HPV Infection and Immunohistochemical Analysis of P16, P53, and PD-L1 Expression as Prognostic Biomarkers in Squamous Cell Anal Cancer Patients Receiving Definitive Radiotherapy/Chemoradiotherapy

PURPOSE/OBJECTIVE(S)

The treatment of anal squamous cell carcinoma (SCC) with definitive radiotherapy (RT)/chemoradiotherapy (CRT) has a high likelihood of success; nevertheless, treatment resistance and recurrence rates cannot be ignored. Therefore, we aimed to identify the relationship between immunohistochemical (IHC) evaluation, treatment response, and prognosis.

MATERIALS/METHODS

This retrospective study included 42 patients with anal SCC treated with definitive RT/CRT at a single institution between 2006 and 2020. Detection of high-risk HPV-DNA and IHC analysis of p16, p53, and PD-L1 expression was performed from diagnostic formalin-fixed, paraffin-embedded (FFPE) biopsies. Positive staining was accepted as >5% in tumor cells for p16 and p53 expression in addition to ≥1% combined positive score (CPS) [(PD-L1 positive tumor, lymphocyte, macrophage count/total viable cell count) x100] for PD-L1 expression.

RESULTS

Thirty patients (71.4%) had a complete response to definitive RT/CRT. Recurrence was observed in 16 (38.1%) patients, with 3 (7.1%) having locoregional recurrence (LRR), 6 (14.3%) having distant metastases (DM), and 7 (16.7%) having both LRR and DM. Twenty-four (57.1%) patients were alive. Thirty (71.4%) patients were HPV+, while 12 (28.6%) were HPV-. There was a significant correlation between HPV+ and p16+ status (p<0.001). HPV- status was associated with the male gender (p = 0.001). HPV- and p16- status were significantly associated with a lack of complete response to definitive RT/CRT (p<0.001, p<0.001, respectively). Furthermore, there was a significant relationship between lack of complete response and increased recurrence (p = 0.016) and distant metastases (p = 0.015). Ten of the 16 patients with recurrence were p53+; a significant correlation was found between recurrence and p53+ status (p = 0.006). Similarly, p53+ status was associated with increased LRR (p = 0.014). PD-L1 CPS ≥ 1% was found in 31 (73.8%) patients. PD-L1 positivity was significantly correlated with HPV+ (p = 0.026) and p16+ (p = 0.013) status. All 10 (23.8%) patients with LRR were PD-L1+; PD-L1 CPS ≥ 1% was associated with poor local control (p = 0.031). In univariate analysis, age [<65] (p = 0.049), complete response (p = 0.015), and HPV+ status (p = 0.010) were related to increased 5-year (y) overall survival (OS); complete response (p = 0.001), HPV+ status (p = 0.025) and p53- status (p = 0.010) were associated with increased 5-y disease-free survival (DFS). In multivariate analysis, age [<65] (p = 0.010) and HPV+ status (p = 0.002) were significant prognostic factors for 5-y OS, whereas complete response (p = 0.007) and p53- status (p = 0.038) were significant prognostic factors for 5-y DFS.

CONCLUSION

Patients with HPV- status and/or poor prognostic biomarkers should be identified at diagnosis. Thus, better outcomes can be achieved with different treatment options, such as combining immunotherapy and standard CRT.

Can we define any marker associated with brain failure in patients with locally advanced non-small cell lung cancer?

PURPOSE

To define the factors which may be related to brain metastasis (BM) in patients with locally advanced non-small cell lung cancer (LA-NSCLC) who developed brain metastases after definitive treatment.

PATIENTS AND METHODS

A total of 208 patients with LA-NSCLC, without BM who received definitive radiotherapy (RT) or RT+chemotherapy (CT) between January 2005 and January 2016 were evaluated retrospectively. Platelet, neutrophil, lymphocyte counts, LDH, CRP, Hb levels, neutrophil-to-lymphocyte radio (NLR), platelet-to-lymphocyte radio (PLR), advanced lung cancer inflammation index (ALI) and FDG-PET/CT parameters (SUVmax of the primary tumor and mediastinal lymph nodes), and patient characteristics were evaluated for brain metastasis free survival (BMFS).

