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Year : 2019  |  Volume : 56  |  Issue : 4  |  Page : 330--334

Biological tailoring of adjuvant radiotherapy in head and neck and oral malignancies – The potential role of p53 and eIF4E as predictive parameters

Bindhu Joseph1, Rekha V Kumar2, G Champaka2, Ashok Shenoy3, KS Sabitha4, V Lokesh2, C Ramesh5, CR Vijay5,  
1 Department of Radiotherapy, Kidwai Memorial Institute of Oncology, Bangalore, Karnataka, India
2 Department of Pathology, Kidwai Memorial Institute of Oncology, Bangalore, Karnataka, India
3 Department of Head and Neck Oncology, Kidwai Memorial Institute of Oncology, Bangalore, Karnataka, India
4 Department of Oral Oncology, Kidwai Memorial Institute of Oncology, Bangalore, Karnataka, India
5 Department of Epidemiology and Statistics, Kidwai Memorial Institute of Oncology, Bangalore, Karnataka, India

Correspondence Address:
Bindhu Joseph
Department of Radiotherapy, Kidwai Memorial Institute of Oncology, Bangalore, Karnataka
India

Abstract

BACKGROUND: Recent advances in radiation technology has allowed to significantly reduce toxicity and improve the efficacy of radical radiotherapy in head and neck and oral squamous cell cancers. Insights into molecular biology of carcinogenesis has opened a window for identifying aggressive clinical situations that may benefit with larger clinical target volume (CTV ) margin, broader levels of nodal coverage, or alternative radiation sensitizers. AIM: To evaluate the potential role of eukaryotic translation initiation factor 4E (elF4E) and p53 as predictive biomarkers in resected margins of head and neck and oral cancers. MATERIAL AND METHODS: Forty patients with oral cancers and 26 patients with head and neck cancers were evaluated for p53 and eIF4E in their negative surgical margins, for pattern of distribution and outcome. RESULTS: In oral cancers, 27 patients (67.5%) were positive for p53 and 10 (25%) for eIF4E in surgically negative margins. For head and neck cancer, the values were 13 (50%) for p53 and 9 (34.6%) for eIF4E. Twelve patients with oral cancers and 8 patients with head and neck cancers had local failure or death. The association with these biomarkers did not achieve statistical significance. However, adjuvant radiotherapy had a significant protective value. It improved median survival from 15 to 21 months in patients positive for p53 (P = 0.018) and from 12 to 20 months (P = 0.03) in those with eIF4E. There was no predictive association of subsite, tumor size, or nodal status. CONCLUSION: The overexpression of p53 and eIF4E in pathologically negative margins may represent a subset of patients who would benefit from early initiation of adjuvant radiation and tailored intensity-modulated radiotherapy (IMRT).



How to cite this article:
Joseph B, Kumar RV, Champaka G, Shenoy A, Sabitha K S, Lokesh V, Ramesh C, Vijay C R. Biological tailoring of adjuvant radiotherapy in head and neck and oral malignancies – The potential role of p53 and eIF4E as predictive parameters.Indian J Cancer 2019;56:330-334


How to cite this URL:
Joseph B, Kumar RV, Champaka G, Shenoy A, Sabitha K S, Lokesh V, Ramesh C, Vijay C R. Biological tailoring of adjuvant radiotherapy in head and neck and oral malignancies – The potential role of p53 and eIF4E as predictive parameters. Indian J Cancer [serial online] 2019 [cited 2019 Dec 7 ];56:330-334
Available from: http://www.indianjcancer.com/text.asp?2019/56/4/0/267600


Full Text



 Introduction



Head and neck cancers are the most common malignancy worldwide, and the Asian population bears the major burden of this disease. With 77,000 cases diagnosed per year, it is currently the second most common cancer in the Indian population.[1]

The past decade has shown a changing paradigm of risk factors for head and neck cancers, with the positive predictive and prognostic association of human papillomavirus (HPV) being the most clinically relevant. HPV-related head and neck cancers, however, remain less prevalent in the Asian population, and the positive prognostic benefit is diluted with the co-association of tobacco exposure.[2]

As 80% of our head and neck cancers remain tobacco related, it appears logical to focus on other predictive biological parameters to improve outcome. In head and neck cancers, inactivation of p53, either through endogenous regulators or more commonly, mutations, predispose cells to initiate tumorogenesis.[3] Their presence in surgical margins may indicate an environment that could benefit with treatment intensification. Its strong association in tobacco and alcohol-related cancers also make it a more relevant prognostic marker in the Asian population. The eukaryotic translation initiation factor 4E (eIF4E) is a protein that plays a central role in cell growth and proliferation. Its overexpression in surgically negative margins has been associated with an aggressive tumor type, with potential for early local recurrence and metastatic progression. Identifying a high-risk molecular profile that predicts tumorigenesis prior to pathological cell changes may help to tailor a more aggressive and effective adjuvant treatment.

