Evofosfamide for the treatment of human papillomavirus-negative head and neck squamous cell carcinoma

Evofosfamide (TH-302) is a clinical-stage hypoxia-activated prodrug of a DNA-crosslinking nitrogen mustard that has potential utility for human papillomavirus (HPV) negative head and neck squamous cell carcinoma (HNSCC), in which tumor hypoxia limits treatment outcome. We report the preclinical efficacy, target engagement, preliminary predictive biomarkers and initial clinical activity of evofosfamide for HPV-negative HNSCC. Evofosfamide was assessed in 22 genomically characterized cell lines and 7 cell line-derived xenograft (CDX), patient-derived xenograft (PDX), orthotopic, and syngeneic tumor models. Biomarker analysis used RNA sequencing, whole-exome sequencing, and whole-genome CRISPR knockout screens. Five advanced/metastatic HNSCC patients received evofosfamide monotherapy (480 mg/m2 qw × 3 each month) in a phase 2 study. Evofosfamide was potent and highly selective for hypoxic HNSCC cells. Proliferative rate was a predominant evofosfamide sensitivity determinant and a proliferation metagene correlated with activity in CDX models. Evofosfamide showed efficacy as monotherapy and with radiotherapy in PDX models, augmented CTLA-4 blockade in syngeneic tumors, and reduced hypoxia in nodes disseminated from an orthotopic model. Of 5 advanced HNSCC patients treated with evofosfamide, 2 showed partial responses while 3 had stable disease. In conclusion, evofosfamide shows promising efficacy in aggressive HPV-negative HNSCC, with predictive biomarkers in development to support further clinical evaluation in this indication.

Prediction of pharyngocutaneous fistulas after laryngectomy

OBJECTIVE

To assess the predictive value of wound amylase as an indicator for pharyngocutaneous fistula development following laryngectomy for cancer.

DESIGN AND SETTING

We conducted a prospective observational study at a tertiary referral center of 102 consecutive laryngeal or hypopharyngeal cancer patients undergoing laryngectomy with or without pharyngectomy.

INTERVENTION

Data were collated on potential predictors of fistula formation compared with rate of development of clinical fistulas, all confirmed radiologically.

MAIN OUTCOME MEASURES

Rate of fistula formation was determined for the following potential predictors: extent of resection (extended laryngectomy), postoperative wound (drain) amylase, previous radiotherapy, neck dissection, preoperative and postoperative hemoglobin and albumin levels, and postoperative transfusion. Sensitivity, specificity, and positive and negative predictive values of significant predictors were ascertained.

RESULTS

The only significant predictors of fistula formation were extent of resection (extended laryngectomy) and drain amylase >4000 IU/L. If both factors are combined, the sensitivity, specificity, and positive and negative predictive values for fistula development are 83, 94, 63, and 98 percent, respectively.

CONCLUSION

We advocate that patients be managed postoperatively according to the presence or absence of these given predictors to reduce occurrence of fistula formation in the high-risk group.

Acinic cell carcinoma of the parotid gland: Auckland experience and literature review

Acinic cell carcinoma is an uncommon malignancy of the salivary glands and as such it has been difficult to accurately delineate its natural history. The aim of this study is to assess the behaviour of acinic cell salivary cancer of the parotid gland presenting to a single head and neck surgical unit in Auckland. The study is a structured review of cases of acinic cell carcinoma of the parotid gland presenting from 2000 to 2006 to the Head and Neck Unit at Auckland Hospital, those identified from the pathology database and the Otobase head and neck database. Case records and pathology reports were reviewed. Fifteen patients were identified, 9 men and 6 women. The mean age was 67.2 years, with range 50-85 years. The mean follow up was 4.4 years and range 1.1-7 years. There was one case of local recurrence during study period and no deaths. Five of 15 patients received postoperative radiotherapy. Postoperative complications consisted of one wound haematoma and two cases of marginal mandibular weakness (one transient and one permanent). Current management strategies are obtaining appropriate rates of recurrence and postoperative complications within the Auckland population.

