Prognostic significance of the harmonized maximum standardized uptake value of 18F-FDG-PET/CT in patients with resectable oral tongue squamous cell carcinoma: a multicenter study

OBJECTIVES

To investigate the usefulness of harmonized 18F-FDG-PET/CT parameters for predicting the postoperative recurrence and prognosis of oral tongue squamous cell carcinoma (OTSCC).

METHODS

We retrospectively analyzed the cases of 107 OTSCC patients who underwent surgical resection at four institutions in Japan in 2010-2016 and evaluated the harmonized PET parameters of the maximum standardized uptake value (SUVmax), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) for the primary tumor as the pSUVmax, pMTV, and pTLG. For lymph node metastasis, we used harmonized PET parameters of nodal-SUVmax, nodal-total MTV (tMTV), and nodal-total TLG (tTLG). The associations between the harmonized PET parameters and the patients' relapse-free survival (RFS) and overall survival (OS) were evaluated by the Kaplan-Meier method and Cox proportional hazard regression analysis for model 1 (preoperative stage) and model 2 (preoperative  +  postoperative stages).

RESULTS

The harmonized SUVmax values were significantly lower than those before harmonization (p=0.012). The pSUVmax was revealed as a significant preoperative risk factor for RFS and OS. Nodal-SUVmax, nodal-tMTV, and nodal-tTLG were significant preoperative risk factors for OS. The combination of pSUVmax + nodal-SUVmax significantly stratified the patients into a low-risk group (pSUVmax <3.97 + nodal-SUVmax <2.85 or ≥2.85) and a high-risk group (pSUVmax ≥3.97 + nodal-SUVmax <2.85 or pSUVmax ≥3.97 + nodal-SUVmax ≥2.85) for recurrence and prognosis (RFS: p=0.001; OS: p<0.001).

CONCLUSIONS

The harmonized pSUVmax is a significant prognostic factor for the survival of OTSCC patients. The combination of pSUVmax and nodal-SUVmax identified OTSCC patients at high risk for recurrence and poor prognosis at the preoperative stage.

Incidence and spread pattern of lymph node metastasis from submandibular gland cancer

OBJECTIVES

To clarify the indication of neck dissection (ND) for patient with submandibular gland (SMG) cancer.

METHODS

A total of 43 patients with SMG cancer were retrospectively analyzed. Forty-one patients underwent ND: Levels I-V in 19 patients, Levels I-III in 18 patients, and Level Ib in 4 patients. The other two patients did not undergo ND, since preoperative diagnoses were benign. Postoperative radiotherapy was performed in 19 patients with positive surgical margin, high grade cancer or stage IV disease.

RESULTS

LN metastases were pathologically confirmed in all patients with cN + and 6 out of 31 patients with cN-. No patients developed regional recurrence during follow-up periods. Ultimately, LN metastases were pathologically confirmed in 17 of 27 high grade, one out of 9 intermediate grade, but not in 7 low grade.

CONCLUSIONS

Prophylactic neck dissection should be considered in T3/4 and high grade SMG cancers.

COVID-19 presenting as acute epiglottitis: A case report and literature review

Coronavirus disease 2019 (COVID-19) occasionally causes acute laryngitis, requiring emergency treatment. Understanding the characteristic laryngeal findings can help diagnose COVID-19 earlier, prevent worsening infection, and properly manage airway obstruction. Herein, we report the case of a 44-year-old male with acute epiglottitis likely caused by COVID-19. On presentation, chest computed tomography (CT) showed no signs of pneumonia. However, the larynx had extensive necrotic-like erosive lesions resembling those of tuberculous laryngitis. COVID-19 was diagnosed by reverse-transcription polymerase chain reaction, and secondary bacterial superinfections were suspected after blood testing. The symptoms improved after administration of antibiotics (sulbactam sodium/ampicillin sodium), steroids (dexamethasone), and favipiravir. The patient developed a high fever on the sixth day of hospitalization, and pneumonia was identified on CT. Various culture tests, including tuberculosis, were negative. Thus, remdesivir was administered for COVID-19-induced pneumonia. The patient gradually recovered, was transferred to another hospital, and was discharged on the 35th day of hospitalization. Six previous case reports of COVID-19-induced acute epiglottitis suggested that acute epiglottitis preceded the onset of pneumonia. The laryngeal findings from this report may be useful for diagnosing COVID-19 that does not cause pneumonia and for bringing attention to pneumonia after a COVID-19 diagnosis.

Three Cases of Hematoma in the Retropharyngeal Space

OBJECTIVES

Hematoma in the retropharyngeal space (RPS) is a life-threatening condition that leads to rapid airway obstruction. However, the indication for airway management remains unclear. Additionally, the requirement for surgical hematoma evacuation remains undetermined. Therefore, we attempt to suggest some criteria for the management of hematoma in such cases.

METHODS

We report three cases of hematoma in the RPS wherein one patient was treated without surgery and the other two underwent tracheotomy followed by hematoma evacuation.

RESULTS

We found that airway management should be based on whether the glottis could be visible on laryngoscopy and dyspnea severity. The degree of hematoma, swelling, subcutaneous bleeding in the anterior neck, and emotional stability should also be considered. Proper management during the acute phase may allow for conservative treatments. Hematomas extending below the tracheal bifurcation may help ease upper airway obstruction due to pressure distribution, allowing for conservative treatment. When hematomas are surgically evacuated, tracheotomy should be performed simultaneously. Our report suggests that mediastinal hematoma evacuation could be avoided.

CONCLUSION

We should determine a therapeutic strategy for hematoma in RPS based on glottis visualization, patient's condition, and extent of hematoma growth under careful observation.

Intraoperative quantitative assessment of parathyroid blood flow during total thyroidectomy using indocyanine green fluorescence imaging ‐ surgical strategies for preserving the function of parathyroid glands

Objective

We investigated the factors affecting postoperative parathyroid gland (PTG) function and devised an objective index to predict the postoperative PTG function during total thyroidectomy.

Method

This was a retrospective clinical review of 21 consecutive patients who were diagnosed with papillary thyroid carcinoma and underwent total thyroidectomy. The maximum intensity ratio (MIR) was determined as the maximum fluorescence intensity after ICG injection divided by the intensity before ICG injection.

Results

Postoperative hypoparathyroidism is significantly associated with simultaneous central neck dissection (CND) and lateral neck dissection (LND) (p = .032). The Spearman correlation test showed a moderate correlation between the MIR and iPTH levels (p = .0047). The optimal MIR cutoff value for predicting postoperative hypoparathyroidism was 2.14 with area under the curve = 0.904 (sensitivity: 0.769 and specificity: 1.00).

Conclusion

CND + LND was significantly associated with postoperative hypoparathyroidism. MIR was found useful in predicting the postoperative PTG function.

Level of Evidence: 3b.

