Association of Intraoperative Frozen Section Controls With Improved Margin Assessment During Transoral Robotic Surgery for Human Papillomavirus-Positive Oropharyngeal Squamous Cell Carcinoma

Importance

Intraoperative margin assessment is an important technique for ensuring complete tumor resection in malignant cancers. However, in patients undergoing transoral robotic surgery (TORS) for oropharyngeal carcinomas, tissue artifact may provide pathologic uncertainty.

Objective

To assess the benefit of providing frozen section control samples ("positive tumor biopsies") for use during intraoperative margin assessment for patients undergoing TORS for human papillomavirus (HPV)-16-positive oropharyngeal squamous cell carcinoma (OPSCC).

Design, Setting, and Participants

In this cohort study, patients receiving curative-intent TORS for biopsy-proven HPV-16-positive OPSCC performed by a single attending surgeon (A.H.M.) at Ronald Reagan UCLA Medical Center from 2017 to 2021 were included in a retrospective data analysis. Exclusion criteria included HPV-negative status, participation in clinical trials, and tumors of unknown primary origin.

Main Outcomes and Measures

Survival outcomes investigated included overall and disease-free survival. Adverse pathologic outcomes measured included occurrence of nondiagnostic margins and margin reversal from frozen to fixed pathology.

Results

Of the 170 patients included (mean [SD] age, 61.8 [9.9] years; 140 [82%] male), 50% of patients (n = 85) received a frozen section control. Use of a frozen section control was associated with statistically significantly improved sensitivity of intraoperative margin assessment, from 82.8% to 88.9% (difference, 6.1%; 95% CI, 3.9%-8.3%). Eleven percent (n = 18) of all tumors evaluated exhibited at least 1 nondiagnostic intraoperative margin, and 11% (n = 18) experienced margin reversal from frozen to fixed pathology. In patients with nondiagnostic margins, use of frozen section controls was associated with statistically significantly reduced time spent in the operating room (Cohen d, 1.14; 95% CI, 0.12-2.14).

Conclusions and Relevance

In this cohort study, frozen intraoperative margins assessed during TORS resections of HPV-16-positive OPSCC were diagnostically challenging. Adverse pathologic outcomes, such as margin status reversal from positive on frozen pathology to negative on formal analysis, were common. Providing intraoperative frozen section control biopsies may offer clarity in cases with nondiagnostic margins, reducing the need for additional sampling and time spent in the operating room.

Implementing a Tailored Psychosocial Distress Screening Protocol in a Head and Neck Cancer Program

OBJECTIVES/HYPOTHESIS

Psychosocial distress is common among patients with head and neck cancer (HNC) and is associated with poorer quality of life and clinical outcomes. Despite these risks, distress screening is not widely implemented in HNC care. In this study, we investigated the prevalence of psychosocial distress and its related factors in routine care of patients with HNC.

METHODS

Data from medical records between September 2017 and March 2020 were analyzed. Psychosocial distress was measured by the National Comprehensive Cancer Network's Distress Thermometer (DT), and a modified HNC-specific problem list; depression and anxiety were assessed using the Patient Health Questionnaire-4. Descriptive statistics and logistic regression were conducted to report prevalence of distress, depression and anxiety, and factors associated with clinical distress. Implementation outcomes, including rates of referrals and follow-up for distressed patients, are also reported.

RESULTS

Two hundred and eighty seven HNC patients completed the questionnaire (age 64.3 ± 14.9 years), with a mean distress score of 4.51 ± 3.35. Of those, 57% (n = 163) reported clinical distress (DT ≥ 4). Pain (odds ratio [OR] = 3.31, 95% CI = 1.75-6.26), fatigue (OR = 2.43, 95% CI = 1.1.7-5.05), anxiety (OR = 1.63, 95% CI = 1.30-2.05), and depression (OR = 1.51, 95% CI = 1.04-2.18) were significantly associated with clinical distress (P < .05). Of patients identified as distressed, 79% received same-day psychosocial evaluation.

CONCLUSIONS

Clinical distress was identified in 57% of patients who completed the questionnaire, suggesting that an ultra-brief psychosocial screening protocol can be implemented in routine ambulatory oncology care, and identifies patients whose distress might otherwise go unrecognized.

LEVEL OF EVIDENCE

4 Laryngoscope, 132:1600-1608, 2022.

Spindle Cell Lipoma Arising from the Supraglottis: A Case Report and Review of the Literature

Lipomas are common benign mesenchymal neoplasms. Although 13% of lipomas are found in the head and neck, only 0.6% have been reported in the larynx. Of all lipomas, the spindle cell variant is the least common. In the present study, we report a case of supraglottic spindle cell lipoma and review the literature of laryngeal spindle cell lipoma. A 35-year-old male presented with dysphagia and dyspnea and was found to have bilateral supraglottic lesions causing airway obstruction. The masses were resected endoscopically. Final pathology demonstrated mature adipocytes and spindle cells, with immunohistochemical patterns supportive of spindle cell lipoma. Spindle cell lipomas have rarely been reported in the upper airway. To our knowledge, this is the youngest patient reported to date. These lipomas are uncommon benign neoplasms and should be distinguished from aggressive mesenchymal neoplasms such as liposarcoma variants to guide appropriate conservative but curative therapy.

Acoustofluidic Salivary Exosome Isolation: A Liquid Biopsy Compatible Approach for Human Papillomavirus-Associated Oropharyngeal Cancer Detection

Previous efforts to evaluate the detection of human papilloma viral (HPV) DNA in whole saliva as a diagnostic measure for HPV-associated oropharyngeal cancer (HPV-OPC) have not shown sufficient clinical performance. We hypothesize that salivary exosomes are packaged with HPV-associated biomarkers, and efficient enrichment of salivary exosomes through isolation can enhance diagnostic and prognostic performance for HPV-OPC. In this study, an acoustofluidic (the fusion of acoustics and microfluidics) platform was developed to perform size-based isolation of salivary exosomes. These data showed that this platform is capable of consistently isolating exosomes from saliva samples, regardless of viscosity variation and collection method. Compared with the current gold standard, differential centrifugation, droplet digital RT-PCR analysis showed that the average yield of salivary exosomal small RNA from the acoustofluidic platform is 15 times higher. With this high-yield exosome isolation platform, we show that HPV16 DNA could be detected in isolated exosomes from the saliva of HPV-associated OPC patients at 80% concordance with tissues/biopsies positive for HPV16. Overall, these data demonstrated that the acoustofluidic platform can achieve high-purity and high-yield salivary exosome isolation for downstream salivary exosome-based liquid biopsy applications. Additionally, HPV16 DNA sequences in HPV-OPC patients are packaged in salivary exosomes and their isolation will enhance the detection of HPV16 DNA.

