Anti-EGFR-based therapies have limited success in HNSCC patients. Predictive biomarkers are greatly needed to identify the patients likely to be benefited from these targeted therapies. Here, we present the prognostic and predictive association of biomarkers in HPV-negative locally advanced (LA) HNSCC patients.
Treatment-naive tumour tissue samples of 404 patients, a subset of randomised Phase 3 trial comparing cisplatin radiation (CRT) versus nimotuzumab plus cisplatin radiation (NCRT) were analysed to evaluate the expression of HIF1α, EGFR and pEGFR by immunohistochemistry and EGFR gene copy change by FISH. Progression-free survival (PFS), locoregional control (LRC) and overall survival (OS) were estimated by Kaplan–Meier method. Hazard ratios were estimated by Cox proportional hazard models.
Baseline characteristics of the patients were balanced between two treatment groups (CRT vs NCRT) and were representative of the trial cohort. The median follow-up was of 39.13 months. Low HIF1α was associated with better PFS [HR (95% CI) = 0.62 (0.42–0.93)], LRC [HR (95% CI) = 0.56 (0.37–0.86)] and OS [HR (95% CI) = 0.63 (0.43–0.93)] in the CRT group. Multivariable analysis revealed HIF1α as an independent negative prognostic biomarker. For patients with high HIF1α, NCRT significantly improved the outcomes [PFS:HR (95% CI) = 0.55 (0.37–0.82), LRC:HR (95% CI) = 0.55 (0.36–0.85) and OS:HR (95% CI) = 0.54 (0.36–0.81)] compared to CRT. While in patients with low HIF1α, no difference in the clinical outcomes was observed between treatments. Interaction test suggested a predictive value of HIF1α for OS (P = 0.008).
High HIF1α expression is a predictor of poor clinical response to CRT in HPV-negative LA-HNSCC patients. These patients with high HIF1α significantly benefited with the addition of nimotuzumab to CRT.
Clinical trial registration
Registered with the Clinical Trial Registry of India (Trial registration identifier—CTRI/2014/09/004980).
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Bray, F., Ferlay, J., Soerjomataram, I., Siegel, R. L., Torre, L. A. & Jemal, A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J. Clin. 68, 394–424 (2018).
Leemans, C. R., Braakhuis, B. J. & Brakenhoff, R. H. The molecular biology of head and neck cancer. Nat. Rev. Cancer 11, 9–22 (2011).
Tian, Y., Lin, J., Tian, Y., Zhang, G., Zeng, X., Zheng, R. et al. Efficacy and safety of anti-EGFR agents administered concurrently with standard therapies for patients with head and neck squamous cell carcinoma: a systematic review and meta-analysis of randomized controlled trials. Int. J. Cancer 142, 2198–2206 (2018).
Allan, D. G. Nimotuzumab: evidence of clinical benefit without rash. Oncologist. 10, 760–761 (2005).
Ramakrishnan, M. S., Eswaraiah, A., Crombet, T., Piedra, P., Saurez, G., Iyer, H. et al. Nimotuzumab, a promising therapeutic monoclonal for treatment of tumors of epithelial origin. mAbs 1, 41–48 (2009).
Patil, V. M., Noronha, V., Joshi, A., Agarwal, J., Ghosh-Laskar, S., Budrukkar, A. et al. A randomized phase 3 trial comparing nimotuzumab plus cisplatin chemoradiotherapy versus cisplatin chemoradiotherapy alone in locally advanced head and neck cancer. Cancer 125, 3184–3197 (2019).
Amado, R. G., Wolf, M., Peeters, M., Van Cutsem, E., Siena, S., Freeman, D. J. et al. Wild-type KRAS is required for panitumumab efficacy in patients with metastatic colorectal cancer. J. Clin. Oncol. 26, 1626–1634 (2008).
