Prognostic significance of EGF receptor expression in early glottic cancer

To Study the Role of PTEN, EGFR and HER2 in Early Glottic Squamous Cell Carcinoma

Laryngeal carcinoma is the most common site of malignancy in head and neck region worldwide. Surgical options are limited in cases of laryngeal malignancy and moajority of cases are treated with chemoradiotherapy. Targeted therapy is an evolving novel approach to treat laryngeal carcinoma. The study was conducted to evaluate the role of PTEN, EGF and HER2 in early glottic squamous cell carcinoma cases. 52 samples of early glottis carcoinoma were collected in UCMS and GTB hospital, New Delhi after patients had undergone CO2 laser excision at the centre. Histopathologic and IHC examination was conducted on the specimen for PTEN, EGFR and HER2 molecules. PTEN was negative in 82.69% cases compared to the stroma with three year local control rate of 72.09%. EGFR was positive in 67.31% samples with three year local control rate of 68.57%. HER2 was negative in all the samples. PTEN and EGFR can be used as prognostic markers as well as novel agents for targeted therapy in the future.

Evaluation of Risk Factors for Laryngeal Squamous Cell Carcinoma: A Single-Center Retrospective Study

Background

The survival rate of patients with laryngeal squamous cell carcinoma (LSCC) is correlated with several factors. However, the independent prognostic factors of patients with LSCC remain unclear. Thus, we sought to identify prognostic factors affecting LSCC outcomes in the Chinese population.

Methods

The survival and potential prognostic factors of 211 patients with LSCC between April 2011 and July 2019 were retrospectively analyzed. Overall survival (OS) and progression free survival (PFS) were estimated by the Kaplan Meier method, and a log-rank test was used to compare the possible prognostic factors between different groups. The Cox proportional hazard model was used to perform multivariable analysis of significant covariants.

Results

A total of 211 LSCC patients were included, of which 164 (77.7%) were male and 47 (22.3%) were female. Mean age was 62.19 ± 8.328 years. A univariate analysis showed that seven factors including pathological differentiation, clinical stage, tobacco consumption, alcohol consumption, T stage, N stage, and concurrent chemoradiotherapy were correlated with survival (P<0.05). Cox proportional hazards regression analyses revealed that clinic stage (hazard ratio=3.100, p=0.048), pathological differentiation (hazard ratio = 2.538, p=0.015), alcohol consumption (hazard ratio = 8.456, p =0.004) were associated with OS in LSCC. Pathological differentiation (hazard ratio =5.677, p=0.000), alcohol consumption (hazard ratio =6.766, p=0.000) were associated with PFS in LSCC.

Conclusions

Pathological differentiation, alcohol consumption, are independent prognostic factors and predictors of recurrence in LSCC. These factors could help inform guidelines for clinical treatment and prognosis.

Prognostic factors in laryngeal squamous cell carcinoma

BACKGROUND

The current treatment results of laryngeal squamous cell carcinoma still remain modest. Various prognostic factors have been investigated and need to be included in the management decision making.

METHODS

We reviewed the pertinent literature regarding host, tumor, and treatment factors as prognostic indicators that influence outcome in patients diagnosed with laryngeal squamous cell carcinoma.

RESULTS

Host, tumor, and treatment factors all have an important impact upon an individual patient's prognosis with laryngeal squamous cell carcinoma, whereas staging systems only take into account tumor factors. There is much work yet to be done to establish reliable, independent biomarkers that predict survival and response to treatment.

CONCLUSIONS

Optimal outcomes for an individual patient can be achieved when taking into account tumor, host, and treatment factors.

Association between EGFR expression and clinical outcome of laryngeal HPV squamous cell carcinoma

Background: Expression of the epidermal growth factor receptor (EGFR) and human papillomavirus (HPV) DNA can serve as independent prognostic factors in squamous cell carcinoma (SCC) of the larynx. EGFR correlation with the course of disease and its effect on survival makes EGFR expression a negative prognostic factor, whereas HPV DNA is a positive prognostic factor. Aim: To assess the association of EGFR expression with clinical outcome of laryngeal HPV SCC. Materials and methods: This retrospective study included 196 SCC patients operated on at the Department of ENT, Head and Neck Surgery, Split University Hospital Center in Split, Croatia, between 1 January 2000 and 31 December 2009. Results: The association of HPV infection and EGFR expression was found to be statistically significant, and so was the difference in survival between patient groups with different HPV to EGFR expression ratio. Conclusions: The group of laryngeal HPV SCC patients with increased EGFR expression had shorter survival, confirming EGFR as a major component in predicting patient prognosis and survival. Significance: This article confirms the importance of EGFR expression as a biomarker in laryngeal SCC.

Prognostic Factors in Early Glottic Carcinoma Implications for Treatment

Aim

In this study we aimed to determine the prognostic factors affecting local control (LC) in limited glottic carcinoma treated with definitive radiotherapy (RT).

Material and methods

Between June 1991 and December 2001, 114 patients with early squamous-cell carcinoma of the glottis were treated with definitive RT at our institution. Only four (3.5%) patients were women. The median age was 60 (27-79). Fifteen percent, 72% and 13% of the patients had Tis, T1 and T2 tumors, respectively. Forty-three (37.7%) patients had anterior commissure invasion. Prior to RT 35 (31%) patients had undergone vocal cord stripping and two (2%) cordectomy. A median dose of 66 Gy (50-70.2) was given over a median period of 46 days (20-60). Univariate and multivariate analyses were performed for LC. The prognostic parameters analyzed for LC were T classification, anterior commissure involvement, total RT dose, and overall treatment time.