Predictive factors for malignant neoplasms veiled in deep neck infections

Background: Malignant neoplasms (MNs) in the head and neck are occasionally hidden in deep neck infections (DNIs) that require emergency treatment, which potentially leads to delayed diagnosis of MNs.Objectives: This study aimed to identify predictive factors that can prevent delays in diagnosing MNs in patients with DNIs.Methods: We retrospectively analysed data from 83 patients admitted to our hospital who were diagnosed with DNIs.Results: Four patients (4.8%) had DNIs veiling MNs in the head and neck. Statistical analyses revealed a significant association (p = .0481) of platelet to albumin ratio (PAR; ≥ 98.9 × 10³) with hidden MNs in DNIs. Furthermore, concomitant cervical lymphadenopathy, especially multiple lymphadenopathies and excluding abscesses, was higher in patients with DNIs veiling MNs (p = .0142 and p = .0023, respectively).Conclusions and Significance: The PAR, which can be easily measured and readily detected, was a potential predictive factor. Moreover, performing fine-needle aspiration for lymphadenopathies could help diagnose hidden MNs in DNIs.

Blowing time ratio and high-resolution manometry to evaluate swallowing function of patients with oral and oropharyngeal cancer

OBJECTIVE

The blowing time ratio, which is the ratio of the blowing time when the nostrils are open and closed, is significantly correlated with velopharyngeal pressure, not only during speech but also during swallowing. This study aimed to further evaluate the usefulness of the blowing time ratio as a screening tool to evaluate the swallowing pressure of patients treated for oral and oropharyngeal cancers using high-resolution manometery (HRM).

METHODS

Ten patients treated for oral or oropharyngeal cancer were recruited for this study. Swallowing pressures at the velopharynx, oropharynx, and upper esophageal sphincter (UES) were measured using HRM. Their correlations with the blowing time ratio were analyzed.

RESULTS

The blowing time ratio was significantly correlated with the swallowing pressures of the oropharynx (CC = 0.815, p = 0.004) and the velopharynx (CC = 0.657, p = 0.039), but not of the UES.

CONCLUSIONS

The present results further support our previous finding that the blowing time ratio is a useful screening tool to evaluate velopharyngeal and oropharyngeal swallowing pressures in patients treated for oral and oropharyngeal cancer.

Up-front neck dissection followed by chemoradiotherapy for T1-T3 hypopharyngeal cancer with advanced nodal involvement

Background

The advantage of up‐front neck dissection (UFND) followed by chemoradiotherapy (CRT) for hypopharyngeal cancer (HPC) with advanced neck involvement remains controversial. We aimed to determine the indications.

Methods

The data of 41 and 14 patients with stage IVA/B (T1–T3 and ≥N2a) HPC who underwent UFND followed by CRT and received CRT, respectively, were retrospectively analyzed and compared.

Results

The 5‐year overall survival (OS) and disease‐specific survival rates for the UFND and CRT groups were 61% and 52% (p = 0.1019), and 89% and 74% (p = 0.2333), respectively. Moreover, patients aged ≥70 years or those with a pulmonary disease history had a significantly poorer prognosis due to aspiration pneumonia in the UFND group. The 5‐year regional control (RC) for the UFND and CRT groups were 92% and 57%, respectively (p = 0.0001).

Conclusions

UFND followed by CRT was feasible with satisfactory RC. To further improve OS, aspiration pneumonia prevention is essential.

Docetaxel plus cisplatin in recurrent and/or metastatic non-squamous-cell head and neck cancer: a multicenter phase II trial

The clinical utility of systemic therapy and genomic profiling in non-squamous-cell head and neck cancer (NSCHNC) has not been fully elucidated. This phase II trial evaluated the efficacy and safety of docetaxel and cisplatin combination in the first-line setting. Eligibility criteria were recurrent and/or metastatic NSCHNC; progressive disease within the last 6 months; no prior systemic therapy; and ECOG performance status of 0-1. Patients received docetaxel (75 mg/m² on day 1) and cisplatin (75 mg/m² on day 1), repeated every 21 days for 6 cycles. The primary endpoint was confirmed objective response rate (ORR). The secondary endpoints included progression-free survival (PFS), overall survival (OS), and adverse events. Next-generation sequencing (NGS) was performed using the Ion AmpliSeq Cancer Hotspot Panel v2. Twenty-three patients were enrolled from November 2012 to October 2016, of whom 8 were male. Median age was 57 years. Ninety-six percent of cases were metastatic. Among 22 evaluable patients, confirmed ORR was 45% (95% confidential interval 24-68%). With a median follow-up period of 18.8 months, median PFS and OS were 6.7 and 20.1 months, respectively. Grade 3/4 adverse events included febrile neutropenia (39%) and anemia (22%). No treatment-related deaths were observed. NGS analysis revealed potential treatment targets, including ERBB2, KIT, and ALK. The docetaxel and cisplatin combination regimen can be considered a new treatment option in recurrent and/or metastatic NSCHNC, although primary prophylaxis for febrile neutropenia should be considered. Diverse genomic alterations may lead novel treatment options.This trial was registered with the UMIN Clinical Trials Registry as UMIN000008333 on [September 1st, 2012].

A novel parotid carcinoma with a prominent ghost cell population: a masquerading tumor or "salivary ghost cell carcinoma"?

Ghost cell is one of several unique cellular morphologies associated with aberrant keratinization. We encountered a novel parotid tumor containing numerous ghost cells and herein describe its histological features and discuss diagnostic problems. The patient was a 90-year-old Japanese male, who complained of swelling of the left parotid area for four months. Positron emission tomography indicated no cervical lymph node metastasis or distant metastasis. The tumor was successfully resected with no signs of recurrence or metastasis for six months after surgery. Histologically, the tumor was mainly composed of squamous cells forming irregularly shaped nests with a mixture of pleomorphic giant or multinucleated cells and bland basaloid cell. Keratinized areas were occupied by a prominent ghost cell population. Immunohistochemically, CK5/6 and CK19 were widely positive as well as AE1/AE3, p40 and p63. Nuclear expression of β-catenin was also observed. The present case can be regarded as a particular form of squamous cell carcinoma and is believed to contain a large number of ghost cells resulting from an unclear mechanism. However, it seems difficult to consider such tumors as a clinicopathologically independent entity at present. Applying a term such as "salivary ghost cell carcinoma" would be premature.

Prognostic factors after transoral resection of early hypopharyngeal cancer

OBJECTIVE

This study aimed to investigate risk factors predictive of local recurrence and/or lymph node metastasis after transoral resection of early hypopharyngeal cancer.

METHODS

Forty-nine consecutive patients who underwent transoral videolaryngoscopic surgery (TOVS) as an initial treatment for hypopharyngeal cancer were evaluated. On univariate and multivariate analysis, local recurrence rates were assessed respectively using log-rank test and cox regression analysis according to the following parameters: subsite, pT, mucosal margin, lymphatic invasion, vessel invasion, tumor thickness (> 4 mm vs ≤4 mm), history of esophageal cancer, and multiple Lugol-voiding lesions (LVLs) in the esophagus. Categorical variables were evaluated for their associations with lymph node metastasis using chi-squared test or Fisher's exact test.

