carcinoma [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 3859.

Pilot Study: Pneumatic Compression Garment Therapy for Postradiotherapy Laryngopharyngeal Edema

OBJECTIVES

Pneumatic compression garment therapy (PCGT) has been established as treatment for postradiotherapy lymphedema, and its use in head and neck patients is becoming more common. Although effects on interstitial edema of the cervical soft tissues have been studied, effects on internal laryngopharyngeal edema, as well as associated symptoms of dysphagia and dysphonia, have yet to be published.

METHODS

We surveyed 7 patients treated with radiation for head and neck cancer (HNC) who had also been prescribed PCGT for cervical lymphedema. Patients were asked about subjective experience with the device, and also administered the Eating Assessment Tool-10 (EAT-10) and Voice Handicap Index-10 (VHI-10) surveys regarding their symptoms after using PCGT. Laryngoscopy videos from these same periods were also reviewed and scored using a validated tool for assessing laryngopharyngeal edema.

RESULTS

85% of patients reported at least some improvement in dysphagia and dysphonia following PCGT. Average EAT-10 score after PCGT was 11.4 and average VHI-10 score after PCGT was 8.7. These compare more favorably to historical scores for the same questionnaires in similar patient populations. Laryngeal edema scores on endoscopic examination were not significantly different after at least 3 months of therapy (pre: 20.15, post: 20.21, P = .975); however, the utility of this result is limited by a low inter-rater reliability (Krippendorff α = .513).

CONCLUSIONS

While we are unable to show any difference in objective assessment of laryngopharyngeal edema on endoscopic examination in this small pilot study, patients report substantial subjective improvement in postradiotherapy dysphagia and dysphonia following cervical PCGT that warrants more formal investigation.

Factors Influencing the Development of Pneumonia in Patients With Head and Neck Cancer: A Meta-analysis

Objective

The aim of this study was to identify factors that are associated with the occurrence of pneumonia in patients with head and neck cancer (HNC) after treatment.

Data Sources

PubMed, Scopus, OVID, and Cochrane Library from inception to November 26, 2019.

Review Methods

A systematic review in accordance with the PRISMA guidelines and an assessment of bias were performed. Included studies reported on the risk factors of pneumonia development after HNC treatment via odds ratios and subdistribution hazard ratios from regression analysis.

Results

Fifteen studies were included, comprising 30,962 patients with a mean age of 70 years (range, 19-95 years). Of these, 71.6% are male. The results of our study indicate that the following were independent risk factors contributing to the development of pneumonia: male sex, habitual alcohol consumption, poor oral hygiene before treatment, pretreatment dysphagia, hypopharynx and nasopharynx tumor sites, use of radiotherapy with or without chemotherapy versus surgery alone, addition of chemotherapy to radiotherapy, reirradiation, neck dissection, increased duration of tracheotomy, and use of sedatives for sleeping.

Conclusion

Multiple patient-, tumor-, and treatment-specific risk factors were identified in predicting pneumonia. Recognition of these risk factors early on may help prevent or at least detect pneumonia in this vulnerable group of patients.

Comparison of Survival Estimates Following Recurrence, Persistence, or Second Primary Malignancy in Oropharyngeal Squamous Cell Carcinoma

OBJECTIVE

This study investigated survival among patients with oropharyngeal squamous cell carcinoma (OPSCC) after recurrence, persistence, and second primary malignancies (SPMs).

STUDY DESIGN

Retrospective cohort study.

SETTING

Patients were treated at a tertiary cancer center.

SUBJECTS AND METHODS

Patients with OPSCC who had completed treatment between 2001 and 2017 were included. Survival estimates of 4 groups of patients were calculated: (1) patients who were disease free after initial treatment, (2) patients who had persistent disease, (3) those with recurrent disease, and (4) patients with SPMs. Cox proportional hazard models and parametric survival analyses (using Weibull distributions) were used to obtain hazard ratios (HRs) and time ratios (TRs).

RESULTS

The cohort included 364 patients. The crude overall SPM prevalence was 8.2%. Mean overall survival (OS) time in years for patients who remained disease free after treatment was 4.02 years. Among patients who experienced recurrence, the recurrence-free survival (RFS) was 2.58 years while their mean (SD) OS was 3.67 (2.7) years. Participants who experienced persistence had a mean (SD) OS of 1.67 (1.68) years. Patients with observed SPMs had a mean (SD) OS of 6.39 (4.06) years since their primary cancer but shortened survivals of 1.75 (2.34) years since the secondary diagnosis. Differences were present even after accounting for human papillomavirus (HPV) and smoking status.

