Clinical prognostic factors for patients with recurrent head and neck cancer: implications for randomized trials

Pattern of metastasis of head and neck cancer in Nigeria: A 10 year review

Introduction

Head and neck cancer is a common and aggressive malignancy with a high morbidity and mortality profile that occur in several anatomical sites in the head and neck region. They constitute the tenth most common cancer in the world. Metastatic head and neck cancers are associated with severe morbidities and its treatment is mainly palliative. This study examined the patterns of metastases of head and neck cancer in patients in a tertiary hospital in Nigeria.

Method

The data extraction form was used to obtain information from the Radiotherapy treatments records and the case notes of patients with histological diagnosis of Head and Neck Cancers between 2002 and 2011 at the Radiotherapy department, University College Hospital, Ibadan. Analyses was done using statistical Package for Social Sciences (SPSS) Version 20.0.

Results

A total of 481 patients were seen in this study. The age of the patients ranged from 11 years to 80 years with mean age of 42 years. The male to female ratio was 2:1. The peak age of incidence was between 40-49 years. Most patients presented with stage III and IV. Nasopharyngeal carcinoma had the highest proportion of occurrence 205 (42.6%) followed by paranasal sinuses. Lung had the commonest site of metastasis followed by bones.

Conclusion

More than half of the patients presented late with the commonest cancer being nasopharyngeal carcinoma. Lung was the commonest site of distant metastasis with nasopharyngeal carcinoma having the highest proportion of metastasis to the lungs at two years follow up.

Prognostic factors in salvage surgery for recurrent head and neck cancer: A systematic review and meta-analysis

INTRODUCTION

Although salvage surgery (SS) is considered the best curative choice in recurrent head and neck cancer, the identification of patients who can benefit the most from this treatment is challenging.

METHODS

We systematically reviewed the prognostic role of pre- and post-surgery factors in patients undergoing SS for recurrent head and neck cancer (oral cavity, oropharynx, hypopharynx, and larynx).

RESULTS

Twenty-five studies met the inclusion criteria out of 1280 screened citations. Pre-surgery factors significantly associated with worse overall survival were age>60 years, advanced initial stage, early recurrence, and regional recurrence; no heterogeneity between study emerged. Among post- surgery factors, worse survival emerged for positive surgical margins, extracapsular extension and perineural invasion.

CONCLUSION

The identification of pre-surgery factors associated with poor outcomes may help the selection of the best candidate to SS; alternative treatments should be considered for high-risk patients. Post-surgery predictors of worse prognosis may guide clinicians in tailoring patients' surveillance.

Salvage surgery in head and neck cancer

Salvage surgery after failed organ preservation treatment offers challenges for both the patient and the surgeon. The outcome is often uncertain and even today, 5‐year overall survival does not exceed 50 per cent. The chemoradiotherapy induced toxicity asks for meticulous discussion and planning in a multidisciplinary manner in a changing environment of increasing incidence of human papillomavirus induced oropharyngeal tumours, evolving surgical techniques and patient participation. Herein, we discuss the latest literature on salvage surgery and the need for identifying the proper prognosticators to ensure for an optimal treatment plan in potentially salvageable patients.

Benefit of salvage total pharyngolaryngoesophagectomy for recurrent locally advanced head and neck cancer after radiotherapy

Background

The treatment modalities for recurrent locally advanced head and neck cancer failure after radiotherapy are limited with poor prognosis. Salvage supra-radical operation seems to be an option. It has not been established which patients will benefit from salvage total pharyngolaryngoesophagectomy.

Methods

We retrospectively reviewed 66 patients with previously irradiated recurrent T4 head and neck cancer who underwent salvage total pharyngolaryngoesophagectomy at our institution between January 2001 and June 2014. The clinical outcome and toxicities were analyzed.