RESULT

The subsites of primary lesions were piriform sinus in 24 patients, posterior wall in 15 patients, and postcricoid in 10 patients. Thirty patients had esophageal cancer. Local recurrence occurred in 14 patients. Three patients had lymph node metastasis at the time of diagnosis and four patients developed lymph node metastasis after the initial treatment, resulting a total of seven patients having lymph node metastasis. While mucosal margin and LVLs showed significant associations with local recurrence on univariate analysis, only LVLs remained as a significant risk factor on multivariate analysis (P = .0395; hazard ratio = 8.897; 95% confidence interval, 1.113-71.15). Most cases of local recurrence were satisfactorily controlled by repeated TOVS. While multivariate analysis could not be performed due to the small number of the patients with lymph node metastases, venous invasion (P = .0166) and tumor thickness (P = .0092) were significantly associated with lymph node metastasis on univariate analysis.

CONCLUSIONS

Local recurrence was more frequent in patients with LVLs, but most of them were salvaged by repeated TOVS. Patients with venous invasion and/or tumor thickness greater than 4 mm should be followed up with special attention to lymph node metastasis.Level of Evidence: 3.

Exploratory Analysis to Predict Optimal Tumor Burden for Starting Lenvatinib in Patients With Radioiodine-Refractory Differentiated Thyroid Cancer

Background

We previously reported that a high tumor burden is a prognostic factor based on an analysis of 26 patients with radioactive iodine-refractory differentiated thyroid cancer (RR-DTC) who were treated with lenvatinib. However, the optimal tumor burden for starting lenvatinib still remains to be defined. The aim of this retrospective study was to further explore in the same patient cohort the optimal timing for the start of lenvatinib by focusing on the pre- and post-treatment tumor burden.

Methods

The 26 patients were treated with lenvatinib from 2012 to 2017. We explored the optimal timing for the start of lenvatinib by comparing the characteristics of long-term responders who were defined as patients with progression-free survival ≥ 30 months and non-long-term responders.

Results

Long-term responders had a smaller post-treatment tumor burden at maximum shrinkage than non-long-term responders. Further, post-treatment tumor burden had a strong linear correlation with baseline tumor burden. We created an estimation formula for baseline tumor burden related to prognosis, using these regression lines. Patients with a sum of diameters of target lesions < 60 mm or maximum tumor diameter < 34 mm at baseline were estimated to have significantly better survival outcomes.

Conclusions

We found a strong linear correlation between pre- and post-treatment tumor burden. Our results suggested a cut-off value for baseline tumor burden for long-term prognosis among patients treated with lenvatinib.

Pathological evaluation of tumor grade for salivary adenoid cystic carcinoma: A proposal of an objective grading system

Three pathological grading systems advocated by Perzin/Szanto, Spiro, and van Weert are currently used for adenoid cystic carcinoma (AdCC). In these systems, the amount or presence of the solid tumor component in AdCC specimens is an important index. However, the “solid tumor component” has not been well defined. Salivary AdCC cases (N = 195) were collected after a central pathology review. We introduced a novel criterion for solid tumor component, minAmax (minor axis maximum). The largest solid tumor nest in each AdCC case was histologically screened, the maximum oval fitting the solid nest was estimated, and the length of the minor axis of the oval (minAmax) was measured. The prognostic cutoff for the minAmax was determined using training and validation cohorts. All cases were evaluated for the four grading systems, and their prognostic impact and interobserver variability were examined. The cutoff value for the minAmax was set at 0.20 mm. Multivariate prognostic analyses showed the minAmax and van Weert systems to be independent prognostic tools for overall, disease‐free, and distant metastasis‐free survival while the Perzin/Szanto and Spiro systems were selected for overall survival but not for disease‐free or distant metastasis‐free survival. The highest hazard ratio for overall survival (11.9) was obtained with the minAmax system. The reproducibility of the minAmax system (kappa coefficient of 0.81) was scored as very good while those of the other three systems were scored as moderate. In conclusion, the minAmax is a simple, objective, and highly reproducible grading system useful for prognostic stratification for salivary AdCC.

Safety and efficacy of cetuximab-containing chemotherapy after immune checkpoint inhibitors for patients with squamous cell carcinoma of the head and neck: a single-center retrospective study

Immunotherapy has been shown to prolong survival in recurrent or metastatic squamous cell carcinoma of the head and neck (SCCHN) in front-line use; however, subsequent systemic therapy has not been optimized. This study aimed to evaluate the safety and efficacy of cetuximab-containing chemotherapy after immunotherapy. We retrospectively analyzed patients with recurrent or metastatic SCCHN who underwent cetuximab-containing regimens after progression on immunotherapy. Of the 22 patients who met the inclusion criteria, 21 received paclitaxel and cetuximab, and 1 carboplatin and fluorouracil and cetuximab after immunotherapy. Nine patients achieved a partial response, 10 patients had stable disease as their best response on cetuximab-containing chemotherapy, yielding an overall response rate and disease control rate of 40.9 and 86.4%, respectively. The median progression-free survival was 5.2 months, and the median overall survival was 14.5 months. Ten patients developed grade 3-4 adverse events, including neutropenia (31.8%), acneiform rash (9.1%), anemia (4.5%), hypertransaminasemia (4.5%) and stomatitis (4.5%). The most frequent cetuximab-related toxicities across all grades were skin reactions (77.3%), hypomagnesemia (40.9%), stomatitis (27.3%), paronychia (13.6%) and keratitis (4.5%). There was no treatment-related death. Taken together, cetuximab-containing chemotherapy was effective and feasible even after immunotherapy.

Boron neutron capture therapy using cyclotron-based epithermal neutron source and borofalan (10B) for recurrent or locally advanced head and neck cancer (JHN002): An open-label phase II trial

BACKGROUND AND PURPOSE

Boron neutron capture therapy (BNCT) can be performed without reactors due to development of cyclotron-based epithermal neutron source (C-BENS), which is optimized for treatment for deeper-seated tumors. The purpose of this study was to evaluate efficacy and safety of cyclotron-based BNCT with borofalan (¹⁰B) for recurrent or locally advanced head and neck cancer.

MATERIALS AND METHODS

In this open-label, phase II JHN002 trial of BNCT using C-BENS with borofalan (¹⁰B), patients with recurrent squamous cell carcinoma (R-SCC) or with recurrent/locally advanced non-squamous cell carcinoma (R/LA-nSCC) of the head and neck were intravenously administered 400 mg/kg borofalan (¹⁰B), followed by neutron irradiation. The tumor dose was determined passively as the mucosal maximum dose of 12 Gy-Eq. The primary endpoint was the objective response rate (ORR). Post-trial observational JHN002 Look Up study was planned for evaluating locoregional progression-free survival (LRPFS).

RESULTS

Eight R-SCC and 13 R/LA-nSCC patients were enrolled. All R-SCC patients had prior radiotherapy with a median dose of 65.5 Gy (range, 59.4-76.0 Gy). The ORR for all patients was 71%, and complete response/partial response were 50%/25% in R-SCC and 8%/62% in R/LA-nSCC. The 2-year overall survival for R-SCC and R/LA-nSCC were 58% and 100%, respectively. The median LRPFS was 11.5 months for R-SCC. Frequently observed adverse events included alopecia (95%), hyperamylasemia (86%), and nausea (81%).

CONCLUSION

These data suggest that BNCT using C-BENS with borofalan (¹⁰B) is a promising treatment option for patients with R-SCC or R/LA-nSCC of the head and neck.

