Preoperative cisplatin and bleomycin therapy in head and neck squamous carcinoma. Prognostic factors for tumor response

Do the Conventional Clinicopathologic Parameters Predict for Response and Survival in Head and Neck Cancer Patients Undergoing Neoadjuvant Chemotherapy?

Aims and Background

Neoadjuvant chemotherapy for head and neck carcinoma is still an important treatment modality. The prognostic value of patient and tumor parameters has been extensively evaluated in several trials, yielding mixed results. We report the prognostic factors emerging from a group of patients undergoing neoadjuvant chemotherapy.

Patients and methods

From April 1986 to June 1992, 149 consecutive patients received cisplatin-5-fluorouracil-based neoadjuvant chemotherapy. After four courses of chemotherapy, patients underwent local-regional treatment with surgery, radiation or both. A variety of patient and tumor characteristics were evaluated as predictors for response to chemotherapy and survival.

Results

The complete response, partial response and no response rates to NAC were 52%, 33% and 15%, respectively. No parameters predicted response to chemotherapy. At a maximum follow-up of 87 months, overall survival was 39% and disease-free survival was 49%. Variables shown to be predictors of survival in univariate analyses were age, performance status, histology, site, T, N, stage, and response to chemotherapy. Using the Cox regression analysis, only complete response to induction chemotherapy ( P = 0.0006), performance status ( P = 0.03), stage ( P = 0.01), age ( P = 0.03) and primary tumor site ( P = 0.04) emerged as independent prognostic factors for survival.

Conclusions

Complete response to chemotherapy was confirmed as the strongest prognostic factor influencing survival. However, conventional clinicopathologic factors did not predict response, hence, potential prognostic biologic and molecular factors for response must be sought. At present, much effort must be made for the improvement of the complete response rate, which seems to be a requisite to prolong survival.

Advances in the care of head and neck cancer patients at Baylor University Medical Center

Editor's note: The Society of Baylor Surgeons held a meeting on August 10 to 11, 2007: "Advances in Surgery and Surgical Education: The Past 20 Years," in honor of Dr. Ronald C. Jones' 20th year as chairman of the Department of Surgery at Baylor University Medical Center. This society was founded in 1981 by Dr. Robert Sparkman, past chief of the department, as a way to reunite former Baylor surgery residents and provide continuing surgical education for residents and members of the medical staff.Under the direction of program director John Preskitt, MD, the 2007 CME-accredited meeting included presentations from four prominent guest speakers: Edward M. Copeland, MD, president of the American College of Surgeons; R. Scott Jones, MD, professor and chairman of surgery emeritus for the University of Virginia Health System; Kirby I. Bland, MD, chairman of the Department of Surgery at the University of Alabama; and Stanley Dudrick, MD, chairman of the Department of Surgery at St. Mary's Hospital, Waterbury, Connecticut. In addition, 12 physicians from Baylor made presentations at this meeting, and some provided summaries, which are reproduced in this issue of Proceedings.

Prognostic value of the epidermal growth factor receptor (EGRF) and p53 in advanced head and neck squamous cell carcinoma patients treated with induction chemotherapy

We measured the expression of the p53 nuclear protein and epidermal growth factor receptor (EGFR) in 46 biopsy samples from patients with advanced head and neck cancer treated with induction combination chemotherapy of 5-fluorouracil, cisplatin, and paclitaxel. Tumour expression of p53 protein was analysed with the monoclonal D07 antibody and EGFR with monoclonal H11 antibody. The overall response, defined as complete (CR) and partial response (PR) rates to treatment, was 88%. p53 positive staining was significantly more frequent in patients who did not respond to the induction treatment. EGFR expression failed to show any correlation with the response rate. Multivariate analysis indicated that a tumour location in the oral cavity together with p53 expression combined with moderate-to-high EGFR staining were independent prognostic factors of a shorter disease-free survival (DFS). Location of the tumour in the oral cavity and EGFR expression had independent prognostic value for overall survival (OS). We conclude that the EGFR status and an oral cavity location of the tumour have independent prognostic value in patients with advanced head and neck carcinoma treated with induction chemotherapy. The p53 status appears to be a determinant of the tumour chemo-sensitivity in advanced head and neck squamous cell carcinoma (HNSCC). The presence in the tumour of a p53-positive stain and moderate-to-high staining of EGFR is associated with a shorter DFS and time to treatment failure (TTF) probably reflecting a more aggressive tumour phenotype.

