A systematic review and meta-analysis of the prognostic role of age in oral tongue cancer

While evidence suggests an increasing incidence of tongue cancer in young adults, published findings regarding the prognostic role of age at diagnosis are inconsistent. We performed a meta-analysis of the literature to highlight key points that might help in understanding the association between age of oral tongue cancer patients at diagnosis and their prognosis. According to age at diagnosis, a systematic literature review of all published cohort studies assessing the recurrence risks and mortality associated with tongue cancer was conducted. We compared the risk estimates between patients aged >45 years and those aged <45 years at diagnosis. Random-effects models were used to calculate summary relative risk estimates (SRRs) according to different clinical outcomes and sources of between-study heterogeneity (I2 ) and bias. We included 31 independent cohort studies published between 1989 and 2019; these studies included a total of 28,288 patients. When risk estimations were not adjusted for confounders, no significant association was found between age at diagnosis and overall survival (OS). Conversely, after adjustment for confounders, older age at diagnosis was associated with a significantly increased risk of mortality. The difference between SRRs for adjusted and unadjusted estimates was significant (p < 0.01). Younger patients had a significantly higher risk of local recurrence. Younger patients with oral tongue cancer have better OS but a greater risk of recurrence than older patients. These findings should be validated in a large prospective cohort study which considers all confounders and prognostic factors.

Multicenter Phase II Study of Panitumumab in Platinum Pretreated, Advanced Head and Neck Squamous Cell Cancer

Lessons Learned.

Panitumumab shows activity in terms of disease control rate and preventing disease progression but not for tumor shrinkage in head and neck squamous cell cancer for second‐line treatment. Epidermal growth factor receptor (EGFR) copy number gain, a property of tumor cells that theoretically could identify patients more likely to experience disease response, was common among patients having disease control.

Our trial, given the lower toxicity with an every‐2‐week schedule, provides guidance for future trials, for example, in combinations of immune therapies and anti‐EGFR‐antibodies.

Background.

The objective of this study was to investigate the efficacy and safety of panitumumab (anti‐epidermal growth factor receptor [EGFR] antibody) given as a single agent in platinum‐pretreated head and neck squamous cell cancer (HNSCC).

Methods.

Patients with advanced HNSCC previously treated with platinum‐containing therapy were included. Panitumumab was administered intravenously every 2 weeks at a dose of 6 mg/kg. Primary endpoint was overall response rate (ORR) according to Response Evaluation Criteria In Solid Tumors (RECIST) version 1.1; secondary endpoints were progression‐free survival (PFS) and safety. A Simon's two‐step design was chosen; 4 partial remissions (PR) in the first 32 patients were required for continuing to step two. An exploratory biomarker analysis was performed.

Results.

Thirty‐three patients were enrolled. Two patients obtained a PR for an ORR of 6%, and 15 (45%) showed stable disease (SD) for at least 2 months, resulting in a 51% disease control rate. Median PFS was 2.6 months (95% confidence interval [CI]: 1.7–3.7), while median OS was 9.7 months (95% CI: 6.3–17.2). The most frequent adverse drug reactions were cutaneous rash (64%) and hypomagnesemia (55%). Overall, 30% of patients experienced grade 3/4 adverse events. No infusion‐related reactions occurred. EGFR copy number gain (CNG) was more frequent in patients who benefitted from panitumumab. Two uncommon KRAS mutations (G48E, T50I) and 3 canonical PIK3CA mutations (all E545K) were detected. High‐risk HPV16 was found in 10 patients and EGFR CNG in 13 treated patients. EGFR CNG seems to be more frequent in individuals with at least SD compared with patients with progressive disease (59% vs. 30%). PFS for patients with EGFR CNG was 4.6 months (95% CI: 1.0–9.2 months) and 1.9 months (95% CI: 1.0–3.2 months) for patients without CNG (p = .02).

Conclusion.

Panitumumab monotherapy in pretreated HNSCC patients was well tolerated but moderately active. We observed a considerable disease control rate. Future strategies with this agent comprise right patient selection through the identification of reliable biomarkers and gene signatures predicting response and, considering good tolerability and convenience, combination strategies with novel agents and immune therapeutic agents.

A Common Interleukin-6 Promoter Polymorphism in Patients With Vulvar Cancer

OBJECTIVE

Besides its important role in immune response and inflammatory processes the cytokine interleukin-6 (IL-6) is crucially involved in carcinogenesis. A common polymorphism within the gene encoding IL-6 (IL6) is known to alter IL-6 protein expression and has been associated with patients' prognosis in various malignancies. No data are available with respect to vulvar cancer. Therefore, we determined the prognostic potential of the common -174(G-->C) single nucleotide polymorphism in the promoter region of IL6 in a series of patients with this disease.

METHODS

The IL6 promoter polymorphism was investigated in 81 Caucasian patients with surgically treated squamous cell vulvar cancer using pyrosequencing. Results were correlated with clinical data.

RESULTS

No association was ascertained between the IL6 promoter polymorphism and the investigated clinicopathologic parameters, ie, tumor stage, lymph node involvement, tumor grade, and patient's age at diagnosis. In an univariate analysis, lymph node involvement and patients' age at diagnosis were associated with patient prognosis. In a multivariate analysis, including tumor stage and lymph node involvement as established prognostic factors and the IL6 promoter polymorphism, lymph node involvement, and the presence of at least one mutant allele, but not tumor stage, were associated with increased disease-free and overall survival.

CONCLUSION

Our data suggest that the IL6 -174(G-->C) promoter polymorphism might serve as an additional prognostic parameter in patients with vulvar cancer.

Elective versus Therapeutic Neck Dissection in Node-Negative Oral Cancer

BACKGROUND

Whether patients with early-stage oral cancers should be treated with elective neck dissection at the time of the primary surgery or with therapeutic neck dissection after nodal relapse has been a matter of debate.

METHODS

In this prospective, randomized, controlled trial, we evaluated the effect on survival of elective node dissection (ipsilateral neck dissection at the time of the primary surgery) versus therapeutic node dissection (watchful waiting followed by neck dissection for nodal relapse) in patients with lateralized stage T1 or T2 oral squamous-cell carcinomas. Primary and secondary end points were overall survival and disease-free survival, respectively.

RESULTS

Between 2004 and 2014, a total of 596 patients were enrolled. As prespecified by the data and safety monitoring committee, this report summarizes results for the first 500 patients (245 in the elective-surgery group and 255 in the therapeutic-surgery group), with a median follow-up of 39 months. There were 81 recurrences and 50 deaths in the elective-surgery group and 146 recurrences and 79 deaths in the therapeutic-surgery group. At 3 years, elective node dissection resulted in an improved rate of overall survival (80.0%; 95% confidence interval [CI], 74.1 to 85.8), as compared with therapeutic dissection (67.5%; 95% CI, 61.0 to 73.9), for a hazard ratio for death of 0.64 in the elective-surgery group (95% CI, 0.45 to 0.92; P=0.01 by the log-rank test). At that time, patients in the elective-surgery group also had a higher rate of disease-free survival than those in the therapeutic-surgery group (69.5% vs. 45.9%, P<0.001). Elective node dissection was superior in most subgroups without significant interactions. Rates of adverse events were 6.6% and 3.6% in the elective-surgery group and the therapeutic-surgery group, respectively.

CONCLUSIONS

Among patients with early-stage oral squamous-cell cancer, elective neck dissection resulted in higher rates of overall and disease-free survival than did therapeutic neck dissection. (Funded by the Tata Memorial Centre; ClinicalTrials.gov number, NCT00193765.).

Squamous differentiation and prognosis in upper urinary tract urothelial carcinoma

Squamous differentiation is the most common histological variation in urothelial carcinoma (UC). However, the clinical significance of squamous differentiation in upper urinary tract UC is unclear. To investigate the significance of squamous differentiation, hematoxylin and eosin stained slides from 140 patients with upper urinary tract UC who underwent nephroureterectomy were reviewed by a single pathologist and the presence of squamous differentiation was recorded. Squamous differentiation was observed in 23 out of 140 studied cases (16%). Squamous differentiation significantly correlated with several adverse prognostic factors including histological grade 3 tumors, presence of lymphovascular invasion, concomitant carcinoma in situ, advanced tumor stage, and occurrence of lymph node metastasis. The Kaplan-Meier and univariate Cox regression analyses revealed that the presence of squamous differentiation was significantly associated with shorter metastasis-free survival [log-rank P = 0.030; univariate hazard ratio (HR), 2.30; 95% confidence interval (CI), 1.06-4.99], cancer-specific survival (log-rank P = 0.0024; univariate HR 3.34; 95% CI, 1.47-7.85), and overall survival (log-rank P = 0.018; univariate HR 2.39; 95% CI, 1.13-5.06) after nephroureterectomy. However, in multivariate analyses, squamous differentiation was not significantly associated with patient outcomes. These findings suggest that squamous differentiation is associated with disease progression, but is not an independent predictor of a worse prognosis in patients with upper urinary tract UC.

