André Lopes Carvalho

Trends in incidence and prognosis for head and neck cancer in the United States: A site-specific analysis of the SEER database

Despite recent advances in the diagnosis and treatment of head and neck cancer, there has been little evidence of improvement in 5‐year survival rates over the last few decades. To determine more accurate trends in site‐specific outcomes as opposed to a more general overview of head and neck cancer patients, we analyzed the site‐specific data collected in the Surveillance, Epidemiology, and End Results—SEER Public‐Use Database 1973–1999. Based on the selection criteria, 96,232 cases were evaluated for trend analysis in incidence, clinical stage, treatment and 5‐year survival. During the period 1973–1999, site‐specific incidence rates for head and neck cancer changed significantly. Site‐specific analysis of survival from 1974–1997 showed significant improvements in 5‐year survival rates for cancers of the nasopharynx, oropharynx and hypopharynx (38.1% to 56.7% for nasopharynx, p < 0.001; 36.3% to 49.1% for oropharynx, p = 0.001 and 28.3% to 33.3% for hypopharynx, p = 0.015). The prognosis for early‐stage salivary gland cancer during 1983–1997 and late‐stage larynx cancer during 1974–1997 also demonstrated improvement (82.7% to 88.5%, p = 0.012 and 22.2% to 38.3%, p = 0.013, respectively). On the other hand, the prognosis for regional stage oral cavity cancer as well as early‐stage larynx cancer patients declined during 1983–1997 (49.2% to 43.8%, p = 0.032 and 82.3% to 74.3%, p = 0.002, respectively). Site‐specific changes in treatment and staging were also noted. Site‐specific analysis allows for a more accurate description of incidence, staging, treatment, and prognostic trends for head and neck cancer.

Evaluation of Promoter Hypermethylation Detection in Body Fluids as a Screening/Diagnosis Tool for Head and Neck Squamous Cell Carcinoma

Purpose: To evaluate aberrant promoter hypermethylation of candidate tumor suppressor genes as a means to detect epigenetic alterations specific to solid tumors, including head and neck squamous cell carcinoma (HNSCC). Experimental Design: Using promoter regions identified via a candidate gene and discovery approach, we evaluated the ability of an expanded panel of CpG-rich promoters known to be differentially hypermethylated in HNSCC in detection of promoter hypermethylation in serum and salivary rinses associated with HNSCC. We did preliminary evaluation via quantitative methylation-specific PCR (Q-MSP) using a panel of 21 genes in a limited cohort of patients with HNSCC and normal controls. Using sensitivity and specificity for individual markers as criteria, we selected panels of eight and six genes, respectively, for use in salivary rinse and serum detection and tested these in an expanded cohort including up to 211 patients with HNSCC and 527 normal controls. Results: Marker panels in salivary rinses showed improved detection when compared with single markers, including a panel with 35% sensitivity and 90% specificity and a panel with 85% sensitivity and 30% specificity. A similar pattern was noted in serum panels, including a panel with 84.5% specificity with 50.0% sensitivity and a panel with sensitivity of 81.0% with specificity of 43.5%. We also noted that serum and salivary rinse compartments showed a differential pattern of methylation in normal subjects that influenced the utility of individual markers. Conclusions: Q-MSP detection of HNSCC in serum and salivary rinses using multiple targets offers improved performance when compared with single markers. Compartment-specific methylation in normal subjects affects the utility of Q-MSP detection strategies.

Pectoralis major and other myofascial/myocutaneous flaps in head and neck cancer reconstruction: Experience with 437 cases at a single institution

Pectoralis major and other myofascial/myocutaneous flaps have been recognized as important reconstructive methods in head and neck cancer surgery. Even with the worldwide use of free flaps, they are still the mainstay reconstructive procedures in many centers.

High Promoter Methylation Levels of APC Predict Poor Prognosis in Sextant Biopsies from Prostate Cancer Patients