Immunologic mediators of outcome for irradiated oropharyngeal carcinoma based on human papillomavirus status

PURPOSE

To investigate the prognostic value of pre-treatment immune parameters including white blood cell count (WBC) and circulating lymphocyte count (CLC) among patients with oropharyngeal carcinoma treated by radiation therapy.

METHODS AND MATERIALS

A total of 136 consecutive patients were treated by radiation therapy for locally advanced (stage III/IV) squamous cell carcinoma of the oropharynx with known human papillomavirus (HPV) status. Medical records were reviewed to identify patients with documented pre-treatment laboratory bloodwork. The Kaplan-Meier method and linear regression models were used to evaluate the association between pre-treatment CBC and CLC values with survival endpoints.

RESULTS

One hundred and eleven patients satisfied inclusion criteria. Median age was 62 years (range, 22-91). Eighty-four patients were HPV-positive (76%) and 27 (24%) were HPV-negative. There was no difference in WBC and CLC mean values at baseline between HPV-positive and HV-negative (p > 0.05, for both). Trends were detected in the HPV-positive cohort favoring patients with higher CLC, with respect to 2-year local-regional control (93% vs. 82%, p = 0.06) and distant control (88% vs. 82%, p = 0.10) using the median CLC as cut-off. HPV-positive patients with CLC values in the lowest quartile had inferior local-regional control compared to those in the upper 3 quartiles (69% vs. 89%, p = 0.01).

CONCLUSION

Low pre-treatment CLC was correlated with local-regional recurrence and distant failure among HPV-positive patients. These associations were not observed in the HPV-negative cohort.

Sentinel lymph node biopsy in cutaneous melanoma of the head and neck using the indocyanine green SPY Elite system

PURPOSE

Lymph node status is the single most important prognostic factor for patients with early-stage cutaneous melanoma. Sentinel lymph node biopsy (SLNB) has become the standard of care for intermediate depth melanomas. Modern SLNB implementation includes technetium-99 lymphoscintigraphy combined with local administration of a vital blue dye. However, sentinel lymph nodes may fail to localize in some cases and false-negative rates range from 0 to 34%. Here we demonstrate the feasibility of a new sentinel lymph node biopsy technique using indocyanine green (ICG) and the SPY Elite near-infrared imaging system.

MATERIALS AND METHODS

Cases of primary cutaneous melanoma of the head and neck without locoregional metastasis, underwent SLNB at a single quaternary care institution between May 2016 and June 2017. Intraoperatively, 0.25 mL of ICG was injected intradermal in 4 quadrants around the primary lesion. 10-15 minute circulation time was permitted. SPY Elite identified the sentinel lymph node within the nodal basin marked by lymphoscintigraphy. Target first echelon lymph nodes were confirmed with a gamma probe and ICG fluorescence.

RESULTS

14 patients were included with T1a to T4b cutaneous melanomas. Success rates for sentinel lymph node identification using lymphoscintigraphy and the SPY Elite system were both 86%. Zero false negatives occurred. Median length of follow-up was 323 days.

CONCLUSIONS

In this pilot study, Indocyanine green near-infrared fluorescence demonstrates a safe, and facile method of sentinel lymph node biopsy for cutaneous melanoma of the head and neck compared with lymphoscintigraphy and vital blue dyes.

It Takes Two: One Resects, One Reconstructs

Care of patients with advanced head and neck cancer is a multidisciplinary effort through all phases of care. Head and neck cancer surgery involves balancing oncologic control, functional preservation, and aesthetics. Given the advances in free tissue reconstruction, the majority of defects can be reconstructed using free tissue transfer flaps. A 2-team approach allows for early, continual communication and meticulous operative planning. Operations can be combined into a single effort. This approach maximizes efficiency and enables multidisciplinary collaboration for comprehensive surgical treatment. We present our experience and an outline of how responsibilities between the ablative and reconstructive teams are shared.

Prognostic significance of HPV status in the re-irradiation of recurrent and second primary cancers of the head and neck

PURPOSE

To evaluate the prognostic significance of human papillomavirus (HPV) status among patients treated by salvage radiation therapy for local-regional recurrences and second primary cancers of the head and neck arising in a previously irradiated field.

METHODS AND MATERIALS

The medical records of 54 consecutive patients who underwent re-irradiation for squamous cell carcinoma of the head and neck occurring in a previously irradiated field were reviewed. Only patients with biopsy-proven evidence of recurrent disease that had previously been treated with doses of radiation therapy of at least 60 Gy were included. Determination of HPV status at the time of recurrence was performed by p16 immunohistochemistry. The median age at re-irradiation was 58.5 years (range, 27.9 to 81.5 years). Thirty patients (55.5%) were lifelong never-smokers. The Kaplan Meier method was used to calculate overall survival, progression-free survival, and local-regional control, and distant metastasis-free survival with comparisons between groups performed using the log-rank test.

RESULTS

HPV status among tumors that were re-irradiated was as follows: 16 positive (29.7%); 7 negative (12.9%); 31 unknown (57.4%). The median overall survival in the entire cohort was 11.7 months (range, 8 to 27 months), with the 1-year and 2-year estimates of overall survival being 47.2% and 38.4%, respectively. A statistical trend was identified favoring patients with HPV-positive cancers with respect to the endpoints of overall survival (p = 0.06) and progression-free survival (p = 0.08) after re-irradiation when compared to the HPV-negative/unknown population. There was no significant difference in distant control between the two cohorts (p = 0.40).

CONCLUSIONS

The favorable prognostic significance of HPV seemingly extends to patients treated by re-irradiation suggesting that this biomarker may be useful in risk stratification in this setting.

Oropharynx-directed ipsilateral irradiation for p16-positive squamous cell carcinoma involving the cervical lymph nodes of unknown primary origin

BACKGROUND

The purpose of this study was to present our findings on the use of limited-field, oropharynx-directed ipsilateral irradiation for p16-positive squamous cell carcinoma of unknown primary origin.

METHODS

Between April 2011 and January 2016, 25 patients with a histological diagnosis of p16-positive squamous cell carcinoma were selectively irradiated to the ipsilateral oropharynx and cervical neck for tumors of unknown primary origin. The dose to the oropharynx ranged from 54-60 Gy (median 60 Gy) in 30-33 fractions. Concurrent cisplatin-based chemotherapy was administered to 8 patients (32%).