T1N0/T2N0 glottic carcinoma: A comparison of two fractionation schedules

The aim of this paper is the retrospective comparison of accelerated/hypofractionated radiotherapy regimen (AHFX) with standard fractionation regimen (SFX) for patients with early glottic carcinoma. One hundred and forty-five patients with T(1)-T(2) glottic cancer between 1986 and 1998 were eligible. Before 1992, patients received 60-66 Gy in 30-33 fractions over 6-6.5 weeks (SFX) with (60)Co and 6-MV beams. After 1992, patients received 52.5-55 Gy in 20 fractions over 4 weeks (AHFX) using 6-MV beams. The end-points were overall survival, laryngectomy-free survival (LFS), loco-regional control and toxicity. One hundred and two were stage T(1)N(0); 43 were stage T(2)N(0). Median follow up was 4.9 years. The 5-year overall survival was 78%. Five-year loco-regional control in T(1)N(0) patients was higher in AHFX than in SFX group (95 vs 75%, P = 0.002). Loco-regional control in T(2)N(0) patients was similar for AHFX and SFX (81 vs 80%, P = 0.813). Overall LFS was 88%. T(1)N(0) AHFX patients had 5-year LFS of 95% compared with 75% for SFX (P = 0.003). For T(2)N(0) AHFX patients, overall LFS was 92% compared with 80% for the SFX group (P = 0.291). No grade 4 or 5 late toxicity occurred. One AHFX patient developed grade 3 toxicity; two of 51 SFX patients developed grade 2 toxicity versus five of 94 AHFX patients. AHFX using 6-MV beams for treatment of early glottic cancer resulted in equivalent LFS and toxicity when compared with SFX.

Effect of immunocompromise on metastatic cutaneous squamous cell carcinoma in the parotid and neck

BACKGROUND

Our aim was to examine the effect of a compromised immune state on the outcomes in patients treated for metastatic cutaneous squamous cell carcinoma (SCC).

METHODS

A retrospective analysis of patients with metastatic cutaneous SCC to the parotid and neck treated at Greenlane Hospital between 1992 and 2002 was conducted. Outcomes were compared between immune-competent and immunocompromised patients. A logistic regression analysis of likely risk factors for poor outcome was done.

RESULTS

Forty-nine patients were identified, nine of whom were immunocompromised. All patients were treated by parotidectomy and/or neck dissection. The facial nerve was sacrificed in 42% of the patients. Thirty-seven patients underwent postoperative radiotherapy (76%). Recurrence was significantly more common in the immunocompromised group (56% vs 28%), with higher rates of local and distant recurrence. Survival at 1 and 2 years was reduced.

CONCLUSION

Immunocompromise has a significant impact on the outcome of metastatic cutaneous SCC to the parotid and neck, affecting recurrence and survival.

Endovascular treatment of epistaxis

AIM

Embolization of external carotid vessels in the treatment of intractable epistaxis is not well documented in Australasia. The aim of the present retrospective study was to audit our experience with the technique, and to compare it with other centres.

METHODS

Retrospective review.

RESULTS

Twenty-nine embolizations were performed in 28 patients. Embolization was successful in 24 out of 28 patients (86%). Three patients required ligation of the anterior ethmoidal arteries, one of whom subsequently underwent successful repeat embolization. There were minor complications in 6/29 procedures (21%), and no major complications.

CONCLUSION

Our outcomes compare favourably with those of larger centres. Embolization is an effective tool in the management of patients with intractable epistaxis.

Pulmonary complications following major head and neck surgery with tracheostomy: a prospective, randomized, controlled trial of prophylactic antibiotics

OBJECTIVE

To test the hypothesis that extended postoperative antibiotic cover would reduce the incidence of pulmonary complications in patients undergoing major head and neck surgery with tracheostomy.

DESIGN

A prospective, randomized, controlled trial was carried out to determine the efficacy of an extended course (5 days) of intravenous amoxicillin-clavulanic acid in reducing the rate of atelectasis and pulmonary infections postoperatively. Other possible risk factors that might predispose to pulmonary complications were also evaluated.

SETTING

Tertiary referral center for head and neck surgery.

