Combined TRIP13 and Aurora Kinase Inhibition Induces Apoptosis in Human Papillomavirus-Driven Cancers

PURPOSE

Human papillomavirus (HPV) causes >5% of cancers, but no therapies uniquely target HPV-driven cancers.

EXPERIMENTAL DESIGN

We tested the cytotoxic effect of 864 drugs in 16 HPV-positive and 17 HPV-negative human squamous cancer cell lines. We confirmed apoptosis in vitro and in vivo using patient-derived xenografts. Mitotic pathway components were manipulated with drugs, knockdown, and overexpression.

RESULTS

Aurora kinase inhibitors were more effective in vitro and in vivo in HPV-positive than in HPV-negative models. We hypothesized that the mechanism of sensitivity involves retinoblastoma (Rb) expression because the viral oncoprotein E7 leads to Rb protein degradation, and basal Rb protein expression correlates with Aurora inhibition-induced apoptosis. Manipulating Rb directly, or by inducing E7 expression, altered cells' sensitivity to Aurora kinase inhibitors. Rb affects expression of the mitotic checkpoint genes MAD2L1 and BUB1B, which we found to be highly expressed in HPV-positive patient tumors. Knockdown of MAD2L1 or BUB1B reduced Aurora kinase inhibition-induced apoptosis, whereas depletion of the MAD2L1 regulator TRIP13 enhanced it. TRIP13 is a potentially druggable AAA-ATPase. Combining Aurora kinase inhibition with TRIP13 depletion led to extensive apoptosis in HPV-positive cancer cells but not in HPV-negative cancer cells.

CONCLUSIONS

Our data support a model in which HPV-positive cancer cells maintain a balance of MAD2L1 and TRIP13 to allow mitotic exit and survival in the absence of Rb. Because it does not affect cells with intact Rb function, this novel combination may have a wide therapeutic window, enabling the effective treatment of Rb-deficient cancers.

Histopathologic features predictive of metastasis and survival in 230 patients with cutaneous squamous cell carcinoma of the head and neck and non-head and neck locations: a single-center retrospective study

BACKGROUND

Staging systems for cutaneous squamous cell carcinoma (cSCC) produce inconsistent risk stratification.

OBJECTIVE

The aim of this study was to identify further prognostic parameters for better stratification.

METHODS

We retrospectively analysed the prognostic significance of clinicopathologic parameters of 230 patients who underwent primary excision of invasive cSCC of the head and neck (n = 115) and non-head and non-neck (n = 115) locations. In addition to known high-risk features, we analysed tumour nest shape, invasion pattern, lymphoid response pattern and tumour budding.

RESULTS

On multivariable analysis, lymphovascular invasion (LVI) and high tumour budding predicted worse disease-specific survival, and ulceration, LVI and high tumour budding predicted worse overall survival. Only ulceration was independently associated with risk of nodal metastasis.

CONCLUSION

High tumour budding, LVI and ulceration are independently associated with poor outcome in cSCC and may be used to refine cSCC prognostic stratification, which is crucial to optimize clinical decision and to identify patients who are more likely to benefit from more aggressive interventions or clinical trials.

Outcomes after definitive surgery for mandibular osteoradionecrosis

OBJECTIVES

To analyze charges, complications, survival, and functional outcomes for definitive surgery of mandibular osteoradionecrosis (ORN).

MATERIALS AND METHODS

Retrospective analysis of 76 patients who underwent segmental mandibulectomy with reconstruction from 2000 to 2009.

RESULTS

Complications occurred in 49 (65%) patients and were associated with preoperative drainage (odds ratio [OR] 4.40, 95% confidence interval [CI] 1.01-19.27). The adjusted median charge was $343 000, and higher charges were associated with double flap reconstruction (OR 8.15, 95% CI 2.19-30.29) and smoking (OR 5.91, 95% CI 1.69-20.72). Improved swallow was associated with age <67 years (OR 3.76, 95% CI 1.16-12.17) and preoperative swallow (OR 3.42, 95% CI 1.23-9.51). Five-year ORN-recurrence-free survival was 93% while overall survival was 63% and associated with pulmonary disease (HR [hazard ratio] 3.57, 95% CI 1.43-8.94).

CONCLUSIONS

Although recurrence of ORN is rare, surgical complications are common and charges are high. Poorer outcomes and higher charges are associated with preoperative factors.

Abstract 368: Aurora kinase inhibitors cause cell death in HPV+ cells: A plausible treatment option for HPV+ cancers

Human papilloma virus (HPV) driven cancers are common and lethal. The standard of care chemo-radiation treatment for HPV+ head and neck squamous cell carcinoma (HNSCC) results in permanent, often life-altering, toxicities in a relatively young population (aged ~45-55). Additionally, those who recur have poor outcomes. Therefore, there is an urgent need for better treatment options. No biomarker-driven targeted therapies are available. To address the current unmet need, we hypothesized that a large-scale High Throughput Drug Screen (HTDS) comparing drug efficacy in HPV+ and HPV- cell lines would identify biomarker driven, effective and less toxic options for HPV+ cancers. We tested the drug- sensitivity of 864 unique drugs (0-3.1 µM) in 51 classes based on their targets in 16 HPV+ and 17 HPV- squamous cancer cell lines. Cells were treated for 72 hours and DAPI+ nuclei counted before and after drug treatment. We used the Area Over the Curve_Lethal Dose (AOC_LD) to measure drug sensitivity because it is independent of cell division. We defined effective drugs as those that led to cell death (i.e., less cells at the end of drug treatment than prior to treatment) in at least one cell line. About half of the drugs tested (439) were effective and certain classes of drugs were enriched in either the effective or ineffective categories (Pearson residual). We found that Aurora kinase inhibitors were the most effective class overall. Other effective drug classes included anthracyclines, vinca-alkaloids, and inhibitors of HDAC, proteasome, EGFR, CDC7, and BTK1. Only 30 drugs had a differential effect based on HPV status. All 16 Aurora kinase inhibitors were more effective in HPV+ than in HPV- cells and the difference in sensitivity (dichotomous variable) was statistically significant in 7 of them. To determine if factors other than HPV status predict response to Aurora kinase inhibitors, we compared the expression of 304 proteins (RPPA) and mutational status for the 50 most commonly mutated genes in HNSCC to drug efficacy. The expression of eight proteins were associated with sensitivity to multiple Aurora kinase inhibitors. We validated RPPA data by immunoblotting and observed that only Rb, pRB(S807/811) and p16 correlated with drug sensitivity. For gene mutations, only TP53 mutations correlated with drug resistance with 7 Aurora kinase inhibitors. Interestingly, these two biomarkers, Rb and TP53, corroborate well with HPV status. To validate the screening results, we treated HPV+ cells with two clinically relevant Aurora kinase inhibitors, alisertib and barasertib, and observed significantly more cell death in HPV+ cells in comparison with HPV- cells. Therefore, our present study portrays Aurora kinase inhibitors as an effective strategy for HPV+ cancer cells. Multiple Aurora kinase inhibitors are currently in clinical development making the clinical application of our data possible soon.

Citation Format: Tuhina Mazumdar, Li Shen, Wei Xu, Soma Ghosh, Reid T. Powell, Clifford Stephan, Curtis R. Pickering, Jeffery N. Myers, Jing Wang, Faye M. Johnson. Aurora kinase inhibitors cause cell death in HPV+ cells: A plausible treatment option for HPV+ cancers [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 368.

Proton Therapy for Head and Neck Cancer: A 12-Year, Single-Institution Experience

PURPOSE

To characterize our experience and the disease control and toxicity of proton therapy (PT) for patients with head and neck cancer (HNC).

PATIENTS AND METHODS

Clinical outcomes for patients with HNC treated with PT at our institution were prospectively collected in 2 institutional review board-approved prospective studies. Descriptive statistics were used to summarize patient characteristics and outcomes. Overall survival, local-regional control, and disease-free survival were estimated by the Kaplan-Meier method. Treatment-related toxicities were recorded according to the Common Terminology Criteria for Adverse Events (version 4.03) scale.

