French Society of ENT (SFORL) guidelines for care pathway organization in head and neck oncology (short version). Early management of head and neck cancer

Early management in oncology is based on coordination and high-quality exchange between the various health-care partners. The present guidelines are based on a literature search with levels of evidence. Treatment waiting time can be optimized by performing assessment as early as possible (Expert opinion), to limit the interval (ideally, less than 4 weeks) between first consultation and data collection. In the first specialist consultation, diagnostic work-up should be scheduled and the data required for management should be determined (Grade B). Work-up may be conducted on a day-care basis or with conventional admission (Expert opinion). The patient's medico-social context should be taken into account from the outset, with social work involvement whenever necessary (Expert opinion). Pain and nutritional management should be planned for (Grade A) and realistic therapeutic education be provided (Expert opinion). Community-hospital teamwork for supportive care should be optimized (Expert opinion). Management should be early and multidisciplinary, to shorten delay between diagnosis and treatment initiation.

Correlation of global expresssion of ERCC1 in head and neck squamous cell carcinoma with prognosis

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Background: The overexpression of excision repair cross-complementation group 1 (ERCC1), element of the Nucleotid Excision Repair (NER) pathway has been associated with resistance to platinum-based chemotherapy. We studied the correlation of ERCC1 immunohistochemical expression with overall survival and cancer-specific survival in patients with locally advanced head and neck squamous-cell carcinoma (HNSCC) treated with cisplatin-based chemotherapy. Methods: Using a monoclonal antibody against ERCC1 (clone 8F1, Neomarker), we analyzed its immunohistochemical expression in pretherapeutic samples of 142 HNSCC patients treated in our center from 2000 to 2006. Forty-three patients were treated with surgery followed by adjuvant radiochemotherapy, 86 with concomitant radiochemotherapy with or without neoadjuvant chemotherapy and 13 with cisplatin-based chemotherapy for metastatic disease. Two independent observers blinded to clinical data evaluated ERCC1 expression using the H-score protocol (ranging from 0 to 3). Survival rates were estimated using the Kaplan-Meier method. Survival univariate analysis was performed using log-Rank test. Results: ERCC1was expressed intensively and diffusely in the nuclei 89% of the tumor samples had an H-score at least equal to 2. Treatment type and metastatic status were predictive of overall survival (respectively, p = 0.003 and p = 0.005). Higher expression of ERCC1 tended to be correlated with longer overall survival (p = 0.08). Conclusions: Our observations are at variance with recently published data about the predictive role of ERCC1 (Handra Luca CCR 2008). Overexpression of ERCC1 has also been associated with better outcome of operated NSCLC. Such differences may be due to inherent biological differences between study populations and certainly attributable to different roles of ERCC1 through oncogenesis.These controversial correlative results among studies and the intense and diffuse patterns of ERCC1 expression might also indicate a central role of ERCC1 in HNSCC oncogenesis and then provide a potential target. Further investigations about the role and predictive value of ERCC1 protein in anticancer treatments including cisplatin are warranted.

No significant financial relationships to disclose.

Oral cavity squamous cell carcinoma in patients aged 80 or older: Risk factors, treatment, and outcome

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Background: We have recently reported a large series of patients aged ≥ 80 years showing that in this population about half of head and neck squamous cell carcinomas (SCC) are located in the oral cavity. There are no specific data on this cancer location outcome in elderly patients. Therefore, we report here the experience of two French cancer centers in the treatment of oral cavity SCC in patients aged ≥ 80 years. Methods: Two hundred sixty patients aged ≥ 80 years with a primary oral cavity SCC were included in this retrospective analysis. Results: Sex ratio was near to 1. The risk factor distribution was significantly different between men and women: tobacco/alcohol consumption (66.3% vs 15.8%, p < 0.001), history of leukoplakia/lichen planus/oral traumatism (10.8% vs 55.3%, p = 0.002). Two hundred patients received a loco regional (LR) treatment with a curative intent (surgery and/or radiotherapy), 29 with a palliative intent and 31 did not receive a LR treatment. Curative treatments were delivered according to the institution policy in 56 patients (28%).The median disease specific survival (DSS) was 16.9 months. In multivariate analysis, independent prognostic factors were stage (HR = 0.45 [0.29–0.69], p < 0.001), and curative intent of treatment (HR = 0.28 [0.17–0.45], p < 0.001). Median overall survival (OS) was 13.9 months. In multivariate analysis, the independent prognostic factors for OS were age (HR = 0.63 [0.33–0.76], p < 0.001), stage (HR = 0.61 [0.40–0.91], p = 0,016), and curative intent of treatment (HR = 0.41 [0.23–0.71], p < 0.001. In patients treated with a curative intent, the standard treatment was not associated with improved overall survival or disease specific survival as compared with those treated with an adapted treatment. However, prophylactic lymph node treatment in early stage cancer decreased the rate of nodal recurrence from 38% to 6% (p = 0.01). Conclusions: This study emphasizes the need for prospective evaluation of standard and adapted schedules in elderly patients with oral cavity cancer.