CONCLUSIONS

Our findings stress the importance of active surveillance as per current National Comprehensive Cancer Network guidelines, irrespective of the HPV status or smoking status. Prospective studies with a larger number of SPM cases and longer follow-up are needed to validate survival trends even beyond 5 years.

Pilot study of loss of the p53/p63 target gene PERP at the surgical margin as a potential predictor of local relapse in head and neck squamous cell carcinoma

BACKGROUND

PERP (p53 apoptosis effector related to PMP22) localizes to desmosomes and suppresses squamous cell carcinoma development. Loss of PERP leads to worse local control in head and neck squamous cell carcinoma (HNSCC), likely by destabilizing desmosomes. We evaluated PERP loss at HNSCC surgical margins as a predictor of local relapse.

METHODS

Combining discovery (n = 17) and validation (n = 31) cohorts, we examined membranous PERP protein expression by immunohistochemistry in surgical mucosal margins with competing risk analysis of the relationship between local relapse and PERP expression.

RESULTS

Of the 44 analyzable patients, the 2-year cumulative incidence of local relapse was 44.4% for the PERP-negative group and 16.4% for the PERP-positive group (P = .01). A trend toward worse progression-free survival (P = .09) and overall survival (P = .06) was observed with loss of PERP.

CONCLUSIONS

PERP loss at surgical margins is associated with higher risk of local recurrence in HNSCC, warranting further evaluation in a larger prospective study.

The role of head and neck cancer advocacy organizations during the COVID-19 pandemic

The COVID-19 pandemic has had a significant impact on many aspects of head and neck cancer (HNC) care. The uncertainty and stress resulting from these changes has led many patients and caregivers to turn to HNC advocacy groups for guidance and support. Here we outline some of the issues being faced by patients with HNC during the current crisis and provide examples of programs being developed by advocacy groups to address them. We also highlight the increased utilization of these organizations that has been observed as well as some of the challenges being faced by these not-for-profit groups as they work to serve the head and neck community.

Gender disparities are present in academic rank and leadership positions despite overall equivalence in research productivity indices among senior members of American Head and Neck Society (AHNS) Fellowship Faculty

BACKGROUND

This study aims to examine potential disparities in scholarly performance based on sex, academic rank, leadership positions, and regional distribution of faculty in accredited Head and Neck Surgery fellowships in the United States.

METHODS

Online faculty listings for 37 accredited fellowships were organized according to academic rank, leadership position, sex, and institutional location. Academic productivity was measured with three bibliometric indices: h-index, m-index, and the weighted relative citation ratio.

RESULTS

A total of 732 faculty members were included, of which 153 (21%) were female. Fifty-eight males (89.2%) held leadership positions, compared to seven females (10.8%). There was no significant difference in overall productivity between male and female senior faculty. There were regional differences in productivity by sex.

CONCLUSIONS

Females are underrepresented in senior faculty and within three common leadership positions, although scholarly productivity for male and female senior faculty and for those in leadership positions is similar.

Abstract 4023: Co-occurring mutations in recurrent/persistent head and neck squamous cell carcinoma (HNSCC) patients