Salvage surgery for structural local recurrence of papillary thyroid cancer: recurrence patterns and surgical outcome

To clarify the patterns of the recurrence and to assess the oncological and functional outcomes after salvage surgery for the patients with structural local recurrence of papillary thyroid cancer (PTC), twenty-five patients who underwent salvage surgery for structural local recurrence of PTC were retrospectively reviewed. Structural recurrences were observed in the tracheal lumen in 5 patients, intraluminal or intramuscular esophagus in 5 patients, trachea, and cricoid cartilage in 9 patients, cricoid and thyroid cartilage in 2 patients, intra-lumen of the larynx in 1 patient and soft tissue around thyroid in 3 patients, respectively. Although all local disease was resected with macroscopically negative margin, 10 patients diagnosed as microscopically positive margin. Major surgical complications occurred in 6 patients, including common carotid artery injury (n = 1), unintentional pharyngeal or esophageal injury (n = 2), recurrent laryngeal nerve paralysis (n = 2), and pharyngeal fistula resulting in common carotid artery rupture (n = 1), and were successfully managed. During the follow-up periods, 6 patients were alive without disease, 15 patients survived with distant metastases and/or locoregional recurrence, and 4 patients died of the disease. While tracheocutaneous fistula remained in 7 patients, the vocal function was preserved in all patients but one who underwent total laryngectomy. Normal oral intake was retained in all patients. In conclusion, although salvage surgery for structural recurrence of PTC has a high risk of complications, it may be worthwhile when macroscopic curative resection is available. The decision should be made considering various factors including curability, risk of surgical procedure, functional outcome, and life expectancy.

Two cases of glottic closure for refractory aspiration pneumonia after vertical partial laryngectomy

Vertical partial laryngectomy is a well-established surgical procedure for early glottic cancers with acceptable functional and oncological outcomes. However, on a long-term basis, aspiration might be a serious problem with aging. Here we presented two cases of refractory aspiration pneumonia after vertical laryngectomy. Case 1: A 76-year old gentleman with a past history of malignant lymphoma treated by chemotherapy and radiotherapy had glottic cancer, which was treated by repeated vertical partial laryngectomies. Although glottic caner had been well controlled, he started to suffer from refractory aspiration pneumonia. Since his cervical skin was very thin and hard and his general condition was poor, we employed modified Kano's method for glottic closure. Case 2: A 87-year old Japanese male had a past history of glottic cancer treated by radiotherapy and vertical partial laryngectomy. He was repeatedly hospitalized for severe aspiration pneumonia. At the age of 87, he had second primary oropharyngeal cancer. Kano's method was simultaneously performed at the time of resection of oropharyngeal cancer. Postoperative courses were uneventful without sign of leakage in both cases. The patients started oral intake 2 weeks after the surgery. They have been alive without aspiration pneumonia and takes normal diet.

Oncolytic effect of Midkine promoter-based conditionally replicating adenoviruses expressing EGFR siRNA in head and neck squamous cancer cell line T891

Background

Epidermal growth factor receptor (EGFR) is overexpressed in head and neck squamous cell carcinomas (HNSCCs). Midkine expression is restricted in adult tissues but is increased in several malignant tumors, including HNSCCs.

Aim

Here, we evaluated the antitumor effect of Midkine promoter–based conditionally replicative adenovirus expressing siRNA against EGFR for targeting HNSCCs expressing Midkine.

Methods and results

A conditionally replicative adenovirus vector controlled by the Midkine promoter, Ad‐MK‐siEGFR, was generated by integrating gene‐expressing siRNA against EGFR. Antitumor effect of Ad‐MK‐siEGFR was tested in vitro using established HNSCC cell line, T891 with strong Midkine expression. Expression of EGFR in T891 infected with Ad‐MK‐siEGFR was significantly lower than that of T891 infected with control. Cytotoxicity assays showed significant growth suppression of Ad‐MK‐siEGFR in T891 cells.

Conclusions

This study demonstrated the possibility of oncolytic therapy using the Midkine promoter–based conditional replication‐selective adenovirus containing siRNA against EGFR in HNSCC cell line T891. Further validation of the findings in more cell lines and in vivo should be performed to clarify the potential clinical application.

Left non-recurrent inferior laryngeal nerve in a patient with right-sided aortic arch and aberrant left subclavian artery

Non-recurrent inferior laryngeal nerve (NRILN) is rare but one of the important anatomical variations in thyroid and parathyroid surgery. Almost all cases were observed on the right side with aberrant right subclavian artery and left NRILN have been reported in only five cases so far. Here, we reported a 38 year-old Japanese male with left NRILN accompanying adenomatous goiter. He was referred to our hospital for the surgical treatment of left thyroid goiter. Preoperative computed tomography revealed right-sided aortic arch and aberrant left subclavian artery with no signs of complete situs inversus viscerum, suggesting possible left NRLN. Left hemithyroidectomy was performed using nerve monitoring system. Intraoperatively, left recurrent laryngeal nerve was not identified along tracheoesophageal groove, but directly originated from vagal nerve and was running horizontally to larynx. Mobility of vocal cords were not impaired and postoperative course was uneventful. During thyroid surgery for the patients with right-sided aortic arch, meticulous care should be taken using nerve monitoring system to avoid nerve injury.

Extent of neck dissection for patients with clinical N1 oral cancer

BACKGROUND

No clear consensus has been reached on the indication of supraomohyoid neck dissection (SOHND) for clinically positive lymph-node metastasis.

PATIENTS

Consecutive 100 patients with previously untreated oral cancer treated at Kobe University Hospital were included in this study. All patients were clinically staged as anyTN1M0 and underwent radical dissection of the primary site and level I-V neck dissection as the initial treatment.

RESULTS

None of the 100 patients had pathological lymph-node metastasis (pLN) to level V. pLN to level IV was observed in two patients with tongue cancer in whom clinical lymph-node metastasis was preoperatively observed at level II.

CONCLUSIONS

Level V may be excluded in the neck dissection for patients with N1 oral cancers. Level IV dissection should be considered in the patient with tongue cancer and clinical lymph-node metastasis at level II.

Acromegaly caused by a somatotroph adenoma in patient with neurofibromatosis type 1

Although acromegaly has been reported in patients with Neurofibromatosis type 1 (NF1), these cases have not been associated with growth hormone (GH)-producing somatotroph adenoma, but with optic pathway glioma. A 68 year-old Japanese woman, who had been clinically diagnosed with NF1, was referred to our hospital due to a thyroid tumor and hypercalcemia. Acromegaly was suspected due to her facial features, and subsequent examinations revealed the presence of GH excess with a pituitary tumor, leading to the diagnosis of acromegaly. Histological and immunohistochemical analysis demonstrated an eosinophilic pituitary adenoma with diffuse positivity for GH, indicating typical somatotroph adenoma. In addition, her thyroid tumor was diagnosed histologically as follicular thyroid carcinoma (FTC) with primary hyperparathyroidism (PHPT). To investigate the pathogenesis of this untypical multiple endocrine tumor case of NF1, genetic analysis was performed using peripheral leukocytes and tissue of resected tumors. A heterozygous novel germline nonsense mutation (p.Arg1534*) in exon 35 of the NF1 gene was detected from peripheral leukocytes, which results in a truncated protein lacking the critical domain for GTPase activity, strongly suggesting its causal role in NF1. The loss of heterozygosity (LOH) in exon 35 of the NF1 gene was not detected in the somatotroph adenoma, parathyroid adenoma, and FTC. Although any mutations of the following genes; MEN1, CDKN1B, and PAX8-PPARγ were not detected, a heterozygous GNAS R201C mutation was detected in the somatotroph adenoma. To our knowledge, this is the first rare MEN1-like case of genetically diagnosed NF1 complicated with acromegaly caused by a somatotroph adenoma.