Rosell, R., Moran, T., Queralt, C., Porta, R., Cardenal, F., Camps, C. et al. Screening for epidermal growth factor receptor mutations in lung cancer. N. Engl. J. Med. 361, 958–967 (2009).
Bossi, P., Resteghini, C., Paielli, N., Licitra, L., Pilotti, S. & Perrone, F. Prognostic and predictive value of EGFR in head and neck squamous cell carcinoma. Oncotarget 7, 74362–74379 (2016).
Batzer, A. G., Rotin, D., Urena, J. M., Skolnik, E. Y. & Schlessinger, J. Hierarchy of binding sites for Grb2 and Shc on the epidermal growth factor receptor. Mol. Cell Biol. 14, 5192–5201 (1994).
Harris, A. L. Hypoxia–a key regulatory factor in tumour growth. Nat. Rev. Cancer 2, 38–47 (2002).
Brown, J. M. The hypoxic cell: a target for selective cancer therapy–eighteenth Bruce F. Cain Memorial Award lecture. Cancer Res. 59, 5863–5870 (1999).
Vaupel, P. & Mayer, A. Hypoxia in cancer: significance and impact on clinical outcome. Cancer Metastasis Rev. 26, 225–239 (2007).
Semenza, G. L. Hypoxia-inducible factors: mediators of cancer progression and targets for cancer therapy. Trends Pharmacol. Sci. 33, 207–214 (2012).
Gong, L., Zhang, W., Zhou, J., Lu, J., Xiong, H., Shi, X. et al. Prognostic value of HIFs expression in head and neck cancer: a systematic review. PLoS ONE 8, e75094 (2013).
Li, X., Lu, Y., Liang, K., Pan, T., Mendelsohn, J. & Fan, Z. Requirement of hypoxia-inducible factor-1alpha down-regulation in mediating the antitumor activity of the anti-epidermal growth factor receptor monoclonal antibody cetuximab. Mol. Cancer Ther. 7, 1207–1217 (2008).
Cerniglia, G. J., Pore, N., Tsai, J. H., Schultz, S., Mick, R., Choe, R. et al. Epidermal growth factor receptor inhibition modulates the microenvironment by vascular normalization to improve chemotherapy and radiotherapy efficacy. PLoS ONE 4, e6539 (2009).
Li, X. & Fan, Z. The epidermal growth factor receptor antibody cetuximab induces autophagy in cancer cells by downregulating HIF-1alpha and Bcl-2 and activating the beclin 1/hVps34 complex. Cancer Res. 70, 5942–5952 (2010).
Wang, W. M., Zhao, Z. L., Ma, S. R., Yu, G. T., Liu, B., Zhang, L. et al. Epidermal growth factor receptor inhibition reduces angiogenesis via hypoxia-inducible factor-1alpha and Notch1 in head neck squamous cell carcinoma. PLoS ONE 10, e0119723 (2015).
Luwor, R. B., Lu, Y., Li, X., Mendelsohn, J. & Fan, Z. The antiepidermal growth factor receptor monoclonal antibody cetuximab/C225 reduces hypoxia-inducible factor-1 alpha, leading to transcriptional inhibition of vascular endothelial growth factor expression. Oncogene 24, 4433–4441 (2005).
Boeckx, C., Van den Bossche, J., De Pauw, I., Peeters, M., Lardon, F., Baay, M. et al. The hypoxic tumor microenvironment and drug resistance against EGFR inhibitors: preclinical study in cetuximab-sensitive head and neck squamous cell carcinoma cell lines. BMC Res. Notes 8, 203 (2015).
Wiechec, E., Hansson, K. T., Alexandersson, L., Jonsson, J. I. & Roberg K. Hypoxia mediates differential response to anti-EGFR therapy in HNSCC cells. Int. J. Mol. Sci. 18, 943 (2017).
Bhosale, P. G., Pandey, M., Desai, R. S., Patil, A., Kane, S., Prabhash, K. et al. Low prevalence of transcriptionally active human papilloma virus in Indian patients with HNSCC and leukoplakia. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. 122, 609–18.e7 (2016).