Single agent cisplatin chemotherapy in surgically resected vulvar cancer patients with multiple inguinal lymph node metastases

OBJECTIVE

The aim of this study was to evaluate acute and long-term morbidity, recurrence rate, and overall survival in patients with multiple groin lymph node metastases treated with postoperative chemotherapy.

METHODS

Patients affected by FIGO stages III, IVA, and IVB (pelvic lymph nodes only) submitted to surgery were then treated with four cycles of cisplatin 100 mg/m(2) given 21 days apart. Toxicity, overall, and disease-free survival were evaluated.

RESULTS

Fourteen patients were evaluated. Median patients age was 58 (range 48-82). Median performance status was 0 (0-2). All patients completed the treatment. No treatment-related deaths occurred. Only two patients suffered from grade 4 neutropenia during chemotherapy. Three patients suffered from long-term severe lymphedema. Four patients suffered a disease recurrence. Three of these patients were subjected to surgery with no severe postoperative complications. Two of the latter patients are still alive. At a median follow-up of 57.5 months (range 23-79 months) actuarial 3-year overall survival and progression-free survival are 86% and 71%, respectively.

CONCLUSIONS

In patients affected by vulvar cancer with multiple lymph node metastases, radical surgery followed by chemotherapy is a feasible strategy, with an acceptable short- and long-term complication rate. Results in terms of overall survival and disease-free survival are promising. Furthermore, due to absence of local long-term tissue toxicity, this strategy allows physicians to surgically treat regional lymph node recurrence safely.

Induction intra-arterial cisplatin and bleomycin in head and neck cancer

Fifty-two consecutive patients, affected by large T2 (greater than 3 cm), T3, T4, N0, or N1 previously untreated squamous cell carcinoma of the head and neck, entered this phase I-II study. Treatment consisted of a continuous 8-day infusion on the following daily schedule: cisplatin 25 mg and bleomycin 15 mg administered for 4 and 20 hours, respectively. Technical-related toxicities were 1 case each of coagulation and displacement of the catheter and 1 case of reversible monoparesis of the contralateral arm. Drug-related relevant toxicities accounted for 4 cass of grade 3 or 4 leukopenia and 2 cases of peripheral palsy of the 7th and 12th cranial nerve, respectively. Forty-five of 50 evaluable patients obtained an objective response. In particular, 13 patients obtained a complete response, 22 a partial response greater than or equal to 75%, and 10 a partial response greater than or equal to 50%. Furthermore, 5 of 31 patients showed a complete pathologic disappearance of the tumor, whereas in 12 of 31 only a microscopic residue was found.

Oncologic and functional considerations of total glossectomy

The efficacy of total glossectomy for advanced carcinoma of the tongue remains controversial. A retrospective chart review was undertaken to evaluate the oncologic and functional results in 17 consecutive patients who underwent this procedure. There were two patients with stage III disease, eight with stage IV disease, and seven with recurrent disease. The larynx was preserved in seven patients. One patient required a secondary laryngectomy. All patients were reconstructed immediately, 11 with a pectoralis major myocutaneous flap and 6 with free-tissue transfer. The operative mortality was 6 percent; the morbidity was 59 percent. At last follow-up, 53 percent of the patients were alive without disease, with a mean disease-free survival period of 36 months. Ninety-three percent of the patients regained swallowing and independent oral alimentation; 80 percent of those with laryngeal preservation regained intelligible speech. We have concluded that total glossectomy should be considered as a primary modality for advanced carcinoma of the tongue and not solely reserved for salvage in hopeless situations. With or without laryngectomy, excellent survival and functional results can be obtained.

Induction chemotherapy for advanced head and neck cancers: a literature review

Induction chemotherapy before surgery and/or radiotherapy for previously untreated head and neck carcinoma results in greater response rates than chemotherapy for recurrent head and neck carcinomas. Its theoretical advantages are presented. Most studies using induction chemotherapy are nonrandomized, uncontrolled pilot efforts. Multiple-drug regimens result in greater response rates than single agents, and multiple courses result in greater response rates than single courses. Prognostic factors are discussed. Toxicities are tolerable, except for several reported regimens combining cisplatin, bleomycin, and methotrexate. Induction chemotherapy for head and neck cancer is promising and needs further studies with controlled, randomized trials with long-term follow-up.