PATIENTS

Consecutive patients younger than 80 years with planned surgery for carcinoma of the oral cavity, pharynx, or larynx were enrolled. Patients with diabetes, those who had received antibiotics within 1 week before surgery, and those with preexisting pulmonary disease were excluded.

INTERVENTION

Patients were randomly assigned no antibiotics or a 5-day course of intravenous amoxicillin-clavulanic acid postoperatively.

MAIN OUTCOME MEASURES

The development of pulmonary complications (pulmonary infection or atelectasis).

RESULTS

Eighty-six patients were enrolled; 73 patients met the criteria for analysis. Thirty-four (47%) developed pulmonary complications; 29 (40%) had a pulmonary infection. An extended course of antibiotics did not reduce the rate of pulmonary infections (P =.57). Positive risk factors for a pulmonary infection were presence of preoperative obstructive lung function and postoperative atelectasis.

CONCLUSIONS

An extended course of antibiotics did not prevent the development of postoperative pulmonary infections in patients undergoing major head and neck surgery with tracheostomy. Poor pulmonary function and postoperative atelectasis emerged as significant risk factors for pulmonary infection.

Comparison of the use of endoscopic and radiologic gastrostomy in a single head and neck cancer unit

BACKGROUND

Head and neck cancer patients frequently require gastrostomy feeding. Different insertion techniques have been described. The aim of the present study was to compare clinical results of percutaneous endoscopic and radiological gastrostomies in patients treated in a regional head and neck cancer unit.

METHODS

The records of patients who received either percutaneous endoscopic gastrostomy (PEG) or percutaneous radiological gastrostomy (PRG) between August 1997 and February 2001 were reviewed retrospectively. Documented complications (leak, infection, nausea and vomiting, ileus, bleeding, peritonitis) were recorded, compared and evaluated.

RESULTS

There were 74 patients (56 PEG, 18 PRG), most with stage III and IV head and neck malignancy. There was a significantly lower incidence of complications in PEG than PRG (11% vs 44%, P = 0.004). There was a delay of feeding due to tube placement in 4% of PEG and 22% of PRG (P < 0.025). Major complications occurred in 3.6% and 5.6% of PEG and PRG, respectively. Generally the complication rate for either form of gastrostomy was comparable with other studies. No procedure-related deaths occurred.

CONCLUSION

Selection bias, technique and tube type appeared to influence the complication rate in the present review. Percutaneous endoscopic gastrostomy will remain the authors' preferred method while PRG will be reserved for those cases for whom endoscopic placement is deemed to be impractical.

Quality of life after parotid and temporal bone surgery for cancer

OBJECTIVES

The purposes of this study were to examine the quality of life (QL) of patients who received treatment for cancer of the parotid or temporal region, and to identify factors contributing to it. The relationships between clinician-based measures of treatment outcome and the patient-based counterparts were also evaluated.

METHODS

A retrospective, cross-sectional study was conducted on 23 patients who had received either a temporal bone resection or a combination of parotidectomy and radiotherapy. The QL survey involved both global QL and measures of the appearance, communication, hearing, physical, psychological, and social domains. Patients were assessed clinically for their performance status, facial nerve function, disfigurement, and hearing and the results were compared with patient-rated QL. Correlation between the QL variables and global QL was identified using Spearman correlation tests.

RESULTS

Ongoing physical symptoms, communication difficulties, and social disturbances were associated with poorer global QL (P <.05). No correlation was detected between global QL and objective disfigurement, facial function, and measures of hearing loss. With the exception of hearing testing, clinical assessments generally did not correlate well with patient ratings.

CONCLUSION

QL measures provide insight into patients' perceptions of the treatment outcome but do not necessarily correlate with the clinicians' views. The use of a global QL measure overcomes the difficulty of extrapolating the impact of symptom scores or observational measures on patients' overall quality of survival.

Thyroid surgery and voice-related outcomes

BACKGROUND

Vocal dysfunction in patients with thyroid pathology has been poorly documented, and dysfunction after thyroid surgery is generally reported in terms of recurrent laryngeal nerve or external laryngeal nerve palsy. But voice dysfunction is more complex than simply nerve integrity. The present study reports the incidence of dysphonia in patients presenting for thyroid surgery, and relates postoperative changes in vocal function to recurrent and external laryngeal nerve function, and the surgical handling of the strap muscles.