Results

Five-year local and regional control rates were 84.2% and 97.7%. RTOG grade 3-4 late side effects were observed only in one (0.9%) patient. In 15 patients with local failure, salvage treatment consisted of partial laryngectomy in eight patients and total laryngectomy in five. One of the remaining two patients was medically inoperable, and the other refused salvage surgery. In one of the three patients with regional failure, salvage surgery was applied and the other two were given palliative chemotherapy because of unresectable disease. Following salvage treatments, the ultimate five-year LC rate was 96.9% and the five-year larynx preservation rate was 91.1%. Second primary cancer was diagnosed in 17 (14.9%) patients. Only one patient developed distant metastases and two patients died of laryngeal cancer. While T2 disease and anterior commissure involvement were found to be unfavorable prognostic factors significantly influencing LC in univariate analyses, only T2 disease remained independent in multivariate analysis.

Conclusion

In patients with early glottic carcinoma, T classification proved to be the only independent prognostic factor affecting LC after primary radiotherapy according to the results of this study.

The evaluation of bcl-2 expression as a prognostic marker in early stage laryngeal cancer

Aims and background

To evaluate the effect of bcl-2 expression on the local control and overall survival of patients with early stage laryngeal cancer treated with radiotherapy alone.

Methods and study design

We included 53 patients with stage Tis, T1, and T2 laryngeal cancer who were irradiated in our department. Paraffin blocks of all biopsy specimens were subjected to immunohistochemical analysis with a bcl-2 oncoprotein mouse clone 124 Scytek kit.

Results

The mean follow-up time was 61 months (range, 7–166). Local-regional recurrence was observed in 10 (19%) patients. Forty-three patients (81%) had negative bcl-2 staining, 5 patients (9%) had + staining, 3 patients (6%) ++ staining, and 2 patients (4%) +++ staining. No relationship was detected between bcl-2 expression and local control or overall survival. The emergence of a recurrence and a younger age (<50 years) were significantly related to poor overall survival (P = 0.000 and P = 0.021, respectively). Patients with hemoglobin levels in the middle of radiotherapy and at the end of radiotherapy higher than 13 g/dl had improved overall survival in multivariate analyses (P = 0.002 and P = 0.001, respectively). Regarding local control, the following were poor prognostic factors: smoking more than 20 cigarettes a day (P = 0.001) and being younger than 50 years of age (P = 0.001).

Conclusions

No correlation was observed between bcl-2 expression and local control or overall survival. Whereas hemoglobin level, age and existence of a recurrence had a prognostic impact on overall survival, patient age and smoking status influenced local control rates.

Interventions for the treatment of oral and oropharyngeal cancers: targeted therapy and immunotherapy

BACKGROUND

Oral cancers are the sixth most common cancer worldwide, yet the prognosis following a diagnosis of oral cavity or oropharyngeal cancers remains poor, with approximately 50% survival at five years. Despite a sharp increase in research into molecularly targeted therapies and a rapid expansion in the number of clinical trials assessing new targeted therapies, their value for treating oral cancers is unclear. Therefore, it is important to summarise the evidence to determine the efficacy and toxicity of targeted therapies and immunotherapies for the treatment of these cancers.

OBJECTIVES

To assess the effects of molecularly targeted therapies and immunotherapies, in addition to standard therapies, for the treatment of oral cavity or oropharyngeal cancers.

SEARCH METHODS

We searched the following electronic databases: Cochrane Oral Health Group Trials Register (to 3 February 2015), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2015, Issue 1), MEDLINE via Ovid (1946 to 3 February 2015) and EMBASE via Ovid (1980 to 3 February 2015). We searched the US National Institutes of Health Trials Register (clinicaltrials.gov), the World Health Organization Clinical Trials Registry Platform, the American Society of Clinical Oncology conference abstracts and the Radiation Therapy Oncology Group clinical trials protocols for ongoing trials. We placed no restrictions on the language or date of publication.

SELECTION CRITERIA

We included randomised controlled trials where more than 50% of participants had primary tumours of the oral cavity or oropharynx, and which compared targeted therapy or immunotherapy, plus standard therapy, with standard therapy alone.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the results of the electronic searches, extracted data and assessed the risk of bias of the included studies. We attempted to contact study authors for missing data or clarification where necessary. We combined sufficiently similar studies in meta-analyses using random-effects models when there were at least four studies and fixed-effect models when fewer than four studies. We obtained or calculated a hazard ratio (HR) and 95% confidence interval (CI) for the primary outcomes where possible. For dichotomous outcomes, we reported risk ratios (RR) and 95% CIs.

