Association of Sarcopenia With Oncologic Outcomes of Primary Surgery or Definitive Radiotherapy Among Patients With Localized Oropharyngeal Squamous Cell Carcinoma

Importance

The negative association of low lean muscle mass (sarcopenia) with survival outcomes in head and neck cancers, including oropharyngeal carcinoma, is established. However, it is not known whether the choice of primary treatment modality (surgery or radiotherapy) is associated with oncologic outcomes of patients with sarcopenia and oropharyngeal squamous cell carcinoma (OPSCC).

Objective

To examine whether primary surgical resection or definitive radiotherapy is associated with improved survival for patients with sarcopenia and localized OPSCC.

Design, Setting, and Participants

A cohort study was conducted of patients with clinically staged T1 to T2, N0 to N2 OPSCC with cross-sectional abdominal imaging within 60 days prior to treatment and treated between January 1, 2005, and December 31, 2017. Skeletal muscle mass was measured at the third lumbar vertebra using previously defined techniques and sarcopenia was defined as less than 52.4 cm2/m2 of muscle for men and less than 38.5 cm2/m2 for women. In addition, associated patient demographic characteristics, cancer data, treatment information, and survival outcomes were assessed. Statistical analysis was performed from December 3, 2018, to August 28, 2019.

Main Outcomes and Measures

Primary outcomes were overall survival and disease-specific survival.

Results

Among the 245 patients who met study inclusion criteria, 209 were men (85.3%) and the mean (SD) age was 62.3 (7.8) years. Sarcopenia was detected in 135 patients (55.1%), while normal skeletal muscle mass was detected in 110 patients (44.9%). For the 110 patients without sarcopenia, primary treatment modality was not associated with improved survival. For patients with sarcopenia at diagnosis, primary surgical resection was associated with improved overall survival (hazard ratio [HR], 0.37; 95% CI, 0.17-0.82) and disease-specific survival (HR, 0.22; 95% CI, 0.07-0.68). This association persisted after propensity score matching, as up-front surgery was associated with improved overall survival (HR, 0.33; 95% CI, 0.12-0.91) and disease-specific survival (HR, 0.17; 95% CI, 0.04-0.75) survival.

Conclusions and Relevance

This study suggests that sarcopenia has a negative association with survival for patients with OPSCC. Primary surgery and radiotherapy confer similar survival associations for patients with normal skeletal muscle mass and localized OPSCC. However, up-front surgical resection may be associated with improved survival outcomes for patients with sarcopenia.

Association Between Sarcopenia and Mortality in Patients Undergoing Surgical Excision of Head and Neck Cancer

Importance

Sarcopenia, or the loss of muscle mass, is associated with poor treatment outcomes in a variety of surgical fields. However, the association between sarcopenia and long-term survival in a broad cohort of patients with head and neck cancer (HNC) is unknown.

Objective

To determine whether sarcopenia is associated with long-term survival in patients undergoing major head and neck surgery for HNC.

Design, Setting, and Participants

A retrospective medical records review was conducted at a tertiary care academic hospital. Two hundred sixty patients undergoing major head and neck ablative procedures with cross-sectional abdominal imaging performed within 45 days prior to surgery were included in the analysis. The study was conducted from January 1, 2005, to December 31, 2016. Data analysis was performed from June 1, 2018, to February 28, 2019.

Interventions

Measurement of cross-sectional muscle area at the L3 vertebra level.

Main Outcomes and Measures

Two- and 5-year overall survival were the primary outcomes.

Results

Of the 260 patients included in the study, 193 were men (74.2%); mean (SD) age was 61.1 (11) years. Sarcopenia was present in 144 patients (55.4%). Two-year overall survival was 71.9% of the patients (n = 82) in the sarcopenia group compared with 88.5% of the patients (n = 85) in the nonsarcopenia group (odds ratio [OR], 0.33; 95% CI, 0.16-0.70). At 5 years, overall survival was 36.5% in patients (n = 23) with sarcopenia and 60.5% in patients (n = 26) without sarcopenia (OR, 0.38; 95% CI, 0.17-0.84). On multivariate analysis, sarcopenia was a significant negative predictor of both 2-year (OR, 0.33; 95% CI, 0.14-0.77) and 5-year (OR, 0.38; 95% CI, 0.17-0.84) overall survival.

Conclusions and Relevance

Sarcopenia appears to be a significant negative predictor of long-term overall survival in patients with HNC undergoing major head and neck surgery. Sarcopenia may be accurately assessed on cross-sectional imaging and may be useful clinically as a prognostic variable and as an area for intervention to improve treatment outcomes.

