Barbara Bachtiary

Impact of multiple HPV infection on response to treatment and survival in patients receiving radical radiotherapy for cervical cancer

To obtain information on the incidence and the clinical significance of infection with various types of the human papillomavirus (HPV) in cancer of the uterine cervix, we retrospectively examined the HPV status of 106 patients who had received radical radiotherapy for cervical cancer stages IB to IIIB. DNA was extracted from formalin‐fixed, paraffin‐embedded biopsies and PCR was carried out to identify HPV types 16, 18, 31, 35, 33 and 45. To detect additional HPV types, consensus PCR products were cloned and sequenced. A catalyzed signal‐amplified colorimetric in situ hybridization was carried out in 84 of 106 specimens as a positive control. Response to therapy, progression‐free survival (PFS) and cervical cancer‐specific survival (CCSS) were the statistical endpoints. Survival analysis was carried out using univariate and multivariate analysis (Cox regression). Ninety‐six patients (90.6%) were HPV‐positive and 42/96 (43.7%) were positive for multiple HPV types. Eight patients had persistent disease after radiotherapy. From these 8 patients, 7 were infected with multiple HPV types and only 1 patient had an infection with a single HPV type. After a median follow up period of 50 months, patients with multiple HPV infection had a significantly shorter PFS and CCSS compared to those with single HPV infection (24.8% and 34.9% vs. 64% and 60.8%, Log rank, p < 0.01 and 0.04). In multivariate analysis, the presence of multiple HPV types (RR 1.9), node status (RR 2.3), tumor size (RR 3.2) and histologic type (RR 4.8) were independent prognostic factors of CCSS. Our results demonstrate that the presence of multiple HPV types is associated with poor response and with reduced survival in cervical cancer patients who receive radiotherapy as the primary treatment.

Impact of Hemoglobin Levels Before and During Concurrent Chemoradiotherapy on the Response of Treatment in Patients with Cervical Carcinoma Preliminary Results

In patients undergoing radiation for cervical carcinoma, there is evidence that anemia is associated with an impaired outcome. For patients undergoing chemoradiation, there are no data available. The objective of this retrospective study was to examine the impact of anemia before and during chemoradiation in patients with cervical carcinoma.

Signal-amplified colorimetric in situ hybridization for assessment of human papillomavirus infection in cervical lesions.

Detection and typing of human papillomavirus (HPV) infection may have a major impact in cervical-screening and follow-up. In this study various commercially available techniques for the detection of HPV were evaluated. HPV-status was determined in 86 samples of cervical cancer by PCR and direct sequencing, catalyzed signal amplified colorimetric DNA in situ hybridization (CSAC- ISH) (GenPoint system, DAKO), immunohistochemistry (IHC) and in 12 selected cases also by conventional, non-amplified ISH. Twenty-one samples of cervical intraepithelial neoplasias grade III (CIN III) were investigated by CSAC-ISH, conventional ISH and by IHC, in corresponding PAP smears HPV-detection and typing was performed by CSAC-ISH and Hybrid Capture test II (HC). In additional 20 PAP smears HPV typing was performed using HC and a novel immunocytochemical system for HPV detection and-typing. CSAC-ISH showed good correlation with PCR analysis in cervical cancers: In 87% of PCR positive cases, HPV infection was also detected by CSAC- ISH (66/76). HPV 16 was detected in 75% of PCR-positive cases (44/59), HPV 18 in 71% of PCR positive cases (5/7). CSAC-ISH detected HPV 31 in only 29% of PCR positive cases (2/7), and HPV 33 in 64% of PCR-positive cases (23/36). Nevertheless, CSAC-ISH- false negative cases for HPV 31 or 33 were nearly always combined infections with other HPV types, which were detectable by CSAC-ISH in most cases. CSAC-ISH revealed HPV infection in 20 of 21 HC-positive cervical smears, while in corresponding biopsies (CIN III) CSAC-ISH detected 100% of HPV infections. Conventional, non-amplified ISH showed significantly lower sensitivity compared with CSAC-ISH, and immunocyto- and -histochemistry were of very low sensitivity for detection of HPV. CSAC-ISH is an easy-to-handle method for detection and typing of cervical HPV infection, and shows sufficient sensitivity for clinical practice.

