Management of the clinically negative neck (N0) of supraglottic laryngeal carcinoma: a systematic review

AIM

The most effective therapeutic approach for patients with supraglottic laryngeal carcinoma (SGLC) and clinically negative neck (cN0) remains a subject of much debate. The purpose of this systematic review was to answer the following question: among patients with SGLC and cN0 neck, are the survival and occurrence of neck metastases significantly different between patients that received neck dissection and those that had another therapeutic treatment (radiotherapy, combined therapy, 'wait and see' policy)?

MATERIALS AND METHODS

An electronic literature search was performed in MEDLINE, EMBASE, Cochrane Library and CENTRAL databases, followed by extensive hand-searching for the identification of relevant studies. The following inclusion criteria were established: the study should (a) include a comparison of neck dissection with one of the other therapeutic procedures for cN0 of SGLC; (b) report the therapy for the initial supraglottic cancer; and (c) use time-to-event analysis of its results. Six studies were eventually identified and systematically reviewed.

RESULTS

All studies included in the systematic review were retrospective (n=792 patients). The survival (overall, disease-specific and neck disease-free) and the site of neck recurrence of the patients with N0 supraglottic cancer were not significantly different between patients in the neck dissection treatment group and those of the rest of the therapeutic strategies examined (neck radiotherapy, combined therapy and 'wait and see' policy).

CONCLUSIONS

The present systematic review highlights the need for further well-designed prospective studies that will provide more reliable answers to the debatable issue of the management of cN0 of SGLC. Currently, based on the best available evidence, it seems that neck dissection is not superior to radiotherapy or combined therapy or a 'wait and see' policy in terms of survival and control of neck disease.

Preoperative evaluation, surgical procedure, follow up and results of 150 cochlear implantations

BACKGROUND

The cochlear implantation is among the most important achievements of medicine and biotechnology in the last 20 years, because it allows individuals who had never heard or had lost their hearing to perceive sound and improve their quality of life. Selection criteria for candidates are strict and are evaluated in each individual by a scientific committee specially trained for implantations which includes Ear Nose and Throat (ENT) surgeon, audiologist, psychiatrist and speech therapist.

PATIENTS AND METHODS

In our department, the first cochlear implantation was performed in 1995. During the last ten years more than 250 individuals have been evaluated due to profound hearing loss and 170 of them were found to be suitable candidates for cochlear implantation. One hundred and fifty (150) have already been operated and most of them are children with congenital hearing loss. No major or permanent complications were recorded in any of our 150 patients. Activation and fitting/mapping of the cochlear implant is initiated three weeks post-operatively. Regular follow-up and mapping of the implant are held, more frequently in children, along with specialized speech therapy. Each new mapping is evaluated according to the record of the patient with regard to the acoustic perception of sounds and speech and the discrimination of individual elements of phonation based on a protocol that we have created for the needs of Greek language.

RESULTS

Speech discrimination (AHEPA Hospital protocol), before the Implantation, at the activation of the cochlear implant and till 4 years of the follow-up showed that in our patients, we obtained better and faster results in post-speech acquisition adults with recent or chronic deafness and in children with congenital deafness operated before the 5th year of age, who underwent special preoperative speech therapy programme, fact which is in agreement with current literature. Patient satisfaction evaluated by "Sanders" psychometrics tests, was achieved in accordance to pre-operative expectations.

CONCLUSIONS

In our patients, we observed better and faster results in children with congenital deafness operated before the third year of age, in post-speech acquisition adults with recent deafness and in post-speech acquisition adults with chronic deafness but with auditory memory reserve.

