Epithelial-to-mesenchymal transition is a prognostic marker for patient outcome in advanced stage HNSCC patients treated with chemoradiotherapy

Abstract

Background: The prognosis of patients with HPV-negative advanced stage head and neck squamous cell carcinoma (HNSCC) remains poor. No prognostic markers other than TNM staging are routinely used in clinic. Epithelial-to-mesenchymal transition (EMT) has been shown to be a strong prognostic factor in other cancer types. The purpose of this study was to determine the role of EMT in HPV-negative HNSCC outcomes. Methods: Pretreatment tumor material from patients of two cohorts, totalling 174 cisplatin-based chemoradiotherapy treated HPV-negative HNSCC patients, was RNA-sequenced. Seven different EMT gene expression signatures were used for EMT status classification and generation of HNSCC-specific EMT models using Random Forest machine learning. Results: Mesenchymal classification by all EMT signatures consistently enriched for poor prognosis patients in both cohorts of 98 and 76 patients. Uni-and multivariate analyses show important HR of 1.6-5.8, thereby revealing EMT's role in HNSCC outcome. Discordant classification by these signatures prompted the generation of an HNSCC-specific EMT profile based on the concordantly classified samples in the first cohort (cross-validation AUC > 0.98). The independent validation cohort confirmed the association of mesenchymal classification by the HNSCC-EMT model with poor overall survival (HR = 3.39, p < 0.005) and progression free survival (HR = 3.01, p < 0.005) in multivariate analysis with TNM. Analysis of an additional HNSCC cohort from PET-positive patients with metastatic disease prior to treatment further supports this relationship and reveals a strong link of EMT to the propensity to metastasize. Conclusions: EMT in HPV-negative HNSCC co-defines patient outcome after chemoradiotherapy. The generated HNSCC-EMT prediction models can function as strong prognostic biomarkers.

The Epithelial-Mesenchymal Transcription Factor Slug Predicts Survival Benefit of Up-Front Surgery in Head and Neck Cancer

“…The high failure rate among Slug-positive patients treated with primary RT/CRT is likely due to the high number of tumor cells in EMT, which is a characteristic associated with radio-and chemotherapy resistance [24,46] and tumor stemness [21]. In previous invitro studies, we observed Slug to be expressed in HNC cell lines, where EMT was induced by co-cultivation with fibroblasts [47].…”

“…In vitro, the induction of EMT in HNSCC cell lines doubled cisplatin resistance and increased radioresistance with a dose-modifying factor of 2 compared with the unmodified cell line [22,23]. EMT-related gene signatures are associated with radio-and chemotherapy resistance in patients with HNSCC [24]. We recently reported that EMT can be quantified in tumor samples from HNSCC patients using multichannel fluorescence image cytometry by evaluating the coexpression of epithelial and mesenchymal proteins in tumor cells [25].…”

Acute Hypoxia Profile is a Stronger Prognostic Factor than Chronic Hypoxia in Advanced Stage Head and Neck Cancer Patients

“…We tested the conformity of the four clinical hypoxia profiles in 224 HNSCC patients. To this end, we combined gene expression data generated from three HNSCC cohorts (Table 1): Pramana (published), de Jong 1 (expanded expression data set with additional samples that could not be used in the original study) and unpublished gene expression data from a patient cohort as described in de Jong 2 et al [32,33,34,35,36]. Patient characteristics of the cohorts are available in Supplementary Materials, Tables S3–S5.…”

“…So, to test whether the prognostic value of acute hypoxia is independent of HPV, we aimed to validate the prognostic relevance of acute hypoxia in a HPV-negative HNSCC cohort. To this end, we collected clinical and gene expression data from a study by Van der Heijden et al [35,36]. This data derived from pre-treatment patient tumor material of two cohorts of HPV-negative advanced stage HNSCC patients, NKI-CRAD and DESIGN, comprising 174 patients in total.…”

“…To validate our findings, we used gene expression data collected and generated within a separate study as described by van der Heijden et al and deposited at [35,36]. The “van der Heijden cohort” combines two independent cohorts, the NKI-CRAD and the DESIGN cohort, and comprises 174 HPV negative advanced stage HNSCC patients.…”