Collagen XVII expression correlates with the invasion and metastasis of colorectal cancer

Collagen XVII has a well-established role as an adhesion molecule and a cell surface receptor located in the type I hemidesmosome of stratified epithelia. Its ectodomain is constitutively shed from the cell surface and suggested to regulate the adhesion, migration, and signaling of cutaneous epithelial cells. Collagen XVII was not previously thought to be expressed by colon epithelial cells. Immunohistochemical analysis of tissue microarray samples of 141 cases of colorectal carcinoma showed that collagen XVII is expressed in normal human colonic mucosa and colorectal carcinoma. In colorectal carcinoma, increased collagen XVII expression was significantly associated with higher TNM stage. It also correlated with infiltrative growth pattern and tumor budding as well as lymph node and distant metastasis. Increased collagen XVII expression was associated with decreased disease-free and cancer-specific survival. Immunofluorescence staining of collagen XVII and its well-known binding partner laminin γ2 chain demonstrated a partial colocalization in normal and tumor tissue. In vitro, the overexpression of murine collagen XVII promoted the invasion of CaCo-2 colon carcinoma cells through Matrigel (BD Biosciences; Bedford, MA). To conclude, this study reports for the first time the expression of collagen XVII in colon epithelium and the association of increased collagen XVII immunoexpression with poor outcome in colorectal carcinoma.

Elderly women above screening age diagnosed with cervical cancer have a worse prognosis

AIM

To analyze the cervical screening history in women with cervical cancer and their outcome.

DESIGN

All women diagnosed with cervical cancer between January 2009 and December 2010 in the South Sweden region were included in the audit.

MATERIALS AND METHODS

Cervical cancer was registered in 165 women in 2009 and 2010. Their screening history was analyzed, and was classified as normal or imperfect. The method of discovering the cancer was either by symptoms or by screening. The main outcome measured was overall survival in cervical cancer related to cervical screening history.

RESULTS

Women above 65 years of age were more frequently diagnosed with advanced-stage disease (The International Federation of Gynecology and Obstetrics II-IV) (n=36 out of 43; 84%) compared to women below 65 years of age (n=35 out of 122; 29%) (p<0.001). All patients diagnosed by the cervical screening program were still alive (30/30) at the median follow-up time (36 months), showing better overall survival compared to women below screening age in whom cancer was discovered due to symptoms (68/98; p<0.001). Cox proportional hazards model showed that women beyond screening age (>65 years old) with normal screening history had a worse prognosis, with a hazard ratio of 4.8 (95% confidence interval=1.9-12.1, p=0.001), and women (>65 years old) who had not followed the screening program had a hazard ratio of 5.9 (95% confidence interval I 2.4-14.6, p<0.001), compared to women under 65 years old who had followed the screening program.

CONCLUSION

Cervical cancer in women above the age of 65 years is discovered at advanced stages of the disease and their prognosis is poor.

DCF (docetaxel, cisplatin and 5-fluorouracil) chemotherapy is a promising treatment for recurrent advanced squamous cell anal carcinoma

BACKGROUND

Squamous cell carcinoma of the anal canal (SCCA) is a rare disease, mostly diagnosed at early stage. After concurrent chemoradiation (CRT) with mitomycin C and 5-fluorouracil (5FU), local or metastatic recurrences occur in >20% of the patients. After treatment failure, cisplatin (CDDP)-based chemotherapy is the standard option, but complete response (CR) is a rare event and the prognosis remains poor.

PATIENTS AND METHODS

Eight consecutive patients with advanced recurrent SCCA after CRT were treated with DCF regimen (docetaxel 75 mg/m(2) day 1, CDDP 75 mg/m(2) day 1 and 5FU at 750 mg/m(2)/day for 5 days every 3 weeks). Tumour samples were analysed for human papillomavirus (HPV) genotyping, as well as p16 and p53 expression.

RESULTS

After a median follow-up of 41 months, the overall survival rate at 12 months was 62.5% (95% CI 22.9-86.1 months). Four patients achieved a complete remission and remain relapse-free at the time of analysis with a progression-free survival of 19, 33, 43 and 88 months. Three of these patients underwent surgery for all involved metastatic sites. For all of them, pathological CR was confirmed. DCF regimen appeared feasible in these patients previously exposed to pelvic CRT, and no grade IV toxicity occurred. All patients in complete remission had HPV-16-positive SCCA, while HPV could only be detected among 50% of the non-responding patients. Of interest, immunohistochemical study revealed a p16(+)/p53(-) phenotype in these patients, while none of non-responders expressed p16.

CONCLUSION

The high level of complete and long-lasting remission among SCCA patients treated with DCF regimen supports the assessment of this strategy in prospective cohorts.

Head and neck cancer in young people: a series of 52 SCCs of the oral tongue in patients aged 35 years or less

CONCLUSION

Prognosis was very poor as soon as a local failure developed. Up-front treatment should be optimized to control this rare disease. We propose producing and reporting recommendations via a concerted oncologic physician referral network.

OBJECTIVES

Squamous cell carcinoma (SCC) in young people is rare and the literature is confusing. This study was carried out to assess the demographics, clinical features, and treatment outcome in a cohort of patients aged 35 years or less with SCC of the oral tongue (SCCOT).

PATIENTS AND METHODS

This was a multicenter retrospective study. Fifty-two patients treated between 1990 and 2000 were identified. Descriptive statistics were analyzed to assess demographic and tumor variables.

RESULTS

The WHO performance status was excellent for all patients. Thirty-seven were classified as T1-T2 and 38 were N0. All of them except one were treated with curative intent. Treatment failures were observed in 25 patients (48%). Four patients could be successfully salvaged after SCCOT recurrence or progression. The disease-free survival (DFS) was 52% at 5 years. The 5-year overall survival (OS) rate was 64%. Factors that affected the OS were invasion of the floor (p=0.009), cross over of the midline (p=0.02), positive lymph nodes (p=0.02), and the lack of disease control (p=0.0001).

[Significance of Arg554Lys AHR gene polymorhism an survival of in squamous cell carcinoma laryngeal cancer in relation to tobacco smoking--preliminary study]

Initiation and progression of laryngeal cancer is associated with tobacco smoking and abusing of strong alcoholic beverages. A significance of genetic factor, although not defined sufficiently yet has been raised as well. The studies were focused on an influence of AHR gene polymorphism on survival of squamous cell carcinoma laryngeal subjects. The study material was 65 archival DNA samples analyzed by RLP-PCR. The samples varying with electrophoretic mobility were DNA sequenced. In the study group 9 heterozygotic variants Arg554Lys (codon 554) were detected. One case was a carrier of two other mutations in codon: 490 (1468 A > G) and 570 (1708 G > A). Survival time, metastasis and occurrence of second primary tumors were compared in carriers of wild type and Arg554Lys variant AHR. Preliminary results indicate for a necessity of further studies as until now the study group is too small to find a conclusive association.

[Prevalence of epithelial squamous cell abnormalities and associated factors in women of a rural town of Colombia]

INTRODUCTION

In spite of implementation of cytology-based cervical cancer screening in Colombia, mortality rates remain stable. The description of factors associated to cervical pre-neoplasic lesions is needed to establish strategies for mortality prevention.

OBJECTIVE

The prevalence of epithelial squamous cell abnormalities was determined to explore the association of cytology abnormalities with described risk factors.

MATERIALS AND METHODS

This population-based, cross-sectional study included 739 women randomly selected by age. A validated face-to-face questionnaire and conventional cervical cytology were used to collect the information. To establish the association between cervical abnormalities and some qualitative variables, the independent chi squared test was used. We also calculated prevalence ratio with their 95% confidence intervals. A logistic regression model was used to explore variables that potentially explain cytology abnormalities.

RESULTS

The prevalence of squamous cell abnormality was 15.8%. Among women with abnormal cytology, 10% presented atypical squamous cells of undetermined significance, 3.9% low grade squamous intra-epithelial lesion and 1.9% high grade squamous intra-epithelial lesion. The adjusted logistical regression analysis showed that history of sexual transmitted disease, two or more sexual partners during entire life and previous abnormal cytology were associated with cytology abnormalities.

CONCLUSION

The relation of epithelial squamous cell abnormalities with sexual behavior history reflexes the link between human papiloma virus infection and cervical cancer pre-neoplasic lesions. The frequency of use and knowledge about the purpose of cytology were factors that suggested other diagnostic limitations such as quality of cervical cytology or barriers to access health care. These latter factors may be the underlying basis for the high cervical cancer mortality rates.

Sex difference in survival of patients treated by surgical resection for esophageal cancer

BACKGROUND

Squamous cell carcinoma accounts for most of the esophageal cancers in Japan and is often related to excessive smoking and drinking. Although esophageal cancer occurs far more frequently in men than in women, it is not certain whether there are sex-specific differences in morbidity and mortality after surgical resection of the esophagus. We conducted a study to determine the influence of sex on the short- and long-term results of surgical resection in patients with esophageal cancer.

