Treatment Outcomes of Head and Neck Cancer Patients in the Elderly Receiving Different Chemoradiation Combinations: A Single-Center Experience

OBJECTIVES

This study aimed to assess the effect of definitive or adjuvant concurrent chemoradiation (CRT) among elderly patients with locally advanced head and neck squamous cell carcinoma (LA HNSCC).

MATERIALS AND METHODS

We retrospectively analyzed 150 elderly LA HNSCC patients (age ≥70) at a single institution. Demographics, disease control outcomes, and toxicities with different chemotherapy regimens were reviewed. The Kaplan-Meier method was used to estimate progression-free survival (PFS) and overall survival (OS) estimates.

RESULTS

Median age at diagnosis was 74 years (range 70-88). Of the cohort, 98 (65.3%) patients received definitive and 52 (34.7%) received adjuvant CRT; 44 (29.3%) patients received weekly carboplatin and paclitaxel, 43 (28.7%) weekly cetuximab, 33 (22%) weekly carboplatin, and 30 (20%) weekly cisplatin. The OS at 2 years was 70% (95% confidence interval [CI]: 63-79%), and PFS at 2 years was 61% (95% CI: 53-70%). There was no significant difference in OS or PFS between definitive and adjuvant CRT (p = 0.867 and p = 0.475, respectively). Type of chemotherapy regimen (single-agent carboplatin vs. others) (95% CI: 1.1-3.9; p = 0.009) was a key prognostic factor in predicting OS in multivariable analysis. Concurrent use of cetuximab was associated with increased risk of PEG tube dependence at 6 months (p < 0.001).

CONCLUSIONS

Management of LA HNSCC in the elderly is a challenging scenario. Our study shows that CRT is a feasible treatment modality for elderly patients with LA HNSCC. We recommend CRT with weekly cisplatin or weekly carboplatin and paclitaxel. A chemotherapy regimen should be carefully selected in this difficult to treat population.

A predictive survival model for patients with head and neck squamous cell carcinoma treated with immune check point inhibitors

BACKGROUND

ICIs have expanded treatment options for HNSCC. A minority of the patients respond to these expensive treatments.

PATIENTS AND METHODS

This is a single institutional retrospective review on 121 unresectable or metastatic HNSCC patients treated with ICIs. We predicted that inflammatory markers available through routine blood work, in addition to clinical characteristics may divide patients into groups more or less likely to respond to these agents. Here we develop and internally validate our nomogram to predict survival in patients treated with ICIs.

Risk Factors Associated With Postoperative Delirium in Patients Undergoing Head and Neck Free Flap Reconstruction

Importance

Postoperative delirium (POD) is associated with an increased rate of adverse events, higher health care costs, and longer hospital stays. At present, limited data are available regarding the risk factors for developing POD in patients undergoing head and neck free flap reconstruction. Identification of patients at high risk of developing POD will allow implementation of risk-mitigation strategies.

Objective

To determine the frequency of and risk factors associated with POD in patients undergoing free flap reconstruction secondary to head and neck disease.

Design, Setting, and Participants

This retrospective cohort study included 515 patients undergoing free flap reconstruction from January 1, 2006, through December 31, 2012, at the James Cancer Hospital and Solove Research Institute, The Ohio State University Comprehensive Care Center, a tertiary care cancer hospital. Preoperative, intraoperative, and postoperative data were collected retrospectively. Data from January 1, 2006, through December 31, 2012, were analyzed, and the final date of data analysis was January 8, 2018.

Interventions

Head and neck free flap reconstruction.

Main Outcomes and Measures

The primary outcome was the development of POD as defined by the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition). Univariable and multivariable logistic regression were used to identify risk factors associated with POD.

Results

Five hundred fifteen patients underwent free flap reconstruction during the study period (66.2% male; mean [SD] age, 60.1 [12.8] years). Of these, 56 patients (10.9%) developed POD. On multivariable analysis, risk factors associated with POD included increased age (odds ratio [OR], 1.06; 95% CI, 1.02-1.11), male sex (OR, 5.02; 95% CI, 1.47-17.20), increased operative time (OR for each 1-minute increase, 1.004 [95% CI, 1.001-1.006]; OR for each 1-hour increase, 1.26 [95% CI, 1.08-1.46]), advanced nodal disease (OR, 3.00; 95% CI, 1.39-6.46), and tobacco use (OR, 7.23; 95% CI, 1.43-36.60). Preoperative abstinence from alcohol was identified as a protective factor (OR, 0.24; 95% CI, 0.12-0.51).

