Glottic versus supraglottic tumors: differential molecular profile

Tumor volumes in T3 supraglottic cancers treated with radiotherapy in the modern era: A study of the Canadian Head & Neck Collaborative Research Initiative

PURPOSE

To evaluate the association of primary tumor volume (TV) with overall survival (OS) and disease-free survival (DFS) in T3 N0-3M0 supraglottic cancers treated with intensity-modulated radiotherapy (IMRT).

METHODS

This was a retrospective cohort study involving 239 patients diagnosed with T3 N0-3M0 supraglottic cancers between 2002 and 2018 from seven regional cancer centers in Canada. Clinical data were obtained from the patient records. Supraglottic TV was measured by neuroradiologists on diagnostic imaging. Kaplan-Meier method was used for survival probabilities, and a restricted cubic spline Cox proportional hazards regression analysis was used to analyze TV associations with OS and DFS.

RESULTS

Mean (SD) of participants was 65.2 (9.4) years; 176 (73.6%) participants were male. 90 (38%) were N0, and 151 (64%) received concurrent systemic therapy. Mean TV (SD) was 11.37 (12.11) cm3 . With mean follow up (SD) of 3.28 (2.60) years, 2-year OS was 72.7% (95% CI 66.9%-78.9%) and DFS was 53.6% (47.4%-60.6%). Increasing TV was associated (per cm3 increase) with worse OS (HR, 1.01, 95% CI 1.00-1.02, p < 0.01) and DFS (HR, 1.01, 95% CI 1.00-1.02, p = 0.02).

CONCLUSIONS

Increasing primary tumor volume is associated with worse OS and DFS in T3 supraglottic cancers treated with IMRT, with no clear threshold. The findings suggest that patients with larger tumors and poor baseline laryngeal function may benefit from upfront laryngectomy with adjuvant radiotherapy.

Prognosis

Prognosis is defined as the likely outcome or course of a disease and is the result of a complex interplay between patient and tumor factors. Unfortunately, the prognosis of patients with laryngeal cancer has not changed significantly over the past several decades. However, as our understanding of these patient and tumor factors becomes more nuanced and the resulting treatment options become more precise, there is the potential to improve the prognosis for these patients.

Mu-Opioid Receptor Expression in Laryngeal Cancer

OBJECTIVES

Expression of mu-opioid receptors (MORs) has not been investigated in head and neck cancer. In this study, we aimed to assess the expression of opioids receptors in laryngeal cancer, compared to adjacent non-malignant tissue.

STUDY DESIGN

A retrospective case series in a single academic center.

METHODS

Sixty-four specimens were taken from 32 matched patients, diagnosed with laryngeal-carcinoma (20 supraglottic and 12 glottic), and were analyzed using immunohistochemical stains for MOR. All sections were examined and evaluated with a semi-quantitative analysis for staining intensity and cell count for a percentage of the positively stained cells. Survival of patients was compared based on MOR expression.

RESULTS

MOR staining intensity was significantly increased in laryngeal-carcinoma compared to the normal tissue adjacent to the carcinoma (P = 0.019). The percentage of stained cells in non-involved supraglottis was significantly higher compared to the non-involved glottis (P = 0.022), yet this difference was no longer found between supra- and glottic-carcinoma tissues.

CONCLUSION

MOR may play a role in the laryngeal cancer environment, as the expression in tumor cells alters from adjacent non-cancerous tissue.

Distinct Biomarker Profiles and Clinical Characteristics in T1-T2 Glottic and Supraglottic Carcinomas

Background

In early stage laryngeal squamous cell carcinoma (LSCC) radiotherapy with curative intent is a major treatment modality. TNM classification is used to define patients eligible for radiotherapy. Studies in early stage glottic LSCC identified several predictive biomarkers associated with local control. However, we recently reported that this predictive value could not be confirmed in supraglottic LSCC.

Objective

To examine whether clinical behavior and protein expression patterns of these biomarkers differ between glottic and supraglottic LSCC.

Study Design

Retrospective cohort study.

Methods

Tumor tissue sections of 196 glottic and 80 supraglottic T1‐T2 LSCC treated primarily with RT were assessed immunohistochemically for expression of pAKT, Ki‐67 and β‐Catenin. Expression data of HIF‐1α, CA‐IX, OPN, FADD, pFADD, Cyclin D1, Cortactin and EGFR in the same cohort of glottic and supraglottic LSCC, were retrieved from previously reported data. The relationship between glottic and supraglottic sublocalization and clinicopathological, follow‐up, and immunohistochemical staining characteristics were evaluated using logistic regression and Cox regression analyses.