RESULTS

The cohort consisted of 573 patients treated from February 2006 to June 2018. Median patient age was 61 years. Oropharynx (33.3%; n = 191), paranasal sinus (11%; n = 63), and periorbital tissues (11%; n = 62) were the most common primary sites. Patients with T3/T4 or recurrent disease comprised 46% (n = 262) of the cohort. The intent of PT was definitive in 53% (n = 303), postoperative in 37% (n = 211), and reirradiation in 10% (n = 59). Median dose was 66 Gy (radiobiological equivalent). Regarding systemic therapy, 43% had received concurrent (n = 244), 3% induction (n = 19), and 15% (n = 86) had both. At a median follow-up of 2.4 years, 88 patients (15%) had died and 127 (22%) developed disease recurrence. The overall survival, local-regional control, and disease-free survival at 2 and 5 years were, respectively, 87% and 75%, 87% and 78%, and 74% and 63%. Maximum toxicity (acute or late) was grade 3 in 293 patients (51%), grade 2 in 234 patients (41%), and grade 1 in 31 patients (5%). There were 381 acute grade 3 and 190 late grade 3 unique toxicities across 212 (37%) and 150 (26%) patients, respectively. There were 3 late-grade 4 events across 2 patients (0.3%), 2 (0.3%) acute-grade 5, and no (0%) late-grade 5 events.

CONCLUSIONS

The overall results from this prospective study of our initial decade of experience with PT for HNC show favorable disease control and toxicity outcomes in a multidisease-site cohort and provide a reference benchmark for future comparison and study.

Channel catfish ovarian fluid differentially enhances blue catfish sperm performance

For externally fertilizing fishes, interactions between male and female gametes have been shown to have remarkable impacts on sperm performance. Ovarian fluid (OF) and its ability to alter the swimming behavior of fish sperm makes it a determining factor of fertility. With the expansion of channel catfish (Ictalurus punctatus) ♀ × blue catfish (Ictalurus furcatus) ♂ hybrid aquaculture, it is essential to understand the impacts during fertilization and the magnitude such gametic interactions have on sperm performance and subsequent male fertility potential. This study was conducted to address the following: 1) activate blue catfish sperm with/without channel catfish OF to determine impacts on sperm performance and 2) assess if sperm behave differently when activated in the OF from individual females. Sperm (n = 4 males) were activated without OF (control) and with diluted OF from unique females (n = 6), creating 24 experimental crosses. Sperm motility (%), velocity (VCL), and longevity were analyzed using computer assisted sperm analyses software. With OF incorporated in the activation media, sperm velocity was significantly higher than the control at 10, 20, and 30 s post-activation. OF did not have an impact on motility for any females at 10 s and 20 s post-activation but became significantly higher than the control at 30 s. In all cases, OF treatments greatly increased longevity. Male × female interactions were highly significant, such that motility, velocity, and longevity were dependent on specific male-female pairs. This information shows that OF should be incorporated in aquatic media to simulate natural spawning conditions and accurately assess the fluid mechanics of sperm propulsion for each male. Additionally, there are mechanisms that drive gamete interactions that need to be explored further, which may improve selection of male-female pairs for in-vitro fertilization. On a broad scale, our results also help to shed light on the complexities of fertilization and fish reproduction overall, which may have implications for recruitment variability and recovery strategies of threatened and/or endangered freshwater species.

PDK1 Mediates NOTCH1-Mutated Head and Neck Squamous Carcinoma Vulnerability to Therapeutic PI3K/mTOR Inhibition

PURPOSE

Head and neck squamous cell carcinoma (HNSCC) is driven largely by the loss of tumor suppressor genes, including NOTCH1, but lacks a biomarker-driven targeted therapy. Although the PI3K/mTOR pathway is frequently altered in HNSCC, the disease has modest clinical response rates to PI3K/mTOR inhibitors and lacks validated biomarkers of response. We tested the hypothesis that an unbiased pharmacogenomics approach to PI3K/mTOR pathway inhibitors would identify novel, clinically relevant molecular vulnerabilities in HNSCC with loss of tumor suppressor function.Experimental Design: We assessed the degree to which responses to PI3K/mTOR inhibitors are associated with gene mutations in 59 HNSCC cell lines. Apoptosis in drug-sensitive cell lines was confirmed in vitro and in vivo. NOTCH1 pathway components and PDK1 were manipulated with drugs, gene editing, knockdown, and overexpression.

RESULTS

PI3K/mTOR inhibition caused apoptosis and decreased colony numbers in HNSCC cell lines harboring NOTCH1 loss-of-function mutations (NOTCH1 ^MUT) and reduced tumor size in subcutaneous and orthotopic xenograft models. In all cell lines, NOTCH1 ^MUT was strongly associated with sensitivity to six PI3K/mTOR inhibitors. NOTCH1 inhibition or knockout increased NOTCH1 ^WT HNSCC sensitivity to PI3K/mTOR inhibition. PDK1 levels dropped following PI3K/mTOR inhibition in NOTCH1 ^MUT but not NOTCH1 ^WT HNSCC, and PDK1 overexpression rescued apoptosis in NOTCH1 ^MUT cells. PDK1 and AKT inhibitors together caused apoptosis in NOTCH1 ^WT HNSCC but had little effect as single agents.

CONCLUSIONS

Our findings suggest that NOTCH1 ^MUT predicts response to PI3K/mTOR inhibitors, which may lead to the first biomarker-driven targeted therapy for HNSCC, and that targeting PDK1 sensitizes NOTCH1 ^WT HNSCC to PI3K/mTOR pathway inhibitors.

Targeting the DNA Damage Response in OSCC with TP53 Mutations

Oral squamous cell carcinoma (OSCC) is the most common type of oral cancer worldwide and in the United States. OSCC remains a major cause of morbidity and mortality in patients with head and neck cancers. Tobacco and alcohol consumption alone or with chewing betel nut are potential risk factors contributing to the high prevalence of OSCC. Multimodality therapies, including surgery, chemotherapy, biologic therapy, and radiotherapy, particularly intensity-modulated radiotherapy (IMRT), are the current treatments for OSCC patients. Despite recent advances in these treatment modalities, the overall survival remains poor over the past years. Recent data from whole-exome sequencing reveal that TP53 is commonly mutated in human papillomavirus-negative OSCC patients. Furthermore, these data stressed the importance of the TP53 gene in suppressing the development and progression of OSCC. Clinically, TP53 mutations are largely associated with poor survival and tumor resistance to radiotherapy and chemotherapy in OSCC patients, which makes the TP53 mutation status a potentially useful molecular marker prognostic and predictive of clinical response in these patients. Several forms of DNA damage have been shown to activate p53, including those generated by ionizing radiation and chemotherapy. The DNA damage stabilizes p53 in part via the DNA damage signaling pathway that involves sensor kinases, including ATM and ATR and effector kinases, such as Chk1/2 and Wee1, which leads to posttranscriptional regulation of a variety of genes involved in DNA repair, cell cycle control, apoptosis, and senescence. Here, we discuss the link of TP53 mutations with treatment outcome and survival in OSCC patients. We also provide evidence that small-molecule inhibitors of critical proteins that regulate DNA damage repair and replication stress during the cell cycle progression, as well as other molecules that restore wild-type p53 activity to mutant p53, can be exploited as novel therapeutic approaches for the treatment of OSCC patients bearing p53 mutant tumors.

Reactive oxygen species and p21Waf1/Cip1 are both essential for p53-mediated senescence of head and neck cancer cells

Treatment of head and neck squamous cell carcinoma, HNSCC, often requires multimodal therapy, including radiation therapy. The efficacy of radiotherapy in controlling locoregional recurrence, the most frequent cause of death from HNSCC, is critically important for patient survival. One potential biomarker to determine radioresistance is TP53 whose alterations are predictive of poor radiation response. DNA-damaging reactive oxygen species (ROS) are a by-product of ionizing radiation that lead to the activation of p53, transcription of p21(cip1/waf1) and, in the case of wild-type TP53 HNSCC cells, cause senescence. The expression of p21 and production of ROS have been associated with the induction of cellular senescence, but the intricate relationship between p21 and ROS and how they work together to induce senescence remains elusive. For the first time, we show that persistent exposure to low levels of the ROS, hydrogen peroxide, leads to the long-term expression of p21 in HNSCC cells with a partially functional TP53, resulting in senescence. We conclude that the level of ROS is crucial in initiating p53's transcription of p21 leading to senescence. It is p21's ability to sustain elevated levels of ROS, in turn, that allows for a long-term oxidative stress, and ensures an active p53-p21-ROS signaling loop. Our data offer a rationale to consider the use of either ROS inducing agents or therapies that increase p21 expression in combination with radiation as approaches in cancer therapy and emphasizes the importance of considering TP53 status when selecting a patient's treatment options.