Head and neck squamous cell carcinoma (HNSCC) is the sixth most common cancer and lacks effective targeted therapies. HPV(-) patients have a 50-60% recurrence rate and could benefit from adjuvant therapy. Although HPV(+) patients have a significantly better survival, 20% have persistent/recurrent disease. Therefore, biomarkers could potentially help identify patients that would benefit from adjuvant targeted agents. Our objective was to evaluate if the mutational and biomarker analysis of tumor samples from OPSCC patients predict recurrence and/ or persistence in patients undergoing definitive therapy with curative intent. 44 advanced stage OPSCC patients that underwent comprehensive genomic profiling by Caris Life Sciences were included in this retrospective study. Next Generation Sequencing (NGS) on genomic DNA from FFPE tumors was performed using the Illumina Nextseq (592-gene, n=17)/MiSeq (44-gene, n=23) platform. Tumors were analyzed for total mutational load (TML), CNV’s and microsatellite instability status. IHC for tumor protein expression of ERCC1, PD-L1, RRM1, TrkA/B/C, TS and TUBB3 was performed using automated platforms. The ASCO/CAP scoring criteria and the cutoff points from published evidence was used in IHC evaluation. Of the 44 patients, 27 were HPV(+) tumors and 11 had HPV(-) disease. Patients with lack of progression free survival data were excluded. Only 4 patients in the entire cohort harbored a pathogenic PIK3CA mutation. Among HPV(+) patients, 22 patients were TP53 WT and 2 patients were found to be TP53 mutant. Although there was no significant change in the TML in smokers compared to nonsmokers (mean 8.77 vs 6.5, respectively; p=0.253), TML was higher in HPV(-) smokers compared to HPV(+) nonsmokers (mean 10.33 vs 6.5, p=0.0661). Our study presented a higher incidence of recurrent/persistent disease in the Caucasians (60%) in comparison to African-Americans (21%). Considering the sample size in the current study, the racial difference in outcomes appears likely to be present regardless of HPV status or disease state. The co-occurrence of multiple deleterious mutations was observed in 70% of the non-responders. Particularly, mutations in CHEK2, PTCH, MUTYH were noted in 50% of the recurrent/persistent patients. CNV mutations in SMAD2, MALT1, NFKBIA in 50% of the recurrent/persistent patients were found. The co-occurrence of multiple mutations were absent in responders in spite of an appreciable sample size in the responder group (n=12). This study also affirmed an improved prognosis in patients with HPV(+), with higher expression of TUBB3, and with positive expression of PD-1 in the tumors. Co-occurrence of multiple deleterious mutations were associated with patients who did not respond to therapy. Therefore, combination rescue therapies that can target multiple pathways to abrogate the mutational effects can aid/enhance therapeutic benefits in HNSCC patients.

Citation Format: Alok R. Khandelwal, Kelsey Poorman, Tara Moore-Medlin, Xiaohui Ma, Abhijit Gundale, Ronald Horswell, San Chu, Michelle Winerip, Cherie-Ann O. Nathan. Co-occurring mutations in recurrent/persistent head and neck squamous cell carcinoma (HNSCC) patients [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 4023.

Abstract 1969: Role of the CXCL17-CXCR8 (GPR35) axis in cutaneous squamous cell carcinoma

Cutaneous squamous cell carcinoma (cSCC) is a keratinocyte-derived invasive and metastatic tumor of the skin and is the second-most commonly diagnosed form of skin cancer (16%) striking 200,000 Americans annually. Increased exposure to Ultraviolet-B (UVB) from solar radiation as a result of the depletion of the ozone layer and the widespread use of tanning beds are the primary reasons for the increased incidence of cSCC. Novel mechanism-based therapeutics are needed to prevent UVB-induced cSCC. Chemokines are a group of small chemotactic cytokines that can exert extensive and complex effects on cancer via interaction with their receptors. Chemokine (C-X-C motif) ligand 17 (CXCL17) is the latest member of the chemokine family, and recent studies have identified both a causative and suppressive role of CXCL17 and its cognate receptor GPR35 in tumorigenesis. The purpose of this study was to determine the role of CXCL17 and GPR35 in the pathogenesis of cSCC. CXCL17 and GPR35 were significantly overexpressed in cSCC cells (SCC12A and SCC118) compared to HaCaT cells. Stimulation with CXCL17 significantly induced cSCC cell proliferation, migration, and motility suggesting an essential role in tumor growth, invasion, and metastasis. Tumor-specific overexpression of CXCL17 was detected in human cSCC and UVB-induced mouse cSCCs that further bolsters our in vitro findings. Recent studies have also identified the role of CXCL17 in tumor cell infiltration and immune invasion leading to tumor progression. In our preliminary studies, increased expression of CXCL17 in cSCC correlated with an augmented number of CD3+, CD4+ and CD8+ T-cells infiltrates. Our data suggest that CXCL17 could potentially exert differential effects based on cell types in the tumor microenvironment. Our studies underscore the importance of CXCL17/GPR35 signaling in cSCC and provide a novel target for the treatment of non-melanoma skin cancer.

Citation Format: Alok R. Khandelwal, Md Maksud Alam, Tara Moore-Medlin, Hillary A. Savage, Cherie-Ann O. Nathan. Role of the CXCL17-CXCR8 (GPR35) axis in cutaneous squamous cell carcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 1969.