RESULTS

The actuarial 2-year estimates of locoregional control, progression-free survival, and overall survival were 91%, 87%, and 92%, respectively. One patient failed in the contralateral neck. There was no grade 3 + toxicity in either the acute or late setting.

CONCLUSION

Oropharynx-directed, ipsilateral radiation results in disease control that compares favorably with historical controls treated by comprehensive mucosal and bilateral neck radiation.

Factors Associated With Survival in Patients With Synovial Cell Sarcoma of the Head and Neck: An Analysis of 167 Cases Using the SEER (Surveillance, Epidemiology, and End Results) Database

IMPORTANCE

Synovial cell sarcoma of the head and neck (SCSHN) is a rare tumor associated with significant morbidity and mortality. The literature regarding these tumors is limited to case series and case reports. We used data from the population-based US Surveillance, Epidemiology, and End Results (SEER) cancer registry to determine factors affecting both overall survival and disease-specific survival of patients with SCSHN.

OBJECTIVE

To determine the clinicopathologic and therapeutic factors determining survival in patients with SCSHN.

DESIGN, SETTING, AND PARTICIPANTS

The SEER registry was reviewed for patients with primary SCSHN from January 1, 1973, to January 1, 2011.

MAIN OUTCOMES AND MEASURES

Overall survival (OS) and disease-specific survival.

RESULTS

A total of 167 cases of SCSHN were identified. The mean (SD) age at diagnosis was 37.9 (17.3) years, and 100 (59.9%) of the patients were males. The monophasic spindle cell and biphasic variants were the most common histologic subtypes. Surgical resection and radiotherapy were performed in 150 (89.8%) and 108 (64.7%) of the cases, respectively. The median OS at 2, 5, and 10 years was 77%, 66%, and 53%, respectively. Univariate Kaplan-Meier survival analysis revealed that age, race, and tumor stage and size were associated with improved survival. Histologic subtype was not associated with significant differences in survival. Radiotherapy was associated with improved disease-specific survival (hazard ratio [HR], 0.29 [95% CI, 0.12-0.68]; P = .003), but surgical management was not associated with improved survival (HR, 0.52 [95% CI, 0.19-1.46]; P = .21). Multivariate Cox regression analysis revealed that size greater than 5 cm (adjusted HR, 3.60 [95% CI, 1.43-9.08]; P = .007) and stage at presentation (adjusted HR, 3.86 [95% CI, 2.01-7.44]; P < .001) were independent determinants of OS. In separate analysis of cohorts with tumors 5 cm or less and larger than 5 cm, stage at presentation was found to be a significant indicator of the probability of survival in both cohorts (adjusted HR, 3.10 [95% CI, 1.46-6.60]; P = .003 and 5.32 [95% CI, 1.49-18.98]; P = .01, respectively); surgical resection and radiotherapy were not associated with differential survival outcomes using this model.

CONCLUSIONS AND RELEVANCE

Synovial cell sarcoma of the head and neck is rare. Independent significant determinants of survival include size (>5 cm) and stage at presentation. Histologic subtype of the tumor is not a significant indicator of the probability of survival. Surgical resection and radiotherapy were not independent determinants of survival.

Angiosarcoma of the tongue: A case series and literature review

PURPOSE

Angiosarcoma of the tongue is an exceedingly rare malignancy of the head and neck. Such lesions can be primary in nature or occur in a previously irradiated field. We examine a series of cases with relation to clinical presentation, diagnosis, management, and outcomes.

MATERIALS AND METHODS

Retrospective chart review of all patients with angiosarcoma of the tongue at a tertiary academic institution yielded a single case between 2005 and 2016. The MEDLINE database was additionally searched for all case series or reports of angiosarcoma arising in the tongue, and pertinent clinical data were extracted.

RESULTS

The clinical presentation, disease course, and management of a patient with angiosarcoma of the tongue are presented. Institutional and literature search yielded a total of eight patients with angiosarcoma of the tongue. The most common primary sites were dorsal and lateral oral tongue. Treatment consisted of surgical resection in 63% of cases with adjuvant therapy administered in 75% of cases. Follow-up times varied per patient, but 63% had persistent or recurrent disease and 67% died of or with disease within two years of index presentation.

CONCLUSION

Angiosarcoma of the tongue is a rare and highly aggressive tumor, accounting for fewer than 1% of all head and neck malignancies. The mainstay of treatment is surgical resection with negative margins followed by adjuvant chemoradiation for high-risk features. Due to rarity of the disease, consensus on optimal treatment approach is lacking, and multi-center prospective studies would be helpful to set clinical guidelines.

Lymph Node Clustering in Head and Neck Squamous Cell Cancer

Objective

Detection of early regional metastasis of head and neck carcinoma is critical for tumor staging, prognosis, and treatment strategies. Clustered cervical lymphadenopathy portends a worse prognosis than isolated lymphadenopathy, but studies analyzing its effect are lacking. Key objectives include: 1) to establish criteria for lymph node clustering and 2) to assess the predictive value of lymph node clustering for metastasis.

Methods

This study retrospectively reviewed preoperative radiographic images of 29 patients with histopathologically proven metastatic head and neck squamous cell carcinoma between January 2006 and December 2007. Patients who had previous radiation or chemotherapy were excluded. CT, MRI, and PET CT images were assessed for lymph node size and number, neck level, and clustering, with respect to primary tumor location and size. A cluster was defined as 3 or more abutting nodes with no definable intervening fat planes.

Results

Statistics comparing histopathologic proven metastatic lymphadenopathy and radiographic clustering of nodes in each neck level were used to elucidate the positive predictive value via logistic regression analysis. Analysis revealed a positive predictive value for clustering of nodes greater than 1 cm to be 82.9%, with a negative predictive value of 100% in the level II region (p<0.05). Nodes in the remaining levels demonstrated less predictive values.

Conclusions

Clustered lymph nodes greater than 1cm in the level II region in head and neck squamous cell carcinoma have a high predictive value, suggesting that clustering is not only an important prognostic indicator but also an important radiographic feature that may assist surgeons in preoperative surgical planning.

The emerging landscape of salivary diagnostics

Saliva contains a variety of biomolecules, including DNA, coding and noncoding RNA, proteins, metabolites and microbiota. The changes in the salivary levels of these molecular constituents can be used to develop markers for disease detection and risk assessment. Use of saliva as an early-detection tool is a promising approach because collection of saliva is easy and noninvasive. Here, we review recent developments in salivary diagnostics, accomplished using salivaomics approaches, including genomic, transcriptomic, proteomic, metabolomic and microbiomic technologies. Additionally, we illustrate the mechanisms of how diseases distal from the oral cavity can lead to the appearance of discriminatory biomarkers in saliva, and discuss the relevance of these markers for translational and clinical applications.