Combination chemotherapy followed by surgery or radiotherapy in patients with locally advanced cervical cancer

Forty-seven patients with locally advanced cervical cancer at high risk of relapse received three cycles of chemotherapy with PVB (cisplatin, vinblastine and bleomycin) before definitive local treatment with either radical surgery or radiotherapy. Thirty-one of the 47 patients (66%) responded to initial chemotherapy, and 11 of them have relapsed compared with 13 of the 16 non-responders. Median time to recurrence was 31 weeks for PVB non-responders but has not yet been reached for PVB responders. After a median follow-up of 128 weeks, 14 of the 31 responders (45%) are alive and disease free compared with 3 of the 16 non-responders (19%). There was a positive correlation between response to chemotherapy and subsequent response to radiotherapy. PVB was in general well tolerated although one death is probably attributable to chemotherapy. A randomized study comparing radiotherapy alone with initial PVB chemotherapy followed by radiotherapy is in progress.

Factors predicting response of end stage squamous cell carcinoma of the head and neck to cisplatinum

Cisplatinum significantly prolongs survival in end stage head and neck cancer but only 30-40% of patients respond. Many receive chemotherapy with little or no benefit and it would obviously be advantageous to determine in advance those patients likely to benefit. In 2 phase III trials of chemotherapy in end stage disease, 129 patients have been treated with cisplatinum, either alone or in 2-drug combination with bleomycin, methotrexate or 5-fluorouracil. Factors analysed in the entire group were age, sex, site, previous treatment, performance status and the use of cisplatinum in combination. A high albumen and oro- or nasopharyngeal site were significantly favourable, while a hypopharyngeal, middle ear, skin or paranasal site were all significantly unfavourable. In the separate analysis of the subgroup with recurrent disease, site of recurrence and time to recurrence were analysed in addition to the factors named above. Although similar trends to those in the entire group were observed none reached significant levels. In the subgroup with advanced previously untreated disease, histological grade was analysed in addition to the above factors. Good performance status emerged as significantly favourable. The emerging trends provide some insight regarding outcome but are not sufficiently clearcut to allow a decision to be made on who should and who should not be treated.

Combined modality therapy utilizing a cisplatin combination for effective chemotherapy in patients with previously untreated head and neck cancer

In patients with locally advanced head and neck cancer, the results of standard definitive treatments of surgery, radiotherapy, or both were disappointing. The local and regional recurrence rates were high, despite adequate surgical resection with negative margins and postoperative radiotherapy to all known or possible disease areas. Combination cisplatin chemotherapy given initially before definitive treatments produced a high overall antitumor response and up to 50 percent clinical complete response. Before answering the question of value of chemotherapy as part of the multimodality treatment, it is important to identify the safest and most form of chemotherapy. The degre of chemotherapy effectiveness is defined by the incidence of clinical and, most important, histologic complete response. To assess this effectiveness, chemotherapy was given before definitive treatments to patients with measurable disease. From our 10 year experience we have concluded that continuing the development of induction chemotherapy, including investigating the timing of such effective treatment and assessing the value of such therapy, is of the utmost importance.

Management of advanced stage squamous cell carcinoma of the head and neck

Squamous cell tumors of the head and neck make up 5% of tumors diagnosed in this country. The combination of excessive tobacco and alcohol use is the most common causative factor for these tumors. Their natural history is characterized by a tendency for early local-regional recurrence and the late appearance of distant metastases. A significant proportion of patients present with advanced (stage III or IV) disease, which has a poor prognosis when treated with surgery and radiotherapy. The use of adjuvant chemotherapy with surgery and radiotherapy in previously untreated patients holds promise for improving cure rates in patients with this disease. The use of chemotherapy in patients with recurrent head and neck tumors results in response in approximately one third of patients. The majority of these responses are partial and short-lived, but those patients achieving a complete remission appear to have a significant prolongation of survival. The combination of chemotherapy and radiotherapy in patients with advanced disease is being tested in a number of trials. It is hoped that this combination will increase the response rate and result in prolonged survival.

Pharmacokinetics of intra-arterial and intravenous cisplatin in head and neck cancer patients

After administration of cisplatin (50 mg/m2 on days 1 and 2) by intra-arterial or intravenous infusions over 1 or 6 hr to a total of 24 patients with head and neck cancer, the main pharmacokinetic parameters of platinum were determined according to a multicompartmental analysis. Elimination half-life of total platinum is greater than 3 days, the amount of platinum recovered in the urine over 7 days accounting for 15-50% of the administered dose. The half-life of filterable platinum species was calculated from the urinary excretion data: 39 +/- 17 min (i.a./1 hr), 37 +/- 24 min (i.a./6 hr), 58 +/- 17 min (i.v./1 hr) and 51 +/- 22 min (i.v./6 hr). Biopsies of the tumor were also analyzed on day 3 for their platinum content. The mean concentrations of platinum in biopsies were: 2.72 micrograms/g (i.a./1 hr), 3.89 micrograms/g (i.a./6 hr), 1.27 micrograms/g (i.v./1 hr) and 1.38 micrograms/g (i.v./6 hr). Tumor regression, based upon clinical and histological data, was only moderate after this single chemotherapy course.