Oncologic and functional outcomes of transoral CO2 laser cordectomy for early glottic cancer

OBJECTIVE

To investigate the oncological and functional outcomes of the patients treated with transoral CO2 laser cordectomy for early glottic cancer.

PATIENTS AND METHODS

Fifty-five consecutive patients who underwent CO2 laser cordectomy for early glottic cancer were retrospectively reviewed.

RESULTS

Overall survival, larynx preservation, and relapse free local control rates were 96%, 100%, and 91%, respectively. Five patients with local recurrences were salvaged with re-cordectomy and/or radiotherapy. In type I cordectomy, VHI-10 consistently improved during postoperative course and VHI-10 at postoperative 12months was significantly better than preoperative value (2.3 vs. 9.4, p=0.02). Perceptual grading, MPT, MFR and AC/DC also improved and were better than preoperative values. In type III cordectomy, shimmer at 12months after cordectomy was significantly better than preoperative value (14.7 vs. 9.3, p=0.007).

CONCLUSIONS

These results further support the rationale of CO2 cordectomy as initial and salvage surgery for early glottic cancer.

Dental intervention against osteoradionecrosis of the jaws in irradiated patients with head and neck malignancy: a single-arm prospective study

BACKGROUND

The purpose of this study was to investigate the effectiveness of dental intervention before and after radiation therapy (RT) for head and neck malignancy on prevention of osteoradionecrosis (ORN) of the jaws.

METHODS

This is a single-arm prospective study according to intervention protocol of prophylactic dental extraction before RT and routine follow-up after RT. The primary endpoint was the occurrence of jawbone exposure during the first 2 years after RT.

RESULTS

Sixty-seven patients were assessed. Before RT, 144 teeth among 39 patients (58%) were prophylactically extracted. The occurrence of transient jawbone exposure during the first 2 years after RT was 7%. Because those jawbone exposures healed with intervention after RT, no jawbone exposure was found at 2 years after RT.

CONCLUSIONS

Dental intervention both before and after RT seemed to be important to prevent ORN development. Further studies in larger cohorts are necessary.

Safety and antitumor activity of accelerator-based boron neutron capture therapy in patients with inoperable recurrent and locally advanced head and neck cancer: A phase II study

6028

Background: To assess safety and efficacy of accelerator-based boron neutron capture therapy (AB-BNCT) using cyclotron-based neutron generator, BNCT30, and 10B-boronophenylalanine (borofalan(10B)) agent, SPM-011, in patients with recurrent squamous cell carcinoma (R-HNSCC) or recurrent/locally advanced non-squamous cell carcinoma (R/LA-HNNSCC) of the head and neck. Methods: The multi-institutional open-label, a world-first phase II trial of AB-BNCT in patients with inoperable R-HNSCC which present resistance to platinum-based chemotherapy, or with inoperable R/LA-HNNSCC, was conducted to assess safety and antitumor activity of AB-BNCT with BNCT30 and SPM-011. SPM-011 was administered at 200 mg/kg/h intravenously for 2 hours, followed by neutron irradiation with continuous infusion of SPM-011 at 100 mg/kg/h. The irradiated dose for tumor was determined passively as a mucosal maximum dose was given 12 Gy-Eq in calculation with a blood boron concentration measured just before the start of neutron irradiation. Primary endpoint was objective response rate (ORR) by central review. Tumor response was assessed using Response Evaluation Criteria in Solid Tumors (RECIST) ver 1.1 every 4 weeks for the first 3 months and every 12 weeks thereafter. Results: Eight R-HNSCC and thirteen R/LA-HNNSCC patients were enrolled and received AB-BNCT. All R-HNSCC patients had prior radiotherapy with a median dose of 65.5 Gy (range 59.4–76.0). The median irradiation time was 43 min (range 26–65). The median tumor minimum dose was 31.0 Gy-Eq (range 16.1–42.6). For adverse event, nausea (81%), dysgeusia (71%), parotitis (67%) were observed more frequently. The ORR for all patients were 71.4%, and CR/PR were 50.0%/25.0% in R-HNSCC and 7.7%/61.5% in R/LA-HNNSCC. At a median follow up of 18.8 months (range 9.2–29.0), 1-year PFS and OS by investigator assessment were 70.6% and 100%, respectively. The data for antitumor activity is still immature and will be further updated. Conclusions: AB-BNCT for R-HNSCC and R/LA-HNNSCC demonstrated an acceptable safety profile and a promising antitumor activity.

Results of free flap reconstruction for patients aged 80 years or older with head and neck cancer

OBJECTIVE

Free flap reconstruction in elderly patients is one of the most challenging surgeries in the treatment of head and neck cancers. The aim of this study was to examine the oncological and functional outcomes of free flap reconstruction for elderly patients with head and neck cancer.

METHODS

We retrospectively reviewed elderly patients who underwent free flap reconstruction for the treatment of head and neck cancers. All patients were 80 years or older. Clinicopathologic features, surgical procedures, oncological and functional outcomes were obtained from medical records.

RESULTS

Free flap reconstructions were performed in 13 patients (3 female, 10 male). The mean age was 82.6 ± 3.4 years (range: 80-91). The mean follow-up period was 23.3 months (range 4-41 months). The mean disease-free survival was 49 ± 6 months (range 4-60 months). All patients had been alive more than one year after surgery. Reconstruction was performed using free jejunum in 10 patients and radial forearm flap in 3 patients. Graft necrosis occurred in 2 patients. Other two patients experienced major postoperative medical complications.

CONCLUSION

Free flap reconstruction in well-selected older adults is safe and effective. Advanced age should not preclude consideration of free flap reconstruction in those patients.

A laryngeal closure technique for the treatment of patients with head and neck cancer

Background

In 2008, Kano developed a new laryngeal closure technique (Kano's method) for the treatment of severe aspiration. The aim of this study was to evaluate the safety and efficacy of this technique in patients with head and neck cancer.

Methods

Since June 2014 until March 2018, six patients underwent Kano's method for management of severe aspiration after the treatment of head and neck cancers. The anterior parts of the thyroid and the cricoid cartilages were excised widely. The glottis was closed by suturing bilateral vocal folds and reinforced by the sternohyoid muscle. A tracheostoma was created with skin flaps, subglottic mucosal flaps, and stumps of cricoid and trachea cartilages.

Results

No severe complications were observed after the surgery. Oral intake improved without developing aspiration.

Conclusions

Kano's method can provide satisfactory functional results with minimal invasion for treating severe aspiration after advanced surgery, chemotherapy, and/or chemoradiotherapy, in patients with head and neck cancer.