Effect of daily fraction size on laryngoesophageal dysfunction after chemoradiation for squamous cell carcinomas of the larynx and hypopharynx

BACKGROUND

The purpose of this study was to determine the effect of fraction size on laryngoesophageal dysfunction among patients treated by chemoradiotherapy for laryngeal and hypopharyngeal cancer.

METHODS

Forty patients underwent chemoradiotherapy for stage III/IV squamous cell carcinomas of the larynx and hypopharynx. Median radiation dose was 70 Gy (range, 69.3-70.4 Gy) with daily fractionation ranging from 2 Gy to 2.2 Gy.

RESULTS

When comparing 2 Gy versus >2 Gy daily fractionation, there was no difference in 2-year overall survival (71% vs 72%; p = .68), locoregional control (79% vs 77%; p = .43), or laryngectomy-free survival (60% vs 61%; p = .72). Use of 2 Gy versus >2 Gy fractionation improved laryngoesophageal dysfunction-free survival (2-year estimates, 49% vs 27%; p = .07). Patient-reported voice and swallowing were improved with the former.

CONCLUSION

As the importance of a functional larynx becomes recognized as an endpoint for patients treated by voice preservation, the results of our study help refine treatment guidelines. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1322-1326, 2017.

Prognostic significance of p16 in squamous cell carcinoma of the larynx and hypopharynx

PURPOSE

To evaluate the prognostic significance of p16 expression among patients with squamous cell carcinoma of the larynx (LSCC) and hypopharynx (HSCC).

METHODS

The medical records of all patients with locally advanced, non-metastatic LSCC/HSCC were reviewed. p16^INK4A (p16) protein expression was evaluated on pathological specimens by immunohistochemistry (IHC), and the Kaplan-Meier method was used to estimate overall survival (OS) and locoregional control (LRC). In select cases, p16 expression was correlated to high-risk and low-risk HPV genotypes using in situ hybridization (ISH).

RESULTS

Thirty-one patients (23 LSCC; 8 HSCC) were identified. Seventeen (54.8%) patients were p16 negative; 14 (45.2%) were p16-positive. The primary treatment modality was radiation therapy for 22 (71.0%) patients and surgery for 9 (29.0%). Nineteen (61.3%) patients were evaluated for high-risk HPV and low-risk HPV genotypes by IHC, of whom 2 (10.5%) patients were positive for high-risk HPV and 1 (5.3%) was positive for low-risk HPV. For high-risk HPV, the positive predictive value (PPV), sensitivity, and specificity of p16 was 20.0%, 100%, and 52.9%. There was no significant difference in the 2-year actuarial rates of OS (91% vs. 64%, p=0.34) or LRC (51% vs. 46%, p=0.69) between the p16-positive and p-16 negative patients.

CONCLUSION

In this small cohort of 31 LSCC and HSCC patients, p16 was not a significant predictive of either LRC or OS. Furthermore, p16 was poorly correlated with HPV genotyping as identified by ISH.

IMRT for head and neck cancer: Cost implications

OBJECTIVES

Intensity-modulated radiotherapy (IMRT) is a dose-delivery technology allowing for a reduction in radiotherapy side effects. It has been rapidly adopted despite the lack of prospective studies showing improved outcomes. We sought to compare the cost through Medicare reimbursement patterns of surgery, IMRT, and conventional XRT in treating head and neck cancer. We then identified factors that correlate with these differences.

METHODS

Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data were examined to determine treatment patterns for 47,237 patients with head and neck carcinoma from 2000 to 2007. We identified 14,748 patients that met our inclusion criteria. We then compared cost related to head and neck cancer treatments on the basis of Medicare payments.

RESULTS

From 2000 to 2007, the usage of IMRT increased from 1.5% to 48.6% while the usage of conventional XRT decreased from 98.5% to 51.4% (p<0.0001). During this time, patients undergoing IMRT had a mean cost of $101,099 compared to $42,843 for XRT. For patients with early stage tumors, surgery alone cost $18,140, traditional XRT $32,296 while IMRT cost $95,047 (p<0.0001). When removing patients who underwent concomitant chemotherapy, patients treated with IMRT cost $67,576 compared to $24,955 for non-IMRT patients (p<0.0001).

CONCLUSIONS

IMRT has become widely adopted as a primary treatment modality in head and neck cancer. We demonstrated that IMRT is significantly more costly than traditional treatment for head and neck cancers. Prospective studies investigating the comparative efficacy of IMRT will be needed in order to determine if this increased cost correlates with patient outcomes.

LEVEL OF EVIDENCE

2b.

Laryngeal Preservation in Glottic Cancer

Objective

When total laryngectomy is not required, organ preservation surgery or radiotherapy is considered the standard of care for primary glottic cancer. These accepted treatment options are available for early and advanced glottic cancers due to equivalent locoregional control and survival rates. However, in today’s climate of accountable care, the financial burden of treatment choices continues to increase in significance. We therefore compared hospital charges and treatment-related morbidity between organ-preserving surgery and radiation with or without chemotherapy—herein, (chemo)radiation—in the primary treatment of glottic cancer.

Study Design

Nationwide Inpatient Sample Database was analyzed to assess clinical and financial information.

Setting

Population-based analysis.

Subjects

Patients (N = 5499) with primary glottic cancer undergoing treatment with laryngeal preservation strategies.

Methods

Patients were subdivided by ICD-9 codes into 3 treatment groups: endoscopic resection, open partial laryngectomy, and (chemo)radiation. Treatment-related outcomes, charges, and length of hospitalization were analyzed among treatment groups.

Results

When adjusting for sex, age, race, comorbidity, and primary payer, (chemo)radiotherapy was associated with increased direct charges ( P < .001; coefficient, $23,658.99; 95% confidence interval [95% CI]: $10,227.15-$37,090.84) and length of hospitalization ( P < .001; hazard ratio, 0.593; 95% CI: 0.502-0.702) when compared with endoscopic surgery. As compared with open surgery, endoscopic surgery was associated with reduced hospital charges ( P = .012; coefficient, $11,967.01; 95% CI: $2,784.17-$21,249.85) and duration of hospitalization ( P < .001; hazard ratio, 0.749; 95% CI: 0.641-0.876).