No significant financial relationships to disclose.

Compliance and toxicity profiles of the CARISSA trial of postoperative cisplatin-based chemoradiation ± gefitinib in head and neck cancer

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Background: Concurrent cisplatin and postoperative irradiation (PORT) is the standard treatment for resected poor-risk squamous cell carcinoma of the head and neck (HNSCC) . However, a substantial number of patients fail to respond. Anti-EGFR agents, such as gefitinib, may improve outcomes and molecular markers might predict treatment efficacy. This was the basis for the CARISSA trial. There was some concern after hemorrhagic events occurred in a large independent trial of recurrent unresectable HNSCC. This caused a temporary interruption and safety profile analysis of CARISSA, which resumed after security reports showed no excess of hemorrhagic events. Methods: The CARISSA multicenter blinded randomized phase II trial compares PORT and cisplatin alone (arm A) or in combination with the EGFR Inhibitor ZD1839 gefitinib (arm B) in HNSCC and analyses EGFR-binding, gene polymorphisms, Western Blotting and immunohistochemistry. Patients are followed weekly. Toxicities are graded according to the NCI/CTCv.3 scale. Results: Thirty-eight patients have been included. Compliance to cisplatin was 56% in arm A and 44% in arm B (NS). Compliance to gefitinib was 60% with half cases interrupting treatment for toxicity. There were 18 and 20 grade (G) 3/4 non-hematological toxicities, 12 and 6 hematological G3/4 toxicities in arms A and B, respectively. Mucositis was the most common toxicity. G3 mucositis occurred in 4 and 5 cases in arms A and B, dermatitis in three cases in each arm and diarrhea in one case in each arm (NS). There were 7 cancer- related deaths and 3 of other causes. One tumor-bleeding event occurred in the arm without gefitinib. Full-dose radiotherapy was delivered in all but one case in each arm. Mean doses were 63.9 ± 1.9 (arm A) and 65.5 ± 0.9 Gy (arm B) or 64.7 ± 0.9 (arm A) and 65 ± 0.9 Gy (arm B) in groups where RT was uninterrupted or temporarily interrupted, respectively (NS). The two patients who did not receive full dose received 60 Gy. Conclusions: Compliance to PORT was similar with cisplatin alone or cisplatin + gefitinib. While there was no excess of hemorrhagic morbidity postoperatively (no gross disease), accrual continues with particular caution.

No significant financial relationships to disclose.

Re-irradiation combined with chemotherapy after salvage surgery in head and neck carcinoma: A randomized trial from the GETTEC and GORTEC groups

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Background: Full dose re-irradiation combined with chemotherapy has been shown to be feasible after salvage surgery with an “acceptable” toxicity (Cancer 2001; 91:2071–6). We performed a prospective, multicentric, randomized study to assess its carcinologic value. Methods: Between 1999 and 2005, 130 head and neck cancer patients were treated with salvage surgery and then randomly assigned either to full dose re-irradiation combined with chemotherapy (arm A) or absence of post-operative treatment (arm B). Patients eligibility criteria were: recurrence or second primary in a previously irradiated area to at least 45 Gy, absence of distant metastasis, salvage surgery with macroscopic complete resection; possibility of starting adjuvant treatment within 6 weeks after salvage surgery. Patients in arm A received 60 Gy in 12 weeks combined with concomitant 5FU, Hydroxyurea, as previously described (Ann Oncol 1996;7:913–8). Cox model was adjusted with stratification factors: tumor site, center, type of event (recurrence vs second primary). Results: 65 patients were randomized in each arm, including 71% of local and/or regional relapse and 29% of second primary. There was no imbalance in the distribution of age, sex, tumor site, T and N re-staging, and histological gravity signs (N+ with ECE and/or positive margin). The most important acute toxicity related to re-irradiation and chemotherapy was mucositis with ≥ grade 3 in 29% of patients. A moderate and acceptable increase in ≥ grade 3 RTOG late toxicity was observed in arm A (trismus, mucosa, fibrosis). Progression-free survival was significantly improved in Arm A with a hazard ratio of 1.6 (CI 95%, 1.1–2.4, p = 0.01), but overall survival was not statistically different. Conclusions: This is the first randomized trial to evaluate the effect of full dose re-irradiation combined with chemotherapy after salvage surgery. The results showed that re-irradiation and chemotherapy were able to significantly improve progression-free survival, with no significant impact on survival and acceptable toxicity. Supported by ARC.

No significant financial relationships to disclose.