Distribution of organotin compounds in the bivalves of the Aegean Sea, Greece

Five bivalve species--Mytilus galloprovinciallis (Mediterranean mussels), Venus gallina (stripped venus), Modiola barbatus L. (bearded horse mussels), Pecten jacobeus (scallops) and Callista chione (hard clams)--were collected from seven areas in Aegean Sea, Greece, between August 2001 and January 2003 and analyzed for organotins (OTs). The concentrations (as geometric means) found were 17.1 ng g-1 for tributyltin (TBT), 18.8 ng g-1 for dibutytltin (DBT), 7.8 ng g-1 for monobutyltin (MBT) and 13.0 ng g-1 for triphenyltin (TPhT) (wet weight), which are at similar or lower levels than those reported worldwide. Studying OTs distribution between different bivalve species, lower concentrations were observed in mediterranean mussels, possibly due to their growth in water column (grown on sea net pens in mussel farms), in contrast to the free-ranging species, collected from fishing grounds. Concentrations of the OTs in the examined bivalves varied seasonally.

Occurrence patterns of pharmaceuticals in water and wastewater environments

The occurrence of pharmaceuticals and their metabolites and transformation products in the environment is becoming a matter of concern, because these compounds, which may have adverse effects on living organisms, are extensively and increasingly used in human and veterinary medicine and are released continuously into the environment. A variety of pharmaceuticals have been detected in many environmental samples worldwide. Their occurrence has been reported in sewage-treatment-plant effluents, surface water, seawater, groundwater, soil, sediment and fish. This paper provides an overview of recent scientific research on the sources, occurrence, and fate of pharmaceuticals in water and wastewater.

Fenton and photo-Fenton treatment of a synthetic tannin used in leather tannery: a multi-approach study

The aim of this work was to compare the behaviour of Fenton and photo-Fenton (UV-A, UV-C) processes to treat synthetic tannin (syntan) used in leather tannery which is one of the most polluting industries, releasing many xenobiotics. Both oxidation processes were performed at pH 3.0 and temperature 40-45 degrees C, which is the original temperature of the re-tanning process, in synthetic solutions containing 100 and 300 mg/L of COD equivalent of syntan. The efficiency of the applied oxidation processes was monitored by chemical oxygen demand (COD), oxidation redox potential (ORP) and aromaticity (UV280) and double bond (UV254) absorbance measurements. Acute toxicity test on Daphnia magna was performed to monitor toxicity in untreated and treated syntan solution. Gas chromatography-mass spectrometry (GC-MS) was applied to identify by-products of partial oxidation occurring in treated samples. The effective ratio of H2O2/FeSO4 for photo-Fenton processes was found to be feasible in terms of reagents used in the process.

Paclitaxel and gemcitabine vs. paclitaxel and pegylated liposomal doxorubicin in advanced non–nasopharyngeal head and neck cancer. An efficacy and cost analysis randomized study conducted by the Hellenic Cooperative Oncology Group

BACKGROUND

The prognosis of patients with recurrent and/or metastatic head and neck cancer (HNC) is poor. Median survival of these patients following chemotherapy is in the range of 6 to 9 months. In the present randomized phase III trial we compared two new combinations containing new drugs with proven activity in phase II studies with patients with HNC.

PATIENTS AND METHODS

From November 1999 until November 2004, 166 eligible patients with HNC were enrolled in the study. They were treated with paclitaxel 175 mg/m(2) on day 1 and gemcitabine 1000 mg/m(2) on days 1 and 8 every 3 weeks (group A, 85 patients) or with paclitaxel, as in group A, and pegylated liposomal doxorubicin 40 mg/m(2) on day 1 every 4 weeks (group B, 81 patients).

RESULTS

There was no significant difference in response rate (20% versus 29%, P = 0.21), time to disease progression (median; 4.4 months versus 6.0 months, P = 0.09) and survival (median; 8.6 months versus 11.05 months, P = 0.25). Both regimens were generally well tolerated. The most frequently reported side effect, apart from alopecia, was neutropenia. Overall, there was no significant difference in severe toxicity between the two treatment arms.

CONCLUSIONS

The present study could not demonstrate a survival benefit with either regimen. Both treatments were well tolerated. Randomized studies comparing each of the two regimens with standard chemotherapy are warranted.