Evaluating repetitive 18F-fluoroazomycin-arabinoside (18FAZA) PET in the setting of MRI guided adaptive radiotherapy in cervical cancer

Abstract Background. The aim of this pilot study was to assess tumour hypoxia in patients with cervical cancer before, during and after combined radio-chemotherapy and Magnetic Resonance Imaging (MRI) guided brachytherapy (BT) by use of the hypoxia Positron Emission Tomography (PET) tracer 18F-fluoroazomycin-arabinoside (18FAZA ). Material and methods. Fifteen consecutive patients with locally advanced cervical cancer referred for definitive radiotherapy (RT) were included in an approved clinical protocol. Stage distribution was 3 IB1, 1 IB2, 10 IIB, 1 IIIB, tumour volume was 55 cm3 (+/− 67, SD). Dynamic and static 18FAZA -PET scans were performed before, during and after external beam therapy (EBRT) and image guided BT +/− concomitant cisplatin. Dose was prescribed to the individual High Risk Clinical Target Volume (HR CTV) taking into account the dose volume constraints for adjacent organs at risk. Results. Five patients had visually identifiable tumours on 18FAZA -PET scans performed prior to radio-chemotherapy and four patients before brachytherapy. One of five 18FAZA PET positive patients had incomplete remission three months after RT, one had regional recurrence. Four of ten 18FAZA-PET negative patients developed distant metastases. The one patient with incomplete remission received 69 Gy (D90) in the HR CTV, whereas all other patients received mean 99 Gy (+/−12, SD). Conclusion. PET imaging with 18FAZA is feasible in patients with cancer of the uterine cervix. However, its predictive and prognostic value remains to be clarified. This applies in particular for the additional value of 18FAZA-PET compared to morphologic repetitive MRI within the setting of image guided high dose radiotherapy which may contribute to overcome hypoxia related radioresistance.

Serum VEGF levels in patients undergoing primary radiotherapy for cervical cancer: impact on progression-free survival

Vascular endothelial growth factor (VEGF) plays an important role in the regulation of tumour growth and metastasis. It was the aim of this study to examine the impact of serum VEGF levels on the likelihood of response to radiotherapy and on the disease-free survival in patients with cervical cancer. Blood was taken before commencing treatment and serum VEGF was assessed by quantitative ELISA in 23 patients with cervical cancer stage IB-IVA undergoing primary radiotherapy. Serum VEGF levels were correlated with clinical and histopathologic factors as well as with response to radiotherapy and time to progression. Nineteen of the 23 patients had a complete response and four patients had persistent disease at 3 months. The median follow-up was 25 months (95% confidence interval: 23.5-26.5 months). At the time of analysis, eight patients were tumour-free and 15 patients had tumour progression; 12 of these 15 patients died of disease. Overall, the median serum VEGF level was 244 pg/ml (range 31.9-817.6 pg/ml). All four patients with local failure had VEGF levels >244 pg/ml, whereas 11 of the 19 patients with complete response had serum VEGF of < or =244 pg/ml (P=0.035). The median time to progression was 5 months in patients with VEGF of >244 pg/ml compared to 19 months in patients with VEGF of < or = 244 pg/ml (log rank, P=0.003). In multivariate analysis, serum VEGF, tumour size and histological type, but not the patients age, stage and grade of histological differentiation influenced the progression-free survival. Elevated pre-therapeutic serum VEGF levels are associated with poor response and a shorter time to progression in patients with cervical cancer undergoing primary radiotherapy.

Incidence of dermatitis in head and neck cancer patients treated with primary radiotherapy and cetuximab

Purpose:To retrospectively assess the incidence of radiation dermatitis in patients with locally advanced squamous cell carcinoma of the head and neck (SCCHN) who received primary radiotherapy in combination with cetuximab in a curative intent.Patients and Methods:A total of 112 consecutively treated patients who received cetuximab in combination with radiotherapy at the Departments of Radiotherapy at the Medical University in Vienna and the Hospital Hietzing (Vienna) were analyzed. Radiotherapy was administered either as conventional radiotherapy (70 Gy in 7 weeks) or using a concomitant boost protocol (72 Gy in 6 weeks). The incidence of dermatitis and mucositis within the radiation portals in 103 eligible patients was compared with a historical control group treated at the Medical University of Vienna as well as with published data.Results:The incidence of grade 1/2, 3, and 4 dermatitis was 57%, 29%, and 1% in the radiotherapy plus cetuximab treated collective. The incidence of grade 1/2, 3, and 4 mucositis was 37%, 47%, and 4%, respectively. The incidence of grade 3 dermatitis during concurrent radiotherapy plus cetuximab was 29% in our patient collective. Only one case of grade 4 dermatitis was observed.Conclusion:These results do not statistically differ significantly from the incidence reported in the Bonner trial and indicate that cetuximab in combination with radiotherapy is well tolerated.Ziel:Retrospektive Prüfung der Inzidenz der Strahlendermatitis bei Patienten mit lokal fortgeschrittenen nicht-resektablen Tumoren der Kopf-Hals-Region, die eine primäre Radiotherapie in Kombination mit Cetuximab in kurativer Intention erhielten.Patienten und Methodik:Insgesamt wurden 112 konsekutiv behandelte Patienten analysiert, die Cetuximab in Kombination mit Radiotherapie an den Abteilungen für Strahlentherapie der Medizinischen Universität Wien und des Krankenhauses Hietzing (Wien) erhielten. Die Strahlentherapie bestand entweder aus einer konventionellen Radiotherapie (70 Gy in 7 Wochen) oder aus einem konkomitanten Boost-Protokoll (72 Gy in 6 Wochen). Die Inzidenz an Dermatitis und Mukositis innerhalb der Bestrahlungsfelder wurde von 103 auswertbaren Patienten ermittelt und mit einer historischen Kontrollgruppe der Medizinischen Universität Wien wie auch mit publizierten Daten verglichen.Ergebnisse:Die Inzidenz von Grad-1/2-, -3- und -4-Dermatitis betrug jeweils 57%, 29% und 1% in der Radiotherapie-plus-Cetuximab-Gruppe. Die Inzidenz an Grad-1/2-, -3- und -4-Mukositis betrug jeweils 37%, 47% und 4%. Die Inzidenz von Grad-3-Dermatitis während einer konkomitanten Radiotherapie und Cetuximab betrug 29% in unserem Patientenkollektiv. Nur ein Fall einer Grad-4-Dermatitis wurde beobachtet.Schlussfolgerung:Die Ergebnisse unterscheiden sich in statistischer Weise nicht signifikant von der in der Bonner-Studie publizierten Inzidenz und weisen darauf hin, dass Cetuximab in Kombination mit Bestrahlung gut vertragen wird.

