Impact of age on treatment effect in locally advanced head and neck cancer (HNC): Two individual patient data meta-analyses

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Background: The Meta-Analysis of Radiotherapy in Carcinomas of Head & Neck (MARCH; Bourhis J, ASTRO 2002) showed that altered fractionation radiotherapy (Alt-RT) could improve survival as compared to standard RT in patients with locally advanced HNC (pooled hazard ratio - HR -: 0.92, 95% confidence interval: 0.86–0.97). The Meta-Analysis of Chemotherapy in Head and Neck Cancer (MACH-NC; Bourhis J, ASCO 2004) demonstrated that concomitant chemotherapy (CT), added to RT, improved survival (HR: 0.82, 95% CI: 0.78–0.86). This study considers age as a potential modifier of the treatment effect. Methods: 15 randomized trials with 6,515 patients were included in MARCH (median follow up: 6.0 years), and 50 with 9,471 patients in concomitant part of MACH-NC (median follow up: 5.6 years). The interaction between age and treatment effect, using HR of death, was tested with heterogeneity test. Effect of prognostic factors on the interaction was analysed using Cox model. Results: The effect of Alt-RT in MARCH and of concomitant CT in MACH-NC on overall survival decreased with increased age ( table ). Patients aged 71+ had a lower performance status, less advanced stage, and more often laryngeal cancer than the younger patients; there were more women in the oldest patients group. However, adjusting on covariates did not modify the results. Causes of death was available in MARCH and in recent (1994–2000) trials of MACH-NC. The proportion of deaths not due to HNC increased with age, from 18% at age 50 to 41% at age 71+ in MARCH, and from 15% to 39% in MACH-NC. Conclusions: Treatment benefit decreases with increasing age. Patients aged 71+ did not benefit from Alt- RT nor from concomitant CT. The increasing risk of death from other causes with age may explain part of these observations. Supported by PHRC, ARC, LNCC

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No significant financial relationships to disclose.

Extranodal lymphomas of the head and neck. A 20-year experience

BACKGROUND

Extranodal non-Hodgkin lymphoma (NHL) of the head and neck is a relatively uncommon disease. Over the last 3 decades, a variety of systems, including the Rappaport, Luke-Collins, and Working Formulation classifications, have been used to classify extranodal NHLs of the head and neck. Most studies have included a relatively small number of patients, used different modalities of therapy, and did not include all head and neck sites. These limitations make comparisons between different studies and drawing any conclusions difficult.

OBJECTIVES

To describe in a uniform fashion a relatively large number of patients with extranodal NHL of the head and neck treated at the same institution, using only the most current classification system and to describe the clinical features, behavior, and outcome of this relatively uncommon, but potentially curable disease.

DESIGN

A retrospective study of 98 patients with extranodal NHL of the head and neck. All patients were reclassified according to the Working Formulation system (regardless of the time of diagnosis) in order to uniformly define the clinical course of this disease in the head and neck.

SETTING

A tertiary care referral center.

RESULTS AND CONCLUSIONS

The sinonasal tract was the most commonly involved site (25%). If the nasopharynx (16%), tonsil (12%), and base of tongue (8%) are grouped together, this combined site (Waldeyer ring) becomes the most common site of disease (36%). Patients with tonsillar lymphoma had a 20% incidence of associated gastrointestinal involvement. Approximately 50% of the patients had associated nodal disease, and only 20% had systemic or B symptoms. Three fourths of the patients had stage I or II disease, and approximately two thirds had intermediate-grade lymphoma. Radiation therapy was the primary modality of therapy for localized disease (stages I and II), especially for low-grade lymphomas. Combination chemotherapy with or without radiation was used for more advanced disease and for intermediate- and high-grade lymphomas. Surgery was limited to establishing the diagnosis. Two thirds of the patients had a remission after initial therapy. Two thirds of these patients had no further relapse. Three fourths of the patients with relapse after initial remission died of their disease. The overall and disease-free survival rates for all patients were 60% and 50%, respectively. Outcome of therapy was related to stage and histologic grade. Patients with lymphomas of high histopathologic grade and recurrent and recurrent and disseminated disease had the poorest prognosis.

Amifostine: potential for clinically useful cytoprotection

The ability to target malignant cells for cytotoxicity while sparing normal host tissues has proven to be limited. These limitations have resulted in unacceptable toxicity or insufficiently effective therapy. Continuing investigation of new, potentially useful cytotoxic agents must continue. An alternative approach, also worthy of study, is the selective protection of normal tissues. This approach, used in conjunction with available therapeutic agents, may open the therapeutic window and incrementally enhance the effectiveness of cytotoxic therapy. A variety of methods have been used to protect normal tissues selectively. Regional protection can be used for certain organ systems, such as the oral mucosa. Selective protection on a systemic level is more difficult but agents that seem to protect normal but not malignant tissues selectively are being developed. Among these is amifostine, which was originally selected by the U.S. defense department for study as a radioprotectant. Pre-clinical studies have suggested that amifostine is differentially concentrated in normal tissues but not in malignant tissues. Tissue-specific differences in the activity of alkaline phosphatase, which dephosphorylates amifostine to its active metabolite WR-1065, and in pH are thought to be involved in this relative specificity. Clinical studies indicate that amifostine can reduce the myelosuppression produced by cyclosphosphamide, the combination of cyclophosphamide and cisplatin, and, perhaps, carboplatin. The protective effects of amifostine on nonhematopoietic toxicities are being investigated. Future trials will investigate the integration of amifostine with cytokine-based supportive care in order to define the role of this potentially clinically useful cytoprotectant agent.