RESULTS

Median follow-up duration was 25 months (range: 3-130months). Cut-off values for platelet, NLR, PLR, LDH, CRP, and Hb were 290×103/μL, 2.6, 198, 468 IU/L, 2.5mg/dL, and 11.5g/dl. We defined each parameter as low or high according to the cut-off values. 56 patients (26.9%) developed brain metastases during follow-up. In univariate analysis, high NLR (P=0.001), PLR (P=0.037), LDH (P=0.028), CRP (P=0.002) values, value ≥7.5 for lymph nodes (P=0.005) and low ALI value (P=0.002) were poor prognostic factors for BMFS. In multivariate analysis, high NLR (P=0.022), PLR (P=0.017), CRP (P=0.006), stage ≥IIIB disease (P<0.001), multi-stational N2 disease (P=0.036), adenocarcinoma histology (P<0.001) and SUVmax value ≥7.5 (P=0.035) were poor prognostic factors for BMFS.

CONCLUSIONS

High NLR, PLR, LDH, CRP values, SUVmax values for lymph nodes, and low ALI which indicates high tumor burden were additional prognostic factors besides stage, histology, and lymph node status.

SARC-F Questionnaire Detects Frailty in Older Adults

BACKGROUND/OBJECTIVES

The physical phenotype of frailty, described by Fried et al., shows significant overlap with sarcopenia. EWGSOP2 recommends the SARC-F questionnaire to screen for sarcopenia. Considering common features between both conditions, we aimed to investigate whether the SARC-F questionnaire could also be a valid and reliable tool to screen or evaluate frailty.

DESIGN

Retrospective, cross-sectional.

SETTING

Istanbul University Istanbul Faculty of Medicine.

PARTICIPANTS

A total of 447 older adults (70.7% female, mean age: 74.5±6.6 years).

MEASUREMENTS

Frailty was assessed by the modified Fried scale. SARC-F questionnaire was performed by all participants. We used a receiver operating characteristics curve to obtain SARC-F cut-off values to detect frailty, and calculated the area under the curve and 95% confidence interval.

RESULTS

There were 93 (20.8%) older adults with frailty according to the modified Fried scale. SARC-F cut-off ≥1 had 91.4% sensitivity and 44.9% specificity. SARC-F cut-off ≥2 presented the best balance between sensitivity and specificity (sensitivity: 74.1% vs. specificity: 73.7%) to identify frailty (area under curve: 0.807; 95% confidence interval: 0.76-0.84, p<0.001). SARC-F ≥4 had high specificity of 92.6% with a sensitivity of 46.2%.

CONCLUSION

We suggest that SARC-F ≥1 point can be used to screen for frailty with high sensitivity, and SARC-F ≥4 can be used to diagnose frailty with high specificity. SARC-F may be used to evaluate frailty in usual geriatric practice.

Randomized clinical trial of short or long interval between neoadjuvant chemoradiotherapy and surgery for rectal cancer

BACKGROUND

The optimal timing of surgery following preoperative chemoradiotherapy (CRT) is controversial. This trial aimed to compare pathological complete response (pCR) rates obtained after an interval of 8 weeks or less versus more than 8 weeks.

METHODS

Patients with locally advanced rectal adenocarcinoma situated within 12 cm of the anal verge (T3-4 or N+ disease) were randomized to undergo total mesorectal excision (TME) within 8 weeks (classical interval, CI group) or after 8 weeks (long interval, LI group) following CRT.

RESULTS

Among the 327 included patients (CI 160, LI 167), the pCR rate was significantly higher in the LI group than in the CI group (10·0 versus 18·6 per cent; P = 0·027). The highest pCR rate (29 per cent) was observed between 10 and 11 weeks. There was statistically significant disease regression in the LI group, with better stage (P = 0·004) and T category (P = 0·001) than in the CI group. There was no significant difference in surgical quality (rates of tumour-positive margins, TME quality, anastomotic leakage and intraoperative perforation) between the groups. The overall morbidity rate was 22·5 per cent in the CI group and 19·8 per cent in the LI group (P = 0·307). Regression analysis including sex, age, clinical stage, tumour location, tumour differentiation, TME quality, concomitant chemotherapy and interval to surgery revealed no statistically significant predictors of pCR.

CONCLUSION

Disease regression and pCR rate are increased with an interval between CRT and surgery exceeding 8 weeks. Registration number: NCT03287843 (http://www.clinicaltrials.gov).