METHODS

There were 295 patients with a newly diagnosed primary malignant neoplasm of the esophagus treated at our University hospital between January 1978 and December 2005. There were 185 patients (166 men, 19 women; age range 39-86 years) who underwent surgical resection for primary esophageal malignant neoplasms. Survival rates were calculated according to the Kaplan-Meier method and tested with the log-rank test. Cox proportional hazards model was used to assess independent predictors of survival.

RESULTS

The cumulative amount of alcohol consumed and number of cigarettes smoked were significantly higher in men than in women. Postoperative complications occurred in 101 men (60.8%) and 9 women (47.4%), but significant sex differences in postoperative morbidity and mortality were not observed. Overall survival was significantly better for women than for men.

CONCLUSION

Postoperative morbidity and mortality do not appear to differ between men and women with esophageal cancer treated by surgical resection. Long-term survival after surgical resection of the esophagus appears to be significantly better for women than for men.

Trends in palatine tonsillar cancer incidence and mortality rates in the United States

OBJECTIVE

The purpose of this paper is to describe the extent of the public health problem presented by palatine tonsillar cancer in the United States by analyzing recent incidence and mortality rate trends.

METHODS

Using the National Cancer Institutes' Surveillance, Epidemiology and End Results (SEER) Program database, age-adjusted incidence rates (1973-2001) for five histological types of palatine tonsillar cancer by race and sex were calculated. For total palatine tonsillar cancer age-specific incidence (1973-2001) and mortality (1969-2001) rates by race and sex were calculated. Mortality and population data were obtained from the National Center for Health Statistics (NCHS) and the U.S. Census Bureau. The Joinpoint Regression Model was employed to establish the statistical significance of incidence and mortality rate trends.

RESULTS

The majority of palatine tonsillar cases diagnosed in SEER-9 registries from 1973 to 2001 occurred among white males, age 40-64 years, with squamous cell carcinoma (SCC). The highest incidence of palatine tonsillar cancer occurred in black males, followed by white males with SCC. For age 40-64 years, palatine tonsillar incidence rates significantly declined for white females and black females, rose and then declined for black males, but increased from 1988 for white males. For age 65+ years, incidence significantly declined among white males. Palatine tonsillar cancer mortality rates for age 40-64 years significantly declined for white females. Rates also declined for black females (1981-2001) and black males (1985-2001) in this age group while rates for white males declined significantly from 1969 to 1987, but stabilized at nearly 0.4 through 2001. Mortality for the age group, 65+, significantly rose and fell for white females and declined for white males.

CONCLUSIONS

Beginning in the late 1980s, and continuing through 2001, the risk for white males, age 40-64 years, of developing palatine tonsillar cancer increased. In contrast, the risk for white males, age 65 years and older, of developing palatine tonsillar cancer and of dying from this disease decreased during the study period.

Chemotherapy with mitomycin c, ifosfamide, and cisplatin for recurrent or persistent cervical cancer

The efficacy and toxicity of mitomycin C (MMC), ifosfamide, and cisplatin in cervical cancer were evaluated. Between January 1997 and August 2003, 46 patients with locally recurrent, persistent, or disseminated cervical cancer were treated with MMC 6 mg/m(2), ifosfamide 3 g/m(2), and cisplatin 50 mg/m(2) (MIC regimen) repeated every 3 weeks (maximum six cycles). In eight patients (17%), the tumor involved the pelvis alone, in 11 (24%) the pelvis and extrapelvic sites, and 27 (59%) had only distant lesions. A total of 213 MIC cycles were administered (median six cycles per patient). Of the 44 evaluable patients, the overall response rate was 34% (9% complete and 25% partial responses). Median progression-free interval was 6 months (95% confidence interval [CI], 4-7 months), and overall survival was 10 months (95% CI, 6-14 months). Objective response was obtained in two patients (11%) with pelvic relapse within previously irradiated area and in 13 (50%) of those with extrapelvic lesions (P= 0.01). Leukopenia was seen in 59% of patients (grade 3 in 9%). Nonhematologic side effects were mild and relatively infrequent. In conclusion, MIC regimen provides satisfactory efficacy with acceptable toxicity in advanced cervical cancer patients. Better response is seen in lesions outside of the previously irradiated area.

[Correlation of serum squamous cell carcinoma antigen with clinico-pathological features and prognosis of squamous cell carcinoma of uterine cervix]

OBJECTIVE

To investigate the correlation of pretreatment serum squamous cell carcinoma antigen (SCCAg) with the clinico-pathological features of squamous cell carcinoma of uterine cervix and its significance as a prognostic factor.

METHODS

One hundred and fourteen patients of squamous cell carcinoma of the uterine cervix (Ib1-IIa), who underwent pretreatment serum SCCAg evaluation and long-term follow-up after treatment were selected for this study. Clinical data were used to investigate the correlation between SCCAg and clinico-pathological features and factors that influence prognosis through univariate and multivariate analysis.

RESULTS

Univariate analysis showed elevation of SCCAg (using < or = 1.5 mg/L as the cut-off value) was correlated with tumor size, deep stromal invasion and pelvic node metastasis (P < 0.05). Multivariate analysis revealed significant correlations between elevation of SCCAg and deep stromal invasion (P = 0.029) and pelvic node metastasis (P = 0.049). The 5 years disease-free survival (DFS) was 78.6%, and recurrence rate was 27.2%. Univariate analysis revealed that elevated pretreatment SCCAg and pelvic node metastasis were significantly correlated with DFS and recurrence (P < 0.05). Multivariate analysis identified elevated pretreatment SCCAg (P = 0.030), pelvic node metastasis (P = 0.003) as independent prognostic factors, and pelvic node metastasis (P = 0.006) as a factor significantly correlated with recurrence after treatment. Comparison between pelvic node metastasis + elevated SCCAg cases and pelvic node metastasis + normal SCCAg cases showed no significant difference in DFS (50.9% vs 50.0%), recurrence rate (47.1% vs 60.0%), local recurrence (20.0% vs 3/8) and distant recurrence (20.0% vs 1/8; all P > 0.05). However, between no pelvic node metastasis + elevated SCCAg cases and no pelvic node metastasis + normal SCCAg cases, there was a significant difference in DFS (71.8% vs 98.0%, P = 0.003), recurrence rate (33.3% vs 9.8%, P = 0.006) and local recurrence (26.5% vs 2.1%, P = 0.001).

CONCLUSIONS

The independent prognostic factors for Ib1-IIa squamous cell carcinoma of uterine cervix include elevated pretreatment SCCAg and pelvic node metastasis. Patients with elevated pretreatment serum SCCAg and no metastasis to pelvic lymph node (s) are at significantly elevated risk of local recurrence, and therefore need individualized treatment to improve local control and long-term survival.

Unusual and Giant Tumors of Head and Neck Region

Head and neck tumors can reach to massive dimensions if patients are uneducated and ignorant about the disease. Resection of such giant tumors creates a significant functional and aesthetic loss due to proximity of vital structures in head and neck region. Reconstruction of these complex defects is a demanding procedure and postoperative results are not always excellent in terms of function and aesthetics. We have reviewed a group of patients with giant head and neck tumors treated in our department. Postoperative results were evaluated in terms of function and aesthetic appearance. Postoperative functional results were good in most of the patients and aesthetic results were acceptable. Early diagnosis and excision of the tumors in head and neck region decrease the morbidity of the disease. Treatment should be planned on individual basis. Most of the patients with head and neck tumors are elderly patients with additional medical problems so reconstructive procedures should be selected by taking this in consideration. Complex and long-lasting operations should be reserved for young patients.

HER-2 overexpression (3+) in patients with squamous cell esophageal carcinoma correlates with poorer survival

The incidence of esophageal carcinoma is increasing worldwide. In Sweden, approximately 400 patients are diagnosed each year. The present study retrospectively investigates survival in 97 patients with esophageal carcinoma in regard to their HER-2 status as examined by immunohistochemistry (IHC) and chromogen in situ hybridization (CISH). Sixty-eight patients had localised disease and 29 patients had advanced disease. Seventy patients had squamous cell carcinoma, and nine of these patients (13%) had HER-2 overexpression (3+). Eight (30%) of 27 adenocarcinoma patients overexpressed (3+) HER-2. In patients overexpressing (3+) HER-2 a statistical trend towards poorer survival was observed (P = 0.057). In squamous cell carcinoma patients, HER-2 overexpression (3+) correlated with poorer survival (P = 0.035), whereas in adenocarcinoma patients, HER-2 status (3+) did not. HER-2 amplification according to CISH was present in five (two squamous cell carcinomas and three adenocarcinomas) out of 17 HER-2 overexpressing (3+) tumours. In conclusion, HER-2 overexpression (3+) seems to be associated with poorer survival in esophageal carcinomas, especially in patients with squamous cell esophageal carcinoma.

A five-year audit of anal cancer in Wales

OBJECTIVES

A retrospective audit has been undertaken of Squamous (epidermoid) type of anal cancer diagnosed and treated in the principality of Wales over a five-year period (1995-99) with follow-up until 2005. The referral pattern, distribution, presenting symptoms, predisposing conditions, clinical findings and staging modalities were documented. The surgical and oncological treatment together with their outcome was analysed.

