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The capacity to modulate host response against metastatic head and neck cancer may eventually lead to improved survival. This phase II study in patients with advanced head and neck cancer evaluated the efficacy of combination systemic recombinant interleukin-2 (IL-2) and interferon-alpha (INF-a) and evaluated laboratory correlates between tumor response and a) tumor differentiation and b) NK cell activation. Five of fourteen patients responded; two had partial responses and three had transient responses (one complete and two partial, each lasting less than four weeks). Patients that responded had relatively lesser tumor burden and poorly-differentiated metastases. No response was observed in those few individuals in whom natural immune function was only minimally enhanced by therapy. Major toxicity, including but not limited to fever, fatigue and pulmonary compromise, allowed only 3 of 14 patients to complete three cycles of therapy. This preliminary phase II study shows that combination IL-2/INF-a therapy has clinical anti-tumor activity and that the level of NK cell activation and the degree of tumor differentiation may correlate with response.

Background Retinoids (vitamin A derivatives) and interferon-alpha (IFN-alpha) are potent regulators of malignant cell differentiation and proliferation, and both have immunomodulatory and antiangiogenesis activity. A large body of preclinical and clinical data supports the use of combination therapy with 13-cis-retinoic acid (13-cRA) and IFN-alpha in patients with squamous cell carcinoma of the skin. This carcinoma is an extremely common and frequently severely disfiguring cancer, for which about 10% of patients remain uncured following standard local therapy. Purpose Our purpose was to test whether a 20% or greater complete response rate could be achieved using a combination of these two agents in patients with advanced squamous cell carcinoma of the skin in whom local therapy had failed or was unfeasible or who had regional and/or distant metastases. Methods Thirty-two patients with heavily pretreated, advanced inoperable cutaneous squamous cell carcinoma of the skin were given a combination of oral 13-cRA (1 mg/kg per day) and subcutaneous recombinant human IFN alpha-2a (3 million units per day) for at least 2 months, unless disease progressed earlier, in a phase II trial. Results Nineteen (68%) of the 28 assessable patients responded, seven (25%) of whom had complete responses. Response rates were 93% (13 of 14) in patients with advanced local disease (six complete responses), 67% (four of six) in patients with regional disease (no complete responses), and 25% (two of eight) in patients with distant metastases (one complete response). The relationship between decreased response rate and increased extent of disease was highly statistically significant (P less than .005, chi-square test). The median response duration was greater than 5 months. No life-threatening toxic effects occurred in assessable patients treated with this combination, although dose reductions were required in 18 patients. The major limiting side effect in this elderly patient population (median age, 67 years) was cumulative fatigue. Conclusion These results indicate that combined systemic therapy with 13-cRA and IFN alpha-2a is highly effective in patients with advanced squamous cell carcinoma of the skin.

Only a fraction of people exposed to carcinogens will ultimately develop cancer. This fact suggests that individuals are unique with respect to cancer risk and that in the general population, there is a broad range of susceptibility to carcinogenesis. These variations in susceptibility as well as in cancer incidence in different ethnic groups may be genetically determined, at least in part. The study of genetic susceptibility and exogenous carcinogens—their relation ship and interaction—is the basis for the important emerging science of ecogenetics.

• Circulating acute-phase proteins may mediate adverse reactions in patients receiving biologic response modifiers, including inhibition of immune responsiveness and clinical toxic effects. Nine patients with unresectable head and neck squamous cell carcinoma were prospectively examined for levels of acute-phase proteins during interleukin 2/interferon alfa immunotherapy and for clinical toxic effects. Simultaneous determination of the in vitro immunomodulatory capacity of autologous serum on the induction of lymphokine-activated killer cells was assessed in 4-hour chromium release assays. Of the seven acute-phase proteins analyzed, haptoglobin and C-reactive protein levels were elevated before therapy was started. Toxic events leading to cessation of interleukin 2/interferon alfa therapy had a high correlation with elevated C-reactive protein and lowered C3 component of complement levels. No relationship was noted between serum levels of acute-phase proteins and induction inhibition of lymphokine-activated killer cell cytotoxicity. The role of C-reactive protein and complement degradation products in mediating interleukin 2/interferon alfa toxicity requires further investigation. ( Arch Otolaryngol Head Neck Surg. 1992;118:41-48)

The anticlastogenic effects of 13-cis-retinoic acid were studied in four human lymphoblastoid cell lines and in primary lymphocyte cultures derived from the peripheral blood of 11 study subjects. Cells were pre-incubated with 13-cis-retinoic acid in the concentration range of 10(-8)-10(-5) mol/l for 24 h and the numbers of chromatid breaks per cell induced by bleomycin were determined. The presence of 13-cis-retinoic acid decreased the number of breaks per cell by 13.0 to 59.5% in lymphoblastoid cell lines and by 0 to 57.4% in primary lymphocyte cultures (in the concentration ranges of 10(-8)-10(-6) mol/l and of 10(-8)-10(-5) mol/l, respectively). Regression analysis showed that there was a statistically significant correlation between the presence of 13-cis-retinoic acid and protection against bleomycin-induced clastogenicity. These data give additional information to the knowledge of possible chemopreventive mechanisms of action of 13-cis-retinoic acid.

