Laryngeal carcinoma in nonsmoking patients

The rising rate of nonsmokers among laryngeal carcinoma patients: Are we facing a new disease?

OBJECTIVES/HYPOTHESIS

Laryngeal squamous cell carcinoma (SCC) is strongly associated with tobacco smoking. With the rising awareness of tobacco's adverse health effects, we have witnessed a global decrease in tobacco use. Nevertheless, laryngeal SCC remains prevalent and includes a subset of patients lacking the traditional risk factors.

STUDY DESIGN

A two-center retrospective cohort.

METHODS

Medical records of patients diagnosed with laryngeal SCC between 2009 and 2016 were reviewed. Data collected included demographics, smoking status, and tumor site. Patients who have never smoked were designated as nonsmokers.

RESULTS

The study included 330 patients with laryngeal SCC, of whom 75 (22.7%) were nonsmokers; this rate was relatively similar for each of the two institutions independently (21.9% and 25%). There were 285 patients with glottic SCC and 45 with supraglottic SCC. All nonsmoking patients in this cohort had glottic SCC, representing 26.3% (75/285) of the glottic SCC cases. The rate of female patients was significantly higher among nonsmokers. Of the patients with glottic SCC, females represented 25.3% (19/75) of the nonsmokers compared with 12.4% (26/210) of the smokers (P = .008). Mean age at diagnosis was 60.2 ± 17.5 years for nonsmoking glottic SCC patients and 63.6 ± 12.4 years for smokers (P = .280). However, nonsmokers demonstrated a distinct age distribution pattern. Nonsmoking females with glottic SCC demonstrated a bimodal age distribution pattern; 73.7% (14/19) were age <40 years or >75 years at diagnosis.

CONCLUSIONS

The rate of laryngeal SCC in nonsmokers is higher than what has previously been reported, representing a growing proportion, and may suggest a shift in etiology. Knowing that laryngeal SCC in nonsmokers predominantly affects the glottis, and that females and age extremities are more vulnerable, the traditional screening paradigm should be revised.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:E108-E115, 2020.

Molecular and immunologic analysis of laryngeal squamous cell carcinoma in smokers and non-smokers

BACKGROUND

Laryngeal squamous cell carcinoma (LSCC) is strongly associated with tobacco use, but recent reports suggest an increasing incidence of LSCC in patients without traditional risk factors, suggesting an alternative etiology of tumorigenesis. The purpose of this study is to characterize this non-smoking population and to compare immunohistochemical markers in tumor specimens from non-smokers and smokers with LSCC.

METHODS

A retrospective chart review of patients with LSCC at Johns Hopkins Hospital (JHH) was performed. A tissue microarray (TMA) was constructed with tumor specimen from non-smokers with stage and age-matched smokers and stained for a variety of immunologic and molecular targets.

RESULTS

In the JHH cohort of 521 patients, 12% (n = 63) were non-smokers. Non-smokers were more likely to be <45 years old at time of diagnosis (OR 4.13, p = 0.001) and to have glottic tumors (OR 2.46, p = 0.003). The TMA was comprised of tumors from 34 patients (14 non-smokers, 20 smokers). Only 2 patients (6%) were human-papillomavirus (HPV) positive by high-risk RNA in situ hybridization (ISH). There was no correlation between smoking status and p16 (p = 0.36), HPV-ISH positivity (p = 0.79), phosphatase and tensin homolog (PTEN, p = 0.91), p53 (p = 0.14), or programmed death-ligand 1 (PD-L1, p = 0.27) expression.

CONCLUSIONS

Non-smokers with LSCC are more likely to be younger at the time of diagnosis and have glottic tumors than smokers with LSCC. In TMA analysis of stage and age-matched specimens from smoker and non-smokers with LSCC, the pattern of expression for common molecular and immunologic markers is similar. Further, HPV does not appear to be a major causative etiology of LSCC in either smokers or non-smokers in our cohort of patients.

Glottic Carcinoma in Young Patients

Introduction:

Recent reported evidence indicates that vocal cord carcinoma is evolving similarly to oropharyngeal cancer with an increasing number of patients without a smoking history having human papillomavirus (HPV) disease. Observations also suggest that an increasing number of patients who present with glottic carcinoma are younger than has been reported in the past. Therefore, an investigation was done to examine the incidence of glottic carcinoma in patients 30 years old (y/o) or younger.