Prognostic value of VEGFC, HER2 and HER3 gene expression in recurrent squamous cell head and neck tumors

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Background: The main prognostic variables of head and neck squamous cell carcinoma (HNSCC) are the location and size of the tumor and the presence of cervical lymph node metastases. Differential gene expression of members of the HER and VEGF families is a common feature in HNSCC. To elucidate the prognostic value and the interrelation of these factors we performed a detailed gene expression analysis within HNSCC tissue samples Methods: We analyzed fresh frozen tissue from 48 recurrent HNSCC tumors stored at -80oC. RNA was isolated with the RNeasy kit (Qiagen, Inc.), followed by kinetic one-step RT-PCR for the expression of 8 candidate genes (EGFR, HER2, HER3, HER4, VEGFA, VEGFB, VEGFC and VEGFD). Raw data (Ct values) were normalized to RPL37A expression (housekeeper gene) and candidate gene expression between patient groups with differential clinical outcomes was analyzed by using Genedata Expressionist and GraphPad Prism 4 software packages. Median patient follow-up from initial diagnosis was 27 months. Results: Overexpression of VEGFA and EGFR was prominent in most tumors, but did not appear to have any prognostic value. However, VEGFC expression was significantly higher (p = 0.0002) in the tumors of patients with poor overall survival (< 27 months). Interestingly, these tumors were further characterized by significantly lower expression levels of HER2 and HER3. Median survival of patients with tumor VEGFC expression levels of >600 was calculated to be 42 months from initial diagnosis (Kaplan-Meier Survival Analysis), compared to 182 months in the rest of the patients. Conclusions: We have found that elevated VEGFC expression and low expression of HER2 and HER3 correlate with poor outcome in recurrent HNSCC patients. VEGFC preferably binds to the VEGFR3, which is predominantly expressed on lymphatic vessels. Overexpression of VEGFC may therefore result in the establishment of intratumoral lymphatic vessels, which have been shown to facilitate the dissemination of tumor cells into lymph nodes and the formation of distant metastases. We conclude that the determination of VEGFC, HER2 and HER3 expression may be of high prognostic value in HNSCC patients and that it may serve in the early identification of aggressive HNSCC subtypes.

No significant financial relationships to disclose.

Laryngeal tuberculosis presenting as supraglottic carcinoma: case report and literature review

Laryngeal tuberculosis is a rare extra-pulmonary manifestation of tuberculosis, and frequently presents with tumour-like symptoms and clinical findings. Uncommon clinical features are to be expected by the ENT specialist, who should be aware of these recently changing presentations. Despite the dramatic reduction of the incidence of the disease during the last few decades, a perceptible increase in case reports has lately been noted and may prove significant. Treatment remains conservative and long-term follow-up is suggested. A relevant case of laryngeal tuberculosis presenting as a supraglottic carcinoma is presented, its diagnosis and management are detailed, and suggestions are offered based on a literature review.

Aerobic biodegradation of organotin compounds in activated sludge batch reactors

The biodegradation behavior of four organotin (OT) compounds, namely tributyltin (TBT), dibutyltin (DBT), monobutyltin (MBT) and triphenyltin (TPhT), was studied in lab-scale activated sludge batch reactors. The activated sludge was spiked with the OT compounds at a level of 100 microg l(-1) as Sn. Determination of the OT compounds by GC-FPD after ethylation in the dissolved and particulate phase revealed that 24 h after the start of the experiments, almost the total of OT compounds has been removed from the dissolved phase and is associated with the suspended solids. Calculation of mass balance in batch reactors showed that OT compounds biodegradation was performed via a sequential dealkylation process. Removals due to biodegradation were differentiated according to the parent compound. In experiments with non-acclimatized biomass, a percentage of 27.1, 8.3, 73.8 and 51.3 was still present as TBT, DBT, MBT and TPhT, respectively, at the end of the experiment (18th day). Half-lives (t1/2) of 10.2 and 5.1 days were calculated for TBT and DBT, respectively, whereas apparent t1/2 values could not be determined for MBT and TPhT (t1/2>18 days). The capacity of activated sludge to biodegrade OT compounds in the absence of supplemental substrate indicated that these compounds can be metabolized as single sources of carbon and energy in activated sludge systems. Excluding TBT, the presence of low concentrations of supplemental substrate did not affect the biodegradation potential of activated sludge. The acclimatization of biomass on OT compounds enhanced significantly biodegradation, resulting in significant decreases of half-lives of OT compounds. As a result in the presence of acclimatized biomass, half-lives of 1.4, 3.6, 9.8 and 5.0 days were calculated for TBT, DBT, MBT and TPhT, respectively.