Results

Glottic LSCC were correlated with male gender (P = .001), hoarseness as a primary symptom (P < .001), T1 tumor stage (P < .001), negative lymph node status (P < .001), and an older age at presentation (P = .004). Supraglottic LSCC patients developed more post‐treatment distant metastasis when adjusted for gender, age, and T‐status. While supraglottic LSCC was associated with higher expression of HIF‐1α (P = .001), Cortactin (P < .001), EGFR (P < .001), and Ki‐67 (P = .027), glottic LSCC demonstrated higher expression of CA‐IX (P = .005) and Cyclin D1 (P = .001).

Conclusion

Differences in clinicopathological and immunohistochemical staining characteristics suggest that T1‐T2 glottic and supraglottic LSCC should be considered as different entities.

Level of Evidence

N/A. Laryngoscope, 2020

Local inflammatory reaction to benign, pre-malignant and malignant glottic lesions: A matched case-control study

OBJECTIVES

To study the inflammatory infiltrates associated with the different stages of laryngeal carcinogenesis.

DESIGN

Observational, matched case-control study of histopathologic specimens.

SETTING

An academic referral centre.

PARTICIPANTS

A total of 45 patients who underwent removal of glottic lesions between 2008 and 2015. Patients were enrolled and categorised into three matched groups according to lesions' histopathologic diagnoses, 15 patients in each group: benign, pre-malignant and squamous cell carcinoma (SCC). Matching was based on age, gender and pack-years.

MAIN OUTCOME MEASURES

Immunohistochemistry staining using monoclonal antibodies against CD4, CD8, CD68, CD20 and S100 representing T-helper cells, cytotoxic T cells, macrophages, B cells and dendritic cells, respectively. Cell counts and distributions were measured and compared between groups. Correlations between the different cells were examined.

RESULTS

The predominant cell type was CD8+, followed by CD68+ and CD4+. All inflammatory cells increased significantly in number in SCC (P-value < 0.001), with no significant difference between benign and pre-malignant groups. Strong correlations between the different cells were demonstrated only in the malignant group. S100+ cells correlated with both T-cell subsets, CD4+ (rho = 0.769, P-value = 0.001) and CD8+ (rho = 0.697, P-value = 0.0004). Infiltrates exhibited more extensive distribution in SCC compared to pre-malignant and benign; CD8+ and CD68+ cells were demonstrated in both intraepithelial and stromal regions in 93% of SCC lesions (P-value = 0.0001).

CONCLUSIONS

Laryngeal carcinoma demonstrates a unique pattern of inflammatory infiltrates, with significant changes in cell counts and distribution. Leucocyte infiltrates increased significantly in the transition from laryngeal pre-malignant lesion to malignancy while no significant differences were seen between benign and pre-malignant lesions.

Phosphorylated FADD is not prognostic for local control in T1-T2 supraglottic laryngeal carcinoma treated with radiotherapy

OBJECTIVE

The Fas-Associated Death Domain (FADD) gene is located in the chromosome 11q13-region and frequently is amplified in head and neck squamous cell carcinoma. Expression of FADD and its phosphorylated isoform (pFADD) have been associated with aggressive tumor growth, lymph node metastasis, and overall survival. Previously, we demonstrated that pFADD expression was related to a significantly improved local control in early stage (tumor [T]1 to T2) glottic laryngeal squamous cell carcinoma (LSCC). The aim of this study was to examine the prognostic value of pFADD and FADD in T1 to T2 supraglottic LSCC treated with primarily radiotherapy.

METHODS

Tumor tissue sections of 60 patients with T1 to T2 supraglottic LSCC treated with primarily radiotherapy were assessed immunohistochemically for expression of pFADD and FADD. Expression percentages and clinical parameters and their associations with clinical outcome were studied using Cox regression and Kaplan-Meier survival analyses. Expression percentages in supraglottic and glottic LSCC were compared using the Mann-Whitney U test.

RESULTS

Expression of pFADD and FADD in supraglottic and glottic LSCC did not significantly differ. In supraglottic LSCC, both pFADD and FADD did not show prognostic value for local control (hazard ratio [HR] 1.00, 95% confidence interval [CI] 0.98-1.03; HR 1.03, 95% CI 0.60-1.78, respectively) and overall survival (HR 0.99, 95% CI 0.98-1.01; HR 1.19, 95% CI 0.83-1.71 respectively). In this cohort, lymph node status was the best predictor for local control (HR 3.73, 95% CI 1.30-10.67).

CONCLUSION

In this homogeneous cohort of T1 to T2 supraglottic LSCC primarily treated with radiotherapy, lymph node status was associated with local recurrence, whereas the expression of pFADD was not.

LEVEL OF EVIDENCE

NA. Laryngoscope, 127:E301-E307, 2017.

Risk factors for radiation failure in early-stage glottic carcinoma: A systematic review and meta-analysis

BACKGROUND

Radiotherapy is one of the main treatment modalities for early-stage glottic carcinoma. Unfortunately, local failure may occur in a group of cases with T1-T2 glottic carcinoma. This meta-analysis sought to determine risk factors for radiation failure in patients with early-stage glottic carcinoma.