To "grow" or "go": TMEM16A expression as a switch between tumor growth and metastasis in SCCHN

PURPOSE

Tumor metastasis is the leading cause of death in patients with cancer. However, the mechanisms that underlie metastatic progression remain unclear. We examined TMEM16A (ANO1) expression as a key factor shifting tumors between growth and metastasis.

EXPERIMENTAL DESIGN

We evaluated 26 pairs of primary and metastatic lymph node (LN) tissue from patients with squamous cell carcinoma of the head and neck (SCCHN) for differential expression of TMEM16A. In addition, we identified mechanisms by which TMEM16A expression influences tumor cell motility via proteomic screens of cell lines and in vivo mouse studies of metastasis.

RESULTS

Compared with primary tumors, TMEM16A expression decreases in metastatic LNs of patients with SCCHN. Stable reduction of TMEM16A expression enhances cell motility and increases metastases while decreasing tumor proliferation in an orthotopic mouse model. Evaluation of human tumor tissues suggests an epigenetic mechanism for decreasing TMEM16A expression through promoter methylation that correlated with a transition between an epithelial and a mesenchymal phenotype. These effects of TMEM16A expression on tumor cell size and epithelial-to-mesenchymal transition (EMT) required the amino acid residue serine 970 (S970); however, mutation of S970 to alanine does not disrupt the proliferative advantages of TMEM16A overexpression. Furthermore, S970 mediates the association of TMEM16A with Radixin, an actin-scaffolding protein implicated in EMT.

CONCLUSIONS

Together, our results identify TMEM16A, an eight transmembrane domain Ca2+-activated Cl- channel, as a primary driver of the "Grow" or "Go" model for cancer progression, in which TMEM16A expression acts to balance tumor proliferation and metastasis via its promoter methylation.

CT imaging correlates of genomic expression for oral cavity squamous cell carcinoma

BACKGROUND AND PURPOSE

Imaging correlates of genetic expression have been found for prognostic and predictive biomarkers of some malignant diseases, including breast and brain tumors. This study tests the hypothesis that imaging findings correlate with relevant genomic biomarkers in oral cavity squamous cell carcinoma.

MATERIALS AND METHODS

Surplus frozen tissue from 27 untreated patients with oral cavity squamous cell carcinoma who underwent preoperative CT imaging was analyzed for gene expression. A team of neuroradiologists blinded to the genomic analysis results reviewed an extensive list of CT findings. The imaging correlated with genomic expression for cyclin D1, angiogenesis-related genes (vascular endothelial growth factor receptors and ligands), which relate to enhancement on the basis of other tumor types; and epidermal growth factor receptor, which may relate to proliferation and mass effect.

RESULTS

Expression of vascular endothelial growth factor receptors 1 and 2 correlated with the enhancement of the primary tumor (P = .018 and P = .025, respectively), whereas the epidermal growth factor receptor correlated with mass effect (P = .03). Other exploratory correlations included epidermal growth factor receptor to perineural invasion (P = .05), and certain vascular endothelial growth factor receptors and ligands to mass effect (P = .03) and increased (P = .01) or decreased (P = .02) primary tumor size.

CONCLUSIONS

We report that CT imaging correlates with gene expression in untreated oral cavity squamous cell carcinoma. Enhancement of the primary tumor and degree of mass effect correlate with relevant genomic biomarkers, which are also potential drug targets. Eventually, treatment decisions may be aided by combining imaging findings into meaningful phenotypes that relate directly to genomic biomarkers.

Tumor grafts derived from patients with head and neck squamous carcinoma authentically maintain the molecular and histologic characteristics of human cancers

BACKGROUND

The patient-derived xenograft (PDX) model is likely to reflect human tumor biology more accurately than cultured cell lines because human tumors are implanted directly into animals; maintained in an in vivo, three-dimensional environment; and never cultured on plastic. PDX models of head and neck squamous cell carcinoma (HNSCC) have been developed previously but were not well characterized at the molecular level. HNSCC is a deadly and disfiguring disease for which better systemic therapy is desperately needed. The development of new therapies and the understanding of HNSCC biology both depend upon clinically relevant animal models. We developed and characterized the patient-derived xenograft (PDX) model because it is likely to recapitulate human tumor biology.

METHODS

We transplanted 30 primary tumors directly into mice. The histology and stromal components were analyzed by immunohistochemistry. Gene expression analysis was conducted on patient tumors and on PDXs and cell lines derived from one PDX and from independent, human tumors.

RESULTS

Five of 30 (17%) transplanted tumors could be serially passaged. Engraftment was more frequent among HNSCC with poor differentiation and nodal disease. The tumors maintained the histologic characteristics of the parent tumor, although human stromal components were lost upon engraftment. The degree of difference in gene expression between the PDX and its parent tumor varied widely but was stable up to the tenth generation in one PDX. For genes whose expression differed between parent tumors and cell lines in culture, the PDX expression pattern was very similar to that of the parent tumor. There were also significant expression differences between the human tumors that subsequently grew in mice and those that did not, suggesting that this model enriches for cancers with distinct biological features. The PDX model was used successfully to test targeted drugs in vivo.

CONCLUSION

The PDX model for HNSCC is feasible, recapitulates the histology of the original tumor, and generates stable gene expression patterns. Gene expression patterns and histology suggested that the PDX more closely recapitulated the parental tumor than did cells in culture. Thus, the PDX is a robust model in which to evaluate tumor biology and novel therapeutics.

Improving imaging diagnosis of persistent nodal metastases after definitive therapy for oropharyngeal carcinoma: specific signs for CT and best performance of combined criteria

BACKGROUND AND PURPOSE

Criteria for detection of persistent nodal metastases in treated oropharyngeal tumors are sensitive but nonspecific, leading to unnecessary nodal dissections. Developing specific imaging criteria for persistent nodal metastases could improve diagnosis while decreasing patient morbidity.

MATERIALS AND METHODS

Patients with oropharyngeal squamous cell carcinoma with nodal metastases treated by definitive radiation therapy and subsequent nodal dissection were retrospectively evaluated. One hundred thirty-eight patients had pre- and posttherapy contrast-enhanced CTs evaluated by radiologists blinded to the status of pathologically proved hemineck persistent nodal metastases. Composite scoring criteria for CT, combined from individual parameters, were compared with radiologists' opinions, previous multiparameter criteria, and outcome data.

RESULTS

New low-attenuation areas and a lack of size change (<20% cross sectional area) were both highly specific for persistent nodal metastases (99%; P = .0004). Extranodal disease on pretherapy imaging was moderately specific (86%; P = .001). The CSC correctly placed 29 patients in a low-risk category compared with 14 by previously reported criteria and radiologist reports. With good second-rater reliability, the CSC cutoff values stratified patients at highest risk of persistent nodal metastases, thereby improving specificity while maintaining sensitivity.

CONCLUSIONS

Comparing pre- and posttherapy examinations improves specificity by discriminating focal findings and size change compared with a single time point. The CSC can categorize the risk of persistent nodal metastases more accurately than previous CT methods. This finding has the potential to improve resource use and reduce surgical morbidity.

Sonographic examination of the neck after definitive radiotherapy for node-positive oropharyngeal cancer

BACKGROUND AND PURPOSE

Radiographic determination of viable disease in cervical adenopathy following RT for head and neck cancer can be challenging. The purpose of this study was to evaluate the utility of US, with or without FNA, in regard to the postradiotherapy effects on documented metastatic adenopathy in patients with oropharyngeal cancer.