Conclusions and Relevance

This study identified variables associated with a higher risk of developing POD. Although many of these risk factors are nonmodifiable, they provide a target population for quality improvement initiatives. Furthermore, preoperative alcohol abstinence may be useful in preventing POD.

NCCN Guidelines Insights: Head and Neck Cancers, Version 1.2018

The NCCN Guidelines for Head and Neck (H&N) Cancers provide treatment recommendations for cancers of the lip, oral cavity, pharynx, larynx, ethmoid and maxillary sinuses, and salivary glands. Recommendations are also provided for occult primary of the H&N, and separate algorithms have been developed by the panel for very advanced H&N cancers. These NCCN Guidelines Insights summarize the panel's discussion and most recent recommendations regarding evaluation and treatment of nasopharyngeal carcinoma.

Free flap salvage from venous thrombosis by creation of a venocutaneous fistula: Case report and review of the literature

BACKGROUND

Venous congestion is the most frequently reported complication of free flap tissue transfer in head and neck patient with cancer. Numerous methods are utilized and prompt correction is necessary to prevent flap failure.

METHODS

A 77-year-old woman underwent oral cavity resection and neck dissection for squamous cell carcinoma followed by radial forearm free flap for reconstruction. Three days later, the flap became congested and surgical exploration revealed extensive venous thrombosis throughout the free flap venous system and internal jugular vein. The flap vein was evacuated and flowing, and a venocutaneous fistula was created thereafter.

RESULTS

Venocutaneous fistula resulted in flap decongestion and successful salvage. The patient was discharged from the hospital with no further flap or surgical complications.

CONCLUSION

When anatomical revision of the venous anastomosis is not feasible in a venous-congested free flap, the creation of a venocutaneous fistula should be considered as a viable option for salvage.

A phase 1 trial of Vorinostat in combination with concurrent chemoradiation therapy in the treatment of advanced staged head and neck squamous cell carcinoma

Purpose Vorinostat is a potent HDAC inhibitor that sensitizes head and neck squamous cell carcinoma (HNSCC) to cytotoxic therapy while sparing normal epithelium. The primary objective of this Phase I study was to determine the maximally tolerated dose (MTD) and safety of Vorinostat in combination with standard chemoradiation therapy treatment in HNSCC. Patients and Methods Eligible patients had pathologically confirmed Stage III, IVa, IVb HNSCC, that was unresectable or borderline resectable involving the larynx, hypopharynx, nasopharynx, and oropharynx. Vorinostat was administered at the assigned dosage level (100-400 mg, three times weekly) in a standard 3 + 3 dose escalation design. Vorinostat therapy began 1 week prior to initiation of standard, concurrent chemoradiation therapy and continued during the entire course of therapy. Results Twenty six patients met eligibility criteria and completed the entire protocol. The primary tumor sites included tonsil (12), base of tongue (9), posterior pharyngeal wall (1), larynx (4) and hypopharynx (3). Of the 26 patients, 17 were HPV-positive and 9 were HPV-negative. The MTD of Vorinostat was 300 mg administered every other day. Anemia (n = 23/26) and leukopenia (n = 20/26) were the most commonly identified toxicities. The most common Grade3/4 events included leukopenia (n = 11) and lymphopenia (n = 17). No patient had Grade IV mucositis, dermatitis or xerostomia. The median follow time was 33.8 months (range 1.6-82.9 months). Twenty four of 26 (96.2%) patients had a complete response to therapy. Conclusion Vorinostat in combination with concurrent chemoradiation therapy is a safe and highly effective treatment regimen in HNSCC. There was a high rate of complete response to therapy with toxicity rates comparable, if not favorable to existing therapies. Further investigation in Phase II and III trials is strongly recommended.