METHODS

Patients were identified from the Welsh Cancer Registry and the pathology databases of the 17 acute hospitals in Wales. Data was collected from the clinical and oncology case notes onto a purpose designed Microsoft access database.

RESULTS

There was a wide variation in data quality from the individual units. Twenty-six anal cancers were diagnosed per year in the region. Median age was 69 years. Ten percent had documented perianal Human Papilloma Virus related disease. Radiology was inconsistently used for staging. Eighty percent were referred for an oncology opinion; 50% had chemo-radiotherapy with a curative intent. The over-all Stoma rate was 35% and of these 18% had an abdomino perineal resection. The overall five-year survival was 45%.

CONCLUSIONS

This is a unique regional audit of anal cancer. Improvements need to be made in documentation particularly of staging, treatment, pathology reporting and outcome. This study concurs that Human Papilloma Virus appears to predispose to Squamous anal cancer. Radiological staging needs to be standardized according to best clinical practice. As recommended by NICE all patients should be referred to a multidisciplinary anal cancer team, which can provide individual treatment plans. Increased specialization could mean specialist regional MDTs for anal cancer.

The prognostic significance of genetic polymorphisms (Methylenetetrahydrofolate Reductase C677T, Methionine Synthase A2756G, Thymidilate Synthase tandem repeat polymorphism) in multimodally treated oesophageal squamous cell carcinoma

The present study retrospectively examined the correlation between the outcome of patients with locally advanced oesophageal squamous cell carcinoma (cT3-4 cN0-1 cM0) after multimodal treatment (radiochemotherapy±surgical resection), and the presence of genetic polymorphisms in genes involved in folate metabolism. In total, 68 patients who took part in a prospective multicentric trial received 5-fluorouracil (FU)-based radiochemotherapy, optionally followed by surgery. DNA was extracted from pretherapeutic tumour biopsies and was subsequently genotyped for common genetic polymorphisms of three genes (MTHFR C677T, MTR A2756G, TS tandem repeat polymorphism) involved in folate metabolism and potentially in sensitivity to 5-FU-based chemotherapy. The genotypes were correlated with tumour response to polychemotherapy, radiochemotherapy and with overall survival. Tumours with the MTR wild-type genotype (2756AA) showed a median survival time of 16 months, whereas tumours with an MTR variant genotype (2756AG/2756GG) showed a median survival time of 42 months (P=0.0463). No prognostic impact could be verified for the genotypes of the MTHFR genes and the TS gene. Among tumours treated with radiochemotherapy and subsequent resection, MTR variant genotype showed higher histopathological response rate than tumours with MTR wild-type genotype (P=0.0442). In contrast, no significant relationship between clinically determined tumour regression after polychemotherapy and polymorphisms of the three genes under analysis was observed. In conclusion, pretherapeutic determination of the MTR A2756G polymorphism may predict survival of multimodally treated oesophageal squamous cell carcinomas. Determination of MTHFR C677T and TS tandem repeat polymorphism has no predictive value.

Maximized combined modality treatment of an unselected population of oral and oropharyngeal cancer patients. Final results of a pilot study compared with a treatment-dependent prognosis index

BACKGROUND

In an attempt to raise the survival of an unselected and representative population of oral and oropharyngeal squamous cell cancer patients, a pilot study of an integrated four-modality treatment was conceived. Final endpoints were compliance, loco-regional control, survival (after complete 5-year follow-up), and a concept of trial assessment using the treatment-dependent prognostic index TPI.

PATIENTS

Eighty-seven consecutive patients with histologically proven untreated stages I-IV disease presented in the period between 1997 and 1999 of whom 14 had to be considered uncurable and 73 were fit to be treated with the intention of achieving a cure.

METHODS

All patients received one cycle of neoadjuvant intraarterial chemotherapy with 150 mg/m(2) cisplatin (systemically neutralized with sodium thiosulphate), and, if possible, by consecutive treatment applying both surgery of the primary tumour and the neck lymphatics, as well as by adjuvant radiation over 5 weeks (51.3 Gy) plus concurrent chemotherapy (weekly systemic docetaxel 25 mg/m(2)).

RESULTS

Ninety per cent of all cases and 96% of the patients treated with curative intention received more than one modality due to study design. Patient non-compliance in the group treated with curative intention has been 18/73 (=25%), and protocol compliance has been 32/73 (=44%). The locoregional control rate for all cases was 71% (62/87 patients) and for the patients treated with curative intention 83.5% (61/73 patients). Thirteen/fourteen non-curable patients died after a mean period of 4 months. After a median observation time of 5 years, the final absolute survival of the unselected population was 53%, and of the patients treated with curative intention 62% (especially, 70% and 50% for patients with operable stages III and IV, respectively).

CONCLUSION

The multimodality regimen as presented proved feasible and showed high objective and relative survival rates in comparison with known data from tumour registries of unselected populations. Intra-arterial chemotherapy should be considered a valuable addition to treatment. The potential of survival benefit from this multimodality regimen in comparison with the prognosis index TPI should be investigated in further studies.

Efficacy of supraomohyoid neck dissection in patients with oral squamous cell carcinoma and negative neck

BACKGROUND

Supraomohyoid neck dissection (SOHND) has been identified as an appropriate staging procedure to provide valuable pathologic information of the neck for patients with oral squamous cell carcinoma. However, the role of SOHND as a therapeutic procedure, compared with the oncologic results of radical neck dissection, remains controversial for lack of adequate data in current literature.

METHODS

Patients with oral SCC who underwent elective SOHND and radical neck dissection (RND) between January 1, 1993, and December 31, 1999, were retrospectively reviewed. The 2 types of treatment were analyzed for incidence of neck recurrence and survival probabilities.

RESULTS

No significant differences were found between patients treated with SOHND versus RND. Occult metastasis rate, regional disease-free survival, overall and disease-free survival, and distant metastasis-free survival rates were found to be comparable.

CONCLUSIONS

SOHND compares favorably with RND for the staging and treatment of patients with oral squamous cell carcinoma and negative neck.

Secular Trends in Outcomes for Fanconi Anemia Patients Who Receive Transplants: Implications for Future Studies

Transplantation protocols for patients with Fanconi anemia are being modified continuously. However, it is unclear how outcomes have changed over time. We determined historical adverse event rates from long-term follow-up of 117 Fanconi anemia patients in the Hôpital Saint Louis transplant cohort, who received low-dose cyclophosphamide- and irradiation-based conditioning, in combination with other modalities, between 1976 and October 2002. In high-risk patients with mismatched donors, the peritransplantation mortality rate during 0 to 6 months declined significantly over time (P = .003), from 28%/month (95% confidence interval [CI], 9%-87%/month) during 1985 to 1989 to 3.3%/month (95% CI, 0.8%-13.3%/month) during 2000 to October 2002. The corresponding proportion of patients who developed severe acute graft-versus-host disease also declined significantly over time (P = .003). In low-risk patients with matched sibling donors, the peritransplantation mortality rate was consistently low, 1.4%/month (95% CI, 0.3%-5.3%/month), during 1990 to October 2002. Sample sizes to detect 2-fold reductions from rates and risks observed since the mid-1990s are larger than recently reported case series. To demonstrate further advances in survival, transplant centers may need to coordinate their protocols and engage in multicenter collaborative studies.

Expression of protein tyrosine kinases in head and neck squamous cell carcinomas

Protein tyrosine kinases (TKs) are overexpressed in many carcinomas and sarcomas. We studied the expression of the following TKs in head and neck squamous cell carcinoma (HNSCC): platelet-derived growth factor receptor (PDGFR), c-kit, epidermal growth factor receptor (EGFR), and a serine-threonine kinase, Akt. Formalin-fixed, paraffin-embedded tumor blocks from 44 consecutive patients with primary HNSCC and 5 specimens of benign pharyngeal and laryngeal mucosa were retrieved for immunohistochemical analysis. Of the specimens, 38 had enough material to stain for all 4 antibodies. The study included 21 pharyngeal (base of tongue, 14; tonsil, 6; soft palate, 1), 16 laryngeal, and 1 floor of the mouth carcinoma. All 4 kinases in the tumor samples were expressed highly (PDGFR, 95%-100%; EGFR, 38%-43%; c-kit, 50%-86%; p-Akt, 57%-81%), with EGFR, c-kit, and p-Akt significantly higher than in benign samples. None of the kinase expressions correlated with disease-free survival. The expression of the kinases raises the possibility of treatment of HNSCC by tyrosine and serine-threonine kinase inhibitors.

[Morbidity and mortality for oral and pharyngeal cancer in Chile]

BACKGROUND

Most oral cancers are squamous cell carcinomas (90%) which are two to four times more common in men than in women. The reasons for these differences are associated with exposure to factors such as tobacco and alcohol. Age is also considered as a risk factor (about 90% of the cases are diagnosed after 45 years of age).

AIM

To analyze the frequency of oral cavity cancer during the last years in Chile.