MATERIALS AND METHODS

This study included 133 patients with node-positive oropharyngeal cancer who were irradiated from 1998 to 2004. Sonographic evaluation was performed within 6 months of completion of radiation. Posttreatment US results were compared with pretreatment CT images and were recorded as the following: progression, suspicious, indeterminate, posttreatment change, or regression (positive) versus nonsuspicious or benign (negative). FNAC was classified as nondiagnostic, negative, indeterminate, or positive. Results of US and US-guided FNAC were correlated with findings at neck dissection and disease outcome.

RESULTS

Of 203 sonographic examinations, 90% were technically feasible and yielded a nonequivocal imaging diagnosis. Of 87 US-guided FNAs, 71% yielded a nonequivocal tissue diagnosis. The PPV and NPV of initial posttreatment US were 11% and 97%. Sensitivity and specificity were 92% and 28%. The PPV and NPV of US-guided FNA were 33% and 95%, and the sensitivity and specificity were 75% and 74%. On serial sonographic surveillance, of 33 patients with nonsuspicious findings, only 1 (3%) had neck recurrence. Of 22 patients with questionable findings on CT and negative findings on US, none had a neck recurrence.

CONCLUSIONS

In experienced hands, serial US is an inexpensive noninvasive reassuring follow-up strategy after definitive head and neck RT, even when CT findings are equivocal.

TrkB induces EMT and has a key role in invasion of head and neck squamous cell carcinoma

Head and neck squamous cell carcinoma (HNSCC) remains a significant public health problem, accounting for over 5% of all cancer-related deaths, and these deaths primarily result from metastatic disease. The molecular processes involved in HNSCC pathogenesis and progression are poorly understood, and here we present experimental evidence for a direct role of the cell surface receptor tyrosine kinase, TrkB, in HNSCC tumor progression. Using immunohistochemical analysis and transcriptional profiling of archival HNSCC tumor specimens, we found that TrkB and its secreted ligand, brain-derived neurotrophic factor (BDNF), are expresses in greater than 50% of human HNSCC tumors, but not in normal upper aerodigestive tract (UADT) epithelia. Studies with HNSCC cell lines reveal that in vitro stimulation with BDNF, the ligand for TrkB, upregulates the migration and invasion of HNSCC cells, and both transient and stable suppressions of TrkB result in significant abrogation of constitutive and ligand-mediated migration and invasion. Furthermore, enforced overexpression of TrkB results in altered expression of molecular mediators of epithelial-to-mesenchymal transition (EMT), including downregulation of E-cadherin and upregulation of Twist. Using an in vivo mouse model of HNSCC, we were able to show that downregulation of TrkB suppresses tumor growth. These results directly implicate TrkB in EMT and the invasive behavior of HNSCC, and correlate with the in vivo overexpression of TrkB in human HNSCC. Taken together, these data suggest that the TrkB receptor may be a critical component in the multi-step tumor progression of HNSCC, and may be an attractive target for much needed new therapies for this disease.

Bypass NFkappaB-mediated survival pathways by TRAIL and Smac

Activation of NFkappaB is frequently associated with human malignancies. The involvement of NFkappaB is in part attributed to its ability to activate various genes promoting cell survival. This property contributes to aggressive tumor growth and resistance to chemotherapy and radiation in cancer treatment. Various reports have shown that inhibition of NFkappaB promotes apoptosis and suppress tumor growth. However, NFkappaB has many important cellular functions and targeting NFkappaB directly may lead to severe side effects. Thus, developing strategies with low cytotoxicity to overcome NKkappaB-mediated cell survival is critical to improve cancer therapy. In this report, we described an approach using TRAIL/ Apo2L (TNF-related apoptosis-inducing ligand TRAIL or Apo2 ligand) and a Smac analog to overcome and bypass NFkappaB activation in cancer treatment. We have shown that a panel of head and neck squamous cell carcinoma (HNSCC) cell lines are highly resistant to TRAIL-induced apoptosis due to activation of NFkappaB-mediated cell survival pathways, and that inhibition of NFkappaB renders HNSCC cells sensitive to TRAIL. We further show that TRAIL and a small molecule mimic of Smac overcome and bypass NFkappaB activation in inducing cancer cell death. Since this treatment has no effect on NFkappaB activation and TRAIL offers tumor selectivity, cotreatment of TRAIL and Smac provides a strategy with potentially low toxicity to overcome NFkappaB activation in cancer cells, which has potential therapeutic benefit.

Epithelial to mesenchymal transition in head and neck squamous carcinoma: association of Src activation with E-cadherin down-regulation, vimentin expression, and aggressive tumor features

BACKGROUND

Epithelial-mesenchymal transformations (EMT) are critical for the invasion, progression, and metastasis of epithelial carcinogenesis. The role of EMT in head and neck squamous carcinoma (HNSC) tumorigenesis remains unexplored. In the current study, the expressions of several factors associated with the induction of EMT in HNSC cell lines and tumor specimens were investigated to define their functional and pathologic role in HNSC.

METHODS

Eleven HNSC cell lines and 50 primary tumor tissue specimens formed the materials of this study. Western blot analysis as well as immunohistochemical, and functional techniques were used to assess the status of activated Src (p-Src), E-cadherin, and vimentin in both cell lines and tumor tissues and the results were correlated with patients' clinicopathologic parameters.

RESULTS

The results demonstrated the inverse expression of p-Src and E-cadherin in the majority of cell lines and in primary tumor tissues compared with normal squamous mucosa. Elevated levels of p-Src were accompanied by down-regulation of E-cadherin and the expression of vimentin in epithelial tumor cells. In vitro inhibition of Src led to E-cadherin reexpression and increased cell contact in squamous carcinoma cell lines. Immunophenotypic analysis of these markers in primary tumor tissues demonstrated a significant correlation between increased p-Src, decreased E-cadherin, and vimentin expression and aggressive tumor features including penetrating invasive fronts, high-grade sarcomatoid transformation, and lymph node metastasis.

CONCLUSIONS

The results of the current study indicate that Src and E-cadherin may play an important role in EMT, invasion, and aggressive clinicopathologic features of HNSC. These proteins may be targeted for the therapeutic intervention of patients with HNSC.

Molecular pathogenesis of oral squamous cell carcinoma: implications for therapy

The development of oral squamous cell carcinoma (OSCC) is a multistep process requiring the accumulation of multiple genetic alterations, influenced by a patient's genetic predisposition as well as by environmental influences, including tobacco, alcohol, chronic inflammation, and viral infection. Tumorigenic genetic alterations consist of two major types: tumor suppressor genes, which promote tumor development when inactivated; and oncogenes, which promote tumor development when activated. Tumor suppressor genes can be inactivated through genetic events such as mutation, loss of heterozygosity, or deletion, or by epigenetic modifications such as DNA methylation or chromatin remodeling. Oncogenes can be activated through overexpression due to gene amplification, increased transcription, or changes in structure due to mutations that lead to increased transforming activity. This review focuses on the molecular mechanisms of oral carcinogenesis and the use of biologic therapy to specifically target molecules altered in OSCC. The rapid progress that has been made in our understanding of the molecular alterations contributing to the development of OSCC is leading to improvements in the early diagnosis of tumors and the refinement of biologic treatments individualized to the specific characteristics of a patient's tumor.