MAIN RESULTS

Twelve trials (2488 participants) satisfied the inclusion criteria. In the included trials, 12% of participants (298 participants) had tumours of the oral cavity and 59% (1468 participants) had oropharyngeal tumours. The remaining 29% had tumours of the larynx or hypopharynx and less than 1% had tumours at other sites.No included trial was at low risk of bias; seven had an unclear risk of bias, and five had a high risk of bias. We grouped trials by intervention type into three main comparisons: standard therapy plus epidermal growth factor receptor monoclonal antibody (EGFR mAb) therapy (follow-up period 24 to 70 months); standard therapy plus tyrosine kinase inhibitors (TKIs) (follow-up period 40 to 60 months) and standard therapy plus immunotherapy (follow-up period 24 to 70 months), all versus standard therapy alone.Moderate quality evidence showed that EGFR mAb therapy may result in 18% fewer deaths when added to standard therapy (HR of mortality 0.82; 95% CI 0.69 to 0.97; 1421 participants, three studies, 67% oropharyngeal tumours, 2% oral cavity tumours).There was also moderate quality evidence that EGFR mAb may result in 32% fewer locoregional failures when added to radiotherapy (RT) (HR 0.68; 95% CI 0.52 to 0.89; 424 participants, one study, 60% oropharyngeal tumours).A subgroup analysis separating studies by type of standard therapy (radiotherapy (RT) or chemoradiotherapy (CRT)) showed some evidence that adding EGFR mAb therapy to RT may result in a 30% reduction in the number of people whose disease progresses (HR 0.70; 95% CI 0.54 to 0.91; 424 participants, one study, 60% oropharyngeal tumours, unclear risk of bias). For the subgroup comparing EGFR mAb plus CRT with CRT alone there was insufficient evidence to determine whether adding EGFR mAb therapy to CRT impacts on progression-free survival (HR 1.08; 95% CI 0.89 to 1.32; 891 participants, one study, 70% oropharyngeal tumours, high risk of bias). The high subgroup heterogeneity meant that we were unable to pool these subgroups.There was evidence that adding cetuximab to standard therapy may result in increased skin toxicity and rash (RR 6.56; 95% CI 5.35 to 8.03; 1311 participants, two studies), but insufficient evidence to determine any difference in skin toxicity and rash in the case of nimotuzumab (RR 1.06; 95% CI 0.85 to 1.31; 92 participants, one study).There was insufficient evidence to determine whether TKIs added to standard therapy impacts on overall survival (HR 0.99; 95% CI 0.62 to 1.57; 271 participants, two studies; very low quality evidence), locoregional control (HR 0.89; 95% CI 0.53 to 1.49; 271 participants, two studies; very low quality evidence), disease-free survival (HR 1.51; 95% CI 0.61 to 3.71; 60 participants, one study; very low quality evidence) or progression-free survival (HR 0.80; 95% CI 0.51 to 1.28; 271 participants, two studies; very low quality evidence). We did find evidence of an increase in skin rash (erlotinib: RR 6.57; 95% CI 3.60 to 12.00; 191 participants, one study; lapatinib: RR 2.02; 95% CI 1.23 to 3.32; 67 participants, one study) and gastrointestinal complaints (lapatinib: RR 15.53; 95% CI 2.18 to 110.55; 67 participants, one study).We found very low quality evidence from one small trial that adding recombinant interleukin (rIL-2) to surgery may increase overall survival (HR 0.52; 95% CI 0.31 to 0.87; 201 participants, 62% oral cavity tumours, 38% oropharyngeal tumours) and there was insufficient evidence to determine whether rIL-2 impacts on adverse effects.

AUTHORS' CONCLUSIONS

We found some evidence that adding EGFR mAb to standard therapy may increase overall survival, progression-free survival and locoregional control, while resulting in an increase in skin toxicity for some mAb (cetuximab).There is insufficient evidence to determine whether adding TKIs to standard therapies changes any of our primary outcomes.Very low quality evidence from a single study suggests that rIL-2 combined with surgery may increase overall survival compared with surgery alone.

Effective Biomarkers and Radiation Treatment in Head and Neck Cancer

CONTEXT

Radiation is a key arm in the multidisciplinary treatment of patients with head and neck squamous cell carcinoma. During the past 2 decades, significant changes in the way radiation therapy is planned and delivered have improved efficacy and decreased toxicity. Refined approaches in the application of radiation and chemoradiation have led to organ-sparing treatment regimens for laryngeal and pharyngeal cancers and have improved local and regional control rates in the postoperative, adjuvant setting. The molecular and genetic determinants of tumor cell response to radiation have been studied, and several potential biomarkers are emerging that could further improve application and efficacy of radiation treatment in head and neck squamous cell carcinoma.

OBJECTIVE

To discuss the current understanding of potential biomarkers related to radiation response in head and neck squamous cell carcinoma.

DATA SOURCES

Existing published literature.

CONCLUSIONS

Several potential biomarkers are actively being studied as predictors and targets to improve the use and efficacy of radiation therapy to treat head and neck squamous cell carcinoma. Several promising candidates have been defined, and new markers are on the horizon.

Epidermal growth factor receptor (EGFR) expression in patients with laryngeal squamous cell carcinoma

To assess the epidermal growth factor receptor (EGFR) correlation with histopathologic and clinical characteristics of laryngeal squamous cell carcinoma (SCC) and the impact of EGFR overexpression on patient survival. This retrospective study included 185 SCC patients treated at Clinical Department of ENT, Head and Neck Surgery, Split University Hospital Center between January 1, 2000 and December 31, 2009. A statistically significant correlation (p < 0.001) was recorded between the level of EGFR expression and SCC histopathologic grade, stage, metastasizing potential, relapsing potential, and patient survival. Kaplan-Meier survival curve yielded a statistically significant difference (χ(2) = 75.05; p < 0.001) among the four patient groups with different levels of EGFR expression. The higher the level of EGFR expression, the poorer is the patient prognosis and survival. In our study, expression of EGFR as a biomarker showed a potential predictive value in laryngeal SCC.