The protective effect of N-acetyl-l-cysteine (NAC) and ascorbic acid on mutagen-induced chromosomal breakage was determined using human lymphoblastoid cell lines as well as freshly cultured lymphocytes from patients with head and neck malignancies and healthy control subjects. Mutagen sensitivity was determined using the previously described bleomycin exposure assay. The toxicities of different concentrations of NAC and ascorbic acid, as well as both the preincubation and dose-dependent protective effects of these two agents, were analyzed. Both test drugs proved to be effective in diminishing mutagen-induced chromatid breakage in established lymphocyte cell lines. In freshly cultured lymphocytes, NAC given in doses ranging from 0.1 to 10 mmol/L decreased the number of mutagen-induced breaks per cell in a range from 23% to 73%, and ascorbic acid decreased chromosomal breakage by 21% to 58% in a dose range from 0.01 to 1 mmol/L. The results of this study demonstrate the protective effect mediated in vitro by both NAC and ascorbic acid against mutagen-induced chromosomal damage. A similar in vivo phenomenon may explain the differences in occurrence of head and neck cancer between populations with different dietary backgrounds.

Effective treatment of head and neck cancer with biologic response modifiers may be benefitted by an understanding of in vivo factors capable of modulating the lymphokine-activated killer (LAK) cell phenomenon. Eighteen patients with squamous cell carcinoma of the head and neck were studied. Killer cells from each patient, activated by recombinant interleukin-2 (10 U/ml), were induced in either complete medium alone or complete medium plus 10% autologous serum solution and analyzed. Cytotoxicity against both K562 and squamous cell carcinoma (MDA686-Ln) cell lines was determined by use of standard chromium-release assays. The immunomodulatory capacity of serum was correlated with levels of various acute phase proteins. Autologous serum significantly inhibited the induction phase of the LAK phenomenon in 61% of patients and stimulated it in 22%. No patients with early stage I or II disease had significant inhibition of induction. No direct correlation between inhibition and serum acute phase protein levels were seen. An inverse relationship was seen between the C3 component of complement and induction inhibition (r = -0.6). These findings suggest that advances of in vivo immunomodulatory therapy will require elucidation of mechanisms of serologic inhibition of the induction phase of the LAK phenomenon. Such studies may lead to serologic modification to enhance treatment efficacy of biologic response modifiers.

To provide comprehensive temporal trend analysis of 5-year relative survival rates of laryngeal cancer using the Surveillance, Epidemiology, and End Results database; and to expand on prior reports by including inclusion of laryngeal tumor location, stage, age at diagnosis, treatment strategy, and histologic grade.Retrospective cohort analysis using the Surveillance, Epidemiology, and End Results database of the National Cancer Institute. The Surveillance, Epidemiology, and End Results data were used to design 5 cohorts of patients with laryngeal cancer: 1977-1978, 1983-1984, 1989-1990, 1995-1996, and 2001-2002. Five-year survival rates were analyzed according to tumor site, stage, and grade; age at diagnosis; and treatment strategy. The joinpoint regression model was used to assess survival trends and their statistical significance.Among patients with supraglottic cancer, 5-year relative survival rates for distant disease worsened over time while rates for local and regional disease did not change (P = .01 and P.05, respectively). For localized glottic cancer, survival remained stable from 1977-1978 to 2001-2002. However, patients with regional and distant glottic cancer demonstrated a significant decrease in survival in the past 3 decades (P.001). This trend was independent of treatment strategy. Finally, the proportion of well-differentiated tumors in patients with regional laryngeal cancer decreased over time (P.001 for supraglottic and P = .007 for glottic).A decreasing 5-year survival trend was found among patients with glottic cancer who had regional disease and in all patients with distant disease. Histopathologic trends not previously reported in those with laryngeal cancer seem to parallel those seen in other tobacco-related cancers. These trends may reflect the effect of birth cohorts and implicate the relationship between carcinogenic exposure and host factors, rather than the influence of treatment.

• Given the association of deficient natural immunity with the risk of metastatic disease, the ability to activate natural killer cell function may have a therapeutic significance. The effect of continuous infusion of interleukin 2 plus intramuscular interferon alfa on natural immune status was, therefore, analyzed in eight patients with head and neck cancer. Also evaluated was the effect of interleukin 2–interferon alfa therapy on lymphokine-activated killer cell activity as well as total lymphocyte count, percent of lymphocyte subsets, and levels of both circulating immune complexes and antibody classes. Both the percent and absolute number of natural killer cells (ie, CD56 CD3 lymphocytes) within peripheral blood as well as natural killer cell activity against K562 targets increased significantly with treatment. The remaining immune parameters were not significantly altered. The demonstrated capacity to modulate natural immune function supports the potential use of interleukin 2–containing regimens as a preventive measure against metastatic disease in patients with head and neck cancer. ( Arch Otolaryngol Head Neck Surg . 1990;116:1302-1308)

• A flow cytometric assay was used to detect the lytic and binding capacities of both fresh peripheral blood lymphocytes and purified Leu-19+natural killer cells against head and neck cancer cell lines. Results demonstrated that natural killer cell-mediated cytotoxicity and effector-target conjugate formation evaluated by flow cytometry was significantly correlated with the standard chromium 51 release assay and the single-cell microscopic assay, respectively. The sorted Leu-19+natural killer cells demonstrated higher lytic capacity with a corresponding higher binding rate compared with the unsorted peripheral blood lymphocytes and sorted Leu-19−cells. Flow cytometric analysis of natural killer cell activity (a rapid, simple, and quantifiable procedure) is an alternative to the standard chromium 51 release assay. (Arch Otolaryngol Head Neck Surg. 1990;116:440-446)