Craig, S. G., Anderson, L. A., Schache, A. G., Moran, M., Graham, L., Currie, K. et al. Recommendations for determining HPV status in patients with oropharyngeal cancers under TNM8 guidelines: a two-tier approach. Br. J. Cancer 120, 827–833 (2019).
Chung, C. H., Ely, K., McGavran, L., Varella-Garcia, M., Parker, J., Parker, N. et al. Increased epidermal growth factor receptor gene copy number is associated with poor prognosis in head and neck squamous cell carcinomas. J. Clin. Oncol. 24, 4170–4176 (2006).
Keren, S., Shoude, Z., Lu, Z. & Beibei, Y. Role of EGFR as a prognostic factor for survival in head and neck cancer: a meta-analysis. Tumour Biol. 35, 2285–2295 (2014).
Swartz, J. E., Pothen, A. J., Stegeman, I., Willems, S. M. & Grolman, W. Clinical implications of hypoxia biomarker expression in head and neck squamous cell carcinoma: a systematic review. Cancer Med. 4, 1101–1116 (2015).
Clark, G. M. Prognostic factors versus predictive factors: examples from a clinical trial of erlotinib. Mol. Oncol. 1, 406–412 (2008).
Polley, M. Y., Freidlin, B., Korn, E. L., Conley, B. A., Abrams, J. S. & McShane, L. M. Statistical and practical considerations for clinical evaluation of predictive biomarkers. J. Natl Cancer Inst. 105, 1677–1683 (2013).
Bland, J. M. & Altman, D. G. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1, 307–310 (1986).
Lin, L. I. A concordance correlation coefficient to evaluate reproducibility. Biometrics 45, 255–268 (1989).
McShane, L. M., Altman, D. G., Sauerbrei, W., Taube, S. E., Gion, M., Clark, G. M. et al. REporting recommendations for tumour MARKer prognostic studies (REMARK). Br. J. Cancer 93, 387–391 (2005).
Altman, D. G., McShane, L. M., Sauerbrei, W. & Taube, S. E. Reporting recommendations for tumor marker prognostic studies (REMARK): explanation and elaboration. PLoS Med. 9, e1001216 (2012).
Boeckx, C., Baay, M., Wouters, A., Specenier, P., Vermorken, J. B., Peeters, M. et al. Anti-epidermal growth factor receptor therapy in head and neck squamous cell carcinoma: focus on potential molecular mechanisms of drug resistance. Oncologist 18, 850–864 (2013).
Chen, L. F., Cohen, E. E. & Grandis, J. R. New strategies in head and neck cancer: understanding resistance to epidermal growth factor receptor inhibitors. Clin. Cancer Res. 16, 2489–2495 (2010).
Lu, Y., Liang, K., Li, X. & Fan, Z. Responses of cancer cells with wild-type or tyrosine kinase domain-mutated epidermal growth factor receptor (EGFR) to EGFR-targeted therapy are linked to downregulation of hypoxia-inducible factor-1alpha. Mol. Cancer 6, 63 (2007).
Pore, N., Jiang, Z., Gupta, A., Cerniglia, G., Kao, G. D. & Maity, A. EGFR tyrosine kinase inhibitors decrease VEGF expression by both hypoxia-inducible factor (HIF)-1-independent and HIF-1-dependent mechanisms. Cancer Res. 66, 3197–3204 (2006).
Ou, D., Garberis, I., Adam, J., Blanchard, P., Nguyen, F., Levy, A. et al. Prognostic value of tissue necrosis, hypoxia-related markers and correlation with HPV status in head and neck cancer patients treated with bio- or chemo-radiotherapy. Radiother. Oncol. 126, 116–124 (2018).