Long-term treatment of deep venous thrombosis with a low molecular weight heparin (tinzaparin): a prospective randomized trial

OBJECTIVES

Evaluation of the effectiveness and safety of the low molecular weight heparin (LMWH) tinzaparin versus unfractionated heparin (UFH) followed by acenocoumarol in proximal deep venous thrombosis (DVT).

DESIGN

Prospective, randomized clinical trial.

MATERIAL AND METHODS

Consecutive patients (n=108) with acute leg DVT, confirmed by duplex, were randomized to either tinzaparin alone or UFH and acenocoumarol for 6 months. Patients were evaluated ultrasonographically at entry, 1, 3, 6 and 12 months. Thrombus regression, reflux distribution and the incidence of complications were studied. A cost-analysis, comparing the two treatments, was performed.

RESULTS

The overall incidence of major events (mortality, DVT recurrence, pulmonary embolism, major bleeding, heparin-induced thrombocytopenia) was significantly different (p=0.035) in favor of tinzaparin (7 versus 17 events). The ultrasonographic clot volume score (an index of recanalization) decreased significantly in both treatment groups. However, tinzaparin produced significantly more extended overall recanalization from 3 months onwards (p<0.02). Thrombus regression was equivalent or in favor of tinzaparin in the different DVT subgroups and venous segments, but the statistical significance varied. Reflux showed non-significant differences overall or in subgroups. A cost-analysis resulted in favor of LMWH.

CONCLUSIONS

A fixed daily dose of tinzaparin for 6 months was at least as effective and safe as UFH and acenocoumarol. Regarding major events and recanalization, there was a significant benefit in favor of tinzaparin. Long-term DVT treatment with tinzaparin could represent an alternative to conventional treatment.

Factors influencing tumour relapse after total laryngectomy

OBJECTIVES

To determine the prognostic factors predictive of tumour recurrence after surgical treatment for laryngeal carcinoma with total laryngectomy.

STUDY DESIGN/METHODS

Retrospective review of 308 patients with laryngeal carcinoma who underwent total laryngectomy in the ENT Department of AHEPA University Hospital between 01/01/1992 and 31/12/1999. In 238 patients, total laryngectomy was performed as primary treatment of laryngeal carcinoma, and in 70 others as treatment of tumour recurrence following radiotherapy or partial surgery. Follow-up was standardized, following a strict protocol, the mean follow-up time was 68 months.

RESULTS

During post-operative follow-up, recurrences were observed in 96 of 308 patients (31%). The relapse rates were 27% (65 of 238) for patients treated with primary total laryngectomy, and 44% (31 of 70) for those treated for recurrence following previous treatment. The difference in relapse rates was statistically significant. In 39 of 238 (16%) cases treated with primary total laryngectomy cervical lymph node infiltration was present at diagnosis and radical or modified neck dissection was performed. The tumour recurrence rate in this group was 46% (18 of 39), while in metastatic node-free patients the relapse rate was 24% (47 of 199) [p < 0.05]. Primary laryngectomy was effective in 82% of glottic, 70% of supraglottic, and only 59% of transglottic carcinoma. Concerning primary tumour extension at the time of surgery, total laryngectomy proved effective in 85% of T2 tumours, 81% of T3, and only 55% for T4. The higher recurrence rates for supraglottic and transglottic tumours seem related mainly to the higher rates of cervical lymph node metastasis at diagnosis. The majority of tumour recurrences were observed during the first two years of post-operative follow-up. Thus, 76% of the 308 patients remained disease-free after the first year of post-operative follow-up, 68% after the second year, and 67% after the fifth follow-up year. Of the 96 recurrences documented until now, 91 were loco-regional (19 at the tracheostomy), and only 5 involved distant metastases. Sixteen of the 308 patients (5%) subjected to total laryngectomy have since developed second primary neoplasms, most often involving the lungs (10 patients).