Evidence that TNF-TNFR1-TRADD-TRAF2-RIP-TAK1-IKK pathway mediates constitutive NF-κB activation and proliferation in human head and neck squamous cell carcinoma

Constitutively activated nuclear factor-kappaB (NF-kappaB) has been associated with a variety of aggressive tumor types, including head and neck squamous cell carcinoma (HNSCC); however, the mechanism of its activation is not fully understood. Therefore, we investigated the molecular pathway that mediates constitutive activation of NF-kappaB in a series of HNSCC cell lines. We confirmed that NF-kappaB was constitutively active in all HNSCC cell lines (FaDu, LICR-LON-HN5 and SCC4) examined as indicated by DNA binding, immunocytochemical localization of p65, by NF-kappaB-dependent reporter gene expression and its inhibition by dominant-negative (DN)-inhibitory subunit of NF-kappaB (IkappaBalpha), the natural inhibitor of NF-kappaB. Constitutive NF-kappaB activation in HNSCC was found to be due to constitutive activation of IkappaBalpha kinase (IKK); and this correlated with constitutive expression of phosphorylated forms of IkappaBalpha and p65 proteins. All HNSCC showed the expression of p50, p52, p100 and receptor-interacting protein; all linked with NF-kappaB activation. The expression of constitutively active NF-kappaB in HNSCC is mediated through the tumor necrosis factor (TNF) signaling pathway, as NF-kappaB reporter activity was inhibited by DN-TNF receptor-associated death domain (TRADD), DN-TNF receptor-associated factor (TRAF)2, DN-receptor-interacting protein (RIP), DN-transforming growth factor-beta-activated kinase 1 (TAK1), DN-kappa-Ras, DN-AKT and DN-IKK but not by DN-TRAF5 or DN-TRAF6. Constitutive NF-kappaB activation was also associated with the autocrine expression of TNF, TNF receptors and receptor-activator of NF-kappaB and its ligand in HNSCC cells but not interleukin (IL)-1beta. All HNSCC cell lines expressed IL-6, a NF-kappaB-regulated gene product. Furthermore, treatment of HNSCC cells with anti-TNF antibody downregulated constitutively active NF-kappaB, and this was associated with inhibition of IL-6 expression and cell proliferation. Our results clearly demonstrate that constitutive activation of NF-kappaB is mediated through the TRADD-TRAF2-RIP-TAK1-IKK pathway, making TNF a novel target in the treatment of head and neck cancer.

Elective neck dissection during salvage laryngectomy

PURPOSE

To evaluate the rate of occult metastases detected with elective neck dissection during salvage laryngectomy for radiation failures.

METHODS AND MATERIALS

Retrospective review of 63 patients failing radiation therapy treated with salvage surgery between 1970 and 1999. Charts were reviewed for tumor stage, neck treatment, complications, surgical time, and survival. Median follow-up for patients with glottic and supraglottic cancers was 7.8 and 4.5 years, respectively.

RESULTS

Thirty-one of 41 glottic cancer patients received elective neck dissections. Three (10%) of 31 had occult metastases. Recurrent staged rT3 and greater tumors showed a 20% rate of occult metastases. No survival advantage was noted between patients treated with elective neck dissection and those followed expectantly (P = .87). Cartilage invasion and perineural invasion in the larynx were associated with a higher risk of occult metastases (P < .05). Ten of 22 supraglottic cancer patients received elective neck dissections. Two (20%) of 10 had occult metastases, and a statistically significant survival advantage was not noted (P = .49).

CONCLUSIONS

We recommend bilateral neck dissection at the time of laryngectomy for recurrent staged rT3/4 tumors and all patients with recurrent supraglottic cancers because of the higher rate of occult metastases.

Differential expression of p63 isotypes (DeltaN and TA) in salivary gland neoplasms: biological and diagnostic implications

To determine the association between the expression of p63 gene isoforms (TA and DeltaN) and salivary gland tumorigenesis, we performed reverse transcription-polymerase chain reaction analysis of these markers in 71 benign and malignant salivary gland neoplasms. The results were correlated with the expression of Notch ligand JAG1 gene and the clinicopathologic features and the full-length p63 protein expression by immunohistochemistry. Both p63 isoforms were either negative or weakly expressed in normal salivary gland tissues. TAp63 was highly expressed in most benign tumors and was either negative or weakly positive in most carcinomas. Conversely, DeltaNp63 was negative or faintly positive in most benign neoplasms and was highly expressed in adenoid cystic, mucoepidermoid, and myoepithelial carcinomas. Immunohistochemical analysis using anti-full-length p63 protein showed ubiquitous nuclear staining in basal and myoepithelial cells in both benign and malignant neoplasms. JAG1 was expressed in most benign and malignant tumors and did not correlate with p63 isoforms expression. We conclude that (1) p63 isoforms are differentially expressed in most benign and malignant tumors and may play distinct biological roles in certain salivary gland neoplasms; (2) p63 immunostaining do not correlate with the isoforms expression; and (3) isoform-specific antibodies are required for better cellular localization and biological correlations.

ICAM-5 (telencephalin) gene expression in head and neck squamous carcinoma tumorigenesis and perineural invasion!

ICAM-5 (telencephalin) is an intercellular adhesion molecule reported to be expressed only in the somatodendritic membrane of telencephalic neurons. We recently identified high ICAM-5 expression in a cDNA array study of head and neck neoplasms with a propensity for perineural invasion. To determine the association of this gene in tumorigenesis and perineural invasion, we analyzed the expression and functional status of ICAM-5 mRNA transcripts in 30 different human cancer cell lines and 25 head and neck squamous carcinoma specimens by reverse-transcriptase polymerase chain reaction (cell lines and specimens) and in vitro functional assays (cell lines). ICAM-5 transcripts were detected in 28 (93%) of 30 cell lines derived from primary head and neck, colon, thyroid, cervical, pancreatic, skin, and adenoid cystic carcinomas. In cell lines, small interfering RNA blocked ICAM-5 expression and inhibited cell proliferation. Treatment with the phosphatidylinositol 3'-kinase (PBK) inhibitor LY294002 resulted in ICAM-5 down-regulation. In tissue specimens, none of the 25 histologically normal oral mucosal specimens had detectable ICAM-5 level, whereas 16 (64%) of the 25 matched primary squamous carcinomas showed expression. Carcinoma specimens high ICAM-5 expression had a high incidence of perineural invasion. Our study indicates that ICAM-5 may play a role in tumorigenesis and perineural invasion, most likely through the P13K/Akt-signaling pathway.

The S100A7-c-Jun Activation Domain Binding Protein 1 Pathway Enhances Prosurvival Pathways in Breast Cancer

S100A7 is among the most highly expressed genes in preinvasive breast cancer, is a marker of poor survival when expressed in invasive disease, and promotes breast tumor progression in experimental models. To explore the mechanism of action, we examined the role of S100A7 in cell survival and found that overexpression of S100A7 in MDA-MB-231 cell lines promotes survival under conditions of anchorage-independent growth. This effect is paralleled by increased activity of nuclear factor-κB (3-fold) and phospho-Akt (4-fold), which are known to mediate prosurvival pathways. S100A7 and phospho-Akt are also correlated in breast tumors examined by immunohistochemistry (n = 142; P &lt; 0.0001; r = 0.34). To explore the underlying mechanism, we examined the role of a putative c-Jun activation domain-binding protein 1 (Jab1)–binding domain within S100A7 using a panel of MDA-MB-231 breast cell lines stably transfected with either S100A7 or S100A7 mutated at the Jab1 domain. Structural analysis by three-dimensional protein modeling, immunoprecipitation, and yeast two-hybrid assay and functional analysis using transfected reporter gene and Western blot assays revealed that the in vitro effects of S100A7 on phospho-Akt and the nuclear factor-κB pathway are dependent on the Jab1-binding site and the interaction with Jab1. Enhanced epidermal growth factor receptor signaling was also found to correlate with the increased phospho-Akt. Furthermore, the Jab1-binding domain is also necessary for the enhanced tumorigenicity conferred by S100A7 expression in murine xenograft tumors in vivo. We conclude that the S100A7-Jab1 pathway acts to enhance survival under conditions of cellular stress, such as anoikis, which may promote progression of breast cancer.

The Akt inhibitor KP372-1 suppresses Akt activity and cell proliferation and induces apoptosis in thyroid cancer cells

The phosphatidylinositol 3′ kinase (PI3K)/phosphatase and tensin homologue deleted on chromosome ten/Akt pathway, which is a critical regulator of cell proliferation and survival, is mutated or activated in a wide variety of cancers. Akt appears to be a key central node in this pathway and thus is an attractive target for targeted molecular therapy. We demonstrated that Akt is highly phosphorylated in thyroid cancer cell lines and human thyroid cancer specimens, and hypothesised that KP372-1, an Akt inhibitor, would block signalling through the PI3K pathway and inhibit cell proliferation while inducing apoptosis of thyroid cancer cells. KP372-1 blocked signalling downstream of Akt in thyroid tumour cells, leading to inhibition of cell proliferation and increased apoptosis. As thyroid cancer consistently expresses phosphorylated Akt and KP372-1 effectively blocks Akt signalling, further preclinical evaluation of this compound for treatment of thyroid cancer is warranted.