Results of hypofractionated whole brain radiotherapy (2×8 Gy) for patients with brain metastases from lung cancer

PURPOSE

To evaluate the clinical and radiologic response rates, toxicity and tolerability of 2×8 Gy whole brain radiotherapy (WBRT) in lung cancer patients with brain metastases (BM).

METHODS

WBRT was delivered to 126 lung cancer patients with BM during 2002-2006. External beam RT was delivered with a fraction dose of 8 Gy on the same day of each consecutive week. Tumor and symptom response and toxicity were recorded at every follow-up. Recursive partitioning analysis (RPA) and the new Graded Prognostic Assessment (GPA) were used for analysis of overall survival (OS).

RESULTS

Twenty-three patients had small cell (SCLC) and 103 had non small cell lung cancer. Pretreatment median Karnofsky performance score (KPS) was 70 (range 20-90). Clinical response rates were as follows: complete 31%; good partial 30.2%; partial 21.4%; stable 7.9%; and progressive 5.6%;. Median palliation and survival duration was 57 and 80 days, respectively. Two- and 6-month survival rates (SR) were 59.5% and 25.4%, respectively. According to recursive partitioning analysis (RPA) 6- month SR for groups 1, 2 and 3 were 61.5, 41.6 and 33.9%, respectively (p=0.002). Six-month SR for the new Graded Prognostic Assessment (GPA) were: GPA 0-1, 7%; GPA 1.5- 2.5, 34.2%; GPA 3, 25%; and GPA 3.5-4.0, 66.6% (p=0.0003).

CONCLUSION

2×8 Gy WBRT was found to be feasible. However, the late morbidity of this schedule is unknown so its use could be restricted to patients with poor performance status, with a short life expectancy and/or social problems, unlikely to tolerate more protracted radiotherapy regimens.

Erythropoietin and radiotherapy in lung cancer patients

PURPOSE

To evaluate the effectiveness of recombinant human erythropoietin (rhEPO) in relation to low hemoglobin (Hb) level, overall tumor response rates, and rhEPO adverse events in patients with lung cancer undergoing radiotherapy (RT).

PATIENTS AND METHODS

Thirteen consecutive patients were included. All of them had measurable tumor before RT. 150 IU/kg of rhEPO-alpha or -beta were administered 3 times per week, 7-10 days before RT. The target Hb value was 13 g/dl. Tumor response was assessed 6 weeks after completion of RT.

RESULTS

Response to rhEPO was seen 62% (n=8) of the patients. Weekly mean Hb increment was 0.69 g/dl (range 0.42-1). The mean Hb value during RT was 13.2 g/dl (range 9-14.7) in responding patients, and 10.7 g/dl (range 9.7-11.8) in non-responding patients (p=0.005). Overall response rates to RT were significantly higher in responding than in non-responding patients (p=0.034).

CONCLUSION

rhEPO increased Hb levels in lung cancer patients undergoing RT. However, safety, and more importantly, indications need further clarifications.

Identification of prognostic factors in patients with brain metastases: A review of 493 patients

11516

Background: Choice of treatment for an individual patient with brain metastases is based on a number of factors: number and localization of brain metastases, systemic tumor activity, performance score, and age are major determinants for selection of treatment modality. Future trials in patients with brain metastases depend on selection of patients with favorable prognosis to allow adequate long-term follow-up to draw conclusions about survival and late toxicity, further stressing the importance of prognostic parameters. Our aim is to report the outcome of patients with brain metastases from solid tumors treated with whole brain radiotherapy (WBRT) in a single institution and identify the prognostic subgroups who will benefit from treatment. Methods: The records of 493 patients with brain metastases who had been admitted for WBRT in the Department of Radiation Oncology in Ege University Hospital between January 1997 and December 2002 was retrospectively evaluated. WBRT at this institution comprised of parallel opposed lateral fields, dosed to the midplane in a cobalt 60 teletherapy device. Radiotherapy fractionation were 10 fr. × 3 Gy, 5 fr × 4 Gy and 2 fr. × 8 Gy. Survival was calculated using the Kaplan-Meier method. Cox regression modeling was used for multivariate analysis and prognostical factors were determined on the basis of log rank test (SPSS 10.00 version). Results: Clinical response evaluation revealed that 254 patients (51%) had response to tretament whereas 104 patients (21.1%) had stable response and the other 43 patients (8.7%) had progressive disease.The median survival was 3 months (1–62 months) and 6 months survival was 41% and one year survival was 19%. Univariate analysis revealed that prognostical factors for survival were younger age (age <57) (p=0.043), female gender (p=0.019) and operation (p=0.0004), and for multivariant analysis female gender (p=0.027) and operation were determined (p=0.000). Conclusion: The prognosticators for survival in this retrospective analysis for patients with brain metastases are age, gender and operation. These factors affecting survival must be taken into consideration when the therapeutic management is to be made. And they may allow better selection of individual treatments.

