Introduction: Cetuximab plus platinum-based chemotherapy regimen is considered as a standard of care in treatment of recurrent or metastatic squamous-cell carcinoma of head and neck (SCCHN). Subgroup analysis of the "Extreme" pivotal phase III randomized trial suggest that this regimen is effective in fit elderly patients (≥65 years), with an acceptable toxicity profile1. Howewer, elderly patients were clearly underrepresented in this trial as only 18% (n = 39) of patients in the cetuximab combination arm were older than 65 years.

La sclérose tubéreuse de Bourneville est caractérisée par un déficit en TSC2, inhibiteur de mTOR. Nous présentons le cas d’un patient de 61 ans, porteur d’une sclérose tubéreuse de Bourneville, qui a souffert de réactions aiguës prononcées associées à une réponse tumorale majeure au cours d’une chimioradiothérapie. Il était traité pour une adénopathie cervicale d’un carcinome épidermoïde sans porte d’entrée retrouvée. Le protocole consistait en une irradiation classique, associée à une chimiothérapie par 5-fluoro-uracile et cisplatine. Après un cycle de chimiothérapie et une dose de 22 Gy, il a souffert d’une toxicité muqueuse et cutanée de grade 3, localisée dans le champ de la radiothérapie et ayant nécessité l’arrêt définitif du traitement, associée à une réponse tumorale majeure. Cette réaction est paradoxale, puisque les mutations observées dans la sclérose tubéreuse de Bourneville portent sur la perte de fonction de la protéine TSC2, avec pour conséquence une activation de la voie de signalisation mTOR. Logiquement, nous devrions avoir observé une « radiorésistance » relative chez ce patient. Ce cas illustre la complexité des phénomènes biologiques sous-jacents à la radiosensibilité et les difficultés à prévoir la réponse tumorale et des tissus sains. L’efficacité des protocoles d’association d’inhibiteurs de mTOR et de radiothérapie devra faire l’objet d’une attention particulière.A 61-year-old man, with a tuberous sclerosis, experienced severe acute reactions during a concomitant chemoradiotherapy regimen after 22 Gy and one cycle of 5-fluorouracil-cisplatinum. He was treated for a cervical squamous cell lymph node of unknown origin. Grade 3 mucitis and epitheliitis were observed only in the irradiated fields and required the end of the radiotherapy. Tuberous sclerosis is characterized by a loss of the TSC2 function, with a permanent activation of the mTOR pathway. Logically, some kind of “radioresistance” should be observed. Increased radiosensitivity is paradoxical. This case illustrates how radiosensitivity is a complex phenomenon and clinically unpredictable. Efficiency of the protocols associations of mTOR inhibitors and radiotherapy should be carefully scrutinized.