CONCLUSIONS

Prognostic factors for recurrence following total laryngectomy include: performance of total laryngectomy as salvage surgery, degree of tumour extension, infiltration of cervical lymph nodes at the time of initial diagnosis, poor initial tumour differentiation and trans-glottic/sub-glottic tumour localization.

Evaluation of the pollution of the surface waters of Greece from the priority compounds of list II, 76/464/EEC directive, and other toxic compounds

The pollution of the surface waters of Greece from the priority compounds of 76/464/EEC Directive was evaluated. The occurrence of 92 toxic compounds, 64 of which belong to priority compounds of List II, candidates for List I, of 76/464/EEC Directive, was studied in surface waters and wastewater through the developed network of 62 sampling stations, which covers the whole Greek territory. The analytical determination was performed by Purge and Trap-Gas chromatography-Mass spectrometry for volatile and semivolatile organic compounds (VOCs), Gas Chromatography-Electron Capture Detection for organochlorine insecticides, Gas Chromatography-Nitrogen Phosphorous Detection for organophosphorous insecticides, High Performance Liquid Chromatography-Photodiode Array Detection for herbicides, and Electrothermal Atomic Absorption Spectrophotometry and Inductively Coupled Plasma-Atomic Emission Spectrometry (ICP-AES) for metals and the toluene extractable organotin compounds. The concentrations of VOCs and insecticides detected in the surface waters of Greece were very low, whereas the concentrations of herbicides and metals ranged generally at moderate levels. VOCs were detected almost exclusively in the rivers and very rarely in the lakes, while the frequency of occurrence of insecticides, herbicides and metals was similar for rivers and lakes. Water quality objectives (WQO) and emission limit values (ELV) have been laid down in national legal framework for a number of compounds detected in the samples, in order to safeguard the quality of surface waters from any future deterioration.

Video-assisted transcervical thymectomy

BACKGROUND

The optimal surgical approach for complete removal of the thymus gland has long been debated. In this report, the excision of the entire gland through a transcervical incision using video-assisted techniques is described.

METHODS

Ten patients, including one with thymoma and myasthenia gravis, underwent surgery via the transcervical approach. After standard dissection up to the level of the innominate vein and ligation of the thymic vessels, a laparoscope was inserted into the mediastinum. In the patient with thymoma, the operation was completed by a small incision in the third intercostal space.

RESULTS

No perioperative mortality or long-term morbitity was observed. The mean hospital stay was 69.6 h. After a mean follow-up period of 63.8 months, eight patients displayed complete remission, whereas one continued to receive minimal medication. The patient with thymoma showed considerable improvement, but remained on same medical regimen No complications were seen throughout the study.

CONCLUSION

Video-assisted thymectomy improves effectiveness of the transcervical approach for thymectomy with a minimum of trauma and excellent results.

Greek adolescents, fitness, fatness, fat intake, activity, and coronary heart disease risk

BACKGROUND

A dramatic increase in adult mortality rates from coronary heart disease (CHD) in Greece, accompanied by increased prevalence of CHD risk factors in children, has been documented. However, there is controversy about the independent effects of certain lifestyle parameters on primary CHD risk factors.

AIMS AND METHODS

To examine the association between CHD risk factors (HDL-C, LDL-C, HDL-C/TC, triglycerides, systolic and diastolic blood pressure) and lifestyle parameters (fitness, fatness, fat intake, and physical activity) in 210 12-year old Greek pupils.