Dacomitinib, an irreversible Pan-ErbB inhibitor significantly abrogates growth in head and neck cancer models that exhibit low response to cetuximab

Aberrant epidermal growth factor (EGF) signaling is associated with tumor growth in squamous cell carcinoma of the head and neck in humans (HNSCC), and is a major focus of targeted therapy. Cetuximab, a monoclonal antibody against EGFR, has been successful at prolonging survival but has only a 10% tumor shrinkage response rate in a clinical setting. The goal of this study was to compare dacomitinib (PF-00299804), a next generation small molecule tyrosine kinase inhibitor that irreversibly blocks multiple HER family receptors (HER-1 (EGFR), HER-2 and HER-4 tyrosine kinases), to cetuximab, the current FDA approved anti-EGFR medication for HNSCC and erlotinib, an EGFR specific small molecule tyrosine kinase inhibitor. Dacomitinib, erlotinib and cetuximab were tested in a panel of 27 HNSCC cell lines. Treatment with 100 ug/ml of cetuximab or 1 uM of erlotinib inhibited growth by at least 50% in 7/27 cell lines, while treatment with 1 uM of dacomitinib had similar growth inhibition in 17/27 lines. Cell lines representing three levels of sensitivity to dacomitinib were further examined using Western blots, cell cycle and apoptosis analysis. Treatment with 100 nM of dacomitinib reduced EGFR activity and downstream AKT and ERK pathways more effectively than treatment with 100 ug/ml of cetuximab in all ten tested lines. Although both compounds induced apoptosis at similar levels, dacomitinib caused greater G0/G1 arrest. Sensitivity to EGFR blockade was associated with levels of EGFR and ERK and was not associated with common oncogenic mutations and copy number variations. Phosphorylated and total EGFR and ERK levels correlate with sensitivity to both cetuximab and dacomitinib. Three of the four lines in the exquisitely sensitive group had the highest levels of phosphorylated and total EGFR and ERK among the ten lines selected, while the three resistant lines collectively had the lowest levels. Neither pAKT nor tAKT was associated with sensitivity.

Biologic therapy in head and neck cancer: a road with hurdles

The epidermal growth factor receptor (EGFR) is overexpressed in the vast majority of cases of squamous cell carcinoma of the head and neck (SCCHN). A high EGFR expression is associated with an unfavorable prognosis. Cetuximab is a chimeric human/murine IgG1 antibody which binds with high affinity to the EGFR. It is the only targeted agent which got approval for the treatment of SCCHN from the regulatory agencies of Europe and the United States, both in locoregionally advanced disease, in association with radiation, and in recurrent/metastatic disease. The outcome of trials involving other EGFR-directed monoclonal antibodies, that is, zalutumumab and panitumumab, was consistent with the results with cetuximab. However these trials failed to meet their primary endpoint. The results with EGFR-directed tyrosine kinase inhibitors have been disappointing. Other potential targets for treatment in SCCHN include the entire ErbB family, the vascular endothelial growth factor (VEGF) and its receptor (VEGFR), the insulin-like growth factor 1 receptor (IGF-1R), the insulin receptor (IR), histone deacetylases (HDAC), the mammalian target of rapamycin (mTOR), the platelet-derived growth factor receptor (PDGFR), heat-shock protein 90 (HSP90), nuclear factor-kappa B (NF-κB), aurora A or B, and phosphatidylinositol 3-kinase (PIK3CA).

Potential prognostic and therapeutic role for angiogenesis markers in laryngeal carcinoma

Angiogenesis is a hallmark of cancer, fundamental to its growth. The 'angiogenic switch' occurs when pro-angiogenic factors are not balanced by anti-angiogenic factors. A correlation between angiogenic properties and oncological prognosis (for laryngeal squamous cell carcinoma (LSCC) too) was first hypothesized in the 1990s. An exhaustive literature review was performed to investigate available data on angiogenesis markers and their biological role and therapeutic potential in LSCC. The prognostic significance of microvascular density in LSCC was investigated with endothelial targets, e.g. CD105, CD34, and CD31. Epidermal growth factor receptor (EGFR), vascular endothelial growth factor (VEGF), VEGF receptor 2, angiogenin, hypoxia-inducible factor 1, and other biological markers were also studied. Only anti-EGFR therapy has been approved by the USFood and Drug Administration (FDA) for head and neck carcinoma in recent years, while several agents interfering with VEGF and its receptors are being studied. Experimental findings indicate that anti-CD105 monoclonal antibodies efficiently inhibit tumor angiogenesis. There are two main ways to approach the vascular profile of solid malignancies: by inhibiting new vessel formation (anti-angiogenic therapy) or selectively damaging neoplastic vessels (vascular targeting therapy). In advanced LSCC, both these strategies seem promising and warrant further preclinical and clinical investigation.

