Lecture by Prof. Hans Kaanders in the context of the Course: "Tumour Hypoxia: From Biology to Therapy III". For the complete e-Course see http://www.myhaikuclass.com/MaastroClinic/metoxia

1. ARCON for T2-4 laryngeal cancer:
a phase III randomized trial
Hans Kaanders
Department of Radiation Oncology
Radboud University Nijmegen Medical Centre
The Netherlands

2. ARCON
Accelerated Radiotherapy + CarbOgen + Nicotinamide
Tumor cell proliferation Chronic hypoxia Acute hypoxia
S
D D S S D S S S
D
S S D S S S S S D S S
D S D S S S S
D S D S S
S S D S S
S
S S
D S DS
D D S S
S
S SS S D S D S
S D S S S DS
S S S S S D S SS S
D S D D D S
S S S S D S S S
D D S D S S D S S
D D D S D S D S S S S S D
D D S D D S D S S S S
S SS D S D
S D D
S S S
SS S D S D D S S S S S S S
D
D
S S SS D D S D D
S
S S D
S SS S S D S S D
S D D SS S D S
D
S D S S SS D S
SS S D D S D S
D D D SSD S S S
S D D S
D Carbogen Nicotinamide
98% O2 + 2% CO2
Accelerated fractionation
S
D DS S D S S S
S S D S S S S S D SD
S
D S D S S S S
D S D S S
S S D S S
S
S S
S stem cell
D differentiated cell

3. ARCON in a mouse mammary carcinoma
Enhancement 2.1
ARCON
ratio at the 2
TCD50 level conventional
1.9 accelerated carbogen
- carbogen nicotinamide
1.8
relative to
conventional 1.7
conventional
radiotherapy 1.6 carbogen
in air
1.5
1.4
1.3 accelerated
1.2
1.1
1
Rojas 1996

4. ARCON, phase II trial in H&N cancer
UMC Nijmegen
Oct. 1993 – Oct. 2000
215 patients larynx: 100
Stage III-IV hypopharynx: 50
oropharynx: 52
Median follow-up:
68 months (37-127) oral cavity: 13

5. ARCON phase II trial:
high local control rates in T3-4 tumors
Local control (%)
44 patients
oropharynx
larynx
79 patients
hypopharynx
oral cavity
21 patients
12 patients
Time (months)

6. Dutch multicenter randomized trial
ARCON vs Accelerated RT
in laryngeal carcinoma
Secondary endpoints:
• larynx preservation
Primary objective: • regional control
• To improve local tumor control • toxicity
• quality of life
• disease-free survival
• overall survival
Translational side study:
Is the hypoxic status of the tumor predictive for outcome?

7. ARCON for T2-4 squamous cell carcinoma of the larynx
Randomization
Accelerated Radiotherapy Accelerated Radiotherapy
+
carbogen and nicotinamide
Fractionation schedule:
primary metastatic nodes
Acc. RT 68 Gy 68 Gy
ARCON 64 Gy* 68 Gy
*Aim: improve tumor control with equal toxicity between arms!

8. Patient characteristics (N = 345)
Standard Experimental
arm arm
Total 174 171
Female 39 30
Male 135 141
Mean age (SD) 61 (9.1) 62 (9.9)
WHO performance status
0 140 137
1 34 33

9. Tumor site and T/N-stage (UICC 1997)
Standard Experimental
arm arm
Glottic 74 74
Supraglottic 100 97
T2 (advanced) 67 55
T3 80 95
T4 27 21
N0 117 115
N1 20 23
N2 37 33
N3 - -

10. Acute toxicity: mucositis
Patchy/confluent mucositis(%)
ARCON
Acc. RT
Weeks after start of treatment

11. Late toxicity
Standard Experimental
arm arm
Severe subcutaneous fibrosis 12 16
Mucosal ulceration 14 11
Nasogastric tube feeding 11 11
(> 6 m after randomisation)
Chondritis 17 22
Cartilage necrosis 15 12
tracheostomy 4 5
laryngectomy 0 0

12. ARCON for larynx carcinoma, local control
Local control (%)
100
90
80
70
60 ARCON
Acc. RT
50
0 12 24 36 48 60
Time (months)

13. ARCON for larynx carcinoma, regional control
Regional control (%)
100
90 p = 0.04
80
70
60 ARCON
Acc. RT
50
0 12 24 36 48 60
Time (months)

14. ARCON for larynx carcinoma, survival
Survival (%)
100
90
80
70
60 ARCON
Acc. RT
50
0 12 24 36 48 60
Time (months)

15. Pimonidazole: an exogenous marker of hypoxia
Hypoxic marker injection prior to biopsy
well oxygenated tumor
Immunohistochemical staining
Pimonidazole hypoxic tumor
Blood vessels

16. ARCON improves regional control in hypoxic tumors
but not local control (N = 79)
well oxygenated hypoxic
92% 93%
91%
80%
local
control
well oxygenated hypoxic
96% 100%
92%
regional 55%
control

17. ARCON vs Acc RT - Conclusions
• High local-regional control rates with ARCON and Acc RT.
• Equal levels of acute and late toxicity.
• No improvement of local tumor control rate
(4 Gy lower dose in ARCON arm).
• Significant improvement of regional control rate
(therapeutic gain).
• Oxygenation status of the primary tumor is predictive
for outcome. ARCON is only effective in hypoxic
tumors.