Cell lines derived from squamous cell carcinoma of the upper aerodigestive tract (head and neck cancer) were phenotypically characterized with regard to differential sensitivity to nonmajor histocompatibility restricted (non-MHCr) killer cell activity. Requirements for detectable lysis of the cell lines in a standard chromium release assay included either isolation of fresh enriched Leu 19+ large granular lymphocytes (both Leu 19+CD3+ and Leu 19+CD3- populations) or interleukin-2 (IL-2) stimulation of peripheral blood lymphocytes (PBL). In neither circumstance could lytic activity be identified among Leu 19- populations. With PBL IL-2 stimulation significant differential sensitivity to lysis expressed by the head and neck cancer cell lines (P less than 0.001 by analysis of variance) was identified and maintained regardless of PBL source, i.e., PBL from healthy controls and three differing populations of head and neck cancer patients categorized by disease status and treatment. One factor associated with a cell line's increased sensitivity was degree of tumor differentiation, poorly differentiated tumors (as defined by intermediate filament cytochemical staining [decreased keratin and increased vimentin]) being more sensitive. Furthermore, as tumor cell lytic sensitivity increased, major histocompatibility complex (MHC)-class I antigen expression diminished concurrently. In 1 of 4 cell lines tested, however, pretreatment of tumor cells with interferon-gamma induced diminished lytic sensitivity independent of changes in MHC-class I expression, indicating factors not related to MHC-class I expression are likewise relevant. In previous studies we defined the in vivo prognostic significance of non-MHCr killer cell cytotoxicity activity against K562 targets, diminished activity being principally predictive of metastatic disease development in persons with poorly differentiated head and neck cancers. This report extends these observations by demonstrating in vitro that poorly differentiated head and neck cancer target cells are highly sensitive to changes in lytic function expressed by Leu 19+ non-MHCr effector cells.

A multicellular tumor spheroid (MTS) model for head and neck cancers has been used to examine the immune function of fresh and 6-day interleukin-2(IL-2)-activated peripheral blood lymphocytes (PBL). MTS are individually cultured in the presence of effector cells, and the spheroids' growth is monitored by sizing them under an inverted microscope. Dose/response studies for IL-2 (0-100 U/ml) alone and for fresh unstimulated PBL (0-10(5) cells/MTS) showed no effects on MTS growth. IL-2-activated PBL (0-10(5) cells/MTS), in contrast, modulated MTS growth in a multiphasic pattern: MTS growth was unperturbed for the first 3 days and then growth inhibition occurred, followed by MTS disintegration. Histological analysis showed that intact MTS histoarchitecture correlated with unperturbed growth, and increasing cell sloughing and MTS dissolution and replacement by activated PBL correlated with growth inhibition and disintegration. Flow-cytometric sorting of lymphocyte subset populations indicated that it was the Leu19+CD3- cells that produced these growth-modulatory effects. In contrast to the initial LAK cell resistance of MTS, single-cell suspensions demonstrated significant lysis in standard 4-h chromium-release assays. Differences between single cells and MTS suggest a potential for tissue-like organization as a factor in lymphokine-activated killing.

The field of head and neck tumor immunology is a rapidly progressing and growing discipline, a fact that restricts the ability to fit a meaningful review of the subject into a single article. This growth is illustrated by figure 1, which indicates the number of articles published between 1970 and 1987 that address the subject. Two sources, each with different perspectives, were utilized in compiling this information. Source one included all articles that address head and neck tumor immunology, from both a basic science and clinical perspective, identified from Index Medicus. Source two was derived by systematically reviewing five journals (as listed in the figure 1 legend) during the same period. Articles from the latter source were identified if the publication utilized an immune parameter to predict a particular clinical outcome, most commonly death with disease. Thus, the broad perspective of immunology is represented, as well as the perspective of clinically relevant immune monitoring. What is evident from figure 1 is the burgeoning number of articles published within the last 3 years. Indeed, two—thirds as many articles found within Index Medicus dealt with head and neck tumor immunology in the last 3 years (83) articles as in the entire preceding era.