Extracapsular spread. A significant predictor of treatment failure in patients with squamous cell carcinoma of the tongue

INTRODUCTION

The presence of nodal metastases remains the most significant predictive factor for regional recurrence and survival in patients treated for squamous cell carcinoma of the head and neck. Survival rates are further decreased in patients with nodal metastases that have spread beyond the lymph node capsule, or extracapsular spread (ECS). To the authors' knowledge, this is the first report on the impact of ECS in a large series of patients treated for squamous cell carcinoma of the oral tongue (SCCOT) at a single institution using surgery as the primary treatment modality.

METHODS

The authors retrospectively reviewed the medical records of all patients treated for SCCOT with resection of the primary and neck dissection at a single institution between 1980 and1995.

RESULTS

Two hundred sixty-six patients were included in the study. Of that number, 146 patients (55%) were pathologically node-negative (pN0), 75 patients (28%) were pathologically node-positive (pN+) without ECS (pN+/ECS-), and 45 patients (17%) were pN+ with ECS (pN+/ECS+). The 5-year disease-specific and overall survival rates for pN0 patients were 88% and 75%; for pN+/ECS- patients, 65% and 50%; and 48% and 30% for pN+/ECS+ patients. The patterns of failure for the pN0, pN+/ECS- and, pN+/ECS+ groups showed overall recurrence rates of 19.8%, 34.2%, and 51.1% with regional failure rates of 11.5%, 19.2%, and 28.9%, respectively, and distant metastases rates of 3.3%, 8.2%, and 24.4%.

CONCLUSIONS

ECS is the most significant predictor of both regional recurrence and development of distant metastasis accounting for decreased survival of patients with SCCOT in the current study. Therefore, intensive regional and systemic adjuvant therapy may be indicated for patients with ECS. Future studies should focus on identifying molecular mediators involved in ECS to determine targets for adjuvant therapies in this subset of patients.

Phase II study of the antiangiogenesis agent thalidomide in recurrent or metastatic squamous cell carcinoma of the head and neck

BACKGROUND

Thalidomide has been shown to have antiangiogenic effects in preclinical models as well as a significant antitumor effect in hematologic tumors such as multiple myeloma. The authors performed this Phase II study to determine the activity, toxicity profile, and antiangiogenic effect of thalidomide in patients with locoregionally recurrent or metastatic squamous cell carcinoma of the head and neck.

METHODS

Twenty-one patients with recurrent or metastatic squamous cell carcinoma of the head and neck were treated with single-agent thalidomide. All patients had received radiation therapy, and most had undergone surgery (95%) and/or chemotherapy (90%). Thalidomide was initiated at 200 mg;3>daily and increased to a target dose of 1000 mg daily. Patients continued treatment until disease progression, unacceptable toxicity, or death occurred.

RESULTS

All 21 patients eventually developed progressive disease. Median time to progression was 50 days (95% confidence interval, 28-70), with median overall survival time of 194 days (95% lower confidence boundary, 151), similar to the progression and survival times reported for this patient group with other agents. Thalidomide was generally well tolerated, with few patients experiencing Grades 3 to 4 toxicities. Serum vascular endothelial growth factor and basic fibroblast growth factor levels increased in six of seven patients, for whom paired serum samples were available and all of whom had progressive disease.

CONCLUSIONS

In this heavily pretreated population of patients with advanced squamous cell carcinoma of the head and neck, thalidomide does not appear to have single-agent antitumor activity. Further evaluation of the mechanism of action of thalidomide is indicated. Potentially, future evaluations of thalidomide may be performed in combination with other antiangiogenic or cytotoxic agents in patients with earlier stage disease or in patients with minimal residual disease.

Extracapsular spread. A significant predictor of treatment failure in patients with squamous cell carcinoma of the tongue

INTRODUCTION

The presence of nodal metastases remains the most significant predictive factor for regional recurrence and survival in patients treated for squamous cell carcinoma of the head and neck. Survival rates are further decreased in patients with nodal metastases that have spread beyond the lymph node capsule, or extracapsular spread (ECS). To the authors' knowledge, this is the first report on the impact of ECS in a large series of patients treated for squamous cell carcinoma of the oral tongue (SCCOT) at a single institution using surgery as the primary treatment modality.

METHODS

The authors retrospectively reviewed the medical records of all patients treated for SCCOT with resection of the primary and neck dissection at a single institution between 1980 and1995.

RESULTS

Two hundred sixty-six patients were included in the study. Of that number, 146 patients (55%) were pathologically node-negative (pN0), 75 patients (28%) were pathologically node-positive (pN+) without ECS (pN+/ECS-), and 45 patients (17%) were pN+ with ECS (pN+/ECS+). The 5-year disease-specific and overall survival rates for pN0 patients were 88% and 75%; for pN+/ECS- patients, 65% and 50%; and 48% and 30% for pN+/ECS+ patients. The patterns of failure for the pN0, pN+/ECS- and, pN+/ECS+ groups showed overall recurrence rates of 19.8%, 34.2%, and 51.1% with regional failure rates of 11.5%, 19.2%, and 28.9%, respectively, and distant metastases rates of 3.3%, 8.2%, and 24.4%.

CONCLUSIONS

ECS is the most significant predictor of both regional recurrence and development of distant metastasis accounting for decreased survival of patients with SCCOT in the current study. Therefore, intensive regional and systemic adjuvant therapy may be indicated for patients with ECS. Future studies should focus on identifying molecular mediators involved in ECS to determine targets for adjuvant therapies in this subset of patients.

Predictors of weight loss during radiation therapy

OBJECTIVE

To define risk factors for weight loss or dehydration during radiation therapy (RT).

STUDY DESIGN AND SETTING

Retrospective chart review, academic tertiary care center.

RESULTS

The incidence of severe weight loss during RT was 32.7%, the incidence of dehydration was 10.9%, and the rate of prophylactic feeding gastrostomy tube placement was 32%. The patients most likely to suffer severe weight loss included patients with tumor sites of nasopharynx and base of tongue, those treated with chemoradiation, and patients with severe pretreatment weight loss. Prophylactic feeding gastrostomy tube placement before RT significantly reduced the incidence of severe weight loss and hospitalization during RT.

CONCLUSION

Severe weight loss and dehydration during RT for head and neck cancer is common. Prophylactic feeding gastrostomy tubes significantly reduce the incidence of severe weight loss and hospitalization for dehydration during RT when placed before onset of RT. Patients at risk for severe weight loss include those with severe pretreatment weight loss, tumors of the nasopharynx and base of tongue, or treatment with chemoradiation.

Phase II study of the antiangiogenesis agent thalidomide in recurrent or metastatic squamous cell carcinoma of the head and neck

BACKGROUND

Thalidomide has been shown to have antiangiogenic effects in preclinical models as well as a significant antitumor effect in hematologic tumors such as multiple myeloma. The authors performed this Phase II study to determine the activity, toxicity profile, and antiangiogenic effect of thalidomide in patients with locoregionally recurrent or metastatic squamous cell carcinoma of the head and neck.

METHODS

Twenty-one patients with recurrent or metastatic squamous cell carcinoma of the head and neck were treated with single-agent thalidomide. All patients had received radiation therapy, and most had undergone surgery (95%) and/or chemotherapy (90%). Thalidomide was initiated at 200 mg;3>daily and increased to a target dose of 1000 mg daily. Patients continued treatment until disease progression, unacceptable toxicity, or death occurred.

RESULTS

All 21 patients eventually developed progressive disease. Median time to progression was 50 days (95% confidence interval, 28-70), with median overall survival time of 194 days (95% lower confidence boundary, 151), similar to the progression and survival times reported for this patient group with other agents. Thalidomide was generally well tolerated, with few patients experiencing Grades 3 to 4 toxicities. Serum vascular endothelial growth factor and basic fibroblast growth factor levels increased in six of seven patients, for whom paired serum samples were available and all of whom had progressive disease.