MATERIAL AND METHODS

Mortality rates were obtained from death records of the "Instituto Nacional de Estadísticas" and publications of the World Health Organization, from 1955 to 2002. Morbidity from 1969 to 2002 was obtained from hospital discharge records of the Chilean Ministry of Health.

RESULTS

Oral cancer corresponded to 1.6% of total cancer cases in Chile, with a male:female ratio of 2.3 to 1. Deaths due to oral cancer was 1% of all cancer deaths, with a male:female ratio of 2.8 to 1. The morbidity rate for both genders increased while the mortality rate was relatively constant. However, we observed an increase in the mortality rate among women from 1980 to 2002, associated with more than 100% increase in the frequency of smoking, between 1970 and 1998. The most common anatomical location was the tongue.

CONCLUSIONS

The incidences of oral cancer is increasing in Chilean women, but men are more commonly affected.

Comparison of Clinical Stage, Therapy Response, and Patient Outcome Between Squamous Cell Carcinoma and Adenocarcinoma of the Esophagus

PURPOSE

To analyze the differences in clinical stage, pathologic response to chemoradiotherapy, patterns of failure, and overall survival (OS) between patients with squamous cell carcinoma (SCC) and adenocarcinoma (ACA) of the esophagus.

PATIENTS AND METHODS

We stratified patients by two histologies, ACA and SCC, and statistically compared their clinical stage, post-therapy pathologic response, patterns of failure, and OS.

RESULTS

Of the 235 patients who underwent preoperative chemoradiotherapy, 42 (18%) had SCC and 193 (82%) had ACA. Among the ACA patients, a significantly larger proportion was male (93% vs 7%; p <0.001), whereas sex was distributed similarly among SCC patients (55% male vs 45% female; p = 0.5). A significantly larger percentage of SCC patients were classified as lower TN and overall stage than ACA patients (T2 = 41% vs 28%, p <0.0001; N0 = 69% vs 48%, p = 0.01; stage II = 76% vs 55%, p <0.001). A significantly greater portion of SCCs was categorized as pathologic N0 after treatment (71% vs 65%; p = 0.02). Among the pathCR patients in clinical stage II, there were significantly greater proportion of SCC patients (77% vs 63%; p <0.001) than ACA patients. Among the pathCR patients in clinical stage III patients, a significantly greater proportion were ACA patients (38% vs 23%; p <0.001) than SCC patients. The median and 5-yr OS was 53 +/- 11 mo and 39% for ACA patients and 35 +/- 14 mo and 37% for SCC (median OS, p = 0.3). Among pathCR patients, median OS of ACA patients (133 mo) was longer than that of SCC patients but nonsignificant (29 mo; p = 0.07); results were similar for non-pathCR patients. DFS results were similar in all subgroups. Among the whole cohort, incidence of local-regional recurrence and distant metastases did not vary significantly. The median time to distant metastases did not vary significantly for pathCR and non-pathCR patients.

CONCLUSIONS

We believe this is the first study that compares failure outcome of ACA and SCC patients with similar clinical stage after trimodality therapy. Our data suggest that significant differences in clinical stage and post-therapy pathologic stage exist between ACA and SCC. Frequent presence of malignant nodes in the resected specimens of ACA patients resulted in a shorter time-to-metastases suggesting that ACA patients need better systemic control.

Expression of PCNA, p53, Bax, and Bcl-X in oral poorly differentiated and basaloid squamous cell carcinoma: Relationships with prognosis

BACKGROUND

The aim of this study was to compare the clinical features and proliferating cell nuclear antigen (PCNA), p53, Bcl-X, and Bax expression in primary oral basaloid squamous cell carcinoma (BSCC) and poorly differentiated squamous cell carcinoma (PDSCC) matched by stage and site and to assess the possible prognostic significance of these variables.

METHODS

Seventeen cases of oral BSCC were compared with 27 PDSCCs matched by stage and tumor site. In addition, PCNA, p53, Bax, and Bcl-X expression in both carcinomas were evaluated in relation to their clinicopathologic features and prognostic values using the Kaplan-Meier method and Cox regression models.

RESULTS

No statistically significant differences were found between the groups (BSCC and PDSCC) in regard to clinical features and immunohistochemical reactivity for antibodies PCNA, p53, and Bcl-X. In comparison with PDSCC, the BSCC group exhibited a higher Bax score (p = .031). The 5-year and 10-year overall survival, cancer-specific survival, and disease-free survival rates demonstrated no significant differences between the BSCC and PDSCC groups, and the PCNA, p53, Bax, and Bcl-X also showed no prognostic value.

CONCLUSIONS

These results suggest that the clinical and biologic course of BSCC is similar to PDSCC in the oral cavity when clinical stage and site are matched.

Selective High-Dose Intra-Arterial Cisplatin as Palliative Treatment for Incurable Head and Neck Cancer

OBJECTIVE

The purpose of the present study was to evaluate the palliative effect of selective intra-arterial chemotherapy in progressive unresectable head and neck cancer previously treated with radiochemotherapy.

PATIENTS AND METHODS

8 patients with advanced residual or recurrent squamous cell carcinoma of the head and neck were evaluated. These patients were included in the present study particularly because of progredient pain and recurrent bleedings due to tumor progression. In addition 6/8 patients suffered from unpleasant tumor-related smell. All patients received simultaneous infusions of cisplatin (150 mg/m2) intra-arterially to the tumor and sodium thiosulfate intravenously (9 g/m2) for systemic neutralization of cisplatin. The patients were treated by at most 4 cycles of selective intra-arterial chemotherapy via femoral approach.

RESULTS

Tumor-associated pain, occurrence of tumor bleeding and tumor-related smell were reduced after at least 2 cycles of intra-arterial chemotherapy in all patients. Clinical and radiological assessment of the primary tumor site revealed a partial response in 4 patients while 4 patients were classified as nonresponders. Intra-arterial cisplatin treatment was well tolerated.

CONCLUSION

Selective intra-arterial cisplatin therapy can be delivered safely for palliation of tumor-related symptoms of incurable head and neck cancer.

Value of routine follow-up for patients cured of laryngeal carcinoma

BACKGROUND

Routine follow-up offered to patients with laryngeal carcinoma in The Netherlands consisted of 22 routine visits over a time period of 10 years after treatment. The primary aims of the follow-up were to detect cancer recurrence in asymptomatic patients and to achieve better survival outcome by reducing cancer-specific mortality rates.

METHODS

A longitudinal cohort study was performed to evaluate the effect of this follow-up schedule. Between January 1990 and January 1995, the authors studied all patients with primary laryngeal squamous cell carcinoma who were treated with intention to cure. For patients who developed cancer recurrence, all routine and extra visits were documented. Reported symptoms and physical evidence of tumor were mapped.

RESULTS

The patients complied with the follow-up protocol closely. In only 2% of all routine visits an asymptomatic cancer recurrence was found. There was no difference in survival and tumor mortality rates for patients with and without symptoms, despite the difference in whether the therapy applied had the intention to cure. It seemed that patients who developed tumor recurrence after therapy for laryngeal carcinoma received no benefit from screening for cancer recurrence detection. The lack of benefit for cancer detection screening among asymptomatic patients might be explained by unfavorable tumor biology parameters.

CONCLUSIONS

The routine follow-up program after treatment for laryngeal carcinoma did not lead to survival benefit for asymptomatic patients with tumor recurrence.

Adjusting for patient selection suggests the addition of docetaxel to 5-fluorouracil-cisplatin induction therapy may offer survival benefit in squamous cell cancer of the head and neck

When induction chemotherapy is used in locally advanced squamous cell cancer of the head and neck (SCCHN), patients often receive cisplatin-5-fluorouracil (PF) followed by radical loco-regional therapy. Phase II studies of docetaxel-cisplatin-5-fluorouracil (TPF) induction therapy, with or without leucovorin (L), have achieved high survival rates versus those reported in phase III PF trials. However, the distribution of prognostic factors may vary between phase II and phase III study populations, making the extrapolation of phase II TPF/L results to phase III PF populations difficult. This study used a patient selection standardization method and Cox model to adjust for potential selection bias. Thus, the survival benefit from adding docetaxel into PF induction regimens in SCCHN could be more accurately assessed. The TPF/L dataset comprised 195 patients from six phase II trials. The PF dataset of 585 patients was derived from five large randomized trials included in the Meta-Analysis of Chemotherapy in Head and Neck Cancer (MACH-NC) database. TPF/L and PF datasets differed significantly concerning the distribution of several prognostic factors. Adjusting for these differences, the relative risk of death in the PF versus TPF/L datasets was 1.85 (95% confidence interval 1.37-2.49), corresponding to a 20% 2-year survival benefit (p < 0.0001). Sensitivity analyses confirmed that this improved 2-year survival rate of TPF/L over PF was robust, irrespective of the distribution of studied prognostic factors between treatment datasets. We conclude that this improved survival might be due either to docetaxel's pharmacologic effect or to uncontrolled prognostic factors.