5540 Background: Recent data (RTOG 90–03 and RTOG 99–14) strongly suggest that concomitant boost radiation (AFX-CB) and concurrent chemoradiation offer a local control advantage in advanced head and neck cancer patients. Based on our previous experience treating unresectable head and neck cancer, we initiated a phase II trial delivering CDDP concurrent with AFX-CB for advanced nasopharyngeal carcinoma (NPC). Methods: From 2/99–7/05, 44 patients with newly diagnosed stage IIa-IV NPC were treated with AFX-CB to 70Gy/6 weeks (BID RT last 2 weeks with a 3D-conformal plan, 6 hr interfraction interval) with 2–3 cycles of concurrent CDDP (100mg/m2) on day 1, 22, 43 of radiation followed by adjuvant 5-Fluorouracil/CDDP. The median age was 46 (24 to 83) and 20 patients were male. Disease characteristics were as follows: 1997 AJCC stage: II-7; III-14 and IV-23, T3/T4 66%, N2/N3 55%. Results: With a median follow-up of 30 mo. (3–78 mo.), the crude local control rate (LC) was 93%, regional control (RC) was 98%, locoregional control (LRC) 91%, freedom from distant metastasis (FFDM) was 86%, disease-free survival (DFS) was 82%, and overall survival (OS) was 89%. Eighty-six percent of patients were able to receive 2–3 cycles of adjuvant chemotherapy. Four of the 6 distant metastases occurred after 3 years post-treatment. One of the 3 local failures was salvaged with additional chemoradiation and is without evidence of recurrence 23 months later. Thus, the total crude local control is 95%. Among 29 T3/T4 patients, local control was 93%. For all patients, the three year actuarial LC, RC, LRC, FFDM, DFS and OS were 95%, 98%, 93%, 94%, 86% and 87%, respectively. Major grade 3 acute toxicities include mucositis (59%), dysphagia (41%), vomiting (20%) and anemia (4.5%). Average hemoglobin drop was 2.3 gm (17.7%). Ninety percent of patients received erythropoietin support and near 20% required blood transfusion. Late toxicities included grade 3 tinnitus in 1, grade 2 serous otitis in 1, osteoradionecrosis in 1 and brain necrosis in 2. Conclusions: AFX-CB with concurrent and adjuvant chemotherapy for advanced NPC provides excellent locoregional control and acceptable toxicity. Future efforts will focus on decreasing toxicity and increasing systemic control. No significant financial relationships to disclose.

This issue of the Proceedings of the Society for Experimental Biology and Medicine presents a forum that assesses the status of cancer prevention via 18 critical reviews of the elements that impact on carcinogenesis. Each article is written by a leading authority in the field of cancer prevention. Contributors were also selected with the goal of providing a broad-based view of the many facets of cancer prevention. We believe that, in addition to presenting the current state of knowledge in cancer prevention, the reviews also facilitate an appraisal of where current research in carcinogenesis is likely to lead in the coming years. Thus, we hope this issue of the Proceedings will prove to be a valuable reference for readers now and in the future, as the various ideas presented begin to unfold.The reviews emphasize that effective use of chemopreventive agents, whether naturally occurring or synthetic, will be realized only in the context of a fundamental understanding of the processes of carcinogenesis and t...

An understanding of the role that immunomodulatory factors play in the effector phase of lymphokine-activated killer (LAK) activity is essential for the development of biologic response modifiers for use in the treatment of advanced carcinoma. Fifteen head and neck cancer patients were studied. Single-donor killer cells activated by recombinant interleukin-2 (10 U/mL) and induced in either a complete medium or complete medium plus a 10% autologous serum solution were used. Effector phase solutions of 25% autologous serum were used in chromium 51 release assays to determine sera immunomodulation of LAK cell cytotoxicity. Both K562 and squamous carcinoma (MDA686-Ln) tumor cell lines were tested. Significant effector phase inhibition (EPI) of cytotoxicity occurred in 40% of studied patients. Seventy percent of patients with stage III or IV or recurrent disease exhibited EPI, whereas only 20% of patients with stage I or II disease and 30% of controls did so. EPI of cancer patient serum correlated directly with alpha 1-antitrypsin, alpha 1-acid glycoprotein, and C-reactive protein (CRP) levels (MDA686-Ln targets) (r = 0.6, 0.7, and 0.6, respectively) (P.02). Neither EPI against K562 targets nor EPI in control patients correlated with acute phase protein levels. These findings suggest that advances in in vivo immunomodulatory therapy will be dependent upon further elucidation of serologic inhibition of the effector phase of the LAK cell phenomenon. The relationship between LAK cell recognition and EPI requires further investigation.

The records of 125 consecutive patients with unresectable pancreatic cancer treated between 1958 and 1979 were evaluated to determine the benefit or morbidity of gastroenterostomy performed on a routine basis. One hundred three patients had no evidence of gastric outlet obstruction from tumor extension as determined at the time of initial operation. Fifty-seven of these patients underwent biliary diversion as their only operative procedure. The morbidity and mortality in this group was 31 and 14 percent, respectively. Six of these 57 patients required decompressing gastroenterostomy at a later date to relieve gastric outlet obstruction. Forty-six patients underwent both biliary and prophylactic gastric outlet diversion with a 15 percent mortality rate and a 46 percent incidence of morbidity. The most common complication in this group was delayed gastric emptying (14 percent). These findings, and the high incidence of delayed gastric emptying after gastroenterostomy and the relatively infrequent occurrence of gastric outlet obstruction (11 percent) after initial biliary diversion, suggest that gastroenterostomy should be performed on a selective basis only.

Natural killer cell activity was assessed in 100 previously untreated pharyngeal carcinoma patients. Diminished natural killer cell function in these patients was associated with an increased risk of death from uncontrolled regional and distant metastases. During the assessment, the cell line MDA686-Ln was established from a metastatic pharyngeal carcinoma of a patient with low natural killer cell cytotoxicity. The initially cytotoxicity-resistant cell line could be lysed when natural killer cell cytotoxicity was enhanced in vitro either through enrichment of a Leu 19+ natural killer cell population by fluorescent-activated cell sorting or by interleukin-2 activation. Additionally, increased circulating immune complexes were identified in these patients, subsequently isolated, and found to block natural killer cell reactivity against MDA686-Ln. In light of this negative interaction, 38 patients were randomly evaluated for both circulating immune complex levels and natural killer cell function. Both parameters examined together were complementary in defining the risk of death with disease; four of five deaths occurred in patients with both high circulating immune complex levels and low natural killer cell function. Results support the biologic modification of natural killer cell activity for controlling metastatic pharyngeal carcinoma and point to the potential confounding influence of circulating immune complex.