RESULTS

Correcting for the fixed factors of gender and maturation, analyses of covariance (ANCOVA) with backward elimination of the lifestyle covariates revealed significant associations between three CHD risk factors (HDL-C, HDL-C/TC, systolic blood pressure) and physical activity levels. In contrast, the covariates aerobic fitness, fatness and fat intake failed to reach significance with any of the CHD risk factors.

CONCLUSIONS

In Greek schoolchildren, primary CHD risk factors are mainly associated with physical activity levels, independently of fitness, fatness, and/or fat intake. Prevention strategies should concentrate on enhancing physical activity early in life, if the increased prevalence of Greek adult CHD mortality is to be diminished.

Monitoring priority substances of directives 76/464/EEC and 2000/60/EC in Greek water bodies

The priority substances of List I, 76/464/EEC Directive, some of which belong to the new Water Framework Directive 2000/60/EC, have been monitored in the surface waters of Greece through the developed network of 53 sampling stations. The analytical methods used for the determination of these substances included Purge and Trap-Gas chromatography-Mass spectrometry for volatile and semivolatile organic compounds, Gas Chromatography-Electron Capture Detection for organochlorine insecticides, High Performance Liquid Chromatography for pentachlorophenol and Atomic Absorption Spectrometry for metals. The results have shown the presence of several priority substances in Greek surface waters, in most cases at concentrations well below the regulatory limits. However, non-compliance was observed for a limited number of compounds. The monitoring network and the analytical determinations have to be expanded to more water bodies and more priority substances, in order to safeguard the quality of Greek surface waters.

Management of tracheal stenosis with a titanium ring and nasal septal cartilage

Surgical management of subglottic laryngeal and upper tracheal stenosis remains a formidable challenge. The significant number of proposed techniques only highlights the difficulties associated with effectively managing this problem. Between 1996 and 1999, seven patients with stenosis of the upper trachea were treated. The stenosis resulted from long-term intubation during intensive-care hospitalization in five patients and from tracheotomy complications in the other two. Six patients were male and one female, their ages ranging between 13 and 60 years. The mean postoperative observation period was 3 years (1.5-4.5 years). In all patients, the stenosis exclusively involved the upper tracheal segment, measuring from 2 to 5 cm in length. The stenotic area of the trachea is exposed, and the local application of a solution of mitomicin C for a duration of 4 min is performed. A graft consisting of cartilage and mucosa is harvested from the nasal septum and is fixed with sutures to a titanium semi-ring. After the fixation of the graft on the ring, the entire construct is placed on the stenosed segment of the exposed trachea. The graft must cover the anterior exposed face of the trachea with the lateral members of the semicircular titanium ring adjacent to the lateral walls of the trachea, externally. The lateral tracheal walls are attracted laterally with sutures and are attached on the edges of the semicircular titanium ring. Four of the patients in whom no tracheotomy had been performed preoperatively needed none at all intraoperatively, and they were decannulated normally at the end of the procedure. Tracheotomy was deemed necessary for one patient's safety and was maintained for 7 days. In one patient with a preoperative tracheotomy, the point of the tracheotomy was displaced lower on the trachea and was maintained there for 7 days. The course of management described here and employed on seven patients involves a safe surgical procedure with excellent results. The placement of the titanium ring offers very good support for the graft and maintains the patency of the tracheal lumen. The main reasons for the failure of techniques using only cartilage grafts are therefore avoided. The number of cases presented here is certainly too small to establish definite conclusions; however, the initial results are extremely satisfying and urge us to suggest the use of this method in indicated cases.

How often is total laryngectomy necessary for the treatment of T1 failures after radiotherapy or cordectomy?