Results

Flap loss occurred in 2 patients, and the incidence of fistulas and anastomosis strictures was 15.6% (10/66) and 13.6% (9/66), respectively. The median survival time of the entire cohort was 12 months. The interval between radiation and salvage surgery, and microscopic carotid artery invasion were identified as independent prognostic factors for overall survival. The 3-year overall survival rates of patients with (n = 33) and without (n = 33) risk factors were 9.1% and 47.2%, respectively (p = 0.007). A time interval between radiation and salvage surgery ≤6 months and previous concurrent chemotherapy or targeted therapy were risk factors for severe post-operative complications.

Conclusions

Salvage total pharyngolaryngoesophagectomy is beneficial to selected patients with recurrent locally advanced head and neck cancer after radiotherapy.

Salvage surgery for oropharyngeal squamous cell carcinomas: A retrospective study from 2005 to 2013

BACKGROUND

In the case of a locoregional recurrence of oropharyngeal squamous cell carcinoma, the curative standard of care is surgery. Our main purpose of this study was to determine the preoperative prognostic factors that would allow us to select the patients on whom we could expect good results with salvage surgery.

METHODS

We conducted a monocentric retrospective study from 2005 to 2013. It included all patients treated for a recurrence of oropharyngeal squamous cell carcinoma with surgery. Their initial treatment included radiotherapy.

RESULTS

Fifty-two patients were included. Poor prognostic factors for survival were the cT status (P = .0039) and local recurrences versus secondary localizations in irradiated areas (P = .016) and a relapse less than a year after the end of the initial treatment (P = .050). Recurrence-free survival was 19% at 5 years. Twenty-nine percent of patients presented local complications, which were mainly fistulas and hemorrhaging at the surgical site.

CONCLUSION

According to the high morbimortality, it is important to carefully select the right patients for surgery.

Failure pattern and salvage treatment after radical treatment of head and neck cancer

Purpose The aim of the study was to test the hypothesis that head and neck cancer (HNC) patients benefit from specialized follow-up (FU), as this strategy ensures timely detection of relapses for successful salvage treatment. This was done by evaluation of the pattern of failure, the temporal distribution of recurrences, and the outcome of salvage treatment in a contemporary cohort of HNC patients. Methods The study evaluated a cohort of 2062 consecutive patients treated with curative intent at Aarhus University Hospital from 1 January 2000 to 31 December 2013. The database of DAHANCA contained recordings of recurrent disease in 567 patients with primary tumors of the larynx, pharynx, oral cavity, nasal cavity, paranasal sinuses and salivary glands. A review of medical records was performed in order to update and supplement the database. Results Failures of the 567 patients were primarily in T-site (65%) followed by N-site (36%) and M-site (22%). The vast majority of the first recurrences occurred within the first years after primary treatment; 62%, 82%, and 91% within the first, second and third year, respectively. Totally, 51% were amenable for salvage treatment, and 44% benefited from salvage in terms of a complete response. Permanent tumor control was observed in 128 patients (23%) after one or two salvage attempts. The highest salvage rate was recorded in patients with primary glottic carcinoma (41%) and the lowest among hypopharyngeal cancers (2%). Asymptomatic recurrence was recorded in 12% of all recurrences and this was found to be a positive prognostic factor for disease-specific survival, as they had significantly better outcome after salvage. Conclusion Our data support the usefulness of specialized FU in terms of early detection of recurrent disease. In particular patients with silent recurrences benefited from early detection, as they had a significantly lower risk ratio of death from primary HNC.

[Observance and results of concurrent chemoradiotherapy after induction chemotherapy by docetaxel, cisplatin and 5-fluoro-uracil for locally advanced head and neck cancers]

PURPOSE

Retrospectively evaluate the safety, feasibility and efficacy of concomitant chemoradiotherapy after induction chemotherapy by docetaxel, cisplatin and 5-fluoro-uracil for locally advanced head and neck cancers.