Fibroblast growth factor receptor promotes progression of cutaneous squamous cell carcinoma

Cutaneous squamous cell carcinoma (cSCC) is a keratinocyte-derived invasive and metastatic tumor of the skin. It is the second-most commonly diagnosed form of skin cancer striking 200 000 Americans annually. Further, in organ transplant patients, there is a 65- to 100-fold increased incidence of cSCC compared to the general population. Excision of cSCC of the head and neck results in significant facial disfigurement. Therefore, increased understanding of the mechanisms involved in the pathogeneses of cSCC could identify means to prevent, inhibit, and reverse this process. In our previous studies, inhibition of fibroblast growth factor receptor (FGFR) significantly decreased ultraviolet B-induced epidermal hyperplasia and hyperproliferation in SKH-1 mice, suggesting an important role for FGFR signaling in skin cancer development. However, the role of FGFR signaling in the progression of cSCC is not yet elucidated. Analysis of the expression of FGFR in cSCC cells and normal epidermal keratinocytes revealed protein overexpression and increased FGFR2 activation in cSCC cells compared to normal keratinocytes. Further, tumor cell-specific overexpression of FGFR2 was detected in human cSCCs, whereas the expression of FGFR2 was low in premalignant lesions and normal skin. Pretreatment with the pan-FGFR inhibitor; AZD4547 significantly decreased cSCC cell-cycle traverse, proliferation, migration, and motility. Interestingly, AZD4547 also significantly downregulated mammalian target of rapamycin complex 1 and AKT activation in cSCC cells, suggesting an important role of these signaling pathways in FGFR-mediated effects. To further bolster the in vitro studies, NOD.Cg-Prkdcscid Il2rgtm1Wjl/SzJ mice with SCC12A tumor xenografts treated with AZD4547 (15 mg/kg/bw, twice weekly oral gavage) exhibited significantly decreased tumor volume compared to the vehicle-only treatment group. The current studies provide mechanistic evidence for the role of FGFR and selectively FGFR2 in the early progression of cSCC and identifies FGFR as a putative therapeutic target in the treatment of skin cancer.

Point/Counterpoint: Do We De-escalate Treatment of HPV-Associated Oropharynx Cancer Now? And How?

HPV-positive (HPV+) oropharyngeal carcinoma (OPC) continues to increase in incidence across the globe. Multimodality treatment offers a high likelihood of cure in HPV+ OPC but comes at a high cost of treatment-related morbidity. As a result, de-escalation of treatment to limit toxicity without compromising high cure rates has emerged as a major trend in head and neck cancer clinical research. Primary surgery with minimally invasive resection of the primary disease may allow for the elimination of chemotherapy and decrease radiation dose intensity. Primary dose-reduced radiation, with or without systemic therapy, is also under study, as is replacing concurrent cisplatin with newer systemic agents. Numerous institutional series and phase II trials have been presented, and the first generation of de-escalation randomized phase III trials have now been published. The various combinatorial multimodality strategies to achieve less intensive and toxic therapy are many. Has the time come for de-escalation as a standard approach to HPV+ OPC? The pros and cons, as well as the best approaches for de-escalated treatment of HPV+ OPC, are debated here.

Perioperative Management of Total Laryngectomy Patients: A Survey of American Head and Neck Society Surgeons

Objectives:

Standards of care for total laryngectomy (TL) patients in the postoperative period have not been established. Perioperative care remains highly variable and perhaps primarily anecdotally based. The aim of this study was to survey members of the American Head and Neck Society to capture management practices in the perioperative care of TL patients.

Methods:

In this survey study, an electronic survey was distributed to the international attending physician body of the American Head and Neck Society. Forty-five-question electronic surveys were distributed. A total of 777 members were invited to respond, of whom 177 (22.8%) fully completed the survey. The survey elicited information on management preferences in the perioperative care of TL patients. Differences in management on the basis of irradiation status and pharyngeal repair (primary closure vs regional or free flap reconstruction) were ascertained. Main outcomes and measures were time to initiate oral feeding, perioperative antibiotic selection and duration, and estimated pharyngocutaneous fistula rates. These measures were stratified by patient type.