Squamous cell carcinoma of the head and neck and oral cavity remains a challenging site to treat despite the vast advances in radiotherapy, radiation sensitizers, and surgery that have been evidenced in the past few decades. The improvements in local control and survival have remained marginal with a majority of patients still recurring locoregionally. A possible reason for this would be genetic tumor heterogeneity and unfavorable adjacent microenvironment. Radiation remains the most effective modality to address the adjacent tumor microenvironment in high to moderate risk patients of resected head and neck and oral cancers. The advantage of adjuvant radiotherapy in terms of overall survival and local control for patients with positive surgical margins and regional node involvement is well established.[4],[5] There is, however, a 30% to 40% chance of local failure in patients without these high-risk factors.[6] In the current era of intensity-modulated radiotherapy, it is possible to selectively administer dose-tailored target volumes depending on the anticipated clinical disease. However, by restricted volumes, there is also the risk of missing occult disease in clinically aggressive tumor scenarios. The expression of molecular markers p53 and eIF4E in clinically negative resected margins of head and neck cancer have been correlated with a high risk of local recurrence and poor survivals.[7],[8],[9] These patients may potentially represent a subset that would benefit with adjuvant radiation (despite histologically negative margins). They may need tailored radiation with wider clinical target volume (CTV) margins and broader categorization of nodal areas at risk.

Earlier studies have suggested that immunohistochemical (IHC) staining with p53 of resected margins can help to identify patients with a higher recurrence rate.[10]p53 mutations are associated with loss of protective mechanism to DNA damage, relative resistance to radiotherapy, and with higher chance of cells accumulating genomic damage. The detection of p53 in histologically negative margins may indicate a subset of patients with an adjacent tumor microenvironment at a higher risk of recurrence that may benefit from adjuvant radiotherapy.

The eIF4E is a protein that plays a key role in tumorigenesis, invasion, and metastasis. The eIF4E gene amplification and protein overexpression usually precede cellular morphological changes. Its expression in histologically negative margins indicate a high risk clinical target region that may be benefited with local radiotherapy.

 Aim



In the current study, we have evaluated the presence of p53 and eIF4E expression in histologically negative surgical margins of 40 patients with oral malignancies and 26 other head and neck cancer sites to analyze their predictive role as negative biomarkers for local control.

 Material and Methods



Study design

The study was conducted in the Department of Radiation Oncology in collaboration with Departments of Pathology, Head and Neck Oncology and Oral Oncology in Kidwai Memorial Institute of Oncology (Regional Cancer Centre in India). In this prospective non-randomized study, we enrolled patients with head and neck and oral cancer who underwent primary surgical resection for their management. Forty patients with newly diagnosed squamous cell carcinoma of oral cavity and 26 patients with other head and neck primaries were included (n = 66). The inclusion criteria were (i) single primary tumor, (ii) no previous history of malignancy, (iii) no neo-adjuvant treatment received, and (iv) presence of histologically negative surgical margins in the excised specimen. The exclusion criteria were (i) age below 18 years and (ii) non-squamous histology. Patients in this study were recruited from 2014 to 2017. This study was approved by the Institutional Review Board. All patients had undergone radical surgical resection as appropriate for the subsite and stage of their disease. However, patients with other high-risk factors of multiple nodal involvement or extracapsular spread received adjuvant radiotherapy. Twenty (50%) patients with oral cancer and 11 patients (42%) in the head and neck subgroup received adjuvant external beam radiotherapy to doses of 60-66 Gy. Patients having multiple pathologically positive nodes also received concurrent cisplatin-based chemotherapy. Four patients with oral cancer and five patients with head and neck cancer had a pathological N2 status and received concurrent chemotherapy. The patients were followed-up for local control and survival. Negative outcome was documented for local failure or disease-specific death.

Histopathological assessment

A pathologist (CG) retrieved and reviewed the slides of all the cases that were included in the study and confirmed histologically negative margins. The blocks with histologically negative margins were further processed for the expression of levels of p53 and eIF4E protein by IHC. The 5% cut-off value was selected for evaluating the IHC staining of the basal layer of the resected margins. Positive tumor margins were reported for p53 according to brown nuclear staining, and for eIF4E, when there was a brown perinuclear cytoplasmic stain involving greater than 5% of cells in the basal epithelial layer for both the biomarkers.