Level of Evidence

4

Exploratory analysis of prognostic factors for lenvatinib in radioiodine-refractory differentiated thyroid cancer

BACKGROUND

Multitarget kinase inhibitors (m-TKI), including lenvatinib, are now available as treatment options for radioiodine-refractory differentiated thyroid cancer (RR-DTC). However, the optimal timing of treatment initiation with m-TKI in these patients remains to be defined.

METHODS

We retrospectively reviewed the clinical records of 30 consecutive patients with RR-DTC. The relationship between clinical characteristics was evaluated, including tumor growth parameters at pretreatment/post-treatment and efficacy of lenvatinib.

RESULTS

A total of 26 patients with RR-DTC treated with lenvatinib were evaluable for response and eligible for analysis. From the results of multivariate analysis, baseline tumor size and tumor-related symptoms were independent negative prognostic factors for overall survival (OS) and progression-free survival (PFS). Pretreatment tumor growth parameters were not prognostic for either PFS or OS.

CONCLUSIONS

Patients with RR-DTC with a high tumor burden and tumor-related symptoms had significantly worse prognosis. Greater tumor reduction after starting lenvatinib may lead to better prognosis, irrespective of pretreatment high tumor growth rate.

Clinical impact of a cytological screening system using cyclin D1 immunostaining and genomic analysis for the diagnosis of thyroid nodules

Background

Fine-needle aspiration (FNA) is the most reliable method for diagnosing thyroid nodules; however, some features such as atypia of undetermined significance or follicular lesion of undetermined significance can confound efforts to identify malignancies. Similar to BRAF, cyclin D1 may be a strong marker of cell proliferation.

Methods

One hundred two patients with thyroidal nodule were enrolled in this prospective study.

Expression of cyclin D1 in thyroid nodules was determined by immunohistochemistry using both surgical specimens and their cytological specimens. The identification of the optimal cut off points for the diagnosis of malignancy were evaluated using the receiver operating characteristic (ROC) curves and the assessment of the area under the ROC curve (AUC). The specificity, sensitivity, positive predictive value (PPV) of markers were evaluated from crosstabs based on cut off points and significance were calculated. We also analyzed genetic variants by target NGS for thyroid nodule samples.

Results

The positive predictive value (PPV) and median stain ratio (MSR) of cyclin D1 nuclear staining was determined in papillary thyroid carcinoma (PPV = 91.5%, MSR = 48.5%), follicular adenoma (PPV = 66.7%, MSR = 13.1%), and adenomatous goiter and inflammation controls (MSR = 3.4%). In FNA samples, a threshold of 46% of immunolabelled cells allows to discriminate malignant lesions from benign ones (P < 0.0001), with 81% sensitivity and 100% specificity. A 46% cutoff value for positive cyclin D1 immunostaining in thyroid cells demonstrated 81% sensitivity and 100% specificity. In surgical specimens, ROC curve analysis showed a 5.8% cyclin D1 immunostaining score predicted thyroid neoplasms at 94.4% sensitivity and 92.3% specificity (P = 0.003), while a 15.7% score predicted malignancy at 86.4% sensitivity and 80.5% specificity (P < 0.0001). Finally, three tested clinico-pathological variables (extra thyroidal extension, intraglandular metastasis, and lymph node metastasis) were significant predictors of cyclin D1 immunostaining (P < 0.001).

Conclusion

Our cytological cyclin D1 screening system provides a simple, accurate, and convenient diagnostic method in precision medicine enabling ready determination of personalized treatment strategies for patients by next generation sequencing using cytological sample.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-5452-4) contains supplementary material, which is available to authorized users.

Relationship between tumor burden to growth rate and treatment outcomes of nivolumab for patients with head and neck squamous carcinoma

68

Background: Nivolumab improved overall survival (OS) in the treatment of platinum-refractory recurrent and metastatic head and neck squamous cell carcinoma (R/M HNSCC) in a phase III clinical trial. However, Kaplan-Meier OS and progression-free survival (PFS) curves for the nivolumab and cytotoxic agent arms crossed at 3-6 months, suggesting that patients with initial resistance to immunotherapy may have better outcomes with cytotoxic treatment. Here, we explored suitable conditions and candidates of predictive factors for nivolumab for R/M HNSCC. Methods: We retrospectively reviewed the clinical records of 28 consecutive patients with HNSCC from 2014-2018. Tumor size was evaluated by computed tomography according to RECIST ver.1.1. Tumor growth rate (Gr) was defined as 3Log (Dt/D0)/t, where D0 and Dt are the sum of the longest diameters of the target lesions (SumTLs) at baseline and pre-baseline, and t is time, with 1 t defined as the 4-week interval between tumor evaluations. Results: After exclusion of 2 patients with unevaluable responses, 26 patients were included in the study. Median follow-up time for survivors was 9.5 months. Median SumTLs at baseline was 43.2 mm (range, 10.1-135.3). Median Gr was 0.22 (range, 0.05-0.76). Median OS and PFS was 7.9 months (95% CI, 5.8 to 34.5) and 3.7 months (95% CI, 2.1 to 12.9), respectively. Patients with progression within 3 months showed significantly worse survival (HR 6.33, 95% CI 2.08-21.67, p=0.001). Moreover, higher Gr and bigger SumTLs appeared to be associated with poorer outcomes. We therefore explored the association between prognosis and the ratio of SumTLs to Gr (SumTLs/Gr). The cut off value of SumTLs/Gr was calculated by ROC analysis. Pre-treatment SumTLs/Gr > 212 was associated with significantly worse OS (HR 8.87, 95% CI 2.33-58.29, p<0.001) and PFS (HR 2.86, 95% CI 1.10-8.33, p=0.03). Conclusions: Although retrospective with a small sample size, these results suggest that pre-treatment SumTLs/Gr > 212 was significantly associated with inferior OS and PFS in R/M HNSCC patients treated with nivolumab. R/M HNSCC patients with pre-treatment SumTLs/Gr > 212 might be unsuitable for treatment with nivolumab.

Clinical management for T1 and T2 external auditory canal cancer

OBJECTIVE

The purpose of this study was to clarify the impact of superficial parotidectomy and postoperative radiotherapy (PORT) for the surgical treatment of early stage squamous cell carcinoma (SCC) in external auditory canal (EAC).

MATERIALS AND METHODS

Thirty-seven patients with T1 (n = 14) or T2 (n = 19) SCC in EAC treated between 2000 and 2016 at Kobe University Hospital were enrolled in this study. Thirty-three patients were operated with sleeve resection or lateral temporal bone resection.

RESULTS

The 5-year overall survival and disease-specific survival rates were 95% and 100%, respectively. Surgical margin was positive in 4 patients, who were treated by PORT and have been alive without disease. Prophylactic superficial parotidectomy was simultaneously performed at the time of initial surgery in 15 patients, in whom no lymph node (LN) metastasis was observed. Among the other 22 patients, regional recurrence in parotid LN was observed in one patient, who was successfully salvaged by total parotidectomy. Potential parotid lymph node metastasis rates of T1 and T2 SCC in EAC was 0% (0/14) and 5% (1/19) respectively.

CONCLUSIONS

Complete resection without positive surgical margins is essential for the treatment of the patients with T1 and T2 ear cancers. Prophylactic superficial parotidectomy or neck dissection is not mandatory for T1 and T2 diseases, as long as precisely extent of disease is assessed preoperatively. PORT should be performed for the patients with positive surgical margins.