Conclusions

This analysis suggests that increased utilization of endoscopic surgery in patients with primary glottic cancer not requiring total laryngectomy may lead to reduced financial burden and duration of hospitalization when compared with open surgery or (chemo)radiation therapy.

Significance of Tumor Stage in Sinonasal Undifferentiated Carcinoma Survival

Objective

To describe the incidence and determinants of survival of patients with sinonasal undifferentiated carcinoma (SNUC) from 1973 to 2011 using the SEER database (Surveillance, Epidemiology, and End Results), with consideration of tumor stage based on the Kadish system.

Study Design

Retrospective database analysis.

Setting

Academic medical center.

Subjects and Methods

The SEER registry was utilized to calculate survival trends for 328 patients with SNUC between 1973 and 2011. Patient data were then analyzed with respect to histopathology, age, sex, race, subsite, modified Kadish stage, tumor size, and treatments rendered.

Results

The cohort was composed of 61.9% males with median age of 60 years. The median overall survival (OS) was 1.9 years. Most tumors presented in the nasal cavity, maxillary sinus, and ethmoid sinus (29.3%, 27.4%, 21%, respectively); 43.7% of patients received both surgical and radiation therapy. OS at 2, 5, and 10 years was 43%, 30%, and 25%, respectively. On univariate analysis, age, Kadish stage, and tumor size were associated with worse OS and disease-specific survival (DSS), while surgery and radiation therapy were associated with improved OS and DSS (all P < .05). On multivariate analysis, radiation therapy and lower Kadish stage were associated with improved OS and DSS, while younger age was additionally associated with improved OS (all P < .05).

Conclusion

SNUC is a rare but aggressive sinonasal malignancy. Tumor stage as determined by the Kadish system is associated with worse survival, with radiation therapy appearing to play a key role in therapeutic management.

Hypopharyngeal venous malformation presenting with foreign body sensation and dysphagia

OBJECTIVE

Review the importance of imaging selection and clinicoanatomic correlation for a vascular malformations presenting with unique symptomatology.

METHODS

Case study and literature review.

RESULTS

A 64-year-old female presented with globus and dysphagia ongoing for 40 years. Esophagogastroduodenoscopy discovered a hypopharyngeal mass. A CT scan showed a soft tissue mass with shotty calcifications. Flexible laryngoscopy revealed a bluish compressible mass. MRI showed T2 hyperintensity with heterogeneous enhancement resulting in the diagnosis of a low-flow vascular malformation.

CONCLUSIONS

All globus is not equal. Attention to symptoms, anatomy, and imaging selection is crucial for the diagnosis and treatment of vascular malformations uniquely presenting with dysphagia.

Laryngeal oncocytic cystadenomas masquerading as laryngoceles

OBJECTIVE

To describe an experience with laryngeal oncocytic cystadenomas and review the published literature regarding this uncommon diagnosis.

METHODS AND RESULTS

A clinical review of patients presenting with cystic laryngeal masses in an urban academic medical center between January and December 2013 was performed. Three patients, two female and one male, with a mean age of 68 years, were diagnosed with oncocytic cystadenomata of the larynx. Major presenting symptoms included dysphonia, globus, and ipsilateral otalgia. Endoscopic examinations revealed a cystic structure arising from varied subsites of the larynx: laryngeal ventricle, aryepiglottic fold, and pre-epiglottic space. Cross-sectional radiographic imaging was obtained in each case. The patients were treated with transoral (CO2) laser microsurgery (TLM). In all three cases, pathological analysis revealed oncocytic cystadenoma with clear margins.

CONCLUSIONS

Oncocytic cystadenoma is a rare entity of the larynx predominantly affecting elderly patients. Clinical presentation and imaging may suggest the diagnosis of an internal laryngocele. Complete excision is both diagnostic and therapeutic, and typically can be achieved using TLM. When clear margins are obtained, no adjuvant therapy is indicated. Although laryngoceles and malignancies are more commonly encountered, oncocytic cystadenomas should remain in the differential of cystic laryngeal masses.

Hyponatremia and perioperative complications in patients with head and neck squamous cell carcinoma

BACKGROUND

Recent studies suggest that hyponatremia is associated with perioperative morbidity and mortality after general surgical procedures, as well as mortality among medical inpatients. We investigated the association of hyponatremia with perioperative complications in patients undergoing surgical resection of head and neck squamous cell carcinoma (HNSCC).

METHODS

All patients with pathologically confirmed HNSCC undergoing either primary or salvage surgical resection from March 1, 2013, until May 31, 2014, at a single tertiary care academic center were included in this retrospective review. The primary outcome was 30-day mortality. Secondary outcomes included postoperative complications (respiratory, cardiac, renal, and wound), hospital and intensive care unit (ICU) length of stay, and need for blood transfusion.

RESULTS

Two hundred fourteen surgical patients with HNSCC were identified for analysis. Patient ages ranged from 22 to 100 years (mean, 67 years). One hundred thirty-eight men and 76 women were included. Primary tumor sites were oral cavity (47.7%), oropharynx (18.7%), larynx (12.6%), salivary glands (7.9%), cutaneous (7.5%), sinonasal (2.8%), and hypopharynx (2.3%). Surgical resections were balanced between primary (48.1%) and salvage (51.9%). Thirty-five patients (16.4%) carried a presurgical diagnosis of diabetes. Fifteen patients (7.0%) demonstrated preoperative hyponatremia, and 46 (24.9%) had postoperative hyponatremia. Within the primary outcome measure, no difference in mortality was identified. Complications were noted in 58 patients (27.1%), and were more frequent in hyponatremic patients, both preoperatively and postoperatively (60.0% and 41.3%, respectively). Binomial logistic regression demonstrated risk of complications significantly associated with preoperative hyponatremia (odds ratio [OR] = 4.374; 95% confidence interval [CI] = 1.231-15.545; p = .023), increasing age (OR = 1.385; 95% CI = 1.032-1.857; p = .030), and increasing length of surgery (OR = 1.234; 95% CI = 1.046-1.455; p = .013). Postoperative hyponatremia was associated with increased hospital length of stay (p = .034).

CONCLUSION

Hyponatremia is a frequent electrolyte abnormality in patients with HNSCC. Both preoperative and postoperative hyponatremia are associated with perioperative morbidity, thus meriting intensive postoperative medical monitoring and treatment. Additional investigation is warranted to identify the pathophysiologic mechanisms behind this association. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1370-E1374, 2016.