We evaluated the prognostic value of the expression of the Human Papillomavirus (HPV) E6/E7 transcript and CDKN2A expression in a retrospective series of 144 oropharyngeal squamous cell carcinoma (OSCC) treated by surgery and adjuvant radiotherapy or concomitant chemoradiotherapy. Patients underwent surgery performed in a curative intent in a single institution and received radiotherapy or chemoradiotherapy between 1988 et 2006 in regional care centers (Strasbourg, Colmar and Mulhouse). Tumors samples collected at the moment of surgery were snap-frozen in liquid nitrogen and stored in our tumor bank. Clinical, pathological and follow up data corresponding to each fragment were collected. The expression levels of the CDKN2A gene and of the HPV E6/E7 mRNAs were measured on RNA extracts from selected samples using a real time quantitative RT-PCR (qRT-PCR) approach. The prognostic value of CDKN2A and HPV E6/E7 expression for 5 years overall survival (OS) and 2 years local and regional disease free survival (LRFS) was evaluated using Kaplan-Meier and multivariate Cox regression models. The median follow up time was 89 months. HPV E6/E7 expression was detected in 17 % of the tumors, CDKN2A was found to be overexpressed in 22 % of the cases. In univariate analysis E6/E7 expression was predictive of OS (p = 0.033), CDKN2A overexpression was predictive of OS (p = 0.042). Five years OS rates for patients with E6/E7 mRNA positive and negative tumors was 72 % and 47 %, respectively. Five years OS rates for patients with and without CDKN2A overexpression was 64 % and 46 %, respectively. In a multivariate analysis including age (>53 versus < 53 years old), pT (pT1 - 2 vs pT3 - 4) and pN (pN0 - 1 vs pN2 - 3), E6/E7 expression was found to relate to an improved 5 year OS (OR = 0.38, 95 % CI: 0.20 - 0.72, p = 0.003). Similarly, CDKN2A overexpression predicts an improved prognosis (OR = 0.51, 95 % CI: 0.30 - 0.86, p = 0.013). In unifactorial analysis, E6/E7 expression and CDKN2A overexpression did not predict 2 years LRFS (p = 0.147 and p = 0.731, respectively). As expected, HPV E6/E7 expression is a good prognosis factor for 5 years OS in our series of patients treated by surgery and adjuvant radiotherapy or chemoradiotherapy. However expression of E6/E7 transcript did not accurately predict LRFS. Similarly the quantification of CDKN2A overexpression predicts 5 years OS but not 2 years LRFS. Since CDKN2A expression can be easily evaluated by histochemistry staining approaches we believe CDKN2A can be used as a surrogate marker for HPV infection. HPV OSCC are thought to be more radiosensitive in patients treated by exclusive radiotherapy or chemoradiotherapy. Our results suggest that this might not be the case for miscroscopic tumors that remain after surgery.

5542 Background: To determine the effect of treatment time-related factors on outcome in patients treated with surgery and postoperative radiation therapy (RT) for locally advanced squamous cell carcinoma of head and neck (SCCHN). The site of the primary tumor was the buccal cavity (38), the oropharynx (151), the larynx (24) and the hypopharynx (95). Univariate and multivariate analysis were performed. Methods: A retrospective study was performed on 308 consecutive patients treated from 1990 to 1998 with surgery and postoperative RT (>= 55 Gy) for SCCHN. Time-related factors considered were interval from surgery to the start of RT, RT duration and total time from surgery to completion of RT (total treatment time). Other variables considered were pT and pN stages, margin status, capsule rupture, tumor site, age and gender. Results: Median follow-up was 36 months. From univariate analysis of overall survival (OS), statistically prognostic factors were pT (p<0.0001) and pN (p=0.008) stages, RT duration (p=0.01), total treatment time (p=0.02) and age (p=0.01). OS at 5 years were 42% and 27% respectively when total time treatment was under and over 100 days. OS at 5 years were 43% and 28% respectively when RT duration was under and over 52 days. Nevertheless, time- related factors were not associated with locoregional control and metastase free survival (MFS) in univariate analysis. From multivariate analysis, only the interval from surgery to the start of RT (p=0.03) was an independent time related factor for MFS. Conclusions: Our results indicate that a short total treatment time and a short RT duration is associated with improved OS. No significant financial relationships to disclose.

5551 Background: Whereas there is increasing interest in adjuvant radio-chemotherapy in head and neck squamous cell carcinomas (HNSCC), the prognostic indicators which allow the therapeutic indications to be established are not yet clearly defined. Thus, we decided to study the influence of pT stage, pN stage, tumor volume and number of lymph nodes invaded on survival of HNSCC in order to improve therapeutic indications. Methods: In this retrospective survival study, 651 patients who were operated on for HNSCC by the same surgical team between 1990 and 1997 and who underwent lymph node clearance were included. The site of the primary cancer was the buccal cavity (109), the oropharynx (291), the larynx (70) and the hypopharynx (181). 445 patients who had lymph node metastases, diseased resection margins or a tumour of large size received adjuvant radiotherapy. Results: From a univariate analysis of overall survival, the statistically significant prognostic histological indicators were the pT stage (p<0.0001), the pN stage (p<0.0001), capsule rupture (p<0.0001), the number of lymph nodes invaded (0, 1–3, 4–9, =10) (p<0.0001) and the total tumor volume (=5, 5–20, 20–50, >50 cm3) (p<0.0001). Cox survival models after adjusting for age, sex, and site of the primary cancer found the independent statistically significant prognostic indicators for overall survival to be pT stage (p<0.0001), pN stage (p<0.0001) and the total tumor volume (p<0.04). When, instead of the pN stage, the number of lymph nodes invaded was considered, it emerged as a statistically independent prognostic indicator. Conclusions: pT and pN stages but also the number of lymph nodes invaded and total tumor volume should be considered as essential prognostic indicators and any clinical trial developed in this field should stratify accordingly. No significant financial relationships to disclose.