PATIENTS AND METHODS

Patients' data from three radiotherapy centres in South of France, with locally advanced head and neck cancers, and treated between December 2007 and July 2013 by concomitant chemoradiotherapy, after induction chemotherapy by docetaxel, cisplatin and 5-fluoro-uracil, were analysed. Adverse effects were graduated according to CTCAE v3.0 criteria. Overall survival and disease-free survival were calculated according to Kaplan-Meier method.

RESULTS

One hundred and sixty-eight patients, mostly oropharynx (38%) T4 (46%) N2 (54%) tumors, received, after induction chemotherapy by docetaxel, cisplatin and 5-fluoro-uracil, a concomitant chemoradiotherapy with platin or cetuximab, which delivered 66 to 70Gy. Grade 3-4 adverse effects were less frequent in the group of patients who received cisplatin (with or withour 5-fluoro-uracil) at 100mg/m(2) each 21 days compared to cetuximab (radiomucositis: 32.5% vs 61%, P=0.018; radioepithelitis: 13% vs 61 %, P<0.0001). Chemopotentiation was incomplete for 21% of patients without impacting survival. Two years overall survival and disease-free survival were respectively of 81% and 64%. Lymph nodes status and WHO status significantly influenced these survivals (overall survival 84% if N<3 vs 56% if N3, P=0.017 and 85 % if WHO status ≤ 1 vs 50% if WHO status>1, P=0.006; disease-free survival 66% if N<3 vs 47% if N3, P=0.046).

CONCLUSION

The association of induction chemotherapy by docetaxel, cisplatin and 5-fluoro-uracil and concomitant chemoradiotherapy shows satisfying results with an acceptable toxicity. The terms of the chemopotentiation and its superiority to a single concomitant chemoradiotherapy treatment still remain to be clarified.

Decision making in the management of recurrent head and neck cancer

Despite substantial improvements in head and neck squamous cell carcinoma (HNSCC) treatment, the major obstacle to long-term survival remains disease recurrence. Salvage options are often limited due to prior therapy and the escalated morbidity of retreatment. The costs of treatment must be measured against the anticipated quality and quantity of life recovered, even with resectable disease. This review surveys the recurrent HNSCC literature to better guide decision making. Across multiple studies, negative prognostic factors include impaired performance status, advanced recurrent stage, brief disease-free interval, previous chemotherapy, and nonlaryngeal sites of recurrence. When possible, surgical salvage remains the principal option for durable disease control, quality of life preservation, and cure. Nonsurgical therapies have also demonstrated measurable improvements in locoregional control. Interpretation of salvage literature must be tempered by recognition of significant selection bias. The decision for salvage therapy must be individualized, with management that involves well-informed patients resulting in the best outcomes.

Clinico-pathological profile of head and neck malignancies at University College Hospital, Ibadan, Nigeria

INTRODUCTION

This retrospective study analysed head and neck malignancies seen over a 19-year period at the University College Hospital, Ibadan.

METHODOLOGY

One thousand, one hundred and ninety two patients with head and neck malignancies were analysed according to age, gender, topography and histology.

RESULTS

There was an annual hospital frequency of 62 cases per year. The overall mean age for these malignancies was 43.9 (SD ± 19.3) years. The lesions from the respiratory tract were the most frequent (43.2%) of all cases. The palate was the most frequent intra-oral site (13.8%). Epithelial malignancies constituted 73.4% of all cases with a male: female ratio of 2:1, a mean age of 48.1 (SD ± 17.5) years and were mostly located in the larynx (19.7%). Lymphomas constituted 17.5% of all head and neck cancers with a male: female ratio of 1.6:1, a mean age of 35.1 (SD ± 20.6) years and nodal involvement (39.7%) was most common. Sarcomas constituted 8.9% of all malignancies with a male: female ratio of 1.5:1, mean age of 27.1 (SD ± 16.7) years and the maxillofacial bones (42.5%) were most commonly involved. Neuroendocrine malignancies accounted for 0.2% of head and neck malignancies with a male: female ratio of 1:1, a mean age of 28.5 (SD ± 6.4) years and both cases involved the nose.