Basaloid squamous cell carcinoma of the maxilla: Report of a case and literature review

PURPOSE

Basaloid squamous cell carcinoma (BSCC) is a rare variant of squamous cell carcinoma characterized by a highly aggressive clinical course. Though typically found in the larynx, oropharynx, and hypopharynx, we report a rare case of BSCC originating in the maxillary sinus in an otherwise healthy 32-year-old male.

MATERIALS AND METHODS

Single case report of a patient with BSCC of the maxillary sinus and retrospective chart review of all cases of BSCC of the maxilla at a single academic institution between January 1, 1986 and December 31, 2013. The MEDLINE database was additionally queried for all case series or reports of BSCC arising in the maxilla, and pertinent clinical data were extracted.

RESULTS

The clinical presentation, disease course, and management of a patient with BSCC of the maxilla are presented. In this recent case, the patient presented with persistent alveolar pain and a nonhealing tooth infection. Radiographic studies demonstrated a large necrotic mass in the left maxillary sinus that was biopsy-proven as BSCC. The patient underwent surgical resection followed by postoperative radiation without complications.

CONCLUSIONS

BSCC of the maxilla is a rare oncologic entity that may progress to late disease stage without obvious clinical signs or symptoms. Optimal treatment involves complete surgical resection followed by postoperative.

Epidemiology and treatment of lacrimal gland tumors: a population-based cohort analysis

IMPORTANCE

Primary tumors of the lacrimal gland are rare and are associated with substantial morbidity and mortality. The literature regarding these tumors is limited to case series and case reports.

OBJECTIVE

To examine the incidence, treatment, and overall survival (OS) and disease-specific survival (DSS) of patients with cancer of the lacrimal gland.

DESIGN, SETTING, AND PARTICIPANTS

Population-based cohort analysis using the Surveillance, Epidemiology, and End Results (SEER) database to identify patients with primary tumors of the lacrimal gland from 1973 to 2010.

MAIN OUTCOMES AND MEASURES

Overall survival and DSS.

RESULTS

A total of 321 patients with nonlymphoid tumors of the lacrimal gland were identified. The most common histological subtypes were adenoid cystic carcinoma (ACC) (32.1%) and squamous cell carcinoma (SCC) (29.9%). Survival analysis revealed a 5-year OS and DSS for all lacrimal gland tumors of 60% and 75%, respectively. On univariate analysis, low tumor grade (P = .04) and surgical treatment (P < .001) were associated with significantly better OS. For ACC tumors, surgery (P = .009), but not radiotherapy (P = .44), was found to significantly improve OS. For SCC tumors, surgical treatment significantly improved both OS (P < .001) and DSS (P = .004); radiation therapy also significantly improved OS (P = .03). Using a multivariable analysis model, age (hazard ratio [HR], 1.03 [95% CI, 1.01-1.04]; P < .001), surgery (HR, 0.43 [95% CI, 0.25-0.75]; P = .003), and T stage at presentation (HR, 1.18 [95% CI, 1.01-1.37]; P = .03) were found to be independent predictors of OS. For ACC alone, age (HR, 1.04 [95% CI, 1.02-1.06]; P < .001) and surgery (HR, 0.35 [95% CI, 0.13-0.91]; P = .03) were independent predictors of OS. For SCC, age (HR, 1.05 [95% CI, 1.02-1.09]; P = .005), surgical resection (HR, 0.31 [95% CI, 0.12-0.83]; P = .02), and radiation therapy (HR, 0.33 [95% CI, 0.14-0.80]; P = .01) were independent predictors of OS.

CONCLUSIONS AND RELEVANCE

Our study demonstrates that ACC is the most common malignant epithelial neoplasm of the lacrimal gland. Determinants of survival for tumors of the lacrimal gland include age at diagnosis and surgical therapy. Radiation therapy is associated with improved DSS in SCC but not in ACC.

Carcinoma ex-pleomorphic adenoma of the parotid gland consisting of high-grade salivary duct carcinoma and keratinizing squamous cell carcinoma

Carcinoma ex-pleomorphic adenoma (CXPA) is a rare salivary gland malignancy that presents diagnostic difficulties partly because of its wide range of histologic presentations. We report a case of a 77-year-old man, who presented with a 6-year history of a parotid mass that had undergone rapid growth within weeks. Magnetic resonance imaging revealed an infiltrative mass in the parotid gland, and the fine-needle aspiration (FNA) biopsy result was highly suspicious for carcinoma. Subsequent excision of the tumor demonstrated a poorly differentiated epithelial neoplasm consisting of keratinizing squamous cell carcinoma (SCC) and adenocarcinoma with regions of both ductal carcinoma in situ and invasive salivary duct carcinoma (SDC). Only focal areas exhibited a benign pleomorphic adenoma component. To our knowledge, this is the first case of a CXPA that consists of both a high-grade SDC and a keratinizing SCC in the parotid gland.

MRI criteria for the diagnosis of pleomorphic adenoma: a validation study

OBJECTIVES

To validate an MRI algorithm characteristic of pleomorphic adenoma (PA).

STUDY DESIGN

Cross-sectional analysis.

SETTING

Academic tertiary-care medical center.

METHODS

A radiologic algorithm for the MRI diagnosis of PA was developed on the basis of five "high probability" criteria that all must be fulfilled for the MRI to qualify as a positive test result: bright T2-signal, sharp margins, heterogeneous nodular enhancement, lobulated contours, T2-dark rim. We then identified MRI images from our institutional database to test the diagnostic accuracy of the proposed algorithm.

RESULTS

A total of 103 parotidectomy cases with adequate MRI studies were identified (pleomorphic adenoma n=41, mucoepidermoid carcinoma n=11, Warthin's tumor n=8, adenoid cystic carcinoma n=6, oncocytoma n=6, acinic cell carcinoma n=5, salivary duct carcinoma n=5, and other n=21). Eighteen of 21 cases that met all five "high probability" MRI criteria were consistent with PA on final histopathology; 3 were consistent with carcinoma. MRI had a specificity of 95.1% [95% confidence interval: 85.6-98.7%] and sensitivity of 43.9% [95% C.I.: 28.8-60.1%] for PA. The positive predictive value was 85.7% [95% C.I.: 70.4-100%] and the negative predictive value was 71.9% [95% C. I.: 62.0-81.9%]. The overall diagnostic accuracy was 74.8% [95% C.I.: 66.2-83.3%].

CONCLUSION

A "high probability" MRI is about 95% specific for pleomorphic adenoma. A subset of patients with MRI imaging that is highly suggestive of PA may reliably avoid further workup. The value of MRI in this setting is especially useful if preoperative fine needle aspiration is not readily available. A significant proportion of PAs, however, have indeterminate imaging features that overlap considerably with other benign and malignant lesions.