BACKGROUND:An attempt was made to improve metachronous oesophageal cancer prognosis through bi-annual systematic esophageal endoscopy screening in patients treated for head and neck cancer.PATIENTS AND METHODS:Bi-annual esophageal endoscopy, without a staining procedure, was performed in 1560 patients from 1987 to 1997. The distribution of previous head and neck cancer was oral cavity (20%), oropharynx (30%), hypopharynx (34%), and larynx (16%). All patients had initial panendoscopic inspection before HNSCC treatment. Esophageal tumors were considered to be second synchronous primaries when discovered within the first six months of initial tumor diagnosis.RESULTS:Fifty metachronous esophageal asymptomatic cancers (42 T1 and 7 in situ carcinomas) were diagnosed by endoscopy. The median time between the HNC and the esophageal carcinoma was 43 months (7-137 months). Metachronous esophageal carcinoma was discovered in 2.6% of patients with oral cavity tumor, 5.7% of patients with oropharynx tumor, 2.3% of patients with hypopharynx tumor, and 1.7% of patients with larynx tumor. Causes of death were: 41.1% related to esophageal tumor with tumor progression, metastatic evolution, or treatment toxicity; 28.9% related to non malignant causes; 26.6% related to a cancer that was not of esophageal origin.CONCLUSIONS:Over a 10-year period, systematic bi-annual esophageal endoscopy uncovered metachronous esophageal tumors in 3.2% of 1560 patients originally treated for head and neck carcinoma, developing in a median time of 47 months. Patients with initial oropharyngeal tumors had a significantly higher risk of metachronous esophageal SCC, compared to the other tumor sites (P < 0.02 with Fisher exact test). Given the elevated death rate not related to the esophageal cancer and the median survival of 16 months, any potential benefit from this time-consuming procedure is debatable.

This study was performed on 282 patients with primary head and neck squamous cell carcinomas to evaluate the prognostic importance of 11q13 amplification. Amplification of the 11q13 DNA markers, HST-1IFGF-4 and BCL-1, evaluated by Southern and slot blot hybridisation, was detected in 52% of tumours. 11q13 amplification was associated with tumour site since this alteration occurred in 76% of tumours arising in the hypopharynx, versus 40% in the other sites (P=0.0007). 11q13 amplification was also significantly related to the presence of involved neck lymph nodes (P=0.013). The relationship between 11q13 amplification and risk of progression was studied in two subgroups of head and neck cancer patients with regard to treatment modalities. The presence of 11q13 amplification in the tumour was not significantly associated with a shorter event-free survival (P=0.82) and crude survival (P=0.61) of the 201 patients treated by surgery and postoperative radiotherapy. Similarly, absence of a relationship was observed for the group of 79 patients treated by surgery alone. These results confirm that 11q13 amplification is a prominent event in head and neck squamous cell carcinoma, indicating that it may be a common genetic event in the development of these neoplasms, but is not a reliable prognostic marker.