Sorafenib enhances the antitumor effects of chemoradiation treatment by downregulating ERCC-1 and XRCC-1 DNA repair proteins

Head and neck squamous cell carcinoma remains a challenging clinical problem because of the persisting high rate of local and distant failure due to the acquisition of chemo- and radioresistance. In this study, we examined if treatment with sorafenib, a potent inhibitor of Raf kinase and VEGF receptor, could reverse the resistant phenotype in tumor and tumor-associated endothelial cells, thereby enhancing the therapeutic efficacy of currently used chemoradiation treatment. We used both in vitro and in vivo models to test the efficacy of sorafenib either as a single agent or in combination with chemoradiation. Sorafenib, as a single agent, showed antitumor and angiogenesis properties, but the effects were more pronounced when used in combination with chemoradiation treatment. Sorafenib significantly enhanced the antiproliferative effects of chemoradiation treatment by downregulating DNA repair proteins (ERCC-1 and XRCC-1) in a dose-dependent manner. In addition, combination treatment significantly inhibited tumor cell colony formation, tumor cell migration, and tumor cell invasion. Combination treatment was also very effective in inhibiting VEGF-mediated angiogenesis in vitro. In a severe combined immunodeficient mouse xenograft model, combination treatment was very well tolerated and significantly inhibited tumor growth and tumor angiogenesis. Interestingly, following combination treatment, low-dose sorafenib treatment alone was highly effective as a maintenance regimen. Taken together, our results suggest a potentially novel strategy to use sorafenib to overcome chemo- and radioresistance in tumor and tumor-associated endothelial to enhance the effectiveness of the chemoradiation therapy.

Nuclear factor-kappaB expression as a novel marker of radioresistance in early-stage laryngeal cancer

BACKGROUND

The aim of this study was to evaluate the significance of nuclear factor-kappa B (NF-kappaB) expression as a marker of radioresistance in early-stage laryngeal cancer.

METHODS

Thirty-five patients with local recurrence and 70 case-matched patients without local recurrence were entered in this study. NF-kappaB expression was compared with Bcl-2 and epidermal growth factor (EGF) receptor expression by immunohistochemistry, using pretreatment biopsy specimens. The prognostic value of NF-kappaB was also evaluated. Twenty-nine recurrent tumors were compared with pretreatment tumors.

RESULTS

NF-kappaB expression in pretreatment tumors significantly correlated with local tumor control (p = .01), but bcl-2 and EGF receptor expression did not. Only NF-kappaB expression showed prognostic significance for local tumor control in both univariate and multivariate analyses (p = .008 and .04, respectively). NF-kappaB expression was markedly enhanced in 23 of 29 (80%) recurrent tumors.

CONCLUSION

NF-kappaB expression may be a novel marker of radioresistance in early-stage laryngeal cancer.

Significance of fascin expression in laryngeal squamous cell carcinoma

OBJECTIVE

Fascin is an actin-binding protein which is expressed in the basal areas of healthy squamous epithelium. Although overexpression of fascin has been shown in many tumours, the relationship between fascin and laryngeal squamous cell carcinoma has not previously been investigated, to the best of our knowledge. This study aimed to investigate the relationship between fascin expression and tumour behaviour in 30 cases of laryngeal squamous cell carcinoma.

MATERIALS AND METHODS

For all lesions, a section of paraffin-embedded tissue was immunohistochemically stained for fascin. The percentage of positive, stained cells was scored from one to five (one = 0-5 per cent, two = 6-25 per cent, three = 26-50 per cent, four = 51-75 per cent and five = 76-100 per cent), and the staining intensity from one to three (one = mild, two = moderate and three = strong). A total immunohistochemical fascin expression score was obtained by multiplying the staining percentage and intensity. The relationship between the total fascin score and each case's age, sex, tumour localisation, tumour-node-metastasis stage and differentiation was evaluated statistically.

RESULTS

Various amounts of fascin expression were observed in all cases. There was a statistically significant relationship between high levels of fascin expression (i.e. a total fascin score of 10 or more) and the cases' tumour stage (p = 0.022), node stage (p = 0.024) and clinical stage (p = 0.014). In addition, worsening tumour differentiation was associated with an increasing fascin score, but this finding was statistically insignificant.

CONCLUSION

These results suggest that laryngeal squamous cell carcinomas with high levels of fascin expression may be more aggressive than those with low expression levels. Further studies with larger series are needed to support these results and to clarify rationales.

A quantitative description of immunofluorescein images using mathematical morphology

This study investigates whether automatic image shape analysis measurements improved by feedforward neural networks [(FFNN), a software application model] showing the activity of small neural groups can be used as an image analysis tool in the interpretation of skin biopsies evaluated by direct immunofluorescence, by identification of local shape characteristics of patterns. An FFNN software was designed with 4 inputs: the "selected digital characteristics" (SDIC), that is, the proportion of node, link, end point, and branch pixels to total pixels; and 6 outputs: "patterns of direct immunofluorescence images" (PDI), that is, basement membrane linear, basement membrane granular, epidermal intercellular, vascular, negative, and nonspecific background staining; and 10 hidden layers for training process. Microscopic images from anti-IgG, IgA, IgM, C3, and fibrinogen stained sections were collected to a computer; 292 direct immunofluorescence images from 72 patients. The FFNN training set included 192 images from 32 patients. SDIC values and a possibility range for PDI category suggested by an experienced pathologist were transferred to FFNN for training. SDIC values were analyzed statistically according to PDI. After the training phase, for determining the accuracy of automatic self-decision process, 100 images from 40 cases were analyzed by FFNN proposing the possibility of PDI. SDIC values were significantly different for PDI groups (1-way ANOVA; P < 0.001) whereas SDIC values of epidermal intercellular group were different from others. FFNN predicted the correct PDI as the first possibility in 83% and second possibility in 14% of the cases. Direct immunofluorescence SDIC measurements processed by FFNN may help inexperienced pathologists in future.