No significant financial relationships to disclose.

The European Organization for Research and Treatment of Cancer QLQ-C30: an examination into the cultural validity and reliability of the Turkish version of the EORTC QLQ-C30

The Turkish version of the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire version 2.0 (EORTC QLQ-C30 v.2.0) has started to be used in clinical trials recently. The objective of the study was to evaluate the validity and reliability of the Turkish version of the EORTC QLQ-C30 v.2.0 and the correlation between the Karnofsky Performance Scale (KPS) and the EORTC QLQ-C30. Two hundred and two lung cancer patients were included in the study between January and March 2000. All the subscales met the minimal standards of reliability (Cronbach's alpha > or = 0.70). Only the role functioning scale differed among the three disease stages of patients (local, locoregional and metastatic). There was no statistically significant difference among therapy types. All interscale correlations were statistically significant (P < 0.01). The strongest correlations were found among the physical functioning, role functioning and fatigue scales. Social functioning was closely related with physical, role, emotional and cognitive functioning. The weakest correlations were between nausea/vomiting and the other scales. Global quality of life (QOL) was substantially correlated with most of the scales except cognitive functioning. The coefficients for the correlation between the items differed between 0.12 and 0.97 and all the subscales were strongly correlated with the scales which they formed. The highest correlation between the EORTC QLQ-C30 and KPS was for physical functioning (r = 0.62, P < 0.05). The Turkish version of the EORTC QLQ-C30 is a valid (by means of interscales validity) and reliable instrument for Turkish lung cancer patients and can be used in clinical studies but needs supporting by the reference data on the QOL of the Turkish population.

High dose rate endobronchial brachytherapy in combination with external beam radiotherapy for stage III non-small cell lung cancer

INTRODUCTION

A phase-II study was planned to test the effect of external beam radiotherapy in combination with endobronchial brachytherapy on the local control and survival of stage-III non-small cell lung cancer patients.

MATERIALS AND METHODS

Thirty patients with stage-III non-small cell lung cancer have been treated with 60 Gy external beam radiotherapy and 3 x 5 Gy HDR endobronchial brachytherapy to control tumor and to prolong survival.

RESULTS

Therapy regimen was found to be very effective for the palliation of major symptoms, palliation rates were 42.8% for cough, 95.2% for hemoptysis, 88.2% for chest pain and 80.0% for dyspnea. There was a 76.7% tumor response (53.3% complete, 23.3% partial) verified by chest CT scans and bronchoscopy. However, median locoregional disease free survival was 9+/-4 months (95% CI: 1-17) and it was only 9.6% at 5 years. Major side effects were radiation bronchitis (70.0%), esophagitis (6.6%) in the acute period and bronchial fibrosis (25%), esophagial fibrosis (12.5%) and fatal hemoptysis (10.5%) in the late period. Median survival was 11+/-4 months (95% CI: 4-18),and 5-year actuarial survival was 10%. Locoregional disease free survival (P=0.008) and the overall survival was longer (P<0.001) in the patients younger than 60, survival was also improved in the patients with complete response (P=0.019). There were no major complications during catheterisation; early side effects were quite tolerable but severe late complications were around 10%.

CONCLUSIONS

It is concluded that endobronchial brachytherapy in combination with external irradiation provides a good rate of response, however does not eradicate locoregional disease and does not prolong survival except for some subgroups such as younger patients.

Endobronchial metastasis from osteosarcoma of bone: treatment with intraluminal radiotherapy

Lung parenchymal metastases are common manifestations in patients with osteosarcoma; however, spread to the major airway itself is extremely rare. We present a young man who had been previously treated with surgical resection following preoperative chemotherapy and immediate postsurgical adjuvant chemotherapy for proximal tibial osteosarcoma. He developed metastasis to the major airways. The patient was treated with intraluminal radiotherapy (ILT) for the endobronchial metastasis. This is the first report of an endobronchial osteosarcoma that was treated with ILT with a complete endoscopic response. ILT provided excellent palliation in this particular case.