LEVELS OF EVIDENCE

4.

Impact of retropharyngeal lymph node dissection in the surgical treatment of hypopharyngeal cancer

OBJECTIVES

To evaluate the impact of retropharyngeal lymph node (RPLN) dissection in the surgical treatment of hypopharyngeal cancer.

METHODS

Between 2007 and 2016, 98 previously untreated patients with pathological diagnosed hypopharyngeal squamous cell carcinoma underwent total pharyngolaryngectomy and bilateral neck dissection at Kobe University Hospital. Bilateral dissection of RPLN was simultaneously performed in all patients. Pharynx was reconstructed with free jejunal transfer in 94 patients and primarily closed in 4 patients. Postoperative chemoradiotherapy was performed in patients with high risk factors including metastasis to RPLN, multiple lymph node metastasis, extranodal invasion, and/or positive/close surgical margins.

RESULTS

The median follow-up period was 25 months ranging from 1 to 105 months. RPLN adenopathy was preoperatively identified in 9 patients in FDG-positron emission tomography. All of them had pathologically diagnosed RPLN metastases, which had been controlled in all patients during the observation periods. Among the other 89 patients, 7 patients had RPLN metastasis. The 2-year overall survival rates of the patients with and without RPLN metastasis were 65.7% and 69.8% (P = .61), respectively.

CONCLUSIONS

In the present study, patients with RPLN metastasis showed equally favorable oncological outcome compared with patients without RPLN metastasis. At least, ipsilateral RPLN dissection should be considered in the surgical treatment of advanced hypopharyngeal cancer and multiple neck lymph node metastasis regardless of primary subsite.

Overexpression of SOCS3 mediated by adenovirus vector in mouse and human castration-resistant prostate cancer cells increases the sensitivity to NK cells in vitro and in vivo

Prostate cancer is one of the most common cancers in men. The overactivation of IL-6/JAK/STAT3 signaling and silencing of SOCS3 are frequently observed in prostate cancer. In the present study we undertook to develop Ad-SOCS3 gene therapy for the treatment of prostate cancer and also investigated whether Ad-SOCS3 increased sensitivity to NK cells. We demonstrated that Ad-SOCS3 could significantly inhibit growth of castration-resistant prostate cancer (CRPC) cell lines expressing pSTAT3, DU-145 (at 10, 20, and 40 MOI), and TRAMP-C2 (at 40 MOI), but not the PC-3 CRPC cell line with the STAT3 gene deleted. Ad-SOCS3 (40 MOI) could suppress IL-6 production in DU-145 cells and PD-L1 expression induced by IFN-γ in TRAMP-C2 cells, and increased the NK cell sensitivity of both TRAMP-C2 and DU-145 cells. In the DU-145 mouse xenograft tumor model, intratumoral injections (twice/week for 3 weeks) of 1 × 10⁸ pfu of Ad-SOCS3 significantly inhibited tumor growth and combining the Ad-SOCS3 treatment with intratumoral injections (once/week for 2 weeks) of 1 × 10⁷ human NK cells showed the highest tumor growth inhibitory effect. These results suggested that a combination of Ad-SOCS3 gene therapy and NK cell immunotherapy could be a powerful treatment option for advanced CRPC overexpressing pSTAT3.

[18F]Fluorodeoxyglucose uptake by positron emission tomography predicts outcomes for oropharyngeal and hypopharyngeal cancer treated with definitive radiotherapy

This study evaluated the prognostic significance of the maximum standardized uptake value of the primary site (pSUVmax) in 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) scans of patients with oropharyngeal or hypopharyngeal cancer who were treated using definitive radiotherapy. The study included 86 patients who were primarily treated with radiotherapy for oropharyngeal or hypopharyngeal cancer. Sixty-nine patients underwent concurrent chemotherapy. The associations between pre-treatment pSUVmax and treatment outcomes were evaluated. The most appropriate pSUVmax cut-off value for predicting disease-free survival (DFS) and local control (LC) was selected using receiver operating characteristic (ROC) curves. The median follow-up time for surviving patients was 60 months, while the median survival time in the entire patient cohort was 55 months. A pSUVmax cut-off value of 9.0 showed the best discriminative performance. Five-year OS and DFS rates were 65.9% and 60.0%, respectively. In univariate analyses, pSUVmax (p = 0.009), T-stage (p = 0.001), N-stage (p = 0.039), and clinical stage (p = 0.017) were identified as significant prognostic predictors for DFS. The multivariate analysis did not identify any statistically significant factors, but the association between pSUVmax and DFS was borderline significant (p = 0.055). Interestingly, pSUVmax was predictive of local controllability in T1–T2 disease (p = 0.024), but there was no significant association for T3–T4 disease (p = 0.735). In this study, pSUVmax was predictive of DFS and LC in patients with oropharyngeal or hypopharyngeal cancer that was treated with definitive radiotherapy. pSUVmax was strongly associated with LC in T1–T2 disease.

Cardiac metastasis in a living patient with oral cancer

Cardiac metastasis from head and neck cancers are very rare. Metastases to heart are mostly diagnosed at autopsy, and seldom found while patients are alive. Patients with cardiac metastasis do not present with specific symptoms in the early stages, and diagnosis is often delayed until the disease has advanced significantly. Here, we report a 66-year-old lady who was diagnosed with cardiac metastasis 10 months after surgical resection of oral cancer. She died one month following the discovery of cardiac metastasis. Cardiac metastasis should be considered when unexplained and progressive decline of general health is observed, even in the absence of abnormalities on the electrocardiogram. Early diagnosis may be made by analyzing the chronological changes in the cardiac accumulation of fluorodeoxyglucose during positron emission tomography-computed tomography scan.

Thrombotic Microangiopathy with Severe Proteinuria Induced by Lenvatinib for Radioactive Iodine-Refractory Papillary Thyroid Carcinoma

Standard therapy for radioactive iodine (RAI)-refractory differentiated thyroid cancer (DTC) is multi-targeted kinase inhibitors (m-TKIs), represented by sorafenib and lenvatinib. One of the main target molecules of m-TKIs is vascular endothelial growth factor receptor (VEGF-R). m-TKIs are known to cause adverse reactions such as hypertension and proteinuria as a class effect. In particular, proteinuria is thought to result from vascular endothelial damage and podocytopathy in glomeruli, and the development of thrombotic microangiopathy (TMA) has been reported for VEGF inhibitors. We encountered a patient with RAI-refractory (RR) papillary thyroid carcinoma (PTC) who developed proteinuria and renal dysfunction due to lenvatinib. Renal biopsy demonstrated that these changes were caused by TMA. To our knowledge, this is the first reported case of TMA due to lenvatinib in a Japanese patient with RR-PTC. A 70-year-old woman developed proteinuria, renal impairment and hypertension while receiving lenvatinib for RR-PTC. Her proteinuria and renal damage continued to worsen despite dose reductions and dose interruptions. Renal biopsy was consistent with the chronic type of TMA. These findings indicate that TMA is a possible cause of proteinuria due to lenvatinib, as has been reported for the VEGF inhibitors.