Organ preservation surgery for laryngeal cancer

The principles of management of the laryngeal cancer have evolved over the recent past with emphasis on organ preservation. These developments have paralleled technological advancements as well as refinement in the surgical technique. The surgeons are able to maintain physiological functions of larynx namely speech, respiration and swallowing without compromising the loco-regional control of cancer in comparison to the more radical treatment modalities. A large number of organ preservation surgeries are available to the surgeon; however, careful assessment of the stage of the cancer and selection of the patient is paramount to a successful outcome. A comprehensive review of various organ preservation techniques in vogue for the management of laryngeal cancer is presented.

Molecular markers predict outcome in squamous cell carcinoma of the head and neck after concomitant cisplatin-based chemoradiation

Not all patients with squamous cell carcinomas of the head and neck (HNSCC) benefit from concurrent cisplatin-based chemoradiation, but reliable predictive markers for outcome after chemoradiation are scarce. We have investigated potential prognostic biomarkers for outcome in a large group of patients. Ninety-one tumor biopsies taken from consecutive HNSCC patients were evaluated for protein expression on a tissue microarray. Using immunohistochemistry, 18 biomarkers, involved in various cellular pathways were investigated. Univariable and multivariable proportional hazard analyses were performed to investigate associations between each individual marker and outcome. In addition, the global test was used to test all variables simultaneously and selected combinations of markers for an overall association with local control. Univariable analysis showed statistically significant increased relative risks of RB, P16 and MRP2 for local control and MDR1 and HIF-1alpha for overall survival. MRP2, MDR1 and P16 levels were positively associated with outcome whereas RB and HIF-1alpha had a negative relationship. Using Goeman's global testing no combination of markers was identified that was associated with local control. Grouping the markers according to their function revealed an association between a combination of 3 markers (P16, P21 and P27) and outcome (p = 0.05) was found. In the multivariable analysis, MRP2 and RB remained significant independent predictive markers for local control. This study describes the prognostic value of biomarkers for the outcome in patients uniformly treated with concurrent chemoradiation. MRP2 and RB were found to be associated with outcome in patients treated with concurrent chemoradiation.

Radiotherapy in laryngeal carcinoma: can a panel of 13 markers predict response?

OBJECTIVES/HYPOTHESIS

To find biomarkers associated with response to radiotherapy in laryngeal cancer that can be used together with clinical parameters to improve outcome prediction.

METHODS

In this study, 26 patients irradiated for laryngeal carcinomas with a local recurrence within two years (cases) and 33 patients without recurrence (controls) were included. All pretreatment biopsies were arrayed onto a tissue array. Immunohistochemistry was performed for 13 biomarkers that were selected from the literature as potential predictors for radioresponse in head and neck (HN) cancer: Bcl-2, Bcl-xL, p16, p21, p27, p53, cyclin D1, HIF-1alpha, CA9, COX-2, EGFR, ki-67, and pRB.

RESULTS

Univariate logistic regression models showed borderline statistically significant increased relative risks, with positivity for CA9, COX-2, and p53. Goeman's global testing revealed an overall association between outcome and the 13 markers together with clinical variables. The most important markers were CA9 and COX-2.

CONCLUSIONS

In laryngeal carcinoma, hypoxia and COX-2 overexpression provide a stronger contribution to an increased risk of local recurrence after radiotherapy compared with the well-known candidate markers p53, Bcl-2, and cyclin D1. However, no robust expression profile for the prediction of radioresistance was found.

Biologically conformal treatment: biomarkers and functional imaging in radiation oncology

'Conformal radiation therapy' is the standard of care in radiation oncology, referring to the process of shaping the radiation beam to precisely match a tumor's physical dimensions. We describe 'biologically conformal radiotherapy', in which the radiation oncologist matches the prescribed treatment to a tumor's biological characteristics and the host's predicted tolerance of radiation. This paradigm emphasizes that not all tumors are equally sensitive to radiation; conversely, some patients are especially susceptible to radiation's side effects. Patients bearing radioresistant tumors or those prone to toxicity may be best treated with the incorporation of targeted radiation modulators or, in extreme cases, by a different modality. The biological characteristics of tumors can be assessed by a wide range of techniques: functional imaging (positron emission tomography and advanced magnetic resonance imaging), single gene/protein molecular techniques and 'omic' technologies. This paper reviews the latest advances in the use of biomarkers and functional imaging in guiding patients to receive the most appropriate treatment.

Aggressive recurrent respiratory papillomatosis in a neonate

Recurrent respiratory papillomatosis is the most common benign laryngeal neoplasm in children. We report an infant with widespread papillomatosis at the time of diagnosis and rapidly progressive disease as a neonate. This child did not have the usual risk factors for recurrent respiratory papillomatosis, being the second child born by cesarean section to a mother without history of condyloma. Repeated surgical debulking has been used to control the disease, along with adjuvant therapies that included systemic therapy with an epidermal growth factor receptor inhibitor and intralesional cidofovir. We report our experience with these therapies.