A retrospective analysis revealed improved survival rates in laryngeal cancer patients who had postoperative wound infection following total laryngectomy and radical neck resection. The overall five-year survival rates were 44% in the infection group and 31% in the control group. On further analysis, the beneficial effect of infection was most evident in patients with stage III disease. Seventy-three percent of these patients with wound infection were alive at five years, compared with 32% of the control group. The protection from recurrent cancer in these patients afforded by the bacterial contamination may be secondary to activated immune mechanisms. The therapeutic implications of our findings suggest that the immune adjuvant is given at the time of surgical treatment rather than when tumor burden is far advanced. Only a few such protocols are under analysis presently.

This study analyzed the capacity of both fresh unseparated peripheral blood lymphocytes and enriched natural killer (NK) cells to lyse head and neck cancer cell lines. In a 6-hour chromium-release assay, only Leu-19+ NK cells mediated significant lysis. Furthermore, cell lines established from poorly differentiated cancers were more sensitive to lysis than were cell lines established from well-differentiated cancers. Cell lines from well-differentiated cancers also less readily inhibited K562 lysis in a cold-target inhibition assay, were not recognized by NK cells in a monolayer absorption assay (unlike poorly differentiated cancers), and failed to form conjugates with NK cells in a single-cell assay. These results indicated that deficient killing of a well-differentiated cancer cell vs a poorly differentiated cancer cell is partly a function of diminished NK cell recognition and tumor binding necessary to initiate lysis. As in previous studies regarding the prognostic implication of quantitated measures of NK cell activity within head and neck cancer patients, the results support the biologic relevance of the NK cell as a defense mechanism against metastatic disease, especially in patients with poorly differentiated, low major histocompatibility complex class I-expressing head and neck cancers.

To define the biologic characteristics of head and neck cancer in the young adult, the clinical course of 83 previously untreated patients less than or equal to 40 years of age with head and neck cancer was reviewed retrospectively. Their course was compared to that in a randomly chosen, concurrently treated, site-matched and stage-matched older head and neck cancer population (matched control). Patterns of recurrence as well as overall disease-free survival in each of the two populations were not significantly different. An important stratification factor, however, was related to tobacco usage. Thirty percent of the young patients denied using tobacco compared with only 9% of the controls (P less than 0.05). The 5-year disease-free survival rate of the young adults who did not use tobacco was 66% compared with 86% for their matched control group with a history of smoking. These differences were most significant in young adults with Stage II disease (P less than 0.05 by log-rank testing). The growth and progression of head and neck cancer in the young adults is characterized by tobacco use patterns; a family history of head and neck cancer in five of 17 nontobacco using young adults raises the issue of an inherent genetic determinant.

Numerous reports have suggested, although never demonstrated, a suppressed immune defense mechanism as a contributing factor in the development of head and neck cancer in the young adult. Twenty-four previously untreated adults less than or equal to 40 years of age with squamous cell carcinoma were examined for lymphocyte function (natural killer cell activity and in vitro lymphocyte blastogenesis response to mitogens), total lymphocyte number and percentage of lymphocyte subsets, and humoral immune status (circulating IgA, IgG, and IgM). As compared with 33 healthy young adults, no significant immunologic deficit could be identified. On the contrary, the young adult cancer population had significantly increased lymphocyte numbers (P less than 0.05) and serum IgA, IgG, and IgM levels (P less than 0.001, respectively). These young cancer patients cannot be considered to be immunosuppressed. Alternative biologic mechanisms must be defined to account for the increasing incidence of head and neck cancer over the last decade among young adults in the United States.

Factors governing the initiation, growth, and progression of squamous cell carcinoma were the focus of a recent Upper Ae-rodigestive Cancer Task Force workshop sponsored by the National Cancer Institute. The goal of the daylong workshop was to identify critical research concepts in head and neck cancer biology. Discussed were the multistep processes potentially involved in tumor evolution, including the role of carcinogens, viral promotors, host and tumor karyotypes, microenvironment growth factors and growth factor receptors, as well as host/tumor components inherent to the metastatic process. Concepts developed from research in other neoplastic processes but potentially relevant to head and neck cancer were emphasized. The process of identifying critical research directions is the first step by the National Cancer Institute in program development designed to advance the treatment of head and neck cancer.

Various measures of immune response were assessed prior to induction chemotherapy (intravenous [IV] cisplatin, fluorouracil [5-FU], and bleomycin) in 43 previously untreated head and neck cancer patients to derive a clinical response prediction model. These were parameters of functional cellular immunity (natural killer [NK] cell activity, lymphocyte blastogenesis response to mitogens), total lymphocyte and lymphocyte subset numbers and percentages, and circulating humoral immunity (total immunoglobulin, immunoglobulin classes, and C1q binding activity [C1q BA]). The C1q BA may reflect levels of circulating immune complexes within peripheral blood. The objective primary tumor response rate was 65% (16 complete responses and 12 partial responses). Univariate logistic regression analysis showed that failure to respond to therapy was significantly related to higher value (vis-à-vis response) of humoral immune parameters total immunoglobulin (Ig), P less than .01; IgG, P less than .01; and C1q BA, P less than .001. No association between cellular immune response measurements and response to chemotherapy was identified. By multivariate logistic regression analysis, only C1q BA levels were predictive of drug therapy responsiveness (P less than .001). Results extend our previous investigations regarding C1q BA measurement in head and neck cancer patients, and show that C1q BA levels add accuracy of prediction of subsequent chemotherapy response to that based solely on standard staging criteria and other parameters of immune status.