Phase I study of WR-2721 and carboplatin

Because WR-2721 reduces the toxicity of cisplatin and carboplatin in preclinical systems, we have treated 35 patients in a phase I study of WR-2721 and carboplatin. As the plasma half-life of WR-2721 is short relative to that of carboplatin, WR-2721 was administered in two divided doses. This schedule produced acceptable toxicity in 24 patients treated with carboplatin 400 mg/m2 and escalating doses of WR-2721. In the subsequent 11 patients, WR-2721 was fixed at 740 mg/m2/dose and the dose of carboplatin was escalated. With WR-2721, grade 3-4 thrombopenia (platelets < 50 x 10(9)/l) was produced in 4/5 patients treated with carboplatin 625 mg/m2 and in 1/6 patients treated with carboplatin 500 mg/m2. Carboplatin pharmacokinetic parameters in 4 patients were similar to those reported for carboplatin alone. These results suggest that WR-2721 might increase the maximum tolerated dose of carboplatin from 400 to 500 mg/m2.

Phase I trial of dipyridamole with 5-fluorouracil and folinic acid

We have performed two Phase I trials of the combination of dipyridamole, 5-fluorouracil (5-FU), and folinic acid in patients with advanced refractory malignancy, based upon in vitro evidence that dipyridamole can modulate the cytotoxicity of 5-FU. In the first trial, patients were treated every 4 wk with dipyridamole (50 mg/m2) p.o. every 6 h on Days 0 to 6, beginning 24 h prior to the i.v. administration of folinic acid (200 mg/m2) and escalating doses of i.v. 5-FU on Days 1 to 5. The maximum tolerated daily dose of 5-FU that could be given with this combination was 375 mg/m2. Because dipyridamole is extensively bound to plasma proteins, it was hypothesized that the concentrations of free dipyridamole achieved with a dose of 50 mg/m2 were inadequate to modulate the cytotoxicity of 5-FU and folinic acid. Therefore, a second Phase I trial of escalating dose of p.o. dipyridamole was performed. Folinic acid (200 mg/m2) and 5-FU (375 mg/m2) were given i.v. on Days 1 to 5 every 4 wk, beginning 24 h after the start of therapy with dipyridamole; dipyridamole was administered p.o. on Days 0 to 6 at doses of 75, 100, 125, 150, 175, or 200 mg/m2/dose to successive cohorts of patients. Dose-limiting neutropenia, mucositis, and nausea were produced at a dose of 200 mg/m2/dose; the recommended dose of dipyridamole for use in Phase II studies is 175 mg/m2 p.o. every 6 h, or 700 mg/m2/day. At this dose, a mean peak plasma concentration of total dipyridamole of 16.32 mumol and a mean peak plasma concentration of free dipyridamole of 38.30 nmol were observed. Trough concentrations of free dipyridamole averaged 60% of the peak concentrations. Objective antitumor responses were seen in a number of tumor types; five of 13 patients with breast cancer treated with high-dose p.o. dipyridamole, 5-FU, and folinic acid responded. High-dose p.o. dipyridamole can produce plasma concentrations of free dipyridamole within the range shown to modulate the cytotoxicity of 5-FU and other agents. Phase II trials of this combination are justified.

Emergence of a new opportunistic pathogen, Candida lusitaniae

Candida lusitaniae has been an infrequently reported opportunistic pathogen. Most previously reported cases of serious infection caused by this organism have proven fatal and were associated with amphotericin resistance of the organism. We report two patients with hematologic malignancies undergoing cytotoxic chemotherapy who developed fungemia with this organism while they were granulocytopenic. The organisms isolated from each patient were fully susceptible and were treated successfully with amphotericin B. When isolated from an immunocompromised host, C. lusitaniae should be considered an opportunistic pathogen and undergo antifungal susceptibility testing. Amphotericin B should be considered the drug of choice, but a poor clinical response may be indicative of a resistant isolate.

Corynebacterium JK: a cause of nosocomial device-related infection

Ten cases of serious infection due to antibiotic-resistant Corynebacterium JK are reported. Five infections occurred in patients with hematologic malignancy and granulocytopenia, an association previously reported. Five additional nosocomial infections occurred in patients without underlying disease previously reported to be associated with JK. Nine of the 10 infections were nosocomial in origin and were associated with plastic devices that had been inserted into the patients. JK organisms were isolated from a variety of sources from an additional 40 uninfected patients. Although the majority of clinical isolates of Corynebacterium JK were contaminants, our experience suggests that as many as 20% of isolations are associated with serious nosocomial infections. Isolation of Corynebacterium JK--particularly in blood cultures--from patients with indwelling catheters or other devices is highly suggestive of the presence of a serious nosocomial infection.