Purpose: Prostate cancer is a highly prevalent malignancy and constitutes a major cause of cancer-related morbidity and mortality. Owing to the limitations of current clinical, serologic, and pathologic parameters in predicting disease progression, we sought to investigate the prognostic value of promoter methylation of a small panel of genes by quantitative methylation-specific PCR (QMSP) in prostate biopsies. Experimental Design: Promoter methylation levels of APC, CCND2, GSTP1, RARB2, and RASSF1A were determined by QMSP in a prospective series of 83 prostate cancer patients submitted to sextant biopsy. Clinicopathologic data [age, serum prostate-specific antigen (PSA), stage, and Gleason score] and time to progression and/or death from prostate cancer were correlated with methylation findings. Log-rank test and Cox regression model were used to identify which epigenetic markers were independent predictors of prognosis. Results: At a median follow-up time of 45 months, 15 (18%) patients died from prostate cancer, and 37 (45%) patients had recurrent disease. In univariate analysis, stage and hypermethylation of APC were significantly associated with worse disease–specific survival, whereas stage, Gleason score, high diagnostic serum PSA levels, and hypermethylation of APC, GSTP1, and RASSF1A were significantly associated with poor disease-free survival. However, in the final multivariate analysis, only clinical stage and high methylation of APC were significantly and independently associated with unfavorable prognosis, i.e., decreased disease-free and disease-specific survival. Conclusions: High-level APC promoter methylation is an independent predictor of poor prognosis in prostate biopsy samples and might provide relevant prognostic information for patient management.

Prognostic factors in salvage surgery for recurrent oral and oropharyngeal cancer

Therapeutic decisions in recurrent oral and oropharyngeal squamous carcinoma (SCC) remain controversial.

Increased Mitochondrial DNA Content in Saliva Associated with Head and Neck Cancer

Alterations of the mitochondrial DNA (mtDNA) have been described in human tumors and in other tissues in association with smoking exposure. We did quantitative PCR of cytochrome c oxidase I (Cox I) and cytochrome c oxidase II (Cox II) genes on oral rinse samples obtained from 94 patients with primary head and neck squamous cell carcinoma (HNSC) and a control group of 656 subjects. Mitochondrial DNA/nuclear DNA in saliva from HNSC patients and controls in relationship to smoking exposure, ethanol intake, and tumor stage were examined. Mean levels of Cox I and Cox II in saliva samples were significantly higher in HNSC patients: Cox I, 0.076 [95% confidence interval (95% CI), 0.06-0.09] and Cox II, 0.055 (95% CI, 0.04-0.07) in comparison with controls Cox I, 0.054 (95% CI, 0.05-0.06), P < 0.0001 and Cox II, 0.046 (95% CI, 0.04-0.05), P = 0.003 (t test). MtDNA levels were elevated in primary tumors when compared with matched, pretreatment saliva and significant correlation was noted (Cox I, r = 0.30, P = 0.005 and Cox II r = 0.33, P = 0.002, respectively, Pearsons correlation). On univariate analysis, smoking, age, HNSC diagnosis, and advanced stage of HNSC were associated with higher level of mtDNA content in saliva. Multivariate analysis showed a significant and independent association of HNSC diagnosis, age, and smoking with increasing mtDNA/nuclear DNA for Cox I and Cox II. mtDNA content alteration is associated with HNSC independently of age and smoking exposure, can be detected in saliva, and may be due to elevation in mtDNA content in primary HNSC.

PGP9.5 Promoter Methylation Is an Independent Prognostic Factor for Esophageal Squamous Cell Carcinoma

PGP9.5/UCHL1 is a member of the carboxyl-terminal ubiquitin hydrolase family with a potential role in carcinogenesis. We previously identified PGP9.5 as a putative tumor-suppressor gene and methylation of the promoter as a cancer-specific event in primary cancer tissues. In this current study, we analyzed PGP9.5 methylation in 50 esophageal squamous cell carcinoma (ESCC) primary tumors with well characterized clinicopathologic variables including patient outcome. Two independent modalities for methylation analysis (TaqMan methylation-specific PCR and combined bisulfite restriction analysis) were used to analyze these samples. The two data sets were consistent with each other, as the 21 patients (42%) with highest methylation levels by TaqMan analysis all showed visible combined bisulfite restriction analysis bands on acrylamide gels. Using an optimized cutoff value by TaqMan quantitation, we found that patients with higher PGP9.5 methylation ratios in the primary tumor showed poorer 5-year survival rates than those without PGP9.5 methylation (P = 0.01). A significant correlation was also seen between PGP9.5 promoter methylation and the presence of regional lymph node metastases (P = 0.03). Multivariate analysis subsequently revealed that PGP9.5 methylation was an independent prognostic factor for ESCC survival (P = 0.03). These results suggest that PGP9.5 promoter methylation could be a clinically applicable marker for ESCC progression.