Abstract 1141: p53-dependent regulation of epithelial-to-mescenchymal transition by nf-κb in head and neck squamous cell carcinoma

PURPOSE:

In head and neck squamous cell carcinoma (HNSCC), mutations of p53 usually coexist with aberrant activation of NF-kappaB (NF-κB) and other transcription factors which promote tumor pathogenesis. However, how these factors mediate oncogenesis and metastasis is not fully understood. Herein we investigate the mechanisms by which p53 and NF-κB contribute to Epithelial-Mesenchymal Transition (EMT) in HNSCC.

EXPERIMENTAL DESIGN:

We evaluated the effects of p65 mutation on the molecular events of EMT in surgical specimens and HNSCC cell lines. We examined the correlation with tumor histologic features.

RESULTS:

In HNSCC cell lines with mutant p53, p65 knockdown promotes EMT. In contrast, in normal oral epithelial cells or HNSCC cells with WT p53, p65 over-expression, instead of knockdown, promotes EMT. Ablation of p53 in normal oral epithelial cells blocks p65 induced EMT. These findings are functionally corroborated herein in three-dimensional cell culture, anchorage-independent growth assays, and tumor cell migration assays.

CONCLUSIONS:

This is the first report indicating the role of p53 status in the NF-κB -induced promotion of EMT in HNSCC. Bortezomib-based regimens have been shown to have minimal activity in recurrent or metastatic head and neck cancer. Our new findings are important in understanding a possible basis for these clinical findings as well as defining important implications for targeted chemoprevention and therapy.

Citation Format: Yuan Lin, Jie Luo, Elliot Abemayor, Sherven Sharma, Steven Dubinett, Maie St John. p53-dependent regulation of epithelial-to-mescenchymal transition by nf-κb in head and neck squamous cell carcinoma. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 1141. doi:10.1158/1538-7445.AM2014-1141

Esthesioneuroblastoma: an update on the UCLA experience, 2002-2013

Objectives To profile the clinical presentation and treatment results of esthesioneuroblastomas at the University of California, Los Angeles (UCLA), from 2002 to 2013. Design Retrospective review. Setting Tertiary academic institution. Participants Forty-one patients with esthesioneuroblastomas treated at UCLA. Main Outcome Measures Overall survival (OS) and recurrence-free survival (RFS). Results Thirty-six patients were included with a mean age of 50.1 years and a median duration of follow-up of 33 months. The 5-year RFS and OS were 54% and 82%, respectively. Modified Kadish stage was the only factor identified to affect OS. Multivariate analysis demonstrated that tumor grade was the only factor that had an independent impact on RFS. There was no statistical difference in survival among the surgical approaches chosen. Conclusions The updated data on the UCLA experience reveals that all three surgical approaches chosen provide comparable survival, although longer follow-up will be needed to ascertain if these findings hold true. The endoscopic approach had a statistically significant decrease in length of hospital stay and a trend toward reduced blood loss, intensive care unit admission, and complications. The modified Kadish staging was the only factor identified to predict OS. Multivariate analysis revealed that tumor grade was an independent predictor of recurrence; therefore, its importance should be emphasized in future staging systems.

Adenoid Cystic Carcinoma of the Lacrimal Gland: A Case Report with a Review of the Literature

Adenoid cystic carcinomas, the most common malignancies of the lacrimal gland, are rare overall. We describe a patient who presented with right periorbital swelling developing over 5 months and magnetic resonance imaging findings of a soft tissue mass in the lacrimal fossa with invasion of the adjacent bone. The patient underwent right lateral orbitotomy with tumor debulking. Pathologic analysis showed neoplastic cells in a predominantly cribriform pattern, and the patient was diagnosed with an adenoid cystic carcinoma of the lacrimal gland. We review the clinical, radiographic, and histopathologic features of these rare, aggressive malignancies as well as treatment options with reference to the current literature.

Head and neck sarcomas: the UCLA experience

PURPOSE

To profile the clinical presentation, subtype distribution, and treatment results of sarcomas of the head and neck at a single tertiary academic center over an 11-year period.

MATERIALS AND METHODS

A retrospective review was performed by examining the records and reviewing the pathology of 186 patients with head and neck sarcomas treated at UCLA Medical Center from 2000 to 2011.

RESULTS

The mean age of the study population was 49 ± 22 years. 58% of the patients were male and 42% were female. Median duration of follow-up for the entire group was 18.5 months. The most common presenting symptom was a mass lesion in 59.9% of patients. The nasal cavity/sinus was the most common presenting site seen in 22% of patients. Solitary fibrous tumor/hemangiopericytoma was the most common subtype. 15% of patients had evidence of prior radiation exposure. 26.3% of tumors were greater than 5 cm and 35.5% were high-grade. Margins were positive in 31.2% of patients. Lymph node metastasis was rare at 6.5%. Perineural invasion was identified in 6.5%. Among all subtypes, 5-year recurrence-free survival and overall survival were 50% and 49%, respectively. Multivariate analysis demonstrated that grade and margin status were predictors of recurrence-free survival while grade and age affected overall survival.

CONCLUSIONS

Head and neck sarcomas are a rare entity frequently presenting as a mass lesion. In our series, lesions tended to be high-grade with a significant portion of surgical specimens having positive margins. Grade and margin status were the most important predictors of survival.

The emerging landscape of salivary diagnostics

Saliva as a diagnostic tool provides a noninvasive, simple and low-cost method for disease detection and screening. Saliva collection is more practical and comfortable compared with other invasive methods, and saliva can be a desirable body fluid for biomarker detection in clinical applications. The integration of omics methods has allowed accurate detection and quantification of transcripts found in saliva and a group of biomarkers has been discovered and validated in a series of studies. Here we review recent developments in salivary diagnostics that have been accomplished using salivaomics, the mechanisms of saliva diagnostics, as well as the translational and clinical application of saliva biomarkers.

Solitary fibrous tumor of the larynx: case report demonstrating the value of MRI in guiding surgical management

A 74-year-old woman presented with persistent dysphagia, dysphonia, and throat gurgling. Prior intraoperative biopsies were negative, and outside imaging revealed supraglottic swelling. Magnetic resonance imaging (MRI) demonstrated a well-defined T1 and T2 hypointense, avidly enhancing hypopharyngeal mass. Deep intraoperative rebiopsies revealed a tumor with CD34+ tissue, diagnostic of a solitary fibrous tumor. A broad range of nonsquamous cell tumors should be considered when a submucosal laryngeal mass is encountered. MRI may be particularly helpful in guiding appropriate biopsy.