CONCLUSIONS

In this heavily pretreated population of patients with advanced squamous cell carcinoma of the head and neck, thalidomide does not appear to have single-agent antitumor activity. Further evaluation of the mechanism of action of thalidomide is indicated. Potentially, future evaluations of thalidomide may be performed in combination with other antiangiogenic or cytotoxic agents in patients with earlier stage disease or in patients with minimal residual disease.

Phase II trial of systemic recombinant interleukin-2 in the treatment of refractory nasopharyngeal carcinoma

BACKGROUND

Interleukin-2 (IL-2) is a cytokine produced by activated T cells, which has shown powerful immunostimulatory and antineoplastic properties. Nasopharyngeal carcinoma (NPC) is an Epstein-Barr virus-associated cancer with abundant lymphocyte infiltration histologically. The activity of IL-2 in the treatment of NPC patients is currently unknown. A phase II study was, therefore, initiated to evaluate the efficacy, toxicity and immunological consequences of intravenous bolus IL-2 in patients with recurrent/metastatic NPC.

METHODS

Between November 1996 and April 1997, 14 patients with recurrent/metastatic NPC were entered into the study. Recombinant IL-2 (Proleukin, Chiron) was injected by intravenous bolus every 8 h at 72,000 IU/kg for a maximum of 15 doses. After 7 days, patients were retreated with a second identical cycle of therapy. Those patients who were stable or responding to treatment 5-6 weeks later went on to receive another course (two cycles) of therapy. All patients received prophylactic antibiotics and antipyretic medicine. Response and toxicities were evaluated. Serial plasma level of TNF-alpha, IL-6, soluble IL-2 receptor, IL-10 and soluble CD8 were determined.

RESULTS

Fourteen patients received a total of 34 cycles of therapy. No response was observed. Fifty percent had stable disease, 50% had progressive disease after a median of two cycles of therapy. There was one treatment-related death from acute myocardial infarction. Body weight increase (>5%) occurred in 80% of cycles, and hypotension (BP <80 mm Hg systolic) occurred in 53%. Serum creatinine increase (>2 mg%) occurred in 24% of cycles, and SGOT/SGPT increase (>3x) in 10% of cycles. Symptoms of somnolence, general malaise, nausea and vomiting, pruritus, xerostomia, desquamation were generally mild to moderate but rapidly reversible.

CONCLUSION

The single modality of intravenous bolus IL-2 at the dose level of 72,000 IU/kg is clinically ineffective in NPC patients. Potential mechanisms of the ineffectiveness of IL-2 therapy on NPC patients are discussed.

Malignant melanoma arising within a burn scar case report and review of the literature

Burn scar carcinomas, also called Marjolin's ulcers, are uncommon tumors that arise from an antecedent burn. Most burn scar carcinomas are diagnosed about 30 years after the burn, and most are well-differentiated squamous cell carcinomas. We report a case in which a squamous cell carcinoma developed within a burn scar on the cheek and then a malignant melanoma arose within the burn scar after the squamous cell carcinoma had been excised. We also review the available literature on burn scar carcinoma, covering the demographics, pathogenesis, diagnosis, prognosis, and treatment of the disease. Given the multifocality of this disease process, we advocate aggressive resection of the entire burn scar, as well as the tumor, to prevent the development of further cancers within the wound.

Squamous cell carcinoma of the tongue in young adults: increasing incidence and factors that predict treatment outcomes

OBJECTIVE

This study was designed to determine whether the incidence of squamous cell carcinoma of the oral tongue (SCCOT) in young adults has changed during the past 25 years and to determine prognostic factors for young adult patients (aged < 40 years) with SCCOT.

METHODS AND PATIENTS

A retrospective review of young adults with SCCOT who sought treatment at the M. D. Anderson Cancer Center between 1973 and 1995 was undertaken.

RESULTS

The percentage of young adult SCCOT patients at M. D. Anderson increased from 4% in 1971 to 18% in 1993. T stage, N stage, perineural invasion, and lymphatic invasion were all associated with decreased survival. Patients who received a neck dissection as part of their primary treatment had a better chance of survival than patients who did not.

CONCLUSIONS

The incidence of SCCOT in the young adult population is increasing in the United States. Appropriate surgical management for young adults with SCCOT includes resection of the primary tumor along with a selective node dissection.

Biochemoprevention for dysplastic lesions of the upper aerodigestive tract

OBJECTIVES

To evaluate the efficacy and secondarily the toxic effects of biochemopreventive therapy (high-dose isotretinoin [13-cis-retinoic acid], alpha-tocopherol, and interferon alfa) in the reversal of advanced premalignant lesions of the upper aerodigestive tract and to correlate the therapeutic events with modulation of biomarkers.

DESIGN

Prospective, nonrandomized chemoprevention trial.

SETTING

Tertiary cancer care referral center and ambulatory care.

PARTICIPANTS

Thirty-six patients with advanced premalignant lesions of the upper aerodigestive tract, without cancer during the 2 years before the intervention, with evaluable lesions, and without retinoid therapy for 3 months before the trial.

INTERVENTION

Administration of oral isotretinoin (100 mg/m2 per day), oral alpha-tocopherol (1200 IU/d), and subcutaneous interferon alfa (3 megaunits per square meter twice weekly) for 12 months, with serial biopsies and clinical examination at 0, 6, 12, and 18 months from study start.

MAIN OUTCOME MEASURES

Clinical and histologic responses to the intervention.

RESULTS

Of the 36 patients, evaluation was possible in 30 for response at 6 months and in 21 at 12 months. At 6 months, there were 10 pathologic complete responses and 7 partial responses; at 12 months, 7 complete and 3 partial responses. A striking difference in response was observed in favor of laryngeal lesions (9/19 [47%] complete response rate at 6 months and 7/14 [50%] at 12 months vs 1/11 [9%] and 0/7 [0%], respectively, for oral lesions). Toxic effects were acceptable and did not exceed grade 3.

CONCLUSION

Biochemoprevention is a promising biologic approach for laryngeal dysplasia and needs to be investigated further.

Successful use of cyclosporine in a lung transplant recipient with tacrolimus-associated hemolytic uremic syndrome

Hemolytic-uremic syndrome (HUS) is a rare, but well-described complication in organ transplant recipients maintained on cyclosporine immunosuppression. Tacrolimus is a newer agent with similar immunosuppressant efficacy. In cases of cyclosporine-related HUS in renal transplant recipients, tacrolimus has been used successfully without recurrence of HUS. Tacrolimus has been reported to cause HUS in renal and more recently in cardiac transplant patients. We report a case of HUS in a lung transplant recipient receiving tacrolimus who was subsequently converted to cyclosporine without recurrence of HUS.

Exercise stress testing. An overview of current guidelines

Exercise stress testing (ET) is an inexpensive noninvasive tool that provides valuable cardiopulmonary information in healthy and diseased populations. It is most commonly used for diagnosing coronary artery disease (CAD) and developing appropriate exercise prescriptions (EP). With its widespread use and application, it is imperative that safe and appropriate guidelines and procedures are used, as there are a number of risks associated with testing in a population with or suspected of having CAD. The focus should be on the patient's safety: personnel must be properly trained and aware of all emergency procedures, contra-indications for ET and indications for test termination must be strictly adhered to. Three main types of testing are prevalent: submaximal, maximal and maximal utilising gas exchange. The maximal test is most commonly used, and the submaximal is appropriate for hospitalised patients. Gas exchange data is essential when assessing congestive heart failure and timing for heart transplantation. ET is commonly performed using a treadmill or a bicycle ergometer. The treadmill provides a more familiar exercise modality and has been shown to have greater diagnostic sensitivity than the bicycle ergometer; it is, however, more expensive and requires more space in the testing room. The bicycle ergometer is more appropriate for those individuals who are severely obese or have problems with extended periods of walking. Regardless of the modality used, an appropriate exercise protocol should be used. In North America, the Bruce protocol is the most common. However, the Bruce protocol, and others that estimate exercise capacity based on equations, tend to overestimate exercise capacity. They may be too demanding for those with limited exercise capacity, and too long for those with high exercise capacity. For these people, an exercise protocol that reaches maximal capacity in 8 to 12 minutes using smaller increments in workload should be considered. Once completed, the results of ET needs to be correctly interpreted. This includes reviewing the test results while considering the patient's history, medications and indication for the test. ET can also be used to develop an EP for the participant. An EP should take into account the intensity, modality of exercise, frequency and duration, as well as being realistic for the individual and the goals to be achieved. All the information from the test results and the pre-test examination should be presented in a report that also includes the advised EP.