Between 1992 and 1998, 547 patients (pts) with laryngeal SCC were diagnosed and treated in our department, 145 (27%) of whom presented with glottic tumors T1N0M0 (125 T1a and 20 T1b). Seventy-eight (54%) were treated surgically with cordectomy and 67 (46%) with radiotherapy. After a median follow-up time of 43 months, 22 (15.2%) of the 145 pts presented with recurrent disease. In more detail, 16 (13%) of the 125 T1a pts and 6 (30%) of the 20 T1b pts had recurrences. Among the 78 surgically treated patients only 4 (5%) had recurrence, while 18 (27%) of the radiotherapy group relapsed. The difference is statistically significant (log rank test, P = 0.0001 < 0.05). After salvage treatment, of the 67 pts of the radiotherapy group 57 (85%) remain disease-free, 49 (73%) retaining their larynx intact and 1 only having undergone cordectomy. Among the cordectomy group 75 (96%) pts remain disease-free with only 1 having had a total laryngectomy. Using the Kaplan-Meier method and calculating the disease-free survival regardless of salvage treatment, there is no doubt that surgical treatment statistically is more successful than radiotherapy (log rank test, P = 0.01 < 0.05). Analysis of parameters such as tumor differentiation and T1a or T1b staging, which indeed influence the overall recurrence rate, did not alter the favorable outcome after surgical treatment.

Factors influencing quality of life in laryngectomized patients

The aim of this study is to estimate the quality of life postlaryngectomy. A questionnaire was used. Fifty-six patients were enrolled answering 26 questions. The mean age was 60.2 (40-76) years and median post-treatment time 43 (7-120) months. The most frequent complaints of the patients were increased bronchial discharge (66%) and reduced olfactory function (63%). Communication problems with strangers was mentioned by 57% and with their family by 29%. With regard to the psychological status, 30% were ashamed of their voice, 32% were ashamed of their appearance, 42% stated that they were rather depressed, and 30% were feeling lonely. More than 3 out of 4 patients believed that their everyday life had been altered. Half of the patients experienced financial difficulties and 37% were not participating in social meetings outside their house. Statistical analysis was used in order to calculate the severity of each category of problems which the patient faced using the scale from 0 to 1. The average grade for functional disorders was 0.31, for communication problems 0.47, for psychological problems 0.29, for social problems 0.27, and for financial problems 0.51.

Paclitaxel and gemcitabine in advanced non-nasopharyngeal head and neck cancer: a phase II study conducted by the Hellenic Cooperative Oncology Group

BACKGROUND

Paclitaxel as monotherapy or in combination with other drugs has demonstrated significant activity in patients with squamous cell carcinoma of the head and neck region (SCCHN). Preclinical studies have shown gemcitabine to be highly active in SCCHN cell lines.

PURPOSE OF THE STUDY

To evaluate the activity and toxicity of the combination of paclitaxel by three-hour infusion and gemcitabine as first-line chemotherapy in patients with recurrent and/or metastatic head and neck cancer (HNC).

PATIENTS AND METHODS

From September 1996 until May 1998, 44 patients with non-nasopharyngeal recurrent and/or metastatic HNC entered the study. There were 37 men and seven women with a median age of 61 years (range 35-79) and a median performance status of 1 (range 0-2). The location of the primary tumor in the majority of them was either the larynx or the oral cavity. Treatment consisted of six cycles of gemcitabine 1100 mg/m2 over 30 min on days 1 and 8 immediately followed on day 1 by paclitaxel 200 mg/m2 by three-hour infusion. The treatment was repeated every three weeks.

RESULTS

Twenty-four (55%) patients completed all six cycles of treatment. A total of 205 cycles were administered, 165 (81%) of them at full dose. The median relative dose intensity (DI) of gemcitabine was 0.93 and of paclitaxel 0.95. Except for alopecia, which was universal, grade 3-4 toxicities included neutropenia (21%), thrombocytopenia (5%), anemia (5%), infection (5%), flu-like syndrome (5%) and peripheral neuropathy (2%). Five (11%) patients achieved complete and 13 (30%) partial responses, for an overall response rate of 41%. After a median follow-up of 13 months, the median time to progression was four months and median survival nine months.

CONCLUSIONS

The combination of paclitaxel and gemcitabine is active and well tolerated in patients with recurrent and/or metastatic HNC-randomized studies comparing this combination with other regimens are warranted.