Are We Following Treatment Guidelines for Papillary Thyroid Carcinoma? Cost Implications: A SEER-Medicare Study

Objectives:

The National Comprehensive Cancer Network (NCCN) guidelines are evidence-based management algorithms for papillary thyroid carcinoma (PTC). We sought to determine whether actual practice patterns coincide with these guidelines and whether management outside NCCN guidelines affected Medicare costs.

Methods:

Surveillance, Epidemiology, and End Results (SEER) Medicare linked data were examined to determine treatment patterns for 4,582 patients with PTC from 1988-2007 that met our inclusion criteria. Indications for lobectomy, total thyroidectomy, and postoperative radioactive iodine ablation (RAI) were based on NCCN guidelines, including tumor size, extrathyroidal extension, positive lymph nodes, and aggressive histology. The cost related to PTC treatments was Medicare payments linked directly to each treatment’s claim code.

Results:

Seventy-six percent underwent total thyroidectomy, and 34% underwent thyroid lobectomy. According to NCCN guidelines, 90% received appropriate surgical management. Of patients with aggressive features based on NCCN guidelines, 33.4% should have received RAI. Based on intermediate tumor size, positive lymph nodes, and aggressive histology, 37.7% would have benefited from RAI. Of patients with tumors less than 1 cm and no ETE, 42% should not have received postoperative RAI. Patients undergoing thyroid lobectomy cost Medicare $50,175, while total thyroidectomy cost $54,455 ( P = 0.293). Postoperative RAI cost Medicare approximately $47,652 yearly.

Conclusions:

Ninety percent of patients received appropriate surgical management. However, 40% of patients did not receive appropriate postoperative RAI management. As the incidence of PTC rises, the use of evidence-based guidelines can reduce cost attributed to Medicare.

A Novel Modular Polymer Platform for the Treatment of Head and Neck Squamous Cell Cancer

Objectives:

Evaluate the therapeutic efficacy of a novel modular polymer platform in the treatment of head and neck squamous cell carcinoma (HNSCC). 50% of HNSCC patients fail primary management, and salvage of the recurrent disease patient is of paramount importance.

Methods:

Study Design: In vivo study. Setting: Academic research laboratory. C3H/HeJ mice were randomized to receive implantation of 1) no polymer; 2) plain polymer; 3) plain polymer containing gene-modified dendritic cells over-expressing CCL21 (DC-AdCCL21); and 4) plain polymer with concurrent daily CCL21 injections. Tumor size was measured until the mice were euthanized. At necropsy, the tumors were excised and weighed.

Results:

Our results using this novel polymer platform demonstrate a remarkable reduction in tumor growth. The dendritic cell CCL21 secreting polymer effectively reduced SCCVII/SF tumors in the C3H/HeJ mice by over 16-fold ( P < 0.01) as compared to control, plain polymer, and plain polymer + intratumoral CCL21 injection groups. We also demonstrate that we can effectively grow dendritic cells in the polymer that can actively secrete CCL21. Treatment with the dendritic cell CCL21 secreting polymer led to a marked reduction in tumor burden with extensive mononuclear cell infiltration of the tumors.

Conclusions:

Our promising results indicate that this polymer may represent a new therapeutic modality for patients with HNSCC. Our data provide a strong rationale for further evaluation of this DC-AdCCL21 polymer in regulation of tumor immunity and genetic immunotherapy for HNSCC. Once this polymer platform is further optimized, we will plan for the ultimate validation in the context of a prospective trial in patients with unresectable advanced or recurrent HNSCC.

Abstract 1490: p38 MAPK mediates epithelial-mesenchymal transition by regulating p38IP and snail in head and neck squamous cell carcinoma (HNSCC)

Objectives:

Understanding the molecular mechanisms that mediate HNSCC metastasis may enable identification of novel therapeutic targets. We have reported the role of the E-cadherin transcriptional repressor, Snail, in the inflammation-induced promotion of EMT in HNSCC. Herein we demonstrate that inflammatory mediators also upregulate p38 and p38 interacting protein (p38IP), thus further defining the cycle by which inflammation promotes tumor progression.

Methods:

A molecular biology study. Real-time quantitative reverse transcriptase-polymerase chain reaction (RT-PCR), Western blot analysis, and 3-D spheroid culture were used to determine how inflammation affects p38, p38IP and EMT.

Results:

p38 kinase inhibitor treated, and p38 shRNA HNSCC cell lines demonstrated a significant upregulation in E-cadherin mRNA and a decrease in the mRNA expression of the transcriptional repressor Snail. p38 shRNA HNSCC cell lines show a less invasive phenotype in a spheroid model, and demonstrate decreased tumor growth in a SCID mouse model. An inverse relationship between p-p38 and E-cadherin was demonstrated in situ by immunohistochemical staining of human HNSCC tissue sections. Activation of p38 is required for the robust IL-1β induced E-cadherin downregulation and Snail upregulation. IL-1β increases p-p38 and has a more rapid and robust effect on p38. Snail overexpression also enhanced p-p38 in vitro. Inhibition of p38 blocked HNSCC tumor growth in vivo. p38 activates p38IP, a p38 downstream component in STAGA transcriptional activator complex, in HNSCC cell lines. p38 bound to and stabilized p38IP, a subunit of histone acetyltransferase STAGA, resulting in enhanced transcription of Snail. Inhibition of p38IP blocked HNSCC migration and invasion both in vitro and in vivo. In HNSCC patient samples, p38IP expression was increased compared to adjacent normal tissue.

Conclusions:

In gastrulation, a Snail-independent P38/P38IP pathway is required in the primitive streak to downregulate E-cadherin expression at the posttranscriptional level. Herein we provide the first report that in HNSCC a snail-dependent p38/p38IP pathway is essential for E-cadherin down-regulation and cell invasion. Our work herein demonstrates for the first time that a snail-p38/p38IP feedback loop jointly down regulates E-cadherin and drives a potent EMT in HNSCC. This newly defined pathway has important implications for targeted chemoprevention and therapy.

Citation Format: Yuan Lin, Guangyu Wang, Jie Luo, Chi Lai, Elliot Abemayor, David Elashoff, Steve Dubinett, Maie A. St. John. p38 MAPK mediates epithelial-mesenchymal transition by regulating p38IP and snail in head and neck squamous cell carcinoma (HNSCC). [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 1490. doi:10.1158/1538-7445.AM2013-1490