The L-myc DNA restriction fragment length polymorphism (RFLF), revealed by EcoRI digestion, has been evaluated in a case-control study including 161 head and neck cancer (HNSCC) patients and 160 normal healthy individuals with similar smoking and alcohol habits. No significant difference in the distribution of L-myc genotypes (LL, LS or SS) was found between the two populations implying thus no predisposition to head and neck tumour by either allele. There was no significant association between L-myc genotypes and the usual clinicopathological features such as T staging, differentiation status and lymph node involvement. Moreover, follow-up data from 154 patients was obtained and correlated with the L-myc pattern. No significant difference was observed in metastasis occurrence, multiple cancer incidence and survival data in the patients classified according to the L-myc genotypes; only a trend to preferentially develop metastasis in lung for patients with S allele was noted. In conclusion, our data shows that the L-myc typing does not contribute to HNSCC risk or prognosis assessment. A review of L-myc RFLP published studies shows contradictory results even on the same type of tumour and emphasizes the lacunae in understanding the biological role of L-myc for valid interpretation of L-myc allelic associations with cancer susceptibility or prognosis.

Amplification of 11q13 DNA markers, particularly hst-1FGF4 oncogene and the bcl-1 locus, was evaluated in 178 head and neck squamous cell carcinomas (SCCs) by Southern blot and slot blot hybridisation. Coamplification of hst-1FGF4 and bcl-1 genes was found in 57% of primary tumours and in 60% of the 89 metastatic lymph nodes tested. The pattern of amplification was significantly similar in matched sets of primary SCCs and metastatic lymph nodes. Levels of amplification, quantified by densitometric analysis of slot blots, ranged from 2 to 18-fold normal gene dosage. Also, c-myc oncogene (8q24) was found amplified less frequently, since 7% of 169 SCCs tested contained amplification of this gene, the level of which ranged from 2 to 8-fold. Hst-1bcl-1 gene amplification was observed more frequently in the tumours arising from the hypopharynx. Coamplification of hst-1 and bcl-1 genes was significantly positively associated with tumours with nodal involvement (P = 0.001). Incidence of hst-1bcl-1 gene amplification is higher in the tumours with a clinical stage III or IV. Hst-1bcl-1 gene amplification was not related to tumour differentiation or local invasiveness. This prospective study shows that amplification of 11q13 DNA markers is a prominent event occurring in head and neck SCC and may contribute to the pathogenesis and evolution of a subset of patients bearing this type of cancer.

Matrix metalloproteinases are believed to play an important role in tumor invasion and metastasis. To examine the expression of the stromelysin 3 (ST3) gene, a new member of the matrix metalloproteinase gene family, 111 head and neck squamous cell carcinomas and 21 metastatic lymph nodes were analyzed by Northern blot. ST3 gene expression was observed in 106 carcinomas and 19 metastatic nodes, but in only 2 of 60 samples of corresponding normal tissue tested in parallel. ST3 RNA, by in situ hybridization, and ST3 protein, by immunohistochemical analysis, were specifically detected in fibroblastic cells immediately surrounding invasive cancer cells. This fibroblastic expression of the ST3 gene is characteristic among the matrix metalloproteinase genes known to be overexpressed in head and neck carcinomas, since stromelysin 2 transcripts were specifically detected in neoplastic cells, and type I collagenase transcripts in both neoplastic cells and stromal fibroblasts. Furthermore, there was a highly significant positive correlation (P < 0.0001) between ST3 RNA levels and local invasiveness by the cancer cells. suggesting that enhanced expression of the ST3 gene may contribute to the neoplastic phenotype in head and neck carcinomas.

We address the question as to whether increased metalloproteinase production might be related to the high regional recurrence rate of some carcinomas, and particularly head and neck squamous-cell carcinomas (SCC). Northern blot of total RNA prepared from 26 lung carcinomas, 107 head and neck carcinoma samples and corresponding normal tissue samples demonstrates the frequent and sometimes concomitant over-expression of the 2 stromelysin genes, the type-I collagenase gene and the pump-I gene in the head and neck tumour tissue samples. In these SCC, over-expression of the 2 stromelysin genes and the type-I collagenase gene (but not the pump-I gene) is associated with a high degree of tumour differentiation. Moreover, a tumour with high levels of the stromelysin mRNAs is more likely to show high local invasiveness, suggesting that the stromelysins may be implicated in the clinical course of head and neck tumours. Evaluation of the corresponding mRNA levels may prove a useful indicator for predicting the clinical aggressiveness of these tumours.