Docetaxel, cisplatin and 5-fluorouracil in patients with locally advanced unresectable head and neck cancer: a phase I-II feasibility study

PURPOSE

To determine the safety profile and activity of the combination of docetaxel, cisplatin and 5-fluorouracil (5-FU) in chemotherapy-naive patients with squamous cell carcinoma of the head and neck (SCCHN).

PATIENTS AND METHODS

Patients with locally advanced unresectable SCCHN were treated with docetaxel and cisplatin both as a 1-h infusion on day 1 followed by a continuous infusion of 5-FU for 5 days. Cycles were planned every 3 weeks up to four cycles, whereafter the patients were treated with locoregional radiotherapy. Two dose levels were studied. Doses in level I were 75 mg/m(2) of docetaxel, 75 mg/m(2) of cisplatin and 750 mg/m(2)/day of 5-FU; in level II the cisplatin dose was escalated to 100 mg/m(2). Following chemotherapy, all patients were to receive curative radiotherapy according to the standards in the different institutions.

RESULTS

Twenty-five patients were treated at dose level I with 86 cycles (median four; range one to four), and 23 at dose level II with 84 cycles (median four; range two to four). The median relative dose intensity was 0.99 (range 0.86-1.04) at level I and 0.94 (range 0.79-1.02) at level II. The response rate in the intention-to-treat population was 64% [95% confidence interval (CI) 42.5% to 82%] in level I and 78.3% (95% CI 56.3% to 92.5%) in level II; all were partial responses. The maximum tolerated dose was reached at level II with renal toxicity, nausea, stomatitis and thrombocytopenia as principal dose-limiting toxicities. The median survival of the 48 patients was 18.5 months. The survival at 12, 18, 24 and 30 months was 69, 54, 41 and 31%, respectively.

CONCLUSIONS

The combination of docetaxel, cisplatin and 5-FU associated with prophylactic ciprofloxacin is feasible and active in patients with SCCHN. Dose level I is recommended for phase III testing.

Liver Metastases from Head and Neck Squamous Cell Carcinomas: Radiological and Biological Features

BACKGROUND

Liver metastases from head and neck cancer are rare (4.4%) and associated with a poor prognosis (median survival 4 months). The objective of the present study was to evaluate the radiological and biological features of liver metastases from head and neck (H and N) squamous cell carcinomas in 24 patients among 550 recurrent H and N cancer patients in our data bank.

RESULTS

At first presentation of liver nodules, liver enzyme levels (LEL) were found to be abnormal in 46% of patients (n = 11). Ultrasound features included miscellaneous presentations such as hypoechogenic (n = 21), hyperechogenic hemangioma-like lesions (n = 2), owl's eye (n = 2) or cyst-like liver nodules (n = 3). Hepatomegaly was present in 48% of the cases without any sign of portal hypertension and without any ascites. 1 month before death, all patients presented with abnormal LEL. Liver imaging showed an increase of 1.8x in size and of 2x in number of the tumor nodules. Hepatomegaly was present in 54%. Little ascites appeared in 2 cases, with no evidence of portal hypertension or liver insufficiency. Median disease-free interval and overall survival from recurrence were 10.8 and 4 months, respectively.

CONCLUSION

Ultrasound is convenient, cheap, without any side effect, and can provide additional information about liver metastases in H and N cancer patients. In patients with a history of H and N carcinoma ultrasound should be used to screen for isolated hepatic nodules even in the presence of normal liver function and if LDH elevation should be the only biological sign of alert.

[The effect of postoperative chemotherapy after esophagectomy on the survival rate to patients with original squamous cell carcinoma of esophagus]

OBJECTIVE

To study the prognostic factors affecting the survival rate after extended radical esophagectomy with three-field lymph node dissection for squamous cell carcinoma and the effect of postoperative chemotherapy.

METHODS

Out of 126 patients with original squamous cell carcinoma of esophagus who accepted extended radical esophagectomy with three-field lymph node dissection from 1987 - 1992 in a hospital, 97 of them were included in this study. Data on the clinical/pathological characters and post surgery survival records of the subjects' were collected. Survival analysis methods included Kaplan-Meier, Log-rank test and Cox multivariable model and the effects of postoperative chemotherapy were analyzed for patients in early and late stages.

RESULTS

There was no significant difference in clinical and pathological character between those patients only undergone surgery and patients accepting postoperative chemotherapy. The size of tumor, grade of differentiation of the tumor cells, infiltration deepness, with or without lymph node metastasis, expression of nm23 and EGFR and treatment after surgery etc. were correlated with the survival rate. For patients in early tumor stage, postoperative chemotherapy with cisplatin and 5-FU after surgery seemed to be a risk factor. For patients in late stage, postoperative chemotherapy with cisplatin and 5-FU after surgery did not seem to improve survival rate.

CONCLUSION

It is imperative to study on the effect of adjuvant postoperative chemotherapy to patients, especially those at early stage with squamous cell carcinoma of esophagus. Doctors must be scrupulous when making decisions.

Alternating gemcitabine and cisplatin with gemcitabine and radiation in stage IV squamous cell carcinoma of the head and neck

BACKGROUND

In order to improve our cisplatin-5-fluorouracil (5-FU)-based alternating chemo-radiotherapy regimen, in 1996 we started an investigational program to explore a modified alternating regimen including gemcitabine given both with radiosensitizing and cytotoxic intent.

MATERIALS AND METHODS

Based on our previous feasibility trial, we conducted a second study testing the feasibility and activity of the following schedule: gemcitabine 800 mg/m(2) on day 1 and cisplatin 20 mg/m(2) on days 2-5 (weeks 1, 4, 7 and 10) alternated with three courses of radiotherapy (RT) (weeks 2-3, 5-6 and 8-9) with conventional fractionation up to 60 Gy. Gemcitabine 300 mg/m(2) was also administered on the Monday of each week of RT.

RESULTS

Forty-seven patients with stage IV (41 patients) unresectable squamous cell carcinoma of the head and neck (SCC-HN) or who had relapsed after surgery (6 patients) were enrolled. None had previously received chemotherapy or radiotherapy. Eight patients (18%) did not complete the treatment. Main grade 3-4 toxicities were as follows: neutropenia (44%); neutropenia with fever (12%); thrombocytopenia (37%); anemia (30% grade 3). One patient died in therapy due to sepsis. Most patients needed hospitalization and tube-feeding or parenteral nutrition. However, 44% of patients had a weight loss >10%. Thirty-four patients had a complete response (72%). Three partial responders were rendered disease-free by surgery (final complete response rate, 79%). At a median follow-up of 38 months actuarial 3-year overall survival, progression-free survival and loco-regional control are 43%, 39% and 64%, respectively. Data of locoregional control favorably compare with those from our database of patients treated with alternating cisplatin-fluorouracil and radiation within controlled clinical trials (64% versus 40%).

CONCLUSIONS

The inclusion of gemcitabine into an alternating regimen seems to improve the results achievable with the original alternating program in stage IV patients. However, due to the high acute toxicity correlated, this intensive regimen should be managed by institutions well trained in multidisciplinary treatments.

Treatment delay and pathology results in women with low-grade squamous intraepithelial lesions. A preliminary study

Regression rate of CIN 1 (LSIL) can reach 85%. The purpose of this study was to investigate retrospectively pathology specimens in CIN 1 cases who delayed treatment > 2 years despite the persistence of the lesion. One hundred and fifteen women diagnosed with CIN 1 were separated in two groups as follows: A) 92 women who underwent ablative treatment within three months after the completion of two years; B) 23 women who delayed ablative treatment for a mean interval of > 1 year after the completion of two years. Exclusion criteria were normal cytology and colposcopy results within the completion of two years. The chi-square, t-test and Kaplan-Meier method were used for analysis. Persistence of LSIL lesions was observed in 84% of the first group and persistence or regression of the lesion in 78% of the second one. The study suggests the possibility of prolongation of the observation period after LSIL diagnosis. Prospective studies with close follow-up are needed for final conclusions.

Impact of comorbidity on the outcome of laryngeal squamous cancer

BACKGROUND

Comorbidity has been shown to be a determinant in treatment selection and survival in various cancers. We have previously shown that the Adult Comorbidity Evaluation-27 index is applicable in a United Kingdom setting, and the process of comorbidity grading by retrospective notes evaluation is an accurate and reliable process.

METHODS

The impact of comorbidity and other factors on survival was examined retrospectively in a cohort of 180 patients with laryngeal squamous cell cancer.

RESULTS

This study shows for the first time that the higher comorbidity burden seen in supraglottic cancers in contrast to glottic tumors might account for the poorer prognosis. This study also externally validates the composite comorbidity-TNM staging system described by Piccirillo and shows the composite system to be a better predictor of outcome than TNM staging system alone.

CONCLUSIONS

Moderate and severe comorbidity have a greater and statistically significant impact on survival than the TNM staging system.