Increasing lean muscle mass in mice via nanoparticle-mediated hepatic delivery of follistatin mRNA

Muscle atrophy occurs during chronic diseases, resulting in diminished quality of life and compromised treatment outcomes. There is a high demand for therapeutics that increase muscle mass while abrogating the need for special dietary and exercise requirements. Therefore, we developed an efficient nanomedicine approach capable of increasing muscle mass.

Methods: The therapy is based on nanoparticle-mediated delivery of follistatin messenger RNA (mRNA) to the liver after subcutaneous administration. The delivered mRNA directs hepatic cellular machinery to produce follistatin, a glycoprotein that increases lean mass through inhibition of negative regulators of muscle mass (myostatin and activin A). These factors are elevated in numerous disease states, thereby providing a target for therapeutic intervention.

Results: Animal studies validated that mRNA-loaded nanoparticles enter systemic circulation following subcutaneous injection, accumulate and internalize in the liver, where the mRNA is translated into follistatin. Follistatin serum levels were elevated for 72 h post injection and efficiently reduced activin A and myostatin serum concentrations. After eight weeks of repeated injections, the lean mass of mice in the treatment group was ~10% higher when compared to that of the controls.

Conclusion: Based on the obtained results demonstrating an increased muscle mass as well as restricted fat accumulation, this nanoplatform might be a milestone in the development of mRNA technologies and the treatment of muscle wasting disorders.

A multicenter, double-blind, randomized comparison of oral ondansetron 8 mg b.i.d., 24 mg q.d., and 32 mg q.d. in the prevention of nausea and vomiting associated with highly emetogenic chemotherapy. S3AA3012 Study Group

The objectives of this study were to compare the efficacy and safety of orally administered ondansetron 8 mg b.i.d., 24 mg q.d., and 32 mg q.d. in the prevention of nausea and vomiting associated with high-dose cisplatin-based chemotherapy (cisplatin > or = 50 mg/m2). This was a randomized, parallel-group, double-blind study conducted in North America. It was planned that all patients would receive one of the following orally administered ondansetron treatments 30 min before starting cisplatin dosing (administered over < or = 3 h): 8 mg b.i.d. with 8 h between doses (124 patients), 24 mg q.d. (116 patients), and 32 mg q.d. (117 patients). Use of prophylactic corticosteroids was not permitted. During the 24-h study period, the highest complete response rate (no emesis, rescue antiemetic therapy, or withdrawal) occurred in patients who received ondansetron 24 mg q.d.: 76/115 or 66%, as against 68/124 (55%) after ondansetron 8 mg b.i.d. and 64/117 (55%) after ondansetron 32 mg q.d. Complete control of nausea (no nausea, no rescue, no withdrawal) occurred in more patients in the ondansetron 24 mg q.d. group (64/114, 56%) than in the ondansetron 8 mg b.i.d. group (43/121, 36%) or in the ondansetron 32 mg group (55/117, 50%). These results demonstrate that following highly emetogenic cisplatin-based chemotherapy (> or =2 50 mg/m2), oral ondansetron 24 mg q.d. is more effective than 8 mg b.i.d. for overall control of nausea, and at least as effective if not more effective in the control of acute vomiting than 8 mg b.i.d. or 32 mg q.d. Ondansetron 24 mg q.d. was well tolerated, and no new or unexpected adverse events were identified.

Phase II trial of 5 day continuous intravenous infusion of 6-thioguanine in patients with recurrent and metastatic squamous cell carcinoma of the head and neck

Fifteen patients with recurrent and/or metastatic squamous cell carcinoma of the head and neck received a 5 day continuous I.V. infusion of 6-thioguanine repeated every five weeks. Dose limiting toxicity was primarily hematological with grade III/IV leucopenia and thrombocytopenia seen in seven patients. Nausea and vomiting was moderate and well controlled with antiemetics. No complete or partial responses were observed, with a median time to progression of 58 days and a median survival of 227+ days for the entire group. Based on these results we do not recommend I.V. 6-thioguanine for the treatment of this disease.

Dronabinol and prochlorperazine in combination for treatment of cancer chemotherapy-induced nausea and vomiting

Dronabinol (Marinol, Roxane Laboratories, Columbus, OH) and prochlorperazine were tested alone and in combination in a randomized, double-blind, parallel group, multicenter study. Patients were randomized to receive either 1) dronabinol 10 mg every 6 hr plus placebo; 2) placebo plus prochlorperazine 10 mg every 6 hr; or 3) dronabinol and prochlorperazine, each 10 mg every 6 hr. Antiemetic treatment was begun 24 hr prior to and continued for 24 hr after the last dose of chemotherapy; all was given orally. Only 29% of patients in group 3 versus 47% in group 1 and 60% in group 2 experienced nausea after chemotherapy. In addition, the median duration per episode and severity of nausea were significantly less with combination therapy. Vomiting occurred after chemotherapy in 41%, 55%, and 35% of patients in groups 1, 2, and 3, respectively. The median duration per episode of vomiting was 1 min in group 3 versus two in group 1 and four in group 2. Side effects, primarily CNS, were more common in group 1 than in group 2; addition of prochlorperazine to dronabinol appeared to decrease the frequency of dysphoric effects seen with the latter agent. The combination was significantly more effective than was either single agent in controlling chemotherapy-induced nausea and vomiting.