• A determination of natural killer cell activity was performed in 67 individuals with advanced head and neck cancer. The mean activity of 28 patients clinically staged T3 NO or T4 NO was 81 ± 11 lytic units (LU), significantly higher than 39 patients with palpable lymph node metastases (54 ± 5 LU). Assessing patients by extent of nodal disease revealed that activity actually increased, though not significantly, with progressive N-staging. A major determinate of increased natural killer cell cytotoxicity in patients with lymph node metastases was extranodal cancer within the neck. The mean activity of nine patients whose tumor was fixed to underlying structures or adherent to skin was 87 ± 15 LU, significantly higher than the 45 ± 4 LU mean value of the remaining patients with clinically determined regional nodal disease. The potential clinical implications of these findings are discussed. ( Arch Otolaryngol Head Neck Surg 1986;112:545-551)

A series of working group discussions were held during the recent Second International Head and Neck Oncology Research Conference. The purpose of these discussions was to define clinical and basic research priorities in the areas of chemotherapy, tumor immunology, tumor model development, flow cytometry, etiology, and virology. The results of these discussions are summarized and condensed in this report. The recommendations of the various Working Groups indicate that intensive basic research efforts in head and neck oncology need to be expanded, particularly in the areas of tumor model development, cell biology, and immunology. These specific Working Group recommendations should serve as a resource for research program development at the local and national levels.

We prospectively determined the intraoperative blood loss in 250 patients who underwent major head and neck surgical procedures over a 13-month period to demonstrate the efficacy of electrosurgical dissection for reducing blood loss and to determine those factors predictive of the need for blood replacement. Transfusions were required in 30 (12%) of the 250 patients, and a total of 66 units of packed red blood cells was administered. Two patients were transfused preoperatively, 16 patients intraoperatively, and 14 patients postoperatively. Factors predicting the necessity for blood replacement included the patient's preoperative hematocrit level, intraoperative blood loss, the duration and type of procedure, and the surgeon's level of experience. The principles of electrosurgical dissection are discussed.

Curative surgery diminished natural killer (NK) cell activity in 17 patients with previously untreated squamous cell carcinoma of the head and neck (37% +/- 17%, preoperatively vs. 21% +/- 11%, postoperatively; p less than 0.001). This operatively induced suppression was dependent on the presence of a nylon wool adherent cell population. With the removal of this surgically generated suppressor population from the in vitro assay, postoperative suppression of natural killer activity was significantly diminished (21% +/- 13%, vs. 30% +/- 23%, p less than 0.01). The capability of fully restoring postoperatively suppressed NK cell activity was subsequently demonstrated by the synergistic effect of removing a nylon wool adherent suppressor population and stimulating NK cells with a naturally occurring immunopotentiator, tuftsin (from 21% +/- 13% to 41% +/- 23%; p less than 0.0001). In utilizing biological response modifiers in the perioperative period in the cancer patient, the interaction of these agents and the surgically generated suppressor cell population needs to be considered.

Squamous cell carcinoma (SCC) of the head and neck, which occurs in this country most commonly between the ages of 40 and 70 years, accounts for 5% of all tumors and affects approximately 26,000 persons each year [1]. More than 90% of patients with head and neck cancer will have a history of tobacco consumption [2–4]. The estimated age-standardized mortality rate for laryngeal cancer is 0.96 deaths per 100,000 person years, less than one-twentieth of the heavy smoker [3]. Evidence from multiple independent investigations indicates that tobacco usage is linearly related to the development of head and neck cancer [4–7]. Areas within the upper aerodigestive tract at risk for the development of SCC relate to the manner in which tobacco is consumed [7]. Moore and Catlin have postulated that the relationship of tobacco usage to the site of head and neck cancer depends on prolonged contact of concentrated carcinogens suspended in saliva and subsequent ‘pooling’ in mucous reservoirs [8]. Such a hypothesis accounts for the observation that in this country 75% of cancers in the oral cavity originate in a horseshoe-shaped area consisting of only 20% of the surface area of the entire oral mucosa. This region extends from the anterior floor of the mouth backward along both lingual-alveolar sulci to include the lateral margin of the mobile tongue and the anterior tonsillar pillar-retromolar trigone complex.

One hundred eighty-two previously untreated head and neck cancer patients were stratified by pretreatment-quantitated natural killer (NK) cell activity (less than 60 lytic units [LU] vs greater than or equal to 60 LU) and followed up longitudinally for the development of distant metastases (DMs). Patients with NK activity of less than 60 LU (n = 99) developed DMs at a higher rate than the remaining group. Further stratification of patients on the bases of both regional nodal disease and treatment demonstrated that the risk of DMs predominantly involved one group, ie, patients with histopathologically documented nodal metastases, NK activity of less than 60 LU, and prior treatment with combined surgery and radiation therapy (12[46%] of 26 patients). If one of these three factors was absent, the risk of DMs was not greater than 12%, regardless of the factor. Head and neck cancer patients should be stratified by pretreatment natural immune status to determine the impact of therapy on disease progression.