Cancer of the larynx: current concepts of diagnosis and treatment

Cancer of the larynx is a potentially fatal disease. Familiarity with current treatment, however, makes it potentially curable. This article discusses the available therapeutic options and their consequences.

A randomized prospective comparison of methotrexate with a combination of methotrexate, bleomycin, and cisplatin in head and neck cancer

Combination chemotherapy with methotrexate, bleomycin, and cis-diamminedichloroplatinum (II) was compared to weekly therapy with methotrexate alone in a randomized prospective trial in 163 patients with recurrent or metastatic squamous cancer of the mucous membranes of the head and neck. The combination produced responses in 48% compared to 35% for methotrexate alone, with 16% complete remissions versus 8%, respectively. The difference in overall and complete remission rates is significant (P = 0.04) using a one-sided binary regression test. Median time to disease progression among responders was 5.8 months for the combination and 5 months for methotrexate, and median survival was 5.6 months in each group. Toxicity was similar in the two groups. Ambulatory patients, those without fixed neck nodes and those without distant metastases, responded more often. Poor performance status, distant metastases, history of heavy smoking, and adjacent organ invasion by the primary tumor were associated with shorter survival, as were weight loss, the presence of tumor in the neck, and heavy alcohol consumption. The addition of bleomycin and cisplatin to methotrexate produces more remissions, and especially complete remissions, but has not made a major impact on the course of far-advanced head and neck cancer.

Neoadjuvant chemotherapy in maxillary sinus carcinoma with cisplatinum and peplomycin intraarterial infusion

The purpose of this paper is to present our preliminary assessment of a new multimodal treatment including neoadjuvant chemotherapy with cisplatinum and peplomycin for maxillary sinus carcinoma. Fifteen patients with squamous cell carcinoma of the maxillary sinus carcinoma seen at Keio University Hospital, with Stage III and IV disease, were enrolled in this trial between January 1982 and January 1985. Regimen of chemotherapy was as follows: day 1, 50 mg/m2 of cisplatinum, intraarterial infusion over 2 hr, days 2-6, peplomycin at a dose of 5 mg/day, intraarterial infusion over 5 hr. Routinely, radiotherapy of 40 Gy by Linac was given to the primary site, concomitantly combined with 5-fluorouracil intraarterial injections only during the first 10 days, 2 weeks after the end of initial chemotherapy. Additional treatment was performed according to the extent of residual tumor. Response to initial chemotherapy revealed that complete response was achieved in 7 and partial response in 6 out of 15 patients with a response rate of 87%. Nine patients required no surgical intervention while 6 underwent a surgical resection. Median follow-up in this group of patients is 20 months. Thirty-month survival rate calculated by Kaplan-Meier's method was 83%. Chemotherapy toxicity was mild in most cases. This pilot study does not provide conclusive survival information, but the results obtained are encouraging.

Predictive factors for tumor response to preoperative chemotherapy in patients with head and neck squamous carcinoma. The Head and Neck Contracts Program

The high tumor response rates associated with intensive chemotherapy in previously untreated patients with advanced head and neck squamous cell carcinoma (HNSCC) led to the initiation of a multi-institutional National Cancer Institute trial. This trial used preoperative chemotherapy in patients with resectable Stage III and IV squamous cell carcinoma of the oral cavity or larynx/hypopharynx. Response rates, toxicity, and a variety of patient and tumor characteristics were analyzed to determine which factors might be useful in predicting tumor response to preoperative chemotherapy. Two hundred eighty-two patients received one course of preoperative cisplatin and bleomycin chemotherapy and were evaluable. There were 22 complete responses (CR) and 114 partial responses (PR) at the primary site (48% response rate). Of 197 patients with clinically positive regional adenopathy, 29 CRs and 73 PRs were observed (52%). Toxicity associated with the chemotherapy regimen was minimal. Primary tumor and regional node responses to chemotherapy were strongly correlated. No significant differences were found in primary or nodal response rates with respect to differing tumor site, stage, histologic differentiation, patient performance status, nutritional status, leukocyte count, hemoglobin level, age, sex, or alcohol use. Primary tumor response, however, was significantly related to T classification (P = 0.048). Nodal response was strongly associated with N classification and nodal size (P = 0.02 and P = 0.075, respectively). These findings suggest that, of the patient and tumor characteristics analyzed, none were more useful in predicting tumor response than clinical tumor staging parameters.