The use of biological therapy in cancer of the head and neck

Exciting progress, in the molecular and cell biology of head and neck cancer has provided us with new ways to target cancer cells more specifically. The possibility now exists with gene therapy of targeting specific genetic defects found in certain tumor types using any one of a number of possible gene delivery systems. Although specific problems with currently existing gene therapy strategies remain to be addressed, encouraging preclinical and clinical data indicate that this is a very promising area. In addition, the exquisite sensitivity of anti/bodies directed at specific molecular targets should make antibody-conjugated toxins, radioimmunoconjugates, and antibodies alone viable therapeutic options. Finally, increased understanding of the antitumor immune response has yielded more rationally designed cytokine as well as cellular-based immunologic treatments for cancer. During the next several years, physicians and scientists alike will need to critically appraise the results of clinical trials of some of these novel treatment approaches and determine how they will fit in with the existing options for the treatment of patients with head and neck cancer. Given that these tumors arise from multiple molecular aberrations, it is likely that biological therapies will be used in combination with other biological approaches or more conventional treatment modalities.

Differential expression of MMAC/PTEN in glioblastoma multiforme: relationship to localization and prognosis

MMAC/PTEN, a tumor suppressor gene located on chromosome 10q, has recently been shown to act as a phosphatidylinositol 3,4,5-triphosphate phosphatase and to modulate cell growth and apoptosis. Somatic mutations of MMAC/PTEN have been reported in a number of human cancers, especially in glioblastoma multiforme (GBM), although the number of identified mutations (approximately 10-35%) is significantly lower than the frequency of LOH affecting the MMAC/PTEN locus in the specimens (approximately 75-95%). To further investigate the possible alterations that may affect MMAC/PTEN, we examined the expression of the gene by reverse transcription-PCR in a series of gliomas. A significant difference (P < 0.001) was observed between the expression of MMAC/PTEN in GBMs versus lower grades of gliomas, thus mimicking the difference in allelic deletion associated with the locus in these tumors. Furthermore, Kaplan-Meier survival plots, adjusted for age and tumor grade, showed a significantly better prognosis for patients whose tumors expressed high levels of MMAC/PTEN. Additionally, immunostaining of GBMs revealed little or no MMAC/PTEN expression in about two-thirds of the tumors, whereas the other approximately one-third of tumors had significantly higher levels of expression. However, in about two-thirds of the high-expressing specimens, a heterogeneous pattern of expression was observed, indicating that certain cells within the tumor failed to express MMAC/PTEN. The combination of these results suggest that, in addition to molecular alterations affecting the gene, altered expression of MMAC/PTEN may play a significant role in the progression of GBM and patient outcome.

Percutaneous fluoroscopic gastrostomy tube placement in patients with head and neck cancer

OBJECTIVE

To study the safety and efficacy of percutaneous fluoroscopic gastrostomy tube placement in patients with head and neck cancer.

DESIGN

We conducted a retrospective case review of 92 consecutive cases. Comparable access procedures and relevant literature were reviewed.

SETTING

Academic tertiary care center.

PATIENTS

Patients with head and neck cancer who underwent percutaneous fluoroscopic gastrostomy tube placement between January 1996 and July 1996.

MAIN OUTCOME MEASURES

Immediate, delayed, and long-term complications; tube malfunction; and tube placement failure.

RESULTS

The major complication rate was 1%; the minor complication rate was 8%; and the tube malfunction rate was 13%. The rate of successful tube placement was 98%. None of the patients required hospitalization as a result of the procedure.

CONCLUSIONS

Percutaneous fluoroscopic gastrostomy tube placement is a safe, economical, and comfortable method that has distinct advantages over other gastrostomy tube placement methods. It is recommended for enteral feeding and nutritional supplementation in patients with head and neck cancer.

Peritumoral CD1a-positive dendritic cells are associated with improved survival in patients with tongue carcinoma

OBJECTIVES

To determine if survival and recurrence rates for patients with squamous cell carcinoma of the tongue correlate with the degree of dendritic cell (DC) infiltration of the primary tumor or adjacent tongue tissue and if there is an association between tumor or nodal stage and DC infiltration.

DESIGN

Hospital and office medical records were reviewed to obtain 5-year follow-up data. Original pathology specimens were recut and stained for the cell surface markers S100 and CD 1a. The number of DCs present in the specimens was quantified microscopically and compared statistically with patient outcome and staging.

SETTING

A university hospital.

PATIENTS

All patients who underwent resection of primary squamous cell carcinoma of the tongue from January 1, 1987, through December 31, 1990, for whom 5-year follow-up data and original pathology specimens were available (N=43).

MAIN OUTCOME MEASURES

Time to recurrence, death, or both.

RESULTS

Patients who had greater numbers of CD1a-positive DCs adjacent to tumor had improved survival (P=.02) and decreased recurrence rates (P=.06). The other subpopulations of DCs examined were not associated with survival or recurrence. In addition, the number of CD 1a-positive DCs in peritumoral epithelium decreased as the tumor stage increased (P=.01) and if nodal metastases were present (P=.05).

CONCLUSIONS

Dendritic cells are antigen-presenting cells that are thought to play a major role in the antitumor immune response. The CD1a surface antigen has been shown to mediate T-cell interactions. The association between CD1a-positive peritumoral DCs and patient outcome suggests an important function for this cell population.

Interleukin-12 gene therapy prevents establishment of SCC VII squamous cell carcinomas, inhibits tumor growth, and elicits long-term antitumor immunity in syngeneic C3H mice

Interleukin-12 (IL-12) is an immunostimulatory agent with very promising antitumor activity. Using a retroviral expression vector, the authors have successfully transduced the genes encoding the two subunits of murine IL-12 to the squamous cell carcinoma cell line, SCC VII. Once IL-12 gene transcription and protein production were successfully verified, IL-12 expression was found to inhibit the establishment of SCC VII tumors in syngeneic C3H/HeJ mice inoculated with 1 x 10(6) SCC VII/IL-12 viable tumor cells. Mice immunized in this manner and rechallenged with parent SCC VII were capable of rejecting tumor up to 40% of the time. Treatment of established SCC VII tumors with irradiated IL-12-producing tumors cells led to significant tumor regression in a high percentage of animals.

Regression of atherosclerosis: a review

In recent years, it has been established in humans that progression of atherosclerosis can be slowed, and in some cases, regressed. This differs from previous decades in which such observations were only considered possible in animals. The emergence of more effective lipid-lowering agents along with aggressive dietary and other lifestyle interventions has brought about this change. Other recent studies, using clinical events as the primary outcome, have shown that both pharmacological and lifestyle interventions decrease cardiovascular morbidity and mortality. With these findings, medical and lifestyle management of coronary disease is taking on an increasingly important role as an alternative to invasive interventions. The optimal pharmacological, dietary or exercise regimen, the relative contribution of each, how to optimally implement these programs in large populations, and their cost effectiveness have yet to be defined. This article explores current research in the area of regression of atherosclerosis in humans.

Malignant melanoma metastatic to the tonsil

Metastasis to the oral cavity from melanoma arising in distant sites is very rare. The authors present three cases of melanoma metastatic to the palatine tonsil: two were cutaneous melanomas and one arose from the mucous membrane of the hard palate. Fewer than 30 cases of metastatic melanoma to the palatine tonsil have been reported, and none have been from mucosal melanoma originating from another mucosal primary site in the head and neck. From this perspective, one of the cases in this article is unique. The authors present clinical histories of the three cases of melanoma metastatic to the palatine tonsil. Two patients were still alive a substantial time after treatment. The case presentations indicate that careful examination of the head and neck should be part of the routine follow-up examination in all melanoma patients.