Successful Management of Aggressive Fibromatosis of the Neck: A Case Report

Background:

Aggressive fibromatoses are histologically benign fibrous neoplasms originating from musculoaponeurotic structures throughout the body. They are locally invasive and erode adjacent vital structures. The head and neck region constitutes 7-25% of all extra-abdominal cases.

Case Report:

Here, we report the case of a patient with aggressive fibromatosis in the left side of the neck. While the tumor deeply invaded the scalene muscles, the lesion was successfully treated by surgery followed by radiotherapy. The patient has been disease free for the last 7 years following treatment.

Conclusion:

Due to its unusual location in the head and neck region, aggressive fibromatosis should be considered in the differential diagnosis of invading lesions of the neck.

Role of intensive nutrition support and prophylactic percutaneous endoscopic gastrostomy during concomitant chemoradiotherapy for oropharyngeal cancer

BACKGROUND

Concomitant chemoradiotherapy (CCRT) produces severe mucositis and swallowing dysfunction, often resulting in malnutrition. Intensive nutrition support (INS) in addition to percutaneous endoscopic gastrostomy (PEG) is reported to decrease adverse effects during CCRT.

PATIENTS AND METHODS

Fifty-eight patients with oropharyngeal cancer treated by CDDP-based CCRT were retrospectively analyzed. Twenty-nine patients treated with INS in addition to PEG were classified as INS group, and other 29 patients treated with PEG but without INS were classified as control group.

RESULTS

INS in addition to PEG significantly increased calorie intake in the second half of CCRT and reduced adverse events including mucositis (p = 0.0019), leukopenia (p = 0.04), and renal function (p = 0.006). Moreover, 21 out of 29 patients had successfully administration of 200 mg/m2 or more of CDDP, while only 10 out of 29 patients had enough amount of CDDP in control group.

CONCLUSIONS

These results suggest that INS in addition to prophylactic PEG not only decreases adverse effects but also may potentially improve oncological outcome of the patients with oropharyngeal cancer treated by CCRT.

Abstract 653: A comparative analysis of pathological features and molecular genetics between salivary duct carcinoma and adenocarcinoma, not otherwise specified

Salivary duct carcinoma (SDC), an aggressive subtype of malignant salivary gland tumors with distinct histopathological features, is often characterized by over-expression of androgen receptor (AR) and HER2. Adenocarcinoma, not otherwise specified (ANOS), is another subtype with ductal differentiation without diagnostic histopathological features. The aim of this study was to compare the pathological features and genetic alterations (GAs) between SDC and ANOS.

We reviewed the 128 pathologically confirmed major salivary gland carcinoma cases and found 15 SDC and 20 ANOS cases, and each of 15 specimens were available for this comparative analysis. The clinicopathological characteristics of the 30 cases were retrospectively reviewed. Immunohisitochemical (IHC) analysis including AR, GCDFP-15, HER2, etc. was performed. Next generation sequencing (NGS) was performed, using multiplex PCR for enrichment of cancer related gene loci covering hotspots of 50 cancer genes.

There were 22 men and 8 women with a median age of 64 years (range, 18-87). The main results summarized in the table below. On IHC analysis, SDC and AR positive (+ve) ANOS showed distinct over-expression of GCDFP-15 and HER2. HER2 amplification (FISH) was detected only in SDC and AR +ve ANOS. The most frequent GAs was observed in TP53, followed by genes involved in PI3K-AKT-mTOR pathway and ERBB2. These frequencies were similar between SDC and AR +ve ANOS. In survival analysis among 25 advanced cases with definitive surgery, AR +ve ANOS appeared to have poorer prognosis than AR -ve ANOS. Univariate analysis revealed that HER2-positivity (IHC 3+, FISH positive, or both) tended to have a poorer prognosis (hazard ratio 3.2, 95% confidence interval, 1.0-10.6).

In conclusion, we found similarity in clinicopathological features and GAs between SDC and AR +ve ANOS. Screening AR and HER2 for ANOS is critical due to the therapeutic and prognostic considerations, as is SDC.

Immunohisitochemical patterns, genomic alterations, and clinical outcomesSDCAR +ve ANOSAR -ve ANOSIHC (N=30)Estrogen receptor (%)2/15 (13)1/9 (11)0/6 (0)Progesterone receptor (%)3/15 (20)3/9 (33)0/6 (0)Androgen receptor (%)15/15 (100)9/9 (100)0/6 (0)Prolactin (%)0/15 (0)0/9 (0)0/6 (0)GCDFP-15 (%)14/15 (93)8/9 (88)0/6 (0)PSA (%)4/15 (27)0/9 (0)0/6 (0)HER2 ≥ 2+ (%)8/15 (53)8/9 (88)0/6 (0)EGFR ≥ 2+ (%)9/15 (60)9/9 (100)5/6 (83)Ki-67 &gt; 30% (%)7/8 (87)3/6 (50)2/5 (40)FISH (N=26)HER2 (%)5/14 (36)4/7 (57)0/5 (0)NGS (N=29)TP53 (%)3/15 (20)2/8 (25)2/6 (33)PI3K-AKT-mTOR pathway (%)3/15 (20)2/8 (25)0/3 (0)ERBB2 (%)2/15 (14)2/8 (25)0/6 (0)Survival analysis (N=25)5-year overall survival61% (N=14)29% (N=8)75% (N=3)5-year recurrence-free survival64% (N=14)14% (N=8)50% (N=3)

Citation Format: Yoshinori Imamura, Naomi Kiyota, Ken-ichi Nibu, Chihoko Ikeda, Tomoo Itoh, Ryohei Sasaki, Kazuko Sakai, Kazuto Nishio, Masanori Toyoda, Hironobu Minami, Naoki Otsuki. A comparative analysis of pathological features and molecular genetics between salivary duct carcinoma and adenocarcinoma, not otherwise specified [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 653.

Successful treatment switch from lenvatinib to sorafenib in a patient with radioactive iodine-refractory differentiated thyroid cancer intolerant to lenvatinib due to severe proteinuria

Sorafenib and lenvatinib showed efficacy for patients with radioactive iodine (RAI)-refractory differentiated thyroid cancer (DTC) in pivotal phase 3 clinical trials. Although the efficacy of lenvatinib in patients who received previous treatment with multi-target kinase inhibitors (m-TKIs), including sorafenib, was reported, the efficacy of sorafenib in patients who previously received lenvatinib remains unknown. A 75-year-old woman diagnosed as RAI-refractory poorly differentiated carcinoma with multiple lung metastases and started treatment with lenvatinib. She continued to receive lenvatinib but with repeated dose interruptions and reductions due to continuous proteinuria. Because of severe and persistent proteinuria as well as newly developed renal impairment, lenvatinib was suspended after two years of treatment. After the 7-month suspension, her proteinuria and renal impairment were partially improved, but her lung metastases progressed. Because she was unable to tolerate previous treatment with lenvatinib, sorafenib was started. At 7 months of treatment with sorafenib, her lung metastases shrank and she could continue sorafenib without exacerbation of proteinuria or renal impairment. This case may suggest that sorafenib does not exacerbate the proteinuria or renal impairment induced by lenvatinib, and may be an effective treatment option for RAI-refractory DTC patients who are unable to tolerate lenvatinib.