Clinical outcomes and prognostic factors in cisplatin versus cetuximab chemoradiation for locally advanced p16 positive oropharyngeal carcinoma

OBJECTIVES

Randomized trials evaluating cisplatin versus cetuximab chemoradiation (CRT) for p16+ oropharyngeal cancer (OPC) have yet to report preliminary data. Meanwhile, as a preemptive step toward morbidity reduction, the off-trial use of cetuximab in p16+ patients is increasing, even in those who could potentially tolerate cisplatin. The purpose of this study was to compare the efficacy of cisplatin versus cetuximab CRT in the treatment of p16+ OPC and to identify prognostic factors and predictors of tumor response.

MATERIALS AND METHODS

Cases of p16+ OPC treated with cisplatin or cetuximab CRT at our institution from 2010 to 2014 were identified. Recursive partitioning analysis (RPA) classification was used to determine low-risk (LR-RPA) and intermediate-risk (IR-RPA) groups. Log-rank/Kaplan-Meier and Cox Regression methods were used to compare groups.

RESULTS

We identified 205 patients who received cisplatin (n = 137) or cetuximab (n = 68) CRT in the definitive (n = 178) or postoperative (n = 27) setting. Median follow-up was 3 years. Cisplatin improved 3-year locoregional control (LRC) [92.7 vs 65.4%], distant metastasis-free survival (DMFS) [88.3 vs 71.2%], recurrence-free survival (RFS) [86.6 vs 50.6%], and overall survival (OS) [92.6 vs 72.2%] compared to cetuximab [all p < .001]. Concurrent cisplatin improved 3-year OS for LR-RPA (97.1 vs 80.3%, p < .001) and IR-RPA (97.1 vs 80.3%, p < .001) groupings.

CONCLUSION

When treating p16+ OPC with CRT, the threshold for substitution of cisplatin with cetuximab should be maintained appropriately high in order to prolong survival times and optimize locoregional and distant tumor control. When cetuximab is used in cisplatin-ineligible patients, altered fractionation RT should be considered in an effort to improve LRC.

Quality Indicators: Measurement and Predictors in Head and Neck Cancer Free Flap Patients

Objective

To determine the predictors of length of stay (LOS), readmission within 30 days, and unplanned return to the operating room (OR) within 30 days in head and neck free flap patients.

Study Design

Case series with chart review.

Setting

Tertiary academic cancer hospital.

Subjects and Methods

All head and neck free flap patients at The Ohio State University (OSU, 2006-2012) were assessed. Multivariable logistic regression to assess the impact of patient factors, flap and wound factors, and intraoperative factors on the aforementioned quality metric outcomes.

Results

In total, 515 patients were identified, of whom 66% had oral cavity cancers, 33% had recurrent tumors, and 28% underwent primary radiotherapy. Of the patients, 31.5% had a LOS greater than 9 days, predicted by longer operative time, oral cavity and pharyngeal tumor sites, blood transfusion, diabetes mellitus, and any complication. A total of 12.6% of patients were readmitted within 30 days predicted by absent OSU preoperative assessment clinic attendance and any complication, and 14.8% of patients had an unplanned OR return predicted by advanced age.

Conclusions

When assessing quality metrics, adjustment for the complexity involved in managing patients with head and neck cancer with a high comorbidity index, clean contaminated wounds, and a high degree of primary radiotherapy is important. Patients seen in a preoperative assessment clinic had a lower risk of readmission postoperatively, and this should be recommended for all head and neck free flap patients. Quality improvement projects should focus on predictors and prevention of complications as this was the number one predictor of both increased length of stay and readmission.

iBH3: simple, fixable BH3 profiling to determine apoptotic priming in primary tissue by flow cytometry

Dysregulation of the mitochondrial pathway of apoptosis, controlled by the BCL-2 family of proteins, leads to disease states including cancer. Rapid analysis of a cell's dependency on the BCL-2 family of proteins is hindered by the complex interactions of more than a dozen proteins. Transcript or even protein levels are therefore generally insufficient to predict a cell's response to perturbations like chemotherapy. Previously, we developed the JC-1 BH3 method to provide a same day functional assay to assess a cell's propensity to undergo apoptosis and demonstrated its utility in predicting response to chemotherapy. We have now improved upon these methods to create a robust assay amenable to high throughput platforms using cytochrome c retention in formaldehyde fixed cells to remove the time sensitivity of JC-1 potential measurements. BH3 profiling by intracellular staining (iBH3) is suitable for 96- and 384-well formats, and can be used to directly screen candidate BH3-mimetic compounds for activity. When used as the final component of dynamic BH3 profiling (DBP), which uses a drug pretreatment prior to iBH3 to assess the change in profile due to treatment, it can predict the response of cells to chemotherapy days before they show signs of death.