A comparison of carboplatin plus methotrexate versus methotrexate alone in patients with recurrent and metastatic head and neck cancer

Patients with recurrent and metastatic squamous cell carcinoma of the head and neck (SCCHN) were stratified by performance status, extent of disease, and prior radiotherapy and subsequently randomized to receive carboplatin (CBDCA; Bristol-Myers, Wallingford, CT) administered intravenously (IV) monthly, initially at doses of 400 mg/m2 in combination with methotrexate (MTX) given IV weekly at doses of 40 mg/m2 or MTX alone at the same dose/schedule. Significant dose-limiting myelosuppression required CBDCA dose reductions to 300 mg/m2 and, subsequently, 200 mg/m2. Nonhematological toxicities were not significant. Our study objective was to determine whether CBDCA plus MTX produce a substantial improvement in response rate over single-agent MTX. A response rate of 50% (complete [CR] plus partial response [PR]) for CBDCA plus MTX compared with 25% for MTX was specified as the difference to be detected. We employed a two-stage study design for randomized trials that allowed for early termination of studies involving relatively ineffective treatment regimens. With this design, the study could be closed after the first stage (20 patients entered onto each treatment arm) if the number of responders to CBDCA plus MTX were not superior to MTX. Five of 20 patients responded to treatment in each arm, and we were able to conclude that the addition of CBDCA to MTX is unlikely to result in a twofold increase in response rate compared with MTX alone in this group of patients. This two-stage design represents a simple and efficient method of testing the relative efficacy of new combinations containing at least one active agent against a suitable control arm in this disease. It addresses scientific and ethical issues of continuing testing with relatively ineffective treatments, and at the same time provides a reliable method for identifying very active regimens likely to represent significant therapeutic advances.

NF-kappa B-mediated activation of the human immunodeficiency virus enhancer: site of transcriptional initiation is independent of the TATA box

The activation of the human immunodeficiency virus (HIV) enhancer in T cells can occur through multiple independent pathways. This enhancer is stimulated by NF-kappa B or through alternative mechanisms, including E1A transactivation, which is dependent on the TATA box. In this report, the role of the TATA box in activation by NF-kappa B is examined. E1A stimulation of the HIV enhancer requires the presence of the TATA sequence in the sense orientation. Analysis of mutant HIV enhancer plasmids shows that basal mRNA levels are reduced when the TATA sequence is altered but that inducibility of NF-kappa B and the site of transcriptional initiation are unchanged. These data suggest that transcriptional initiation in this class II promoter is determined by an initiator factor which does not require binding to the TATA sequence. Because kappa B is found in a variety of viruses, this mechanism may be relevant to the activation of other viral enhancers.

Phase I/II study of Fluosol-DA and 100% oxygen as an adjuvant to radiation in the treatment of advanced squamous cell tumors of the head and neck

Fluosol-DA 20% (Fluosol) is an emulsion of perfluorodecalin and perfluorotripropylamine, which has the ability to carry oxygen and has been shown to enhance the ability of radiation to control tumors in animal studies. Since November 1984, patients with unresectable squamous cell carcinomas of the head and neck have been enrolled in a study to evaluate the safety and potential efficacy of this adjuvant therapy. Forty-six patients were entered of which 37 completed radiation and are evaluable. Patients were infused weekly with Fluosol and then breathed 100% oxygen for a minimum of 30 minutes prior to and during radiation. Eleven patients received 5 infusions of 8 mL/Kg, four patients 6 infusions of 8 mL/Kg, five patients 5 infusions of 9 mL/Kg, seven patients 7 infusions of 7 mL/Kg and eight patients 8 infusions of 7 mL/Kg. Nine patients had Stage III disease, 20 patients Stage IV disease and 8 patients had failed previous therapy with chemotherapy and/or surgery. The radiation doses delivered ranged from 6600 cGy to 7500 cGy. The overall complete response rate for this group was 76%. All 9 Stage III patients were complete responders, 13 of 20 Stage IV responded and 6 of 8 with previous therapy were complete responders. The survival rate at 1 year was 67% for absolute and 78% as determinant. Of those patients achieving a complete response, 75% continued free of disease 1 year after therapy. Out of 254 total test doses, 11 patients experienced a reaction to the test dose of Fluosol. Of 235 total infusions 6 patients experienced a reaction during the Fluosol infusion with 7 patients experiencing post infusion reactions. These were readily controlled with diphenhydramine or acetominophen. Elevated liver enzymes were observed in some patients with a mean time to normalization of 102 days for alkaline phosphatase, 39 days for SGOT, and 46 days for SGPT.