18. What about hemoglobin?

19. Pre-treatment Hb is associated with poor prognosis
(larynx carcinomas)
high Hb
low Hb
p = 0.007
Haugen et al., Clin Cancer Res 2004

20. Randomized trial with EPO
in H&N cancer patients with anemia
Locoregional
tumor control (%)
100
80
p = 0.04
60
placebo
40
20 Epoetin β
0
0 12 24 36 48 60 72
Time after treatment (months)
Henke et al, Lancet 2003

21. Randomized trial with blood transfusions
in H&N cancer patients with anemia (DAHANCA 5)
100
Locoregional
tumor control (%)
75
p = 0.04
50
25
0
0 12 24 36 48 60
Time after treatment (months)
Hoff et al, Radiother. Oncol. 2011

22. ARCON for T2-4 squamous cell carcinoma of the larynx
Randomization
Accelerated Radiotherapy Accelerated Radiotherapy
+
carbogen and nicotinamide
Fractionation schedule:
primary metastatic nodes
Acc. RT 68 Gy 68 Gy
ARCON 64 Gy* 68 Gy

23. Anemic patients have a worse outcome
Accelerated RT
100
80
20%
60
40
20 normal Hb
p < 0.01 low Hb
0
0 12 24 36 48 60
months

24. ARCON improves loco-regional control in anemic patients
Accelerated RT ARCON
100 100
80 80
20%
60 60
40 40
20 normal Hb 20 normal Hb
p < 0.01 low Hb low Hb
0 0
0 12 24 36 48 60 0 12 24 36 48 60
months months

25. and disease-free survival….
Accelerated RT ARCON
100 100
80 80
60 24% 60
40 40
20 normal Hb 20 normal Hb
p < 0.01 low Hb low Hb
0 0
0 12 24 36 48 60 0 12 24 36 48 60
months months

26. …but not overall survival.
Accelerated RT ARCON
100 100
80 80
60 60
40 40
20 normal Hb 20 normal Hb
p < 0.01 low Hb p = 0.03 low Hb
0 0
0 12 24 36 48 60 0 12 24 36 48 60
months months

27. Other prognostic clinical parameters
lysis: N-stage
WHO performance status
Locoregional Disease-free Overall
control survival survival
Multivariate analysis
(p-value) AR ARCON AR ARCON AR ARCON
N-stage: N0 vs. N+ < .01 .11 < .01 .02 < .01 .14
Hemoglobin: low vs. normal < .01 .91 < .01 .21 .06 .02
WHO perf.: 0 vs. 1 .54 .72 .99 .67 < .01 .15

28. Other prognostic clinical parameters
lysis: N-stage
WHO performance status
Locoregional Disease-free Overall
control survival survival
Multivariate analysis
(p-value) AR ARCON AR ARCON AR ARCON
N-stage: N0 vs. N+ < .01 .11 < .01 .02 < .01 .14
Hemoglobin: low vs. normal < .01 .91 < .01 .21 .06 .02
WHO perf.: 0 vs. 1 .54 .72 .99 .67 < .01 .15

29. Pimonidazole: an exogenous marker of hypoxia
Hypoxic marker injection prior to biopsy
well oxygenated tumor
Immunohistochemical staining
Pimonidazole hypoxic tumor
Blood vessels

30. No correlation between Hb and pimonidazole…
1 Normal values
M: 8.5 – 11.0
F: 7.5 – 10.0
0.1
0.01
0.0001
6 7 8 9 10 11 12
HB (mmol/ml)

31. Effect of carbogen breathing
air breathing carbogen breathing
HF=16,3% HF=5,3%
hypoxia vessels hypoxia vessels
Ljungkvist et al., Int J Radiat Oncol Biol Phys 2000

32. “Reduced cord radius theory” (D. Hirst 1986)
Normal Hb
air breathing carbogen breathing
Anemic
blood transfusion or erythropoietin
Anemic
air breathing carbogen breathing
Hirst, Int J Radiat Oncol Biol Phys 1986

33. ARCON in anemic patients - Conclusions
• ARCON is the first treatment modality to demonstrate improved outcome
in anemic patients.

34. ARCON in anemic patients - Conclusions
• ARCON is the first treatment modality