Treatment outcomes and prognostic factors, including human papillomavirus, for sinonasal undifferentiated carcinoma: a retrospective review

BACKGROUND

Sinonasal undifferentiated carcinoma (SNUC) is a high-grade, aggressive neoplasm. Low incidence and poor outcomes make identification of prognostic factors and treatment standardization difficult. Similarly, little is known regarding the association of human papillomavirus (HPV) with SNUC.

METHODS

A retrospective review was conducted. Extracted information included treatment received, tumor recurrence, patient survival, p16 expression, and HPV status. The Kaplan-Meier method was used to estimate overall survival (OS) and disease-free survival (DFS). Survival trends were compared using the log-rank test.

RESULTS

Nineteen patients received multimodality treatment for SNUC. Five-year OS and DFS rates were 45.2% and 50.7%, respectively, with no significant difference between treatment types. Tumors from 11 patients were p16-positive and 9 of these were also HPV-positive. Kaplan-Meier analysis demonstrated improved survival.

CONCLUSION

Our series demonstrates a higher prevalence of HPV in SNUC than previously reported. HPV-positive SNUCs may benefit from improved survival and should be investigated further in future studies.

Primary TEP Placement in Patients with Laryngopharyngeal Free Tissue Reconstruction and Salivary Bypass Tube Placement

The authors examined the feasibility and advantages of primary tracheoesophageal puncture (TEP) with intraoperative placement of the voice prosthesis for patients undergoing laryngopharyngectomy requiring free tissue reconstruction and salivary bypass tube placement. Six patients were identified; 4 underwent total laryngopharyngectomy, and 2 underwent total laryngectomy with partial pharyngectomy. All 6 required free tissue reconstruction, and a salivary bypass tube was placed in all cases. All patients had a 20F Indwelling Blom-Singer prosthesis (InHealth Technologies, Carpinteria, California) placed. No complications were noted with intraoperative prosthesis placement. No prostheses were dislodged in the postoperative period. At 6 months, 4 patients available for evaluation had successful voice outcomes, and 3 were disease free. This study demonstrates the effectiveness of voice prosthesis placement at the time of primary TEP associated with free tissue reconstruction of a laryngopharyngeal defect with salivary bypass tube placement.

Outbreak of 2009 pandemic influenza A(H1N1), Los Lagos, Chile, April-June 2009

On 17 May 2009, the first two cases of 2009 pandemic influenza A(H1N1) were confirmed in the Metropolitan region (Santiago, Chile). On 6 June 2009, Chile reported 500 confirmed cases, seven severe and two fatal. Because six of the severe cases and the two deaths occurred in the region of Los Lagos in southern Chile, a retrospective study was conducted using data on emergency room visits as well as laboratory viral surveillance, during the period from 1 April to 31 May, in order to establish the date of the beginning of the outbreak. From 1 to 27 June, data were collected in real time, to establish the real magnitude of the outbreak, describe its transmission, clinical severity and secondary attack rates. Confirmed cases, their household contacts and healthcare workers were interviewed. This analysis showed that the outbreak in Los Lagos started on 28 April. By 27 June, a total of 14.559 clinical cases were identified, affecting mostly 5-19 year-olds. The effective reproduction number during the initial phase (20 days) was 1.8 (1.6-2.0). Of the 190 confirmed cases with severe acute respiratory infection, 71 (37.4%) presented a risk condition or underlying illness.

Evaluation of voice prosthesis placement at the time of primary tracheoesophageal puncture with total laryngectomy

OBJECTIVES/HYPOTHESIS

Primary tracheoesophageal puncture (TEP) is a well-described and accepted method of surgical voice restoration and is standardly completed with a catheter placement intraoperatively, which is replaced with a prosthesis at a later date. This study evaluates the intraoperative placement of the voice prosthesis at the time of the primary TEP in an effort to understand the potential advantages and disadvantages of voice prosthesis placement at the time of primary TEP completed in conjunction with total laryngectomy.