ICRF-159 in advanced gastric cancer. Absence of activity

ICRF-159, and EDTA derivative antitumor agent, was given to 21 patients with advanced gastric cancer in a weekly dose of 3000 mg/m2. Of the 21 patients, 11 had failed prior drug therapies and 10 were previously untreated. No patient achieved an objective partial response (actual response less than 15% with 95% confidence level). One previously treated patient had a minor response lasting 12 weeks and four patients (three previously untreated) had stable disease lasting 4-8 weeks. Toxicity was acceptable, consisting of mild nausea and moderate myelosuppression. Median survival after treatment was 17.5 weeks in previously untreated patients and 9 weeks in previously treated patients. We conclude that ICRF-159 is inactive in advanced gastric cancer when given on a weekly schedule.

Flow cytometric analysis of DNA content of bone marrow cells in patients with plasma cell myeloma: clinical implications

DNA content analysis by flow cytometry was performed in 32 patients with plasma cell myeloma and 3 patients with Waldenstrom's macroglobulinemia to determine the biologic and potential clinical usefulness of this technique. Hyperdiploid tumor DNA content was found in 23 myeloma patients (72%) during the course of illness, including 16/28 at presentation, but in none of 3 patients with Waldenstrom's macroglobulinemia. There was no significant association of aneuploidy in myeloma patients with age, sex, race, or M-protein class. Myeloma patients with aneuploid tumor cells were more likely to have advanced stage (p = 0.032) than patients with diploid plasma cells, and all patients with renal failure had aneuploid tumors. Pretreatment factors significantly associated with survival included stage (p = 0.01), serum creatinine (p = 0.003), and tumor DNA content (p = 0.005). Multivariate analysis using the Cox life table regression procedure indicated that the significant relation of tumor DNA content with survival remained after adjusting for stage (p less than 0.005). Myeloma patients with diploid tumors at diagnosis frequently had aneuploid plasma cells at the time of relapse, indicating a possible relationship of chromosomal alterations in the tumor to clinical drug resistance. We conclude that aneuploid tumor cells at the time of diagnosis of myeloma are of independent prognostic significance, and the development of aneuploidy is a frequent occurrence at clinical relapse, suggesting the change in DNA content are of biologic and clinical significance.

Methods for production of monoclonal antibodies with specificity for human lung cancer cells

We have developed a screening strategy and technology to produce monoclonal antibodies with specificity for human lung cancer cells. Mice and rats were immunized with well-characterized tissue culture lines of human small cell lung cancer (SCLC), mouse myeloma x spleen hybrids formed by the technique of Kohler and Milstein, and the resulting culture fluids were screened for antibody binding phenotype using a radioimmunoassay. To facilitate testing large numbers of culture fluids, a 96-well, microtiter based, reusable, replicating device was designed. Using this, many hybridoma culture fluids were replica plated for antibody binding tests on a series of human target cell plates. Hybrids producing antibodies that reacted with the immunizing SCLC line and another independent SCLC line, but not with autologous B-lymphoblastoid cells derived from one of the patients, were identified, selected, and then repeatedly recloned using the same screening strategy. With this technology, hybridomas representing less than 0.5% of all hybrids generated could be isolated and stable antibody producing cultures derived. Such antibodies reacted with a panel of well-characterized SCLC lines and SCLC samples taken directly from patients but not with a variety of normal tissues. Using these antibodies we can demonstrate: tumor cell contamination of bone marrow specimens, marked heterogeneity of antigen expression on cells within individual SCLC lines and individual patients, and inhibition of clonal growth of SCLC lines in soft agarose assays. All of these findings have potential clinical and cell biologic application.

Partial deletion of long arm of chromosome 17: a specific abnormality in acute promyelocytic leukemia?

Two patients with acute promyelocytic leukemia had an identical chromosomal abnormality detected by fluoresecence banding. In each case, the clinical course was rapidly fatal, and was characterized by a lack of response to chemotherapy with cytarabine and thioguanine, and was complicated by disseminated intravascular coagulation. Bone marrow cells from each patient contained 46 chromosomes; in each instance, however, one chromosome 17 had a deletion of almost one half of the proximal portion of the long arm [del(17)(q11q21 or 22)].