The expression of chromosome breakage as a response to mutagen exposure may contribute to the development of head and neck cancer. Lymphocytes from 46 previously untreated head and neck cancer patients were cultured in vitro and exposed to the radiomimetic clastogen, bleomycin. The lymphocytes were then arrested in metaphase and analyzed for bleomycin-induced chromosome breaks. Mean bleomycin-induced chromosome breaks per cell (b/c) in head and neck cancer patients (0.94 +/- 0.3 b/c) were significantly higher than in either controls (0.70 +/- 0.3 b/c; p less than 0.001) or a concurrently examined patient population with central nervous system tumors (0.55 +/- 0.3 b/c; p less than 0.001). The expression of mutagen-induced chromosome fragility in the head and neck cancer population was site-specific, being most evident in patients with laryngeal or pharyngeal cancer but not oral cavity disease. The differential responses to mutagen effects may be a reflection of DNA repair deficiency. Head and neck cancer patients express a higher degree of chromosomal mutagen sensitivity, which may contribute to neoplastic development.

Deficient natural killer (NK) cell activity may contribute to the development of distant metastases in the head and neck cancer patient. A total of 246 previously untreated patients expressed deficient NK activity against K562 target cells when compared to 110 age-matched healthy controls (70 +/- 48 lytic units (LU) versus 95 +/- 52 LU) (P less than 0.001). Some 164 consecutive patients have undergone definitive therapy subsequent to NK cell assessment and have been followed for a minimum of 12 months (median = 16 months), and 23 have developed recurrent disease in distant sites. The risk of subsequently (1) developing distant metastases, (2) developing regional metastases, and (3) dying of progressive cancer was inversely related to pretreatment NK LU values (P less than 0.02, less than 0.02, less than 0.005, respectively, by the Cox proportional hazards model). NK cell function within the peripheral blood of the patient with head and neck cancer could be related to the percentage of Leu 11+ NK cell subsets (P less than 0.01 by linear regression analysis) as determined by both single-parameter and multiparameter flow cytometric assessment. Contrastingly, no relationship could be identified between NK function with the percentage of circulating Leu 7+ cell subsets. In vitro measured NK cell function identifies a population at increased risk for developing distant metastases, thus supporting the role of natural immunity as defense mechanism against blood-borne disease.

An evaluation of natural killer cell activity was performed in 42 patients with pharyngeal carcinoma. Compared with age- and sex-matched control subjects, the cancer patients expressed significantly lower cytotoxicity against K562 target cells (68 +/- 8 lytic units versus 99 +/- 8 lytic units, p less than 0.01), with 52 percent of the patients expressing deficient activity (below 1 standard deviation of the mean activity of the control population). The probability of deficient activity was greater in these patients than observed in patients with cancer of other head and neck sites. Although natural killer cell activity was lower in patients who drank alcohol or had nodal metastases, no single clinical factor was predictive of deficient cytotoxic response. Prospective longitudinal evaluation (mean = 12 months) of these pharyngeal cancer patients demonstrated that deficient natural killer cell activity measured before treatment identified a population with a significantly increased risk for the development of distant metastases. Distant metastases developed in 7 of 18 patients (39 percent) with deficient natural killer cell activity. In contrast, none of the 16 patients with normal natural killer cell function had evidence of distant disease at last follow-up (p less than 0.01). Deficient natural killer cell activity exists in patients with pharyngeal cancer and is an independent marker for the subsequent development of distant metastases.

Responses to the genotoxic effect of bleomycin in lymphocytes of blood cultures, expressed as the average number of chromatid breaks per cell (b/c), varied from less than 0.20 to more than 2.00 in 335 normal individuals. More than 11% of the subjects tested showed a b/c rate above 1.00 and more than 22% showed a b/c rate above 0.80. These individuals are considered sensitive to this radiomimetic drug. The distributional profile of bleomycin responses of the control individuals appears to be representative of the normal human population. In patients with cancers of the colon (83), upper aerodigestive tract (head/neck) (77), and lung (71), the frequencies of subjects in the hypersensitive class were found to be between 40 and 50%, and the response profiles were distinctly different from those of the control population. On the other hand, in a group of elderly cigarette smokers, who exhibited no symptoms of lung cancer, the bleomycin sensitivity profile was significantly skewed toward the more resistant stratum, with only one hypersensitive case among 56 individuals tested (1.78%). The sensitivity profile of patients with breast cancer (82) was similar to that of the control population. Our data suggest that: (1) mutagen sensitivity may play an important role in carcinogenesis of organs and tissues that have direct contact with the external environment (respiratory, digestive, and integumentary systems); (2) it appears to have no significant influence on carcinogenesis of tissues that are not directly exposed to the environment (e.g., breast, brain); and (3) it also has little impact on carcinogenesis in individuals with a hereditary predisposition to cancer (e.g., retinoblastoma, Gardner's syndrome). Development of more effective and precise test systems for carcinogen sensitivity is highly desirable for identification of persons at risk.