STUDY DESIGN

Retrospective chart review within an academic medical center.

METHODS

After approval by the institutional review board of the Massachusetts Eye and Ear Infirmary, a retrospective chart review was completed of all cases of primary tracheoesophageal prosthesis placement completed in conjunction with primary tracheoesophageal puncture performed at the time of total laryngectomy.

RESULTS

Thirty patients were identified, 29 of whom underwent laryngectomy for advanced laryngeal carcinoma. Twenty-eight of 29 patients received preoperative full-dose radiation therapy. Twenty-nine of 30 patients had a 20F classic Indwelling Blom-Singer prosthesis (InHealth Technologies, Carpinteria, CA) placed. One had placement of 16F Indwelling Blom-Singer prosthesis. No complications were noted with intraoperative prosthesis placement. No prostheses were dislodged in the postoperative period. Twenty-nine of 30 subjects had initial success with tracheoesophageal voice production. At 1-year follow-up, 23/30 subjects (77%) had successful voice restoration. Five failed because of recurrent disease, one subject never achieved successful voice, and one subject wanted the prosthesis removed although successful voice was achieved. Twenty-three of 25 (92%) disease-free subjects had functional voice restoration at 1-year post-total laryngectomy and primary prosthesis placement.

CONCLUSIONS

This study demonstrates that the voice prosthesis can be safely and effectively placed intraoperatively at the time of primary TEP and laryngectomy. Initial voice acquisition rates were high and long-term success was well within the acceptable range.

Success of Multiple, Sequential, Free Tissue Transfers to the Head and Neck

INTRODUCTION

Free tissue transfer has become the primary reconstructive modality for significant ablative defects in the head and neck. The overall success rate is high, approaching 95% in most centers. The success rate of multiple sequential free flaps has been thought to be lower, based on the absence of optimal vessel availability and the presence of significant scar tissue in the previously operated patient. We evaluated a series of patients who underwent multiple free flaps at different time points to determine the overall success rate and to identify pitfalls encountered in this population.

METHODS

Retrospective review, tertiary care medical center.

RESULTS

From 1995 to 2002, 377 free flaps were performed by our reconstructive service. Of this group, 36 underwent multiple free flaps at different time points. Thirty-two had two flaps, and four had three flaps. Reasons for performing sequential free flap procedures were as follows: recurrent disease/new primary (18), need for further augmentation (10), failed previous flap (6), delayed mandibular reconstruction after plate fracture (2), mandibular osteoradionecrosis (3), and delayed pharyngoesophageal stenosis (1). The overall failure rate on the second and third flap was 2 of 32 and 0 of 4, respectively, with an overall success rate of 94%.

CONCLUSION

Multiple, sequential, free tissue transfer for reconstruction of head and neck defects is a safe and reliable procedure with success rates equal to that in patients undergoing initial free flap reconstruction. Careful preoperative planning can result in optimal outcomes even in this difficult patient population.

p16 and p16 beta are potent growth suppressors of head and neck squamous carcinoma cells in vitro

p16 (CDKN2/MTS1/p16INK4a) is frequently deleted, methylated, or mutated in many malignancies including squamous cell carcinoma of the head and neck (HNSCC). p16 beta is an alternative transcript derived from a newly described exon (exon 1 beta) located more than 15 kb 5' to exon 1 of p16. Moreover, the p16 beta transcript theoretically encodes a protein distinct from p16 derived from a divergent reading frame putatively initiated in exon 1 beta. To test the contribution of both of these transcripts in carcinogenesis, full-length cDNA of p16 and p16 beta were cloned in separate vector constructs and then transfected into HNSCC cell lines characterized for p16 status (p16[+/+], p16[mut/-], and p16[methylated]). Transfection of either p16 or p16 beta resulted in marked growth inhibition in all three HNSCC lines tested, regardless of p16 status. However, p16 beta but not p16 inhibited the growth of HeLa cells, a cell line with inactive pRB due to expression of E7 papillomavirus protein. Moreover, transfection of all three HNSCC lines with either p16 or p16 beta resulted in a marked increase in cells in G0-G1 consistent with a cell cycle arrest in G1. These data are consistent with the hypothesis that p16 and p16 beta are growth-inhibitory genes active in HNSCC and that both act by blocking progression through the G1-S transition of the cell cycle. Furthermore, the suppressive effects of p16 beta on HeLa growth suggest that p16 beta mediates its effect independently from pRB.