Statistical analysis

The data on patient characteristics and their association with the biomarkers p53 and eIF4E in the surgical margin were evaluated with contingency tables and Fisher's exact test.

The local recurrence rates with the expression pattern of these biomarkers in the surgical margins were estimated using the Kaplan–Meier method and compared using the log–rank test (R console statistical package).

 Results



The secondary objectives of this study aimed at finding clinical characteristics that might predict the occurrence of p53 and eIF4E in the surgically resected margins of head and neck and oral cancers. These included tumor subsite, histological grade, and size of primary lesion that was greater than or smaller than 3 cm and the presence or absence of nodal disease. A total of 40 patients with oral cancers and 26 patients with other head and neck site squamous cancers were included. Of the patients with oral cancer, 27 (67.5%) exhibited p53 in the histologically negative resected margins. In the other head and neck sites, this value was 13 (50%); 10 patients with oral cancer (25%) were positive for eIF4E as were 9 patients with other head and neck sites (34.61%). The correlation of these two biomarkers with the aforementioned clinical characteristics is represented in [Table 1]. Contingency tables and Fisher's exact tests were used to evaluate the association of p53 and eIF4E in the surgical margins to subsite, nodal status, grade, and tumor size.{Table 1}

There was no statistical correlation seen that could suggest a predictive role to any of the clinical characteristics evaluated. However, in oral cancers, p53 and eIF4E were more commonly seen in patients with nodal disease with a trend toward significance (P = 0.09 and P = 0.07).

 Clinical Outcomes With Biomarkers p53 and eIF4E



Oral cancer patients

Of the oral cancer patients evaluated, 12 (30%) had local recurrence or failure. All patients had locoregional failure with 7 deaths because of the disease. Twenty-seven patients (67.5%) were positive for p53 in their surgical margins and 10 (25%) for eIF4E. The chance of a negative outcome and the presence of p53 did not achieve statistical significance (P = 0.78), neither did the presence of eIF4E (P = 0.47). Nine patients (22.5%) did not have any negative biomarker. A trend toward better survival was observed (P = 0.078).

Other head and neck site patients

Of these patients, 8 (30.7%) experienced a negative clinical outcome. All patients experienced a locoregional failure with 6 deaths because of the disease. Thirteen patients had p53-positive surgical margins (50%). The association with a negative outcome was not statistically significant (0.244). Nine patients (34.6%) had margins that were positive for eIF4E. This biomarker also did not individually signify a negative outcome (P = 0.479). The combined evaluation of head and neck and oral cancers showed a similar pattern of results. The relative association of tumor markers p53 and eIF4E with a negative outcome or survival is shown in [Figure 1].{Figure 1}

Notably, patients without biomarker immunostaining had a 58% higher chance of survival (P = 0.092).

Considering the unfavorable biological background, the presence of p53 and eIF4E represented, we tried to evaluate whether the addition of radiotherapy had any role in ameliorating this effect. Patients with oral and other head and neck cancers that were p53 positive and received adjuvant RT had a median survival of 21 months vs. 15 months (P = 0.018), that was statistically significant. Similarly, radiotherapy provided a protective function in patients positive for eIF4E with a 45.8% higher chance of survival (P = 0.03).

 Discussion



The past few decades have seen many advances in understanding the biological behavior of several common malignancies as well as the molecular markers that may predict their behavior. The current standard treatment protocols for head and neck and oral cancers are based entirely on clinical and pathological factors pertaining to dimensions and local extent. One-third of patients undergoing organ preservative chemo-irradiation for laryngeal cancers will fail and require salvage laryngectomy.[11] Early stage oral cancer will recur in 30% of the patients undergoing radical surgery.[12],[13]

For patients of head and neck and oral cancer undergoing radical surgery as their primary treatment, the necessity or aggressiveness of further treatment has been according to the conceptual curves of therapeutic benefit from population averages. This considers the pathological parameters of size, nodal status, grade, lymphovascular invasion, and perineural spread. However, it fails to account for the biological heterogeneity of the tumor and its local environment. This includes pre-clinical changes suggestive of initiation of oncogenic process. In this clinical study, we evaluated the role of two established negative biomarkers, namely p53 and eIF4E, their presence in the histologically negative margins of resected head and neck and oral cancer specimens, and their predictive role in treatment and outcome. Our secondary objectives included evaluation of any association of clinical parameters that may allow us to anticipate the presence of these biomarkers and selectively reassess surgical margins.