Rationale for adjuvant fatty acid therapy to prevent radiotherapy failure and tumor recurrence during early laryngeal squamous cell carcinoma

Information from a preceding lipid study contributed to the pathobiological assessment of laryngeal squamous cell carcinoma (LSCC). Lipid-driven signaling pathways are responsible for laryngeal carcinogenesis and immunodeficiency. The construction of fatty acid (FA) profiles for LSCC allowed the identification of FA role players. The integration of lipid and clinicomolecular information encountered in the literature, in turn, allowed the identification of biological prognostic markers to distinguish between early (less aggressive) and advanced (more aggressive) LSCCs. High arachidonic acid (AA) and cyclooxygenase (COX-2) activities are criteria for less aggressive growth, whilst low AA and COX-2 activities occur during more aggressive growth. Excessive tobacco use and environmental smoke or human papillomavirus (HPV) infection and alcohol abuse can, respectively, elicit cumulative oxidative stress and an oxidative burst or interfere with signaling pathways during essential fatty acid (EFA) metabolism, all factors and events which may cause LSCC. Research revealed that enhanced COX-2 activity and Bcl-2 expression prevent apoptosis and, hence, LSCCs become resistant to radiotherapy. It was also observed that recurrent laryngeal cancers become more aggressive after radiotherapy failure. It is predicted that manipulation of AA activity and consequently a cascade of downstream factors that include COX-2 and Bcl-2 expression responsible for LSCC may have therapeutic potential to improve radiotherapy outcome during early LSCC. Adjuvant FA therapy to improve early LSCC management by counteracting radiotherapy failure and unwanted complications for further management is proposed. FA therapeutic strategies before and during radiotherapeutic courses need to be evaluated.

Primary treatment of the anterior vocal commissure squamous carcinoma

Squamous cell carcinoma may involve the anterior commissure (AC) area of the laryngeal glottis, and can be grouped morphologically into four groups; (1) tumor confined to the AC, (2) tumor involving one cord and the AC, (3) tumor involving the AC and a portion of both vocal cords, and (4) tumor involving a greater part of one cord and crossing over to involve a variable length of the other cord. Some of these patients when evaluated by imaging, either CT and/or MRI, may demonstrate thyroid cartilage erosion or involvement, thereby upstaging a T1a, T1b into a T3 or a T4 glottic cancer. The majority of patients treated by radiotherapy have only been staged clinically, and hence a failure or recurrence rate of 15%. In patients treated surgically by endoscopic or external surgery, the local recurrence rates are similar at 15%. Therefore, future reporting of patients treated with AC involvement should be staged radiologically, to include CT or MRI, and documentation of the treatment results be reported in subgroups, according to whether there is no cartilage involvement, inner-table cartilage erosion, or through-and-through cartilage invasion. Should endoscopic cordectomy be used, then the type of surgery performed should be based on the classification as suggested by the European Laryngological Society. The use of the above recommendations would allow for more meaningful results to be reported and for cause specific analysis of failure of treatment techniques applied.

The epidermal growth factor receptor (EGFR) in head and neck cancer: its role and treatment implications

Epidermal growth factor receptor (EGFR) is a member of the ErbB family of receptors. Its stimulation by endogenous ligands, EGF or transforming growth factor-alpha (TGF-α) results in activation of intracellular tyrosine kinase, therefore, cell cycle progression. High levels of EGFR expression are correlated with poor prognosis and resistance to radiation therapy in a variety of cancers, mostly in squamous-cell carcinoma of the head and neck (SCCHN). Blocking the EGFR by a monoclonal antibody results in inhibition of the stimulation of the receptor, therefore, in inhibition of cell proliferation, enhanced apoptosis, and reduced angiogenesis, invasiveness and metastases. The EGFR is a prime target for new anticancer therapy in SCCHN, and other agents in development include small molecular tyrosine kinase inhibitors and antisense therapies.

Renal medullary changes in renal allograft recipients with raised serum creatinine

OBJECTIVE

To test the hypothesis that the renal medulla may reflect rejection related changes and thus have a predictive value in the assessment of acute renal allograft rejection or chronic graft damage.

METHODS

75 post-transplant biopsies from 57 patients were scored according to the Banff 1997 scheme. The biopsies with adequate cortical and medullary tissue (n = 23) were selected and medullary tissues were reviewed for rejection related lesions except intimal arteritis. Chronic damage was determined by image analysis depending on periodic acid-methenamine silver (PAMS)-Masson trichrome (MT) staining. Medullary and cortical changes were compared.

RESULTS

Interstitial inflammation and tubulitis were more frequent and severe in the cortex (p<0.001). Medullary tubulitis was associated with intimal arteritis (p = 0.003, r = 0.598). Medullary interstitial inflammation (n = 8) and tubulitis (n = 4) were associated with cortical borderline changes (n = 5) or allograft rejection (n = 3). The sensitivity, specificity, and positive and negative predictive values of medullary inflammatory changes in predicting cortical allograft rejection were 43%, 69%, 37%, and 73%, respectively. A significant association was observed between medullary MT-SAP and cortical PAMS-SAP values (p = 0.02, R(2) = 0.23).