METHODS

A systematic and comprehensive search was performed for related studies published between 1995 and 2014. The primary end-point was 5-year local control. Data extraction and analysis were performed using the software STATA/SE 13.1 for Windows.

RESULTS

Twenty-seven studies were eligible. A higher risk of radiation failure was demonstrated in male patients [relative risk (RR): 0.927, p<0.001] and those with low hemoglobin level (RR: 0.891, p<0.001) with a high agreement between studies (I-squared=0.0%). Moreover, T2 tumors (RR: 0.795, p<0.001), tumors with anterior commissure involvement (RR: 0.904, p<0.001), tobacco use during/after therapy (RR: 0.824, p<0.001), and "bulky" tumors (RR: 1.270, p<0.001] or tumors bigger in size (RR: 1.332, p<0.001]. Poorly differentiated tumors had a questionable risk of local failure, although a moderate to high interstudy heterogeneity was determined. A statistically significant contribution was not detected for age, presence of comorbidity, alcohol use or subglottic extension.

CONCLUSION

This is the first meta-analysis which assessed the potential risk factors for radiation failure in patients with early-stage glottic carcinoma. Gender and pretreatment hemoglobin level are major influential factors associated with radiation failure in patients with early-stage glottic carcinoma. However, prospective, randomized clinical trials may permit better stratification of their relative contributions, and those who may benefit more from upfront surgery.

The nicotine dependence phenotype, time to first cigarette, and larynx cancer risk

PURPOSE

Cigarette smoking is the major cause of laryngeal cancer. The time to first cigarette after waking in the morning is a behavior associated with several dimensions of nicotine dependence including the dose of smoke uptake. We hypothesized that a short TTFC increases the risk of laryngeal cancer.

METHODS

The analysis was based on data from a hospital-based case-control study of laryngeal cancer. The current analysis included only subjects who were ever cigarette smokers, including 570 cases and 343 controls (832 whites and 81 blacks). Odds ratios (OR) and 95% confidence intervals (CI) were calculated using unconditional logistic regression adjusting for smoking history and other potential confounders. Incidence data from the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute from 1975 to 2006 were analyzed for trends in laryngeal cancer.

RESULTS

There was a dose-response relationship between TTFC and supraglottic cancer. Compared to subjects who smoked more than 60 min after waking, the adjusted odds ratio was 1.51 (95% CI, 0.63-3.61) for 30-60 min and 3.13 (95% CI, 1.56-6.30) for 0-30 min. No association was observed between TTFC and cancer of the glottis. In blacks, the TTFC was not associated with the risk of laryngeal cancer. Trends in SEER rates were similar for cancer of the glottis and supraglottis, indicating that the site-specific differences were not affected by unknown confounders.

CONCLUSION

A nicotine dependence behavior that is associated with cigarette smoke uptake increases the risk of cancer of the supraglottis larynx, but not glottis larynx.

Concurrent inhibition of NF-kappaB, cyclooxygenase-2, and epidermal growth factor receptor leads to greater anti-tumor activity in pancreatic cancer

Inactivation of survival pathways such as NF-kappaB, cyclooxygenase (COX-2), or epidermal growth factor receptor (EGFR) signaling individually may not be sufficient for the treatment of advanced pancreatic cancer (PC) as suggested by recent clinical trials. 3,3'-Diindolylmethane (B-DIM) is an inhibitor of NF-kappaB and COX-2 and is a well-known chemopreventive agent. We hypothesized that the inhibition of NF-kappaB and COX-2 by B-DIM concurrently with the inhibition of EGFR by erlotinib will potentiate the anti-tumor effects of cytotoxic drug gemcitabine, which has been tested both in vitro and in vivo. Inhibition of viable cells in seven PC cell lines treated with B-DIM, erlotinib, or gemcitabine alone or their combinations was evaluated using 3-(4,5-dimetylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay. Significant inhibition in cell viability was observed in PC cells expressing high levels of COX-2, EGFR, and NF-kappaB proteins. The observed inhibition was associated with an increase in apoptosis as assessed by ELISA. A significant down-regulation in the expression of COX-2, NF-kappaB, and EGFR in BxPC-3, COLO-357, and HPAC cells was observed, suggesting that simultaneous targeting of EGFR, NF-kappaB, and COX-2 is more effective than targeting either signaling pathway separately. Our in vitro results were further supported by in vivo studies showing that B-DIM in combination with erlotinib and gemcitabine was significantly more effective than individual agents. Based on our preclinical in vitro and in vivo results, we conclude that this multi-targeted combination could be developed for the treatment of PC patients whose tumors express high levels of COX-2, EGFR, and NF-kappaB.