CONCLUSION

This study has further confirmed that carcinomas remain the most frequent cancers of the head and neck region in south-western Nigeria.

Head and neck cancer--a clinicopathological study in a tertiary care center

Head and neck cancers display diverse patterns of biological behavior and considerable variation in geographical distribution. This study presents an analysis of head and neck cancer in a Nigerian tertiary healthcare center. It comprises cases diagnosed at the University College Hospital, Ibadan, Nigeria, 1991-2005. Out of 1,750 head and neck tumors, 972 (55.5%) were malignant and 778 (44.5%) were benign. Cancers displayed male predominance, with a gender ratio of 1.8:1. The mean age of cancer patients was 43.8 +/- 19.6 years. Carcinomas constituted 71.7% of head and neck cancers, with 2.4% occurring in children and overall mean age of 48.2 years. Squamous cell carcinoma comprised 66.7% of carcinomas and 47.8% of all head and neck cancers. Hematopoietic malignancies constituted 20.4% of head and neck cancers, and comprised mainly lymphomas, which accounted for 19.3% of all head and neck cancers. The mean age of patients with hematopoietic malignancies was 34.9 years. The most common childhood malignancy was Burkitt's lymphoma, which comprised 28.2% of pediatric head and neck cancers. Connective tissue tumors constituted 7.9% of all cancers, the most common being rhabdomyosarcoma, accounting for 44.2% of sarcomas. The mean age of patients with sarcomas was 26.5 years. There is a need for uniformity in the definition of head and neck cancer so as to permit comparison of international studies. In addition, prospective population-based studies are required to determine the national incidence and to identify risk factors for head and neck cancer in the Nigerian population.

Tissue and circulating immunoreactive protein for MMP-2 and TIMP-2 in head and neck squamous cell carcinoma--tissue immunoreactivity predicts aggressive clinical course

Useful markers showing biological aggressiveness of head and neck squamous cell carcinoma (HNSCC) are needed to predict the outcome of the disease. MMP-2 is associated with aggressive behavior of several solid cancers. In this study, the clinical significance of tumor tissue and circulating immunoreactive proteins for MMP-2 and TIMP-2 was assessed in HNSCC. The study group consisted of 74 patients with HNSCC and 44 healthy controls. Expression of MMP-2 and TIMP-2 was examined in paraffin-embedded tumor sections by immunohistochemical methods using specific antibodies. The pretreatment serum levels of MMP-2, TIMP-2 and MMP-2:TIMP-2 complex were quantitatively measured by ELISA assay. The results were compared with the clinicopathological factors of the disease and the patients' outcome. Immunohistochemical overexpression of MMP-2 in tumor was found to be prognostic for shortened survival in HNSCC, the 5-year cumulative relapse-free survival being 42% in patients with high positivity for MMP-2 in tumor vs 61% in cases with a negative or only weakly MMP-2-positive tumor (P=0.045). Tissue MMP-2 positivity was also strongly connected with later lymph node or hematogenic relapses and associated to the cause-specific survival (P=0.055). Similarly, the 5-year cause-specific survival was significantly poorer in patients with extensive positive immunostaining for tumor TIMP-2 than in those with a TIMP-2-negative tumor (40 vs 64%, P=0.038). Patients with a TIMP-2-positive tumor also had an unfavorable 5-year relapse-free survival rate (43 vs 60%, respectively, P=0.071). Additionally, the overexpression of TIMP-2 was a powerful predictor of later lymph node or hematogenous metastases in HNSCC. Serum levels of MMP-2, TIMP-2 or MMP-2:TIMP-2 complex failed to associate with the clinical behavior of HNSCC in this material. The results of this study provide evidence that MMP-2 and TIMP-2 immunoreactive protein in tumor tissue of HNSCC patients, but not when assayed from preoperative serum samples, are prognostic in estimation of the aggressive clinical course of HNSCC.