In 127 patients with squamous cell carcinoma of the upper aerodigestive system, an assessment of natural killer (NK) cell function was performed. The mean lytic unit (LU) value of this cancer population was noted to be less than the mean value of 67 age-matched controls assessed concurrently. The major determinant of cytolytic function was related to the growth pattern of the tumor. Increased NK cell function was observed in patients with lesions that were more locally or regionally aggressive, i.e., that infiltrated surrounding anatomic structures. The magnitude of NK cell response also correlated with increased amounts of circulating IgG immunoglobulin to herpes simplex virus-type 1-associated antigens; elevated IgG levels were also associated with locally aggressive lesions. The clinical significance of NK cell activity in these patients is shown by its relationship to disease-free prognosis. Patients with elevated NK activity followed for a mean of 12 months had an improved disease-free survival as compared to the survival of the remaining population. Furthermore, NK LU values were not reflected in standard staging methods, which suggests that the measurement of NK cell function represents an independent prognostic parameter in the patient with head and neck cancer.

In this study, polyamine biosynthesis required for cellular proliferation showed elevated levels in neoplastic cells. Putrescine, spermidine, and spermine, as well as the rate-limiting enzyme ornithine decarboxylase, were measured to evaluate differences in tissue concentration in squamous cell carcinoma of the oral cavity, and in the normal adjacent, buccal, and retromolar trigone tissues. Mean polyamine levels (nanomoles per gram of tissue +/- standard error of the mean) were significantly elevated in tumor tissue at 136 +/- 42 nmol/g for putrescine compared with 41 +/- 9 nmol/g in adjacent, 25 +/- 5 nmol/g in buccal, and 41 +/- 14 nmol/g in retromolar trigone tissues. Tumor spermidine was 415 +/- 41 nmol/g compared with 192 +/- 34 nmol/g in adjacent, 184 +/- 34 nmol/g in buccal, and 214 +/- 63 nmol/g in retromolar trigone tissues. Tumor spermine was 461 +/- 41 nmol/g compared with 236 +/- 30 nmol/g in adjacent, 233 +/- 35 nmol/g in buccal, and 269 +/- 59 nmol/g in retromolar trigone samples. Ornithine decarboxylase activity was highly variable in tumor tissues. High levels of polyamines appear to be specific for this malignancy, whereas ornithine decarboxylase activity is not. Measurement of polyamine content may be useful in evaluating epithelial changes in the oral cavity.

To the Editor. —Reports have appeared in the literature regarding the increased mortality from tongue cancer among young adults in the United States. 1,2 Shemen et al 1 showed that an increase in head and neck cancer began in the mid-1970s and principally involved men younger than 40 years old. In light of the growing prevalence of the use of smokeless tobacco among the young adult population, 3 Depue 2 suggested a causal relationship between these two trends, but, as yet, direct evidence to support the relationship has not been provided. A review of the patient registry of The University of Texas M. D. Anderson Hospital and Tumor Institute between 1944 and 1984 also has revealed a significant increase in squamous cell carcinoma of the tongue among young adults (younger than age 40 years) (Table). The increase is both in absolute numbers and in the percentage of the total number

Anaerobic organisms are thought to be an important source of wound infection in head and neck oncologic surgery. Antibiotic prophylaxis consisting of agents specific for anaerobes combined with broad-spectrum agents that provide coverage for other well-recognized pathogens should be an effective combination regimen for this group of patients. We conducted a prospective, randomized study comparing the efficacy of prophylaxis using combination of metronidazole and cefazolin-designated group A, to prophylaxis using cefazolin alone-group B, for patients undergoing oncologic procedures of the head and neck. The rate of wound infection in the cefazolin-metronidazole group (158 patients) was 9.5%, compared with 18.6% in the cefazolin group (172 patients) (p = 0.03). Patients undergoing clean procedures had a 4.9% infection rate overall, compared with 17.9% for clean-contaminated procedures, and 33.3% for contaminated procedures. The average length of hospitalization was 20.7 days for patients who developed infections, compared with 8.9 days for patients without infection. Anaerobic organisms were cultured in 12 of 26 patients, ten of whom did not receive metronidazole. The lower rate of wound infection among patients who received metronidazole suggests that anaerobic organisms are an important source of wound infection in head and neck oncologic surgery. Chemoprophylaxis for these patients should, therefore, include specific anaerobic coverage in addition to the broad-spectrum agents that cover the more familiar aerobic organisms.

The relationship of circulating IgA titers and multiple parameters of cell-mediated immunity was examined in 97 patients with head and neck cancer. In 26% of the patients, IgA titers were above one standard deviation of controls, with highest levels noted in patients with advanced disease. In 40 patients for whom multiple immune parameters were tested in vitro, increasing concentrations of IgA were associated with an enhanced immunologic helper state defined by a generalized hypergammaglobulinemia, increased percentage of T4+ lymphocytes, higher T4/T8 ratio, and an increased lymphocyte blastogenesis response to mitogens. IgA concentrations were inversely related to percentages and absolute number of Leu 11+ natural killer cell subsets, and also to disease-free survival (p less than 0.005 by Cox proportional hazards model). The immune correlations identified here are similar to those noted in many autoimmune diseases. Head and neck cancer patients are an immunologically heterogeneous population, among whom elevated IgA blood levels may reflect the autoimmune nature of cancer, an immunologic state defined by its tumor-promoting capacity.