Pre-Golgi degradation of yeast prepro-alpha-factor expressed in a mammalian cell. Influence of cell type-specific oligosaccharide processing on intracellular fate

We demonstrate that expression of yeast prepro-alpha-factor in GH3 rat pituitary cells results in its degradation in an endoplasmic reticulum (ER) or early Golgi compartment, suggesting that this wild-type prohormone is recognized as abnormal or misfolded in the context of a mammalian ER. In GH3 cells, as in yeast, the nascent polypeptide is efficiently targeted to the ER, where it undergoes cleavage of its amino-terminal signal peptide and core glycosylation to form glycosylated pro-alpha-factor (gp alpha f). Subsequently, however, this species disappears from cells with a half-time of 25-30 min (including a 10-20-min lag), and no alpha-factor- or proregion-derived products can be detected. Localization of the degradative process to the ER is suggested by its occurrence in the presence of brefeldin A or chloroquine and by the endoglycosidase H susceptibility of the substrate. We present evidence that Asn-linked oligosaccharide processing, which differs in extent between yeast and mammalian cells, may be an important factor in determining degradation in this heterologous circumstance. When GH3 cells are treated with deoxymannojirimycin, an inhibitor of ER alpha-mannosidases, gp alpha f is essentially stable, suggesting that trimming of core oligosaccharides below Man8 (a process that does not occur in yeast) strongly promotes proteolysis. Inhibition of ER glucosidase activity by treatment with deoxynojirimycin, by contrast, considerably accelerates the disappearance of gp alpha f (t1/2 = 8-10 min). These data indicate that cell type-specific post-translational modifications of a secretory glycoprotein can substantially modify its recognition by the mammalian ER degradative apparatus.

Chondritis of the burned ear: a review

Seventy-six patients with burns of the ears presented to the Western Pennsylvania Hospital Burn Trauma Center over a three year period. To prevent chondritis, all ears were treated prophylactically with periauricular hair shaving, daily cleaning, avoidance of pressure dressings and Sulfamylon Burn Cream. Chondritis developed in two patients. Aspects of auricular chondritis prevention and treatment are reviewed. Biology of the disease is discussed.

Chondritis of the Burned Ear: A Review

Seventy-six patients with burns of the ears presented to the Western Pennsylvania Hospital Burn Trauma Center over a three year period. Toprevent chondritis, all ears were treated prophylactically with periauricular hair shaving, daily cleaning, avoidance of pressure dressings and Sulfamylon Burn Cream. Chondritis developed in two patients. Aspects of auricular chondritis prevention and treatment are reviewed. Biology of the disease is discussed.

Differential effects of ketamine stereoisomers on maze performance in the mouse

The authors studied effects of subanesthetic doses of the d- and l-ketamine stereoisomers on maze performance in mice to determine whether the stereoisomers differed in their ability to disrupt a stable cognitive behavior. Twenty-four Swiss-Webster (CFW) mice were trained to stability in a four-compartment modular maze, using water as a reward. Each compartment contained a central partition with a barrier at the distal end of one of the two passageways. A fixed barrier-sequence was employed. Elapsed time to traverse all four compartments and total number of errors (the number of times a wrong compartment was entered) were measured. A cohort design was employed with the following four groups: saline control, d-ketamine, l-ketamine, racemate. Two subanesthetic doses, 7.5 and 15 mg/kg of each form of the drug were given subcutaneously at five-day intervals. Both the d-isomer and the racemate significantly prolonged elapsed time at 15 mg/kg, the d-isomer having the greatest effect. The l-isomer did not alter elapsed time at either dose but appeared to increase spontaneous locomotor activity after injection. Relative to errors, at the 7.5 mg/kg dose there were no changes from control with any form of ketamine. However, at the 15 mg/kg dose, total errors significantly increased both with the racemate and the d-isomer. The performance decrements observed with the racemate appear to be attributable largely to the d-component.