METHODS

Fifty patients were assessed by Visipitch before and after thyroidectomy. Following surgery the patients filled out a questionnaire.

RESULTS

Overall 26 of 44 patients had no subjective postoperative voice change, while 10 reported subjective deterioration and eight reported subjective improvement in voicing. Postoperative objective assessment of these patients found that 17 were the same, eight refused to come for testing because they felt their voice had not changed, 13 were better and six were worse. Following surgery two patients (4.5%) had temporary recurrent laryngeal nerve palsies (2.5% of nerves at risk), and four patients (10%) suffered external laryngeal nerve palsies. Division of strap muscles was not detrimental to voicing. Six patients were lost to follow-up. Fifteen patients (34%) presented with vocal abnormalities, six (40%) of whom improved postoperatively.

CONCLUSIONS

Patients may have voicing abnormalities before thyroid surgery is performed. Surgery may improve or worsen the voice irrespective of the pre-operative voice status.

Audit in the management of T3 fixed-cord laryngeal cancer

PURPOSE

To determine results of various treatments for T3 fixed-cord lesions and the subset T3 glottic cancer in Auckland from 1979 to 1995.

PATIENTS AND METHODS

Data were collected retrospectively from a departmental database, and the notes were reviewed. Because of the difficulty in determining the subsite of some fixed-cord lesions, the entire group of T3 fixed-cord lesions was examined, and those tumors that were considered to be definitely arising from the glottis were then analyzed as a specific subset.

RESULTS

Fixed-cord lesions were diagnosed in 75 patients (21 supraglottic, 54 glottic). Primary surgery (total laryngectomy) was performed on 46 patients, primary radical dose radiotherapy was undertaken on 25 patients, and four patients were treated palliatively. For T3 fixed-cord lesions, disease-specific survival for radiotherapy and surgery was 36% and 66%, respectively, and 32% and 67%, respectively, for T3 glottic lesions. For both T3 fixed-cord and T3 glottic lesions, surgery produced significantly better survival than did radiotherapy (<60 Gy; P = .0157). With radiotherapy greater than 60 Gy, cancer of the larynx has been controlled in seven of 13 patients, although only five patients are alive, with a median follow-up of 24 months (range, 12-49 months).

CONCLUSION

Radiotherapy less than 60 Gy produced markedly inferior results to surgery for T3 fixed-cord lesions and T3 glottis in Auckland. Radiotherapy at more than 60 Gy shows promise, but an ongoing audit is essential to ensure that survival is similar to surgery and to that reported by those promoting organ-preservation protocols.

Plunging ranula: clinical observations

BACKGROUND

The plunging ranula is a relatively uncommon phenomenon which represents a mucus escape reaction occurring from disruption of the sublingual salivary gland. We present a series of 20 patients managed at Green Lane Hospital (Auckland, New Zealand) over a 9-year period.

METHODS

A retrospective review of 13 patients with this condition was undertaken, and a prospective study was conducted on 7 patients. Information was collected on age, sex, ethnic origin, history of onset, predisposing factors, treatment, and outcome of treatment.

RESULTS

The patients were all young adults with a median age of 31 years. The sex distribution was relatively equal, with 11 men and 9 women. All patients were Maori or Pacific Island Polynesians. Six patients gave a clear history of preceding trauma to the neck or oral cavity. Two recurrences were seen, both in patients who had had the sublingual gland excised via a cervical approach. Five patients sustained lingual nerve damage during surgery. Full function recovered in four patients, but the complication was still present in the fifth patient at 2 years, after which he was lost to follow-up.

CONCLUSIONS

Plunging ranulas appear to occur with greater incidence in the Maori and Pacific Island Polynesian populations. The precise etiology of their predisposition is unknown, although local trauma or inherent mylohyoid dehiscences may play important roles. Removal of the sublingual gland via either a cervical or intraoral approach is important in the management of this condition. Excision of the pseudocyst is probably unnecessary and places surrounding structures at risk of damage, but a biopsy of the pseudocyst wall is important to confirm the diagnosis.