Survival of patients with HPV-positive oropharyngeal cancer after radiochemotherapy is significantly enhanced

ZusammenfassungHINTERGRUND: Der Zweck dieser retrospektiven Studie war, die Inzidenz und klinische Signifikanz von Infektionen mit HPV (Humanes Papillomavirus) in Patienten mit Kopf-Hals-Tumoren, die eine Strahlentherapie erhalten hatten, zu evaluieren. PATIENTEN AND METHODEN: Bei 88 Patienten mit Karzinomen des Kopf-Hals-Bereiches wurde eine Untersuchung zur Identifizierung von high-risk HPV mittels Immunhistochemie, PCR (Polymerase Chain Reaction) und in-situ Hybridisierung durchgeführt. 26 Patienten hatten ein Karzinom der Mundhöhle, 45 des Oropharynx, sieben ein Larynx- und 10 ein Hypopharnyxkarzinom. 29 der 45 Patienten mit einem Plattenepithelkarzinom des Oropharynx erhielten entweder eine alleinige Strahlentherapie oder eine Kombination mit Cisplatin oder Cetuximab. ERGEBNISSE: Von den 29 untersuchten Patienten, die zur Therapie ihres Oropharynxkarzinoms eine konservative Therapie erhielten, hatten 11 Patienten einen HPV positiven und 18 einen HPV negativen Tumor. Den Patienten wurde eine Strahlentherapie ± Cisplatin oder Cetuximab verabreicht, wobei die Patienten mit einem HPV positiven Tumor ein signifikant besseres Ansprechen auf die Therapie zeigten (p = 0.015). Auch das krankheits-spezifische Überleben war deutlich besser in HPV positiven Patienten (p = 0.001). SCHLUSSFOLGERUNG: Patienten mit einem Oropharynxkarzinom und einem positiven HPV Status sprechen deutlich besser auf eine Radiochemotherapie an als Patienten mit einem HPV negativen Tumor. Das HPV Screening ist eine sehr einfache Prozedur und kann einfach routinemässig in die Standard Operational Procedures inkludiert werden.SummaryBACKGROUND: The purpose of this study was to evaluate the incidence and clinical significance of HPV (Human papilloma virus) infection in patients with head and neck cancer who had received radiotherapy in Eastern Austria. PATIENTS AND METHODS: 88 patients with head and neck cancer including 26 patients with oral cavity cancer, 45 patients with oropharyngeal cancer, seven patients with laryngeal carcinoma and ten patients with carcinoma of the hypopharynx were screened for high risk HPV by immunohistochemistry, PCR (Polymerase Chain Reaction) and in-situ hybridization. 29 out of 45 patients with a squamous cell carcinoma of the oropharynx received radiotherapy alone, radiotherapy in combination with cisplatin or cetuximab. RESULTS: Of the investigated 29 patients with oropharyngeal cancer receiving conservative treatment, 11 had a HPV-positive and 18 a HPV-negative tumor. Patients received radiation ± cisplatin or cetuximab, where the HPV-positive patients had a significant better response to treatment and overall survival (p = 0.015) as well as disease-free survival (p = 0.001) after therapy. CONCLUSION: Patients with oropharyngeal carcinoma and a positive HPV status respond considerably better to radiochemotherapy than patients with HPV-negative tumors. HPV screening is a simple procedure and can easily be implemented in routine pathology investigations and should be included in standard operational procedures for the diagnosis and therapy of head and neck cancer patients.