A trial of IRX-2 in patients with squamous cell carcinomas of the head and neck

A Phase II trial in 42 patients with squamous cell cancer of the head and neck (H and NSCC) was performed using a combination immunotherapy with 10-20 days of perilymphatic injections of a natural cytokine mixture (NCM: IRX-2; 200 units IL-2 equivalence) preceded by low dose cyclophosphamide (CY; 300 mg/m(2)) and followed by daily oral indomethacin (25 mg t.i.d.) and zinc (65 mg in a multivitamin preparation). Thirty-nine patients underwent subsequent surgical resection and 22 stage IV patients received additional radiotherapy. Forty-two percent were adjudged to have complete and partial clinical responses (>50% tumor reduction); an additional five patients had minor responses for a total of 58%. Comparison of post-treatment biopsies or surgical specimens showed 90% of patients had reduction in tumor area from 79% to 48% (over half of which was fragmented) and increased area of leukocyte infiltration from 9% to 32% (79% of which was lymphoid). The treatment with IRX-2 was not associated with significant side effects and 24 of patients showed improvement in eating, breathing or phonation or reduced pain and bleeding. Fifteen patients with lymphocytopenia (lymphocyte counts [LC] less than or equal to 1500 mm(3)) showed significant increases in LC, CD3+, CD4+ and CD8+ T lymphocytes of 401, 147, 95 and 100/mm(3), respectively. Analysis of outcome of 32 on protocol patients after 36 months versus 32 concurrent institutional H and NSCC controls showed delayed recurrences and significant increases in mean survival time (MST) and survival (p's<0.02). The data document immunotherapy induced regression of H and NSCC with delayed recurrence and improved mean survival time.

Concurrent chemoradiotherapy for squamous cell carcinoma of the anus using a shrinking field radiotherapy technique without a boost

Chemoradiotherapy (CRT) is now widely accepted as the primary treatment modality for squamous cell cancer of the anus. While randomised trials have clearly shown CRT to be more effective than radiotherapy alone, there remains uncertainty over the optimal integration of chemotherapy and radiation. We describe a series of 50 patients treated by a site specialist gastrointestinal nonsurgical oncologist with CRT at a single UK centre. Chemotherapy comprised mitomycin C (MMC) (day 1) and 5-fluorouracil (5-FU) (days 1-4, and 29-32), concurrent with 50 Gy in 25 fractions radiation, using a two-phase shrinking field technique. A radiation boost was not planned. At a median follow-up of 48 months, 11 (22%) of the patients have failed locally, of which three have been surgically salvaged. Nine (18%) have died of anal cancer. These results are comparable with those from large randomised studies, and suggest that a two-phase shrinking field radiotherapy technique with no boost, concurrent with MMC/5-FU chemotherapy, is an effective regimen for this disease. The CRT regimen described here provides the basis for the 'control arm' of the current UK-randomised CRT trial in anal cancer (ACT2).

The effect of waiting time on local control and survival in head and neck carcinoma patients treated with radiotherapy

PURPOSE

To determine the influence of waiting time for radiotherapy on local control and survival in a cohort of patients with head and neck carcinoma of different locations and stages treated with radiotherapy.

MATERIAL AND METHODS

Retrospective study of 797 patients with squamous cell carcinoma located in the oral cavity, pharynx or larynx, treated with radiotherapy, and with a minimum follow-up of 3 years. Local recurrence and survival were analyzed in function of the waiting time, defined as the interval between date of histologic diagnosis and date of radiotherapy. A univariate and multivariate analysis was carried out.

RESULTS

Median waiting time to radiotherapy was 44 days (25 and 75% quartiles: 33 and 60 days). There were significant differences in the waiting time period in relation to the primary location and the local extension of the tumor. Both univariate and multivariate analysis showed that waiting time had no significant impact either on local control or survival.

CONCLUSION

Within the range of the waiting time observed in our study, delay in the initiation of radiotherapy did not affect local control or survival in patients with head and neck carcinoma.

[Preliminary results of accelerated hyperfractionated split course radiotherapy of advanced head and neck cancers]

The treatment results of new hyperfractionated, accelerated, split course irradiation schedule were presented. The material consisted of 27 (22 men, 5 women) advanced (T2N2C-3, T3-4 N2-3), inoperable head and neck (11--oropharynx, 9--larynx, 6--tongue, 1--hypopharynx) squamous cell cancer patients. Patients were in good performance status (Zubrod < or = 2). The age varied from 44 to 70 years (mean 56). All patients were irradiated using 6 MV photon beams, 1.6 Gy per fraction delivered twice a day with 6 hours of gap to the total dose of 64 Gy in the overall treatment time of 28 days (with 8 days long gap in the middle of treatment) to avoid accelerated clonogens repopulation. No one patient had a gap caused by treatment adverse effects. The highest mucosal acute reaction evaluated using Dische scale appeared in 3-4 week of treatment and varied from 6 to 25 points (mean 16 points). The analysis shown 34% total survival and 41% survival excluding death caused by a distant dissemination, in the period of 50 months. No correlation between T and N stage, tumour and nodes diameters and degree of regression and survival probability was found. The obtained results allow to conclude that CHA-CHA schedule is safe and acceptable by patients irradiation modality giving promising treatment results but the final confirmation of its value should be proven in a next, randomised phase of trial.

An intergroup phase III comparison of standard radiation therapy and two schedules of concurrent chemoradiotherapy in patients with unresectable squamous cell head and neck cancer

PURPOSE

The Head and Neck Intergroup conducted a phase III randomized trial to test the benefit of adding chemotherapy to radiation in patients with unresectable squamous cell head and neck cancer.

PATIENTS AND METHODS

Eligible patients were randomly assigned between arm A (the control), single daily fractionated radiation (70 Gy at 2 Gy/d); arm B, identical radiation therapy with concurrent bolus cisplatin, given on days 1, 22, and 43; and arm C, a split course of single daily fractionated radiation and three cycles of concurrent infusional fluorouracil and bolus cisplatin chemotherapy, 30 Gy given with the first cycle and 30 to 40 Gy given with the third cycle. Surgical resection was encouraged if possible after the second chemotherapy cycle on arm C and, if necessary, as salvage therapy on all three treatment arms. Survival data were compared between each experimental arm and the control arm using a one-sided log-rank test.

RESULTS

Between 1992 and 1999, 295 patients were entered on this trial. This did not meet the accrual goal of 362 patients and resulted in premature study closure. Grade 3 or worse toxicity occurred in 52% of patients enrolled in arm A, compared with 89% enrolled in arm B (P <.0001) and 77% enrolled in arm C (P <.001). With a median follow-up of 41 months, the 3-year projected overall survival for patients enrolled in arm A is 23%, compared with 37% for arm B (P =.014) and 27% for arm C (P = not significant).

CONCLUSION

The addition of concurrent high-dose, single-agent cisplatin to conventional single daily fractionated radiation significantly improves survival, although it also increases toxicity. The loss of efficacy resulting from split-course radiation was not offset by either multiagent chemotherapy or the possibility of midcourse surgery.

Clinical relevance of urokinase-type plasminogen activator and its inhibitor type 1 (PAI-1) in squamous cell carcinoma of the uterine cervix

OBJECTIVE

The expression of uPA and PAI-1 as parameters of tumour-associated proteolysis has been implicated in the process of tumour cell invasion and the metastatic process. However, there is limited information on the impact of these parameters in cervical carcinoma.

METHODS

Quantitative levels for uPA (n = 114) and PAI-1 (n = 103) were researched in operatively treated, surgically staged squamous cell cancer of the uterine cervix, using an ELISA-technique. Results were assessed regarding their impact in predicting pelvic lymph nodes metastases, tumour recurrence rate and recurrence free survival (RFS) using uni- and multivariate analysis.

RESULTS

Median levels of both parameters were significantly higher in tumour tissue than in normal cervical tissue (p < 0.001). Detection of uPA gave no useful prognostic information. PAI-1 concentration showed a positive correlation with advanced tumour stage (p = 0.008), but no significant correlation with nodal status (pN0: 2.6 vs. pN1: 4.0 ng/mg protein; p = 0.092). Using a cut-off level of 2.4 ng/mg protein, patients with elevated PAI-1 levels demonstrated reduced RFS (45.9 versus 52.9 months; p = 0.1). Multivariate analysis, including nodal status, tumour stage, lymphovascular space involvement and grading failed to demonstrate any prognostic impact of uPA and PAI-1.

CONCLUSIONS

The results indicate, that PAI-1 expression is of some prognostic impact in cervical cancer, indicating an association of elevated PAI levels with local tumour progression and reduced recurrence-free survival.

Surgical treatment of thoracic esophageal carcinoma: report of 326 cases

OBJECTIVE

To review our experience in surgical treatment of 326 cases of thoracic esophageal carcinoma.

METHODS

The clinical data of 326 patients with thoracic esophageal carcinoma from January 1990 to January 2001 were analyzed retrospectively. Among the 326 patients, the lesions of 32 patients were identified in the upper thoracic segment of the esophagus, and were found in the middle segment in 213 cases with the left 81 cases having lesions in the lower segment. Left cervical esophagogastrostomy was performed through triple incision (left cervical, right thoracic and abdominal) in 79 cases. Esophagocolostomy through triple incision was performed in 5 cases. Another 156 patients received left cervical esophagogastrostomy through two incisions (left cervical and left thoracic). Supra-aorticarch esophagogastrostomy through left posterola- teral thoracotomy was performed in 53 cases, and sub-arch esophagogastrostomy through left posterolateral thoracotomy in 33 cases.