Stransky, N., Egloff, A. M., Tward, A. D., Kostic, A. D., Cibulskis, K., Sivachenko, A. et al. The mutational landscape of head and neck squamous cell carcinoma. Science 333, 1157–1160 (2011).
Smeets, S. J., Braakhuis, B. J., Abbas, S., Snijders, P. J., Ylstra, B., van de Wiel, M. A. et al. Genome-wide DNA copy number alterations in head and neck squamous cell carcinomas with or without oncogene-expressing human papillomavirus. Oncogene 25, 2558–2564 (2006).
Slebos, R. J., Yi, Y., Ely, K., Carter, J., Evjen, A., Zhang, X. et al. Gene expression differences associated with human papillomavirus status in head and neck squamous cell carcinoma. Clin. Cancer Res. 12, 701–709 (2006).
Dok, R. & Nuyts, S. HPV positive head and neck cancers: molecular pathogenesis and evolving treatment strategies. Cancers 8, 41 (2016).
Ang, K. K., Harris, J., Wheeler, R., Weber, R., Rosenthal, D. I., Nguyen-Tan, P. F. et al. Human papillomavirus and survival of patients with oropharyngeal cancer. N. Engl. J. Med. 363, 24–35 (2010).
Tian, S., Switchenko, J. M., Jhaveri, J., Cassidy, R. J., Ferris, M. J., Press, R. H. et al. Survival outcomes by high-risk human papillomavirus status in nonoropharyngeal head and neck squamous cell carcinomas: a propensity-scored analysis of the national cancer data base. Cancer 125, 2782–2793 (2019).
Li, H., Torabi, S. J., Yarbrough, W. G., Mehra, S., Osborn, H. A. & Judson, B. Association of human papillomavirus status at head and neck carcinoma subsites with overall survival. JAMA Otolaryngol. Head Neck Surg. 144, 519–525 (2018).
Nicolay, N. H., Wiedenmann, N., Mix, M., Weber, W. A., Werner, M., Grosu, A. L. et al. Correlative analyses between tissue-based hypoxia biomarkers and hypoxia PET imaging in head and neck cancer patients during radiochemotherapy-results from a prospective trial. Eur. J. Nucl. Med. Mol. Imaging 47, 1046–1055 (2020).
Eze, N., Lee, J. W., Yang, D. H., Zhu, F., Neumeister, V., Sandoval-Schaefer, T. et al. PTEN loss is associated with resistance to cetuximab in patients with head and neck squamous cell carcinoma. Oral Oncol. 91, 69–78 (2019).
Lui, V. W., Hedberg, M. L., Li, H., Vangara, B. S., Pendleton, K., Zeng, Y. et al. Frequent mutation of the PI3K pathway in head and neck cancer defines predictive biomarkers. Cancer Discov. 3, 761–769 (2013).
Micaily, I., Johnson, J. & Argiris, A. An update on angiogenesis targeting in head and neck squamous cell carcinoma. Cancers Head Neck 5, 5 (2020).
We acknowledge all the participating patients.
Ethics approval and consent to participate
This study was approved by the institutional ethics committee of Tata Memorial Center (IEC approval 50 of 2011) and was performed in accordance with the Declaration of Helsinki. All patients provided written informed consent.
Consent to publish
All data generated or analysed during this study are included in this published article (and its supplementary information file). However, if required, we can submit the clinical outcomes/follow-up and biomarker data.
The authors declare no competing interests.
This work was supported by the Department of Science & Technology—Science and Engineering Research Board (EMR/2015/001591), Tata Memorial Centre, Seed In Air grant (TMC/SIA/2696) and Council of Scientific & Industrial Research for fellowship (to U.P.).
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Patel, U., Pandey, M., Kannan, S. et al. Prognostic and predictive significance of nuclear HIF1α expression in locally advanced HNSCC patients treated with chemoradiation with or without nimotuzumab. Br J Cancer (2020). https://doi.org/10.1038/s41416-020-01064-4