We considered the molecular marker p53 because mutated Tp53 is one of the most common altered genes in head and neck and oral cancers.[14],[15] and has an established role in locoregional failure following treatment. Immunodiagnostic investigation of overexpression may contribute to early detection of preclinical residual disease. Li et al. in an earlier study had observed an overexpression of p53 in 63/112 patients (56.3%).[16] Our results were similar, i.e., 50% in head and neck cancer patients. Although there was no clinical parameter that could predict the overexpression of p53, it was observed more commonly when lymph nodes were positive. The presence of p53 in histologically negative tumor margins did not have statistically significant impact on tumor recurrence or survival, however, it did have a predictive role for patients who would benefit from adjuvant radiotherapy. Patients with oral and head and neck cancer who were positive for p53 and received radiation had a median survival of 21 months vs. 15 months (P = 0.018) for those who did not, which was statistically significant.

eIF4E was the second biomarker we chose for this study because of its stronger specificity for local recurrence. Several recent studies have shown a strong correlation of eIF4E in histologically negative margins with high rates of early local recurrence. Nathan et al. in a prior study had observed an expression rate of 52% for eIF4E in surgical margins of head and neck cancers.[17] In a more recent study by the same author, a recurrence propensity of 42% (12/26) was observed in patients who had elevated eIF4E in their histologically negative surgical margins. In addition, notably, the recurrence occurred at an average period of 3.4 months after surgery suggesting its potential role as a bio-indicator of tumor aggressiveness.[17] The elevation of eIF4E as a prognostic marker has a few more advantages. If the assays of eIF4E are optimized, it can be used to reassess the surgical margins at the time of the surgery. The pattern of early local recurrence may suggest that adjuvant radiotherapy would benefit these patients even in the absence of other high risk factors. There are ongoing preclinical strategies evaluating targeting or subduing eIF4E activity.[18] In the clinical set up, ribavaran, a competitive inhibitor of the natural ligand of eIF4E has shown some remarkable results when used for patients suffering from refractory acute myeloid leukemia (French American British subtype M4/M5 AML). These poor response leukemias are characterized by elevated levels of eLF4E. In this phase II trial, the use of ribavaran as the sole of chemotherapeutic agent for induction lead to remarkable results in terms of clinical improvement, complete remission, partial remission, and blast response.[19] However, we have a negative biomarker that besides indicating the initiation of the oncogenic process can also be potentially targeted.

In our study, 9 patients with head and neck cancer (34.6%) were positive for eIF4E of which 4 recurred (44%). All recurrences were within 12 months. In this clinical scenario as well, we observed a protective effect for adjuvant radiotherapy; patients with overexpression of eLF4E receiving radiation had a 68.9% better chance of survival (P = 0.083) with a median survival of 12 months vs. 20 months. Seven head and neck patients and 9 patients with oral cancers did not express any biomarker in their surgical margins. These patients did have a better chance of survival although it did not attain statistical significance (P = 0.092).

Our study is one of the few that has identified the potential of tailoring adjuvant treatment with radiotherapy to negate the preclinical changes of malignancy in the tumor's adjacent microenvironment.

We do recognize that the statistical significance of the findings is diluted by the small study cohort and heterogeneity of tumor subsite and treatment. Molecular profiling of p53 mutations would be a better prognostic tool with the possibility of identifying disruptive mutations that have a stronger clinical correlate to a negative outcome. eIF4E is a fairly newer prognostic tool and may require larger multi-institutional studies to establish its clinical impact.

 Conclusion



There appears to be a potential role of tailoring the intensity and indication of adjuvant radiotherapy for head and neck and oral cancer according to the immunoprofiling of resected surgical margins.

The overexpression of p53 and eIF4E in histologically negative margins of head and neck and oral cancers may represent a subset of patients with more aggressive tumors who may benefit from early institution of adjuvant radiation. Further clinical studies should be considered to analyze the sensitivity and specificity of p53 and eIF4E in the management following radical surgery of head and neck and oral cancers and to unmask the contribution of overexpression toward local failure and survival.

Acknowledgments

We would like to thank Dr Shubha Supriya A, Dr Poorna Chandra Tejaswi, Dr Nisma, and Dr Kurian J Puthur, Residents, Department of Radiotherapy, for their assistance that was vital for the investigative follow-up of the subjects. We would like to also thank the Department of Oral Oncology and Head and Neck Oncology for their assistance and contribution to the study.

We would also like to acknowledge Rajiv Gandhi University of Health Sciences (RGUHS) for their support, encouragement, and financial assistance.

Financial support and sponsorship

The present clinical study was supported by a research grant from Rajiv Gandhi University of Health Sciences.

Conflicts of interest

There are no conflicts of interest

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