Role of Epstein-Barr virus in fine-needle aspirates of metastatic neck nodes in the diagnosis of nasopharyngeal carcinoma

BACKGROUND

The patient with nasopharyngeal carcinoma (NPC) frequently is initially seen with regional node dissemination. Preliminary investigations suggest that the presence of Epstein-Barr virus (EBV) genomes in neck metastases from an occult primary may be diagnostic and predictive of NPC. The goal of this study was to test this proposition.

METHODS

The polymerase chain reaction (PCR) was used to detect the presence of EBV DNA in fine-needle aspirate (FNA) samples obtained from malignant neck nodes. Control samples were obtained from other locations in the head and neck.

PATIENTS

The patients in this study were evaluated at the Toronto Princess Margaret Hospital, a province-wide tertiary-care cancer treatment center. Of the 23 patients evaluated with malignant neck masses, 6 had NPC, 5 patients had metastatic squamous cell carcinoma of an unknown primary, and 12 patients served as controls with other known head and neck carcinomas. One of the patients initially diagnosed as an unknown primary later demonstrated NPC. FNA specimens were also obtained from 24 normal parotid, submandibular, or thyroid glands for comparison.

RESULTS

In the samples with sufficient DNA for analysis, EBV was detected in 5 of 5 neck nodes from patients with known NPC. EBV was also detected in the neck node of a patient who went on to develop NPC and in a cervical node from 1 of 2 patients in whom the primary tumor remained unknown. None of the evaluable control neck nodes of FNA controls from other sites demonstrated EBV.

CONCLUSIONS

These results demonstrate the utility of NPC-diagnostic EBV gene amplification in FNA samples of neck metastases and suggest that the presence of the EBV genome in FNA samples of neck nodes is predictive of the presence of NPC.

Nasopharyngeal carcinoma and middle ear effusion: natural history and the effect of ventilation tubes

Middle ear effusion is a common occurrence in nasopharyngeal carcinoma, and is often treated by myringotomy and ventilation tube insertion. However, this can be complicated by a high rate of otorrhoea after radiotherapy. The natural history and management of middle ear effusion was examined in this retrospective study of 81 patients. An effusion was noted in 52% of patients at presentation and developed in 26% of patients after radiotherapy. At the end of the observation period there was no difference in the rate of resolution of effusions in patients with ventilation tubes insertion compared with patients with no tube insertion. A significantly greater incidence of otorrhoea and persistent perforation was found in patients with tubes (P = 0.0497). When otorrhoea occurred it was often persistent and troublesome, and so conservative management of effusions in patients with nasopharyngeal cancer should be considered.

Ultrasonography and ultrasound-guided fine-needle aspiration biopsy of head and neck lesions: a surgical perspective

A head and neck ultrasound-guided fine-needle aspiration clinic was set up to determine the role of ultrasound and ultrasound-guided fine-needle aspiration in the evaluation of patients with lesions in this region. One hundred ninety-five lesions were biopsied by ultrasound-guided fine-needle aspiration in 203 patients. Ultrasound detected 2 or more lesions in 14 (48%) of 29 patients with a clinically solitary thyroid nodule. Three (8.8%) of 34 lesions thought to be within the parotid gland were determined to be external. A pronounced learning curve was evident in the technique of ultrasound-guided fine-needle aspiration, particularly for nonpalpable disease. Adequacy of sampling for each 3-month period was 71%, 89%, and 94%, respectively. Seventy-four percent of central aspirations were satisfactory compared to 54% of peripheral aspirations. Ultrasound-guided fine-needle aspiration did not alter the clinical staging of metastatic neck disease in 8 patients having 10 neck dissections but proved useful in detecting nodal recurrence in 3 irradiated necks that did not proceed to surgery. The smallest node to harbor malignancy had 4-mm maximal axial diameter. We conclude that ultrasound and ultrasound-guided fine-needle aspiration are valuable adjuncts to the clinical examination.