Correlation between response to cisplatinum-combination chemotherapy and subsequent radiotherapy in previously untreated patients with advanced squamous cell cancers of the head and neck

Induction chemotherapy, followed by surgery and/or radiotherapy was utilized in patients with advanced squamous cell carcinoma of the head and neck. During these trials, the authors observed that response to chemotherapy predicts further response to subsequent radiotherapy. This study was comprised of 57 patients with 60 separate neoplasms who demonstrated less than complete response (partial or no response) to initial treatment with a combination chemotherapy containing cisplatin. Subsequently radiotherapy, either 5000 rad preoperatively or 6600 rad as definitive therapy, was employed. Forty-one of the 42 tumors with initial partial response to chemotherapy also responded to radiotherapy (97.6%). Only one of the 18 tumors that initially failed to respond to chemotherapy subsequently responded to radiotherapy (5.5%). This observation suggests that patients with head and neck cancer sensitive to initial chemotherapy share parameters that are also radiation sensitive.

Adjuvant chemotherapy after surgery and radiation for stage III and IV head and neck cancer

Twenty consecutive patients with Stage III and IV squamous head and neck cancer were treated with surgery, radiation, and adjuvant multiagent chemotherapy. Eleven other patients who were referred for local recurrent disease were treated with second surgery or radiation and also with adjuvant chemotherapy. The actuarial survival of these two groups of patients combined (N = 31) was 87% at 6 years. Four patients died of recurrent cancer (two in each group), six of unrelated causes during a 6-year follow-up. The side effects of adjuvant chemotherapy were mild to moderate and of short duration.

Sinus tumors invading the orbit

Forty -seven of 79 patients with sinus and paranasal tumors had clinical, radiographic or operative evidence of orbital involvement. Seventy percent of those patients with orbital extension had clinical or radiographic involvement of the orbit at the time of initial presentation. Common presenting signs and symptoms included proptosis, nasal obstruction or discharge, nasal mass, facial and/or eye pain, visual loss, facial and/or lid edema and diplopia. The most common tumor seen was squamous cell carcinoma. The maxillary sinus was the most frequent site of origin. Three patients were misdiagnosed as having sinusitis on initial evaluation. A diagnosis of sinusitis is tentative and should be reevaluated early with repeat roentgenographic studies and biopsy, especially in the presence of protracted facial and eye pain. When ordering CT scans, one must specifically request cuts of the base of the sinuses and skull as routine brain CT scans do not evaluate those regions. Two of four patients with intractable pain unrelieved by narcotics obtained pain relief with cisplatinum.

A prospective randomized trial of methotrexate versus cisplatin in the treatment of recurrent squamous cell carcinoma of the head and neck

A prospective randomized study was conducted to determine the relative effectiveness, toxicity and tolerance of methotrexate (MTX) versus cisplatin (DDP) in patients with recurrent head and neck squamous cell carcinoma. Forty-four patients were randomized to receive either MTX, 40 mg escalated to 60 mg/m2 IV push weekly, or DDP, 50 mg/m2 6 hour infusion days 1 and 8 every 4 weeks. All patients had objectively measurable disease and a performance status greater than 60% (Karnofsky scale). All had been treated with surgery and/or radiotherapy. No patients had prior chemotherapy. Prior treatment, performance status, and site of primary disease were comparable in both groups. Complete and partial objective responses were achieved in 23.5% of the MTX group and 28.6% of the DDP group (P = 0.51). Median duration of response was 84 days in the MTX group and 92 days in the DDP group. Median survival of patients was 6.1 months with MTX and 6.3 months with DDP. Mucositis was noted in 38% of patients in the MTX group (P = 0.001) compared to none in the DDP group. Vomiting occurred in 87% of patients in the DDP group (P less than .0001) compared to 10% of patients in the MTX group. This study demonstrates that in the treatment of recurrent head and neck squamous cell carcinoma, MTX and DDP are equally effective, although MTX appears to be better tolerated.