RESULTS

The post-operative mortality was 1.23% (4/326), with a five-year survival rate of 35.3%.

CONCLUSION

Subtotal esophagectomy combined with thorough lymph node dissection can be the first choice for thoracic esophageal carcinoma to improve the postoperative survival rate and the quality-of life-of the patients.

Smoking-induced squamous-cell cancer of the nose

Squamous-cell cancer (SCC) isolated to the anterior nose is uncommon. Numerous industrial and environmental contaminants have been implicated as causative factors in nasal carcinoma. The association between nasal cancer and smoking was recognized in the 1980s, but results have not been consistent and no possible mechanisms have been suggested. The case histories of 11 patients with SCC limited to the anterior nasal cavity were reviewed. The authors found no relationship with exposures to chemicals previously implicated in nasal cancer. Nine patients with SCC were exposed to cigarette smoke (mean = 103 pack-years). Cigarette smoke may induce cancer directly, thus affecting the mucosa, or by inducing genetic alterations. The authors favor the former mechanism.

Three-field lymph node dissection for squamous cell and adenocarcinoma of the esophagus

OBJECTIVE

To determine the prevalence of occult cervical nodal metastases in patients with squamous cell cancer and adenocarcinoma of the esophagus, and to determine the impact of esophagectomy with three-field lymph node dissection on survival and recurrence rates.

SUMMARY BACKGROUND DATA

Although esophagectomy with three-field lymph node dissection is commonly practiced in Japan, its role in the surgical management of esophageal cancer in the United States, especially in patients with esophageal adenocarcinoma, is essentially unknown.

METHODS

This is a prospective observational study of esophagectomy with three-field lymphadenectomy. Eighty patients underwent resection between August 1994 and April 2001. Clinicopathological information and follow-up data were collected on all patients until death or June 2001.

RESULTS

Hospital mortality and morbidity rates were 5% and 46%, respectively. Metastases to the recurrent laryngeal and/or deep cervical nodes occurred in 36% of patients irrespective of cell type (adenocarcinoma 37%, squamous 34%) or location within the esophagus (lower third 32%, middle third 60%). Overall 5-year and disease-free survival rates were 51% and 46%, respectively. Sixty-nine percent presented with nodal metastases. The 5-year survival rate for node-negative patients was 88%; that for those with nodal metastases was 33%. The 5-year survival rate in patients with positive cervical nodes was 25% (squamous 40%, adenocarcinoma 15%).

CONCLUSIONS

Esophagectomy with three-field lymph node dissection can be performed with a low mortality and reasonable morbidity. Unsuspected metastases to the recurrent laryngeal and/or cervical nodes are present in 36% of patients regardless of cell type or location within the esophagus. Thirty percent of patients were upstaged, mainly from stage III to stage IV. An overall 5-year survival rate of 51% suggests a true survival benefit beyond that achieved solely on the basis of stage migration.

The role of docetaxel in the management of squamous cell cancer of the head and neck

The activity of docetaxel (Taxotere) as a single agent (overall response rates, 24%-45%) in the treatment of patients with recurrent squamous cell cancer of the head and neck has resulted in the investigation of docetaxel-based doublet and triplet combinations in both the recurrent and neoadjuvant settings. When combined with cisplatin, with or without fluorouracil (5-FU), in the treatment of recurrent disease, response rates of 33% to 44% have been observed for docetaxel, with median survival ranging from 9.6 to 11 months. In the neoadjuvant setting, response rates have been typically greater than 90%, with promising disease-free and overall survival results. Randomized trials are now under way to assess the value of docetaxel-based therapy relative to that of the standard cisplatin/5-FU combination in both the neoadjuvant and recurrent settings. Preclinical data indicate that docetaxel is a potent radiosensitizer and its initial evaluation with concurrent radiation in patients with locally advanced unresectable squamous cell cancer of the head and neck suggests feasibility. Phase II evaluation of this approach is in progress.

Preoperative serum SCC, CA125, and CA19-9 levels and lymph node status in squamous cell carcinoma of the uterine cervix

BACKGROUND

We wanted to investigate the clinical usefulness of determining the pretreatment levels of multiple serum tumor markers in predicting lymph node status and the prognosis for patients with cervical carcinoma.

METHODS

The preoperative serum levels of squamous cell carcinoma antigen (SCC), cancer antigens CA125 and CA19-9 were assayed simultaneously in 103 patients with stages IB to IIB cervical SCC undergoing radical hysterectomy. The cut-off values of SCC, CA125, and CA19-9 in this study were 1.5 ng/ml, 35 U/ml, and 37 U/ml, respectively. The relation between preoperative tumor marker levels and histopathologic prognostic factors including lymph node metastasis and patient survival was studied.

RESULTS

Preoperative serum SCC, CA125, and CA19-9 levels were significantly related to the FIGO stage. In addition, serum SCC and CA125 levels were significantly related to tumor diameter, depth of cervical stromal invasion, lymph-vascular space invasion, and lymph node metastasis. We subsequently created a double-tumor-marker (DTM) index, which incorporated the number of positive markers of SCC and CA125. The DTM index was strongly related to the number of positive pelvic lymph nodes (p = 0.0002) and to the site of positive nodes (none vs. pelvic only vs. common iliac/paraaortic) (p = 0.0005). Probability of lymph node metastasis according to the DTM index = 0, 1, and 2 was 6/48 (12.5%), 14/45 (31.1%), and 8/10 (80.0%), respectively. The rate of common iliac/paraaortic node metastasis according to the DTM index = 0, 1, and 2 was 1/48 (2.1%), 2/45 (4.4%), and 3/10 (30.0%), respectively. By logistic regression analysis, it was shown that the DTM index and tumor diameter were independently related to lymph node metastasis. Using multivariate Cox regression analysis including singly determined serum SCC and CA125 levels, clinical stage (IB/IIA vs. IIB), tumor diameter (<or= 2 vs. 2-4 vs. > 4 cm), parametrial invasion, lymph node metastasis, and the DTM index, the DTM index was found to be the most important prognostic factor (p = 0.0005). However, when the sites of positive nodes were included in the multivariate analysis, only the sites of positive nodes (p = 0.0008) and parametrial invasion (p = 0.041) showed independent prognostic significance.

CONCLUSION

Combination assay of pretreatment serum SCC and CA125 levels seems to be useful in estimating lymph node status and the prognosis for patients with cervical SCC in a preoperative setting.

[The expression of erbB/HER family in lung cancer]

OBJECTIVE

To study the expression of human epidermal growth factor receptor (HER) family in lung cancer.

METHODS

Paraffin-embedded tissues from 70 cases of lung cancer (43 cases of squamous cell cancer and 27 cases of adenocarcinoma) and 20 cases of non-cancerous lung diseases were stained for the expression of HERs by means of immunohistochemistry.

RESULTS

All HERs were weakly expressed in non-cancerous lung tissues; over-expression of HER(1), HER(2), HER(4), HER(1 + 2), HER(1 + 4) and HER(2 + 4) and HER(1 + 2 + 4) was found in lung cancer and correlated with lymph node metastasis, TNM staging and post-operation survival.

CONCLUSIONS

erbB(1), erbB(2) and erbB(4) are the genes regulating the growth of lung cancer at advanced stages. Targeting the HER(1), HER(2) and HER(4) over-expression might be a new approach to the treatment of lung cancer at advanced stages.

Squamous cell carcinomas of the mandibular alveolus: analysis of prognostic factors

BACKGROUND

To assess the effect of clinicopathologic factors on local tumor control and survival in patients with mandibular alveolar carcinoma.

METHODS

Fifty patients with mandibular alveolar carcinoma treated surgically were included in this study. There were 3 patients with T1, 25 with T2, 5 with T3, and 17 with T4 disease. Clinical evidence of bone invasion was noted in 47 patients. A hemi- or segmental mandibulectomy was performed on 37 patients, whereas 10 patients had a marginal mandibulectomy. The impact of clinicopathologic variables on local tumor control and patient survival was assessed by univariate analysis. Variables included T and N stage, dental extraction, treatment modality, tumor differentiation, nodal status, surgical margin, and bone invasion.

RESULTS

Eleven patients (22%) develop recurrent disease, including 8 local recurrences, 1 neck, and 2 distant metastases. Overall, the 5-year actuarial rates of local control and disease-specific survival were 85 and 73%, respectively. Most local recurrences after surgical treatment were caused by inadequate resection margins. When resection margins were negative, the survival and local control rate were significantly better than when there were positive resection margins (survival, 91 vs. 11%; local control, 100 vs. 49%; p < 0.01). Neither T and N stages, clinical stage, tumor differentiation, dental extraction, bone invasion, extent of bone resection, nor treatment modality influenced outcome.

CONCLUSIONS

The status of surgical margins was of major importance for the outcome of patients with gingival carcinoma of the mandible.