Epstein-Barr virus and nasopharyngeal carcinoma: bringing molecular genetics strategies to head and neck oncology

In this article, we consider the tools of molecular genetics and strategies that have, or likely will have, an impact in otolaryngology, either as diagnostic tools or as strategies, with more far-reaching applications in tumour therapy, relapse monitoring, and ultimately, approaches to tumour prevention. Nasopharyngeal carcinoma (NPC) is closely associated with Epstein-Barr virus (EBV). Detection of the virus following gene amplification by the polymerase chain reaction (PCR) can provide a diagnostic tumour marker, both in primary and metastatic sites. NPC can be considered as a model disease on which molecular genetics is and likely will be of considerable impact. NPC is characterized by the presence of a genetically stable, viral agent of proven oncogenicity. The presence of attractive experimental systems for the study of EBV-associated tumours and their accessibility may combined with new molecular approaches towards diagnostic and, eventually, therapeutic improvements in the treatment of this clinically ominous malignancy.

Use of tissue expansion in head and neck reconstruction

Esthetic reconstruction of facial defects requires the use of skin with similar characteristics to that of the deficient site. Local and regional skin are the most suitable, but the amount available may be insufficient for both reconstruction and primary closure of the donor site. We describe three illustrative cases in which tissue expansion of local and regional skin allowed satisfactory reconstruction and donor site closure that would otherwise not have been possible.

Validity of test occlusion studies prior to internal carotid artery sacrifice

Twenty-nine patients with lesions of the neck, skull base, and cavernous sinus had test balloon occlusions of the internal carotid artery (ICA) to determine the feasibility of sacrifice of the artery. Only one patient (3.4%) showed evidence of cerebrovascular compromise. Sixteen patients who tolerated test occlusions went on to ICA sacrifice. Ten patients had permanent balloon occlusion (PBO) of the ICA for cavernous aneurysms or to "trap" carotid-cavernous fistulae (CCF). Complications occurred in three patients (30%) with permanent morbidity in one patient (10%). One patient with CCF had PBO of the proximal ICA only, resulting in an unstable neurologic state and ultimately in death. Two patients had resection of skull base tumors 2 and 6 days after PBO of the ICA. Both suffered strokes and one died. Three patients had surgical sacrifice of the ICA without PBO. Two of these patients suffered cerebral ischemia without permanent sequelae. We conclude that test occlusion of the ICA with clinical monitoring will miss a significant number of patients with inadequate cerebrovascular reserve. Sensitivity is improved by controlled reduction of systemic blood pressure during the test occlusion. Resection of a skull base tumor soon after PBO of the ICA should be done in a delayed fashion or preceded by extracranial-intracranial arterial bypass. Patients who have had the artery sacrificed should be monitored in an intensive care setting for 48 hours to avoid hypotension, which could cause cerebrovascular ischemia.

Ultrasonography of the thyroid and parathyroid glands

High-frequency ultrasonography is ideally suited to imaging of the thyroid and parathyroid glands by virtue of their superficial location in the neck. Ultrasonography of the thyroid is most commonly used in the evaluation of the solitary nodule. Ultrasonography of the parathyroid glands is usually performed to evaluate and localise parathyroid abnormalities in patients with hypercalcemia. The increased diagnostic acumen offered by this modality allows a realistic working diagnosis and leads to a rational management strategy.

Value of fine-needle aspiration in the diagnosis of Hürthle cell neoplasms

The cytologic and histologic slides on all patients with a diagnosis of Hürthle cell tumor at Mount Sinai Hospital during the last 12 years were reviewed. There were 67 Hürthle cell tumors of which 15 (22%) were malignant. Four carcinomas (27%) occurred in a background of thyroiditis. Forty-three patients with Hürthle cell tumors had undergone preoperative fine-needle aspiration, of which 31 had satisfactory aspirates. For Hürthle cell neoplasia, fine-needle aspiration cytology had a sensitivity of 83.8% (26 of 31) and positive predictive value of 93% (26 of 28), provided that the aspirate was of adequate cellularity. All 3 cases predicted as Hürthle cell carcinoma on the basis of cellular and nuclear atypia were correctly predicted, but 3 carcinomas composed of bland cells were incorrectly predicted as adenomas. We conclude that aspiration cytology can differentiate nonneoplastic from neoplastic Hürthle cell lesions with high accuracy, but that the differentiation between benign and malignant lesions is less reliable.