An Epigenetic Marker Panel for Detection of Lung Cancer Using Cell-Free Serum DNA

Purpose: We investigated the feasibility of detecting aberrant DNA methylation of some novel and known genes in the serum of lung cancer patients. Experimental Design: To determine the analytic sensitivity, we examined the tumor and the matched serum DNA for aberrant methylation of 15 gene promoters from 10 patients with primary lung tumors by using quantitative methylation-specific PCR. We then tested this 15-gene set to identify the more useful DNA methylation changes in the serum of a limited number of lung cancer patients and controls. In an independent set, we tested the six most promising genes (APC, CDH1, MGMT, DCC, RASSF1A, and AIM1) for further elucidation of the diagnostic application of this panel of markers. Results: Promoter hypermethylation of at least one of the genes studied was detected in all 10 lung primary tumors. In majority of cases, aberrant methylation in serum DNA was accompanied by methylation in the matched tumor samples. In the independent set, using a single gene that had 100% specificity (DCC), 35.5% (95% CI: 25–47) of the 76 lung cancer patients were correctly identified. For patients without methylated DCC, addition of a logistic regression score that was based on the five remaining genes improved sensitivity from 35.5% to 75% (95% CI: 64–84) but decreased the specificity from 100% to 73% (95% CI: 54–88). Conclusion: This approach needs to be evaluated in a larger test set to determine the role of this gene set in early detection and surveillance of lung cancer. Clin Cancer Res; 17(13); 4494–503. ©2011 AACR.

Hemostasis in thyroid surgery: Harmonic scalpel versus other techniques—a meta-analysis

Objective: The objective is to systematically review the literature studying the harmonic scalpel versus other hemostatic techniques in thyroid surgical patients. Although thyroidectomy is one of the most common surgical procedures, the safest, most efficient, and cost-effective way to achieve hemostasis is hotly debated. Data Sources: We searched the electronic databases Medline and the Cochrane Library using relevant search strategies. Review Methods: Two reviewers (G.W., T.E.) independently assessed titles and abstracts of 72 identified studies. Twelve prospective randomized controlled studies were considered relevant and included in this meta-analysis (1153 patients). Results: In all studies, operating time was reduced by using the harmonic scalpel. Compared with surgical hemostasis by suture ligation or suture/clip ligation combined with electrocauterization or electrothermal bipolar vessel sealer (n = 602), the mean operating time reduction for the harmonic scalpel was equivalent to 22.67 minutes (95% CI, −27.98; −17.37, P < 0.00001) or nearly 25 percent of the total operating room time. When harmonic scalpel was used, blood loss was reduced significantly by 20.03 mL (95% CI, −27.83; −12.22, P < 0.00001), and a mean reduction in postoperative pain (0.86 points [95% CI, −1.60; −0.13, P = 0.02]) was measured. Length of stay was reduced by 0.12 days (95% CI, −0.25; 0.00, P = 0.05). Differences regarding volume of drainage fluid were in favor of harmonic scalpel but not statistically significant; complications were similar in both groups. Conclusion: There is clear evidence that using the harmonic scalpel for hemostasis in thyroid surgery significantly reduces operating time and blood loss and that it is not associated with an increase in volume of drainage fluid, complication rate, or hospital stay.

Feasibility of quantitative PCR-based saliva rinse screening of HPV for head and neck cancer

Human papilloma virus (HPV) 16 is likely to be an etiologic factor in a subset of head and neck squamous cell carcinomas (HNSC). We investigated the ability of a quantitative PCR‐based assay to detect HPV 16 in salivary rinses as a screening method for HNSC. Real time quantitative PCR was applied to detect HPV16 E6 and E7 DNA level in 92 primary tumors and salivary rinses from patients with HNSC and 604 control subjects without HNSC. A total of 45.6% (42/92) of primary HNSC and 32.6% (30/92) of saliva rinse samples from HNSC patients had any detectable HPV 16 DNA, 30.4% (28/92) of tumors had HPV 16 levels >0.1 copies/cell. HPV16 was detected in 50% (confidence interval [CI] = 34.2–65.8%) (21/42) of the saliva rinse samples from HNSC patients with detectable HPV16 level in their tissue, 18% (CI = 8.4–30.9%) (9/50) of saliva rinse samples from patients with HPV 16 negative primary HNSC, in 2.8% (CI = 1.7–4.5%) (17/604) of the normal controls (p < 0.001). Using a cutoff of HPV 16 >0.001 copies/cell in saliva rinse yielded a sensitivity of 30.4% and a specificity of 98.3%. Nonsmokers had significant higher HPV 16 level than smokers in the cohort of cancer patients. HPV 16 DNA in saliva rinses can reflect HPV 16 status of primary HNSC. Quantitative analysis of HPV 16 DNA in salivary rinses allows for detection of HPV‐related HNSC, however, specific limitations exist that prevent the application of this as a screening technique for a broad population.