A phase II evaluation of a 3-hour infusion of paclitaxel, cisplatin, and 5-fluorouracil in patients with advanced or recurrent squamous cell carcinoma of the head and neck

BACKGROUND

Previous data from an institutional pilot study in patients with advanced or recurrent squamous cell carcinoma of the head and neck (SCCHN) who received treated a combined chemotherapy regimen of paclitaxel, cisplatin, and 5-fluorouracil indicated an overall response rate of 60% and a median survival of 6 months. To validate these results and to determine the feasibility of this combination, a Phase II study was conducted by the Southwest Oncology Group (SWOG S0007).

METHODS

Patients with advanced or recurrent SCCHN were eligible if they had received 1 previous regimen of induction/adjuvant chemotherapy or no prior systemic therapy. Patients received treatment with paclitaxel (135 mg/m(2) on Day 1), followed by cisplatin (75 mg/m(2) on Day 1), and 5-fluorouracil (1000 mg/m(2)per day as a 96-hour continuous infusion on Days 1-4) every 21 days.

RESULTS

Seventy-six patients received a combined total of 286 cycles of chemotherapy. Sixty-nine patients were evaluable for response. There were 5 complete responses (7%) and 23 partial responses (33%) partial responses, for an overall response rate of 41%. The median progression-free survival was 4 months, and the median overall survival was 10 months. Six treatment-related deaths were documented, including deaths in 2 patients who had a Zubrod PS of 2. Grade 3 or 4 neutropenia (according to National Cancer Institute Common Toxicity Criteria [version 2.0]) was observed in 47% of patients. Other Grade 3 or 4 adverse events included mucositis (34% of patients), nausea (20% of patients), anemia (9% of patients), and neuropathy (8% of patients).

CONCLUSIONS

The combination of paclitaxel, cisplatin, and 5-fluorouracil had efficacy similar to that of standard treatment regimens in patients with advanced or recurrent SCCHN but with increased toxicity.

Clinical and prognostic value of [(18)F]FDG-PET for surveillance of oral squamous cell carcinoma after surgical salvage therapy

[(18)F]FDG-PET was found to be useful for recurrence detection in patients with oral squamous cell carcinoma (OSCC), as a negative PET scan predicted a favorable outcome and survival. Here, we evaluate PET performance in the management of OSCC patients with recurrent/second primary disease after potentially curative second-line therapy. Forty one OSCC patients underwent salvage surgery and 31/41 had received radiation therapy. Thirty five/41 developed recurrent and 6/41 second primary OSCC. Patients had PET evaluation 8.4months (median) after surgery and were followed for at least 6months until disease recurrence or death. For surviving patients, the median follow-up was 33.6months after PET. In OSCC patients who had undergone potentially curative second-line therapy, PET had an overall sensitivity of 85% (92% for recurrence or second primaries, 88% for lymph node failure and 73% for distant metastases). Overall survival was 71% in the PET negative group and 35% in the PET positive group (p<0.01, log-rank test). Moderate glucose metabolism (standardized uptake value4) suggested promising outcome, while SUV>4 indicated a fatal disease course. The data suggest that [(18)F]FDG-PET can facilitate re-staging and clinical management in "high-risk" patients with OSCC.

Serum matrix metalloproteinase-9 in head and neck squamous cell carcinoma is a prognostic marker

The aim of this study was to determine whether serum matrix metalloproteinase-9 (MMP-9) could predict cause-specific and relapse-free survival in patients with squamous cell carcinoma of head and neck. Furthermore, this study was designed to investigate whether there is an association between MMP-9 immunohistochemical staining and serum MMP-9 levels. Pretreatment serum levels of MMP-9 were quantitatively measured by ELISA assay in 67 patients presenting with a primary head and neck squamous cell carcinoma. The results were compared with the corresponding immunohistochemical staining results, clinical data and the patients' outcome. The follow-up time for all of the patients was at least 5 years. There was a statistically significant correlation between circulating MMP-9 and MMP-9 immunohistochemical staining in the corresponding tumors (p = 0.028). The cause-specific and relapse-free survival rates were clearly lower among patients with high MMP-9 serum levels (> 73 ng/ml). The 5-year cause-specific survival-rate was 40% in a patient group with high serum MMP-9, and 69% for patients with a low MMP-9 level (p = 0.027). In the same follow-up period, the cumulative relapse-free survival rate was 36% in patients presenting with a high serum MMP-9 and 66% in those with a low MMP-9 level. No correlation was found between MMP-9 serum levels and the traditional clinical or histopathologic factors. The results suggest for the first time that pretreatment serum MMP-9 level could serve as a prognostic factor in head and neck squamous cell carcinoma.

Tissue Inhibitor of Matrix Metalloproteinase-1 Is Prognostic in Head and Neck Squamous Cell Carcinoma: Comparison of the Circulating and Tissue Immunoreactive Protein

PURPOSE

Tissue inhibitors of metalloproteinases (TIMP) are capable of inhibiting the matrix metalloproteinases, but they also possess other biological functions. Little is known about the role of TIMP-1 in the progression and spreading of cancer cells among patients with head and neck squamous cell carcinoma (HNSCC). In this study, the pretreatment serum levels of TIMP-1 or the overexpression of TIMP-1 immunoreactive protein in the primary tumor was correlated to the clinical course in patients with HNSCC.

EXPERIMENTAL DESIGN

The TIMP-1 immunoreactive protein was studied in 74 cases representing HNSCC. The tissue immunoreactive protein was evaluated from paraffin-embedded tumor sections in 68 cases using immunohistologic staining with a specific antibody, and in 68 cases the pretreatment serum levels of TIMP-1 were quantitatively measured by ELISA assay. The results were compared with the clinicopathologic factors of the disease and the patients' outcome.

RESULTS

A positive correlation was found between the size of the primary tumor (T) and the circulating TIMP-1 level (P = 0.021) or the positive immunoreaction of TIMP-1 in tumor (P = 0.039). The 5-year cause-specific survival was significantly lower in patients presenting with a high serum TIMP-1 level than in those with a low level of TIMP-1 (38% versus 64%, P = 0.034). They also had an unfavorable 5-year relapse-free survival rate (37% versus 56%, respectively). Similarly, the expression of TIMP-1 in tumor was prognostic for shortened survival, the 5-year cumulative relapse-free survival being 42% in patients with a TIMP-1-positive tumor versus 75% in cases with a negative tumor (P = 0.035). Tissue TIMP-1 positivity also seemed associated to the cause-specific survival (P = 0.075) and to be connected with later lymph node or hematogenic relapses.

CONCLUSIONS

This study shows for the first time that both circulating and tissue TIMP-1 immunoreactive protein predicts the clinical course and dissemination in HNSCC, suggesting that TIMP-1 might be related to both tumor growth and metastasis in HNSCC.

Prognostic significance of late cervical metastasis and distant failure in patients with stage I and II oral tongue cancers

Stage I and II oral tongue cancers (OTC) generally have a favorable prognosis, but there are some early OTC cases with a poor prognosis. OTC is known for its propensity for subclinical nodal metastasis and, moreover, we must devise a strategy that takes account of the possibility of recurrence and distant metastasis. In the current study, 90 previously untreated patients with stage I or II OTC who underwent surgical treatment were eligible for review. The authors investigated the associations of their clinico-pathologic factors with disease outcomes, and also examined the postoperative course for patients with a poor prognosis. The most common cause of death was distant metastasis and late cervical lymph node metastasis (LCM) was the significantly independent prognostic variable. Since LCM can be treated with salvage surgery, the central issue is to control patients with distant metastises who are free of disease in their loco-regional sites.

Phase II study of OSI-211 (liposomal lurtotecan) in patients with metastatic or loco-regional recurrent squamous cell carcinoma of the head and neck. An EORTC New Drug Development Group study

The purpose of this study was to evaluate the activity and safety of OSI-211, the liposomal form of lurtotecan, in patients ineligible for curative surgery or radiotherapy and with metastatic/locoregional recurrent squamous cell carcinoma of the head and neck (SCCHN) and target lesions either within a previously irradiated field ("within") or outside a previously irradiated field ("outside"). OSI-211 was given intravenously over 30 min on days 1 and 8 at 2.4 mg/m2/day, repeated every 21 days (1 cycle). From July 2001 to March 2002, 32 patients from 14 institutions were enrolled in the "within" arm and 18 in the "outside" arm. In the "within" arm, two patients were ineligible because their tumour site was not allowed in the protocol (nasopharynx, skin) and two other patients never started treatment. Of the 46 eligible patients who started treatment, there was one objective response (response rate: 2.2% (95% Confidence Interval (CI): [0-11.5%]). Twelve patients in the "within" arm and 6 in the "outside" arm had stable disease, with a median duration of 18 weeks, 95% CI (12.7-25.7). The median time to progression was 6 weeks (95%CI: [5.9-12.7] weeks). Haematological toxicity was moderate in both arms. The most common haematological toxicity was grade 1-2 anaemia in 79% of patients. Non-haematological toxicity was mild in both arms. The most common grade 3-4 non-haematological toxicity was infection in 8.5% of patients. OSI-211 administered on d1 and d8, every 3 weeks, is well tolerated, but shows only minimal activity in locally advanced/metastatic SCCHN.

Expression of matrix metalloproteinase-9 in head and neck squamous cell carcinoma: a potential marker for prognosis

PURPOSE

Previous studies have shown that matrix metalloproteinase-9 (MMP-9) is expressed in malignant head and neck squamous cell carcinoma. The prognostic role of MMP-9 is still unclear. The aim of this study was to investigate the role of MMP-9 immunoreactive protein as a prognostic marker for survival in head and neck squamous cell carcinoma.

EXPERIMENTAL DESIGN

Overexpression of the immunoreactive protein for MMP-9 was evaluated in tissue sections of 74 primary head and neck carcinomas with a monoclonal antibody using a biotin-streptavidin immunohistochemical staining method. The staining results were compared with the clinical data and to the patients' outcome.

RESULTS

Positive immunostaining for MMP-9 was observed in 82% of the head and neck carcinomas, 39% of the cases being extensively positive. MMP-9 protein expression was independent of the stage or the grade of the tumor. The expression of MMP-9 was prognostic for shortened survival, the 5-year cause-specific survival being 45% in MMP-9 positive cases, and 92% in cases negative for MMP-9 (P = 0.013). MMP-9 positivity also correlated to the relapse-free survival (P = 0.019). At the 5-year follow-up, the cumulative relapse-free survival rate was 79% for patients with MMP-9-negative tumor and 42% for the patients with positive immunostaining for MMP-9. High expression of MMP-9 seemed to be linked with more aggressive relapses, appearing in 33% of the cases in local relapses, in 52% of cases with lymph node relapses, and in 60% of the cases with hematogenic relapses.

CONCLUSIONS

This is the first study with a long follow-up showing that the immunoreactive protein of MMP-9 in head and neck carcinoma is associated with shortened relapse-free and cause-specific survival, suggesting that MMP-9 has a role in tumor progression of head and neck carcinomas, as well as in estimation of the prognosis of these diseases.

Matched-Pair Analysis of Survival of Never Smokers and Ever Smokers With Squamous Cell Carcinoma of the Head and Neck

Purpose

To compare survival rates between patients with squamous cell carcinoma of the head and neck (SCCHN) without a history of smoking (never smokers) and those with a current or previous history of smoking (ever smokers).

Patients and Methods

Fifty never smokers with newly diagnosed SCCHN were matched to 50 ever smokers according to sex, age, tumor site, overall stage, nodal stage, and treatment. Survival analysis was performed using Kaplan-Meier estimates. Matched-pair survival was compared using the Cox proportional hazards model.

Results

The never smokers had a greater overall survival (P = .020), disease-specific survival (P = .022), and recurrence-free survival (P = .016). Furthermore, matched-pair analysis demonstrated smoking was associated with a significant increase in risk of overall death (relative risk [RR] = 3.50; 95% CI, 1.14 to 10.77; P = .029), risk of death owing to disease (RR = 3.98; 95% CI, 1.11 to 14.33; P = .034), and risk of disease recurrence (RR = 3.29; 95% CI, 1.18 to 9.14; P = .023). Smoking was associated with three-fold increases in risk for overall death, death owing to disease, and recurrence after adjustment for cancer-associated symptom severity and alcohol use, but the 95% CI for these adjusted risk estimates each included the null.

Conclusion

Survival differed significantly between never smokers and ever smokers with SCCHN. These results are not substantively explained by differences in cancer-associated symptoms or alcohol use, but the CIs are wide and some imprecision remains. Regardless, possible fundamental differences in SCCHN between ever smokers and never smokers may exist, and further molecular characterization of these tumors is needed to determine whether biologic differences needing targeted therapies exist.

Results of randomised phase II studies comparing S16020 with methotrexate in patients with recurrent head and neck cancer

BACKGROUND

The purpose of this study was to carry out two randomised phase II trials of S16020, a new olivacine derivative, tested as a single agent in patients with recurrent head and neck cancer, using methotrexate as the control arm to validate the results.

PATIENTS AND METHODS

S16020 at either 80 or 100 mg/m2 was administered as a 3-h infusion every 3 weeks. Methotrexate, 40 or 50 mg/m2, was given by bolus injection, weekly for a minimum of 6 weeks. In total, 36 patients were entered in the randomised studies (25 in an initial study, 11 in a confirmatory study) of whom 24 received S16020 and 12 received methotrexate.

RESULTS

A scheduled interim analysis showed one patient having a non-confirmed objective response with S16020 and three patients having a confirmed objective response with methotrexate. In the methotrexate group, there were no patients with severe non-haematological toxicity. With S16020, there was a high incidence of severe non-haematological toxicities, including asthenia, oedema of the face, oedema and pain at the tumour sites and erythematous rash; consequently, both studies were stopped.

CONCLUSIONS

Both studies were stopped due to the poor anticipated benefit/risk ratio for S16020, although time to progression and overall survival time were similar in both treatment arms.

Result of two randomized trials comparing nolatrexed (Thymitaq) versus methotrexate in patients with recurrent head and neck cancer

We report on two randomized trials performed in the USA and Europe, which compared methotrexate and nolatrexed as treatment for patients with recurrent head and neck cancer. Eligibility criteria included: histologically confirmed squamous-cell carcinoma, measurable disease, adequate hematological, renal and hepatic functions, failure of a first-line chemotherapy, and informed consent. Methotrexate 40 mg/m2 was weekly given by short infusion, and nolatrexed 725 mg/m2 per day was administered as a five-day continuous infusion, every three weeks. A total of 139 patients (63 in the USA. 76 in Europe) were randomized based on a ratio of 2/1: 93 and 46 received nolatrexed and methotrexate, respectively. Patient characteristics included 115 males and 24 females; median age 60 years. In the nolatrexed arm, the following grade 3-4 toxicities occurred: neutropenia (29.9%) with 3.1% of febrile neutropenia, mucositis (33.3%), and vomiting (10.3%). In the MTX arm, the grade 3-4 toxicities were neutropenia (7.1%) and mucositis (6.9%). There was no difference in activity between the nolatrexed and the methotrexate treatment: 3.3% and 10.8% of objective responses, 1.9 versus 1.5 months of disease-free progression and 3.5 versus 3.7 months of overall survival, respectively. Nolatrexed has demonstrated a similar activity to methotrexate.