Methods:

A retrospective review was done with Institutional Review Board approval to evaluate the incidence of patients 30 y/o or younger presenting with glottic carcinoma in 2 symmetric-length time periods over 28 years. These data were comprised from glottic cancer patients evaluated by the senior author (S.M.Z.) at the Massachusetts Eye and Ear Infirmary (July 1990-June 2004) and subsequently at the Massachusetts General Hospital (July 2004-June 2018). HPV testing was done on those patients identified as having a disease process at 30 y/o or younger.

Results:

Between July 1990 and June 2018, 353 patients were diagnosed with glottic carcinoma. From July 1990 to June 2004, there were 112 patients, with none being 30 y/o or younger. From July 2004 to June 2018, 241 patients were diagnosed with glottic carcinoma; 11 patients (7 females, 4 males) were 30 y/o or younger. Of the 11 patients, 3 (1 female, 2 males) were 10 to 19 y/o, 3 (2 females, 1 male) were 20 to 25 y/o, and 5 (4 females, 1 male) were 26 to 30 y/o. Moreover, 10 of the 11 cases were tested and were positive for high-risk HPV. None of the 11 glottic cancer patients had been previously treated for benign recurrent respiratory papillomatosis although it was initially suspected prior to biopsy due to the morphology of the lesions and the patients’ young age. Three of 11 had a history of smoking; all 3 had less than 3 pack-years. One of the 11 glottic cancer patients was treated with serial Cidofovir injections that resulted in dramatic acceleration in the growth of the cancer.

Conclusion:

Historically, glottic carcinoma is considered to be a tobacco-induced disease associated with a multidecade process of initiation, promotion, transformation, and progression. However, recent published evidence shows that glottic carcinoma can be an HPV-related disease with increasing incidence in nonsmokers. It isn’t surprising that alternate malignant pathways may have a different timeline. In this investigation, an increased incidence of HPV-positive glottic cancer in patients 30 y/o or younger was documented in the past 14 years. This finding further supports the concept that glottic carcinoma is an evolving disease, and it demonstrates the increasing importance of discriminating potential glottic carcinomas in young patients from benign low-risk HPV recurrent respiratory papillomatosis.

Clinical Significance of miR-149 in the Survival of Patients with Laryngeal Squamous Cell Carcinoma

MicroRNAs (miRNAs) play critical roles in the progression of laryngeal cancer (LC). In this study, we aimed to investigate whether miR-149 is associated with the prognosis of patients with LC. A total of 97 laryngeal squamous cell carcinoma patients who underwent tumor resection were included in our follow-up study. In vitro studies was performed in cancer cell line Hep-2 to explore the antitumor role of miR-149 in LC. We found that the expression of miR-149 was significantly lower in tumor tissues, compared with vocal cord polyp tissues (P < 0.05). Kaplan-Meier analysis revealed that miR-149 expression status is significantly associated with survival duration (log rank test, P < 0.05), and multivariate Cox regression analysis revealed that patients with low miR-149 expression had shorter survival times compared with patients with high miR-149 expression. In vitro studies revealed that the exogenous expression of miRNA-149 inhibits the proliferation of human Hep-2 cells and induces cell apoptosis. Our study suggests that miR-149 expression in laryngeal squamous cell carcinoma tissues is critically associated with the prognosis of patients, and the ectopic expression of miR-149 in Hep-2 cells inhibits proliferation and cell cycle progression.

Glottic Cancer

Objective:

Conventional wisdom is that the overwhelming majority of glottic cancer patients have a smoking history. However, in recent years observations suggested that an increasing number of glottic cancer patients had never been smokers. Therefore, an investigation was done examining the incidence of having a smoking history in a recent cohort of glottic cancer patients.

Method:

Retrospective review of 100 patients with glottic cancer to determine those reporting never having smoked.

Results:

Thirty-one of 100 did not have a smoking history. Clinical observations of those cases revealed that the disease morphology tended to be exophytic, papillary, and very vascular, often resembling recurrent respiratory papillomatosis (RRP). Remarkably, 2 of 31 were initially treated elsewhere assuming they had RRP and underwent 5 cidofovir injections. Both presented with advanced cancer, and the disease growth markedly accelerated coincident with the injections.

Conclusions:

Observations herein provide new insights that glottic cancer may be an evolving disease in which smoking is less exclusive, not unlike HPV-induced pharynx cancer. Similar to RRP, the angiogenic papillary disease morphology is well suited for voice-preserving angiolytic KTP laser treatment. Given the resemblance of some glottic cancers to RRP, great care should be taken when using cidofovir for papillary glottic neoplasms.