Results:

Most respondents completed head and neck fellowships (77.0%) and practice at academic tertiary centers (72.3%). Ampicillin/sulbactam was the most preferred perioperative antibiotic (43.2%-49.1% depending on patient type), followed by cefazolin and metronidazole in combination (32.0%-33.7%) and then clindamycin (10.8%-12.6%). Compared with nonirradiated patients, irradiated patients were significantly more likely to have longer durations of antibiotics ( P < .05), longer postoperative times to initiate oral feeding ( P < .05), and higher estimated fistula rates ( P < .05). Additionally, in nonirradiated patients, flap-repaired patients (vs primary repair) were significantly more likely to have longer durations of antibiotics (odds ratio, 1.29; 95% confidence interval, 1.13-1.48) and postoperative times to initiate oral feeding (odds ratio, 2.24; 95% confidence interval, 1.76-2.84).

Conclusions:

Perioperative management of TL patients is highly variable. Management of antibiotics and oral feeding are significantly affected by irradiation status and scope of pharyngeal repair. Further studies are needed to standardize perioperative care for this unique patient population.

Local and systemic Curcumin C3 complex inhibits 4NQO-induced oral tumorigenesis via modulating FGF-2/FGFR-2 activation

Head and Neck Squamous cell carcinoma (HNSCC) can be characterized by synchronous tumors in the upper aerodigestive tract. Second primary tumors as a result of field cancerization are a significant problem amongst patients with risk factors for HNSCC, indicating a need for chemo preventive agents. We investigated the efficacy of local and systemic Curcumin C3 complex (C3); a purified mixture of Curcumin, bisdemethoxy Curcumin and demethoxy Curcumin as a chemo preventative agent in 4-nitroquinoline-1-oxide (4NQO)-induced tumorigenesis in mice. The effect of local C3 application was compared to C3 administered orally and in combination with systemic administration. C57Bl/6 mice were administered 4NQO (50 µg/ml) in the drinking water for 16 weeks. At 12 weeks, mice were subjected to daily treatment with either vehicle (control), or 15 mg C3 complex by local delivery, gavage, or combined local and gavage for 28 days (16 week time point), and followed up to 22 weeks. Compared to local and oral systemic C3 administration, combination of local and systemic application significantly decreased multiplicity of 4NQO-induced preneoplastic and neoplastic lesions (p<0.05). Treatment with C3 correlated with a decrease in cell proliferation compared to the 4NQO group. Further, pre-treatment with C3 complex significantly attenuated 4NQO induced expression of basic fibroblast growth factor (FGF-2) and its cognate receptor FGFR-2, suggesting an important role of FGF-2/FGFR-2 axis in chemoprevention of HNSCC (p<0.05). Our findings suggest that a combination of local and systemic C3 complex could effectively target proliferation and inhibit 4NQO-induced tumorigenesis via modulation of the FGF-2/FGFR-2 axis as a mechanism for its efficacy.

Curcumin gum formulation for prevention of oral cavity head and neck squamous cell carcinoma

OBJECTIVES/HYPOTHESIS

Head and neck squamous cell carcinoma represents the sixth most common cancer. As a result of field cancerization, second primaries and recurrences are high. Hence, research has focused on chemoprevention. Curcumin, a polyphenol compound with anticarcinogenic properties, is one such promising nutraceutical. As poor bioavailability limits curcumin's use, a novel gum formulation was tested allowing for direct mucosal absorption into the bloodstream. This preliminary study validates curcumin gum efficacy by assessing release and transmucosal absorption, along with measuring its effects on serum cytokine levels.

STUDY DESIGN

Clinical trial.

METHODS

Protocols consisting of initial chew (chewing gum for 30 minutes) and revised chew (alternating chewing and parking gum against buccal mucosa for 30 minutes) were tested in healthy volunteers. High-performance liquid chromatography measured remnant curcumin in chewed gum, serum, and saliva. Serum levels were assayed for 15 proinflammatory cytokines via multiplex analysis.

RESULTS

Revised chew samples demonstrated significantly higher curcumin release and absorption (P = .0078). Curcumin serum levels were significantly higher at 4 hours in samples > 2.0 g of curcumin release (P = .01). As saliva levels decreased, a concurrent increase in serum levels was observed, with no significance in the inverse relationship (P = .1423). When evaluating differences between gender, race, and age, the Asian population showed significantly lower curcumin release and serum levels (P = .009). CXCL1 (GRO-α) and TNF-α were significantly decreased in serum after chewing the gum (P = .036, P < .001, respectively).

CONCLUSIONS

Enhanced mucosal contact appears critical in improving curcumin release and absorption. CXCL1 and TNF-α both represent potential biomarkers for the future study of curcumin chemoprevention.

LEVEL OF EVIDENCE

2b Laryngoscope, 129:1597-1603, 2019.