CONCLUSIONS

Acute rejection related lesions are more common and severe in the cortex, and the renal medulla does not sufficiently reflect cortical rejection. The positive and negative predictive values of medullary changes for allograft rejection are low, and medullary inflammation is not a reliable indicator of allograft rejection. Increased medullary fibrosis is correlated with chronic cortical damage.

Glutamine Administration Enhances the Healing of Lung Parenchymal Injuries and Reduces Air Leakage in Rats

Beneficial effects of glutamine on wound healing are well known. Parenchymal injuries in the lung cause air leakage that resolves with wound healing. We aimed to determine the effect of glutamine on the healing of lung injuries. Wistar albino female rats were randomized in three groups. One group (control, n = 7) received intraperitoneal injection of 0.9% sodium chloride (1.5 ml /day), while other group (GLN, n = 7) received glutamine (1.5 g/kg/day), beginning two days prior to the operation for total four days. After thoracotomy, a lung parenchymal lesion was made with a scalpel in the right upper lobe. Only thoracotomy was performed to sham group (n = 4). Air leakage was observed in the isolated lungs of control group, but not GLN and sham groups, at 5 cm H(2)O of positive airway pressure (p < 0.001). The threshold of positive airway pressure for air leakage was 4.85 +/- 0.37 and 19.42 +/- 4.54 cm H(2)O for control and GLN groups, respectively (p < 0.001). For measurement of collagen content in the healing parenchyma, digital images were processed to calculate the stained area percentage (SAP). SAP for immature collagen, a marker for wound healing, was 0.36 +/- 0.18% and 1.48 +/- 0.83% (p = 0.02) in control and GLN groups, respectively, but no significant difference was noted in SAP for mature collagen. The grade of inflammation was not significantly different between control and GLN groups. We conclude that glutamine enhances lung parenchymal healing by increasing immature collagen secretion.

Assessing epidermal growth factor receptor expression in tumours: What is the value of current test methods?

Over-expression of the epidermal growth factor receptor (EGFR) in tumours is associated with aggressive disease and poor clinical prognosis. In theory, the EGFR status of a tumour provides an indication of the likelihood of response to EGFR-targeted therapy. However, the clinical data do not support a relationship between EGFR expression and response to EGFR-targeted therapies cetuximab, gefitinib and erlotinib. Recently, patients who appear to lack EGFR expression have been shown to respond to cetuximab. Possible causes for this paradox include false negative results due to a lack of sensitivity in the detection system, heterogeneity of EGFR expression within the tumour and specific mutations that mediate response to the tyrosine kinase inhibitors. Immunohistochemistry is the most reliable assay for EGFR expression but its interpretation is confounded by the lack of non-standard techniques. Other approaches for measuring EGFR expression can be considered at best exploratory at this point. Further work is needed to identify how EGFR contributes to carcinogenic and metastatic processes. As tumours that appear to be EGFR negative can respond to cetuximab, there is some doubt as to the usefulness of immunohistochemistry as a screen to select patients for treatment. Histopathology will continue to be essential for unravelling the role of this enigmatic molecule and refining its status as a legitimate target in cancer therapy.

Desmoplasia measured by computer assisted image analysis: an independent prognostic marker in colorectal carcinoma

AIMS

The assessment of desmoplasia by traditional semiquantitative methods does not provide reliable prognostic data. The aim of this study was to quantify desmoplasia by computerised image analysis in primary colorectal carcinomas and to investigate its ability to predict overall survival.

METHODS

In total, 112 colorectal adenocarcinomas, with a median follow up of 66 months, were studied. The representative tumour sections were stained by the van Gieson method, which stains collagen rich stroma red. For quantitative histochemical measurement, digital images were analysed by a computerised image analysis program to calculate the percentage of red stained tissue area. The percentage of desmoplasia (PD) was related to conventional clinicopathological prognostic factors and overall survival.

RESULTS

The mean (SD) PD was 4.85 (3.37). PD was found to be significantly associated with lymph vessel and venous invasion. By Kaplan-Meier analysis, PD was associated with survival-patients with PD > 4 had a shorter survival than those with PD

CONCLUSION

Desmoplasia measured by image analysis seems to be a significant prognostic indicator in patients with colorectal carcinoma and the improved method described in this study would be useful for routine prognostication.

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Key Words

• desmoplasia
• colorectal carcinoma
• prognosis
• quantitative histochemistry
• image analysis

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MESH Headings

• Adenocarcinoma/pathology
• Adenocarcinoma/secondary
• Adult
• Aged
• Aged, 80 and over
• Blood Vessels/pathology
• Colorectal Neoplasms/pathology
• Fibrosis
• Follow-Up Studies
• Humans
• Image Processing, Computer-Assisted/methods
• Lymphatic Vessels/pathology
• Middle Aged
• Neoplasm Invasiveness
• Neoplasm Staging
• Prognosis
• Reproducibility of Results
• Survival Analysis

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Affiliation(s)

B Sis Department of Pathology, Dokuz Eylül University School of Medicine, Inciralti, Izmir 35340, Turkey
S Sarioglu
S Sokmen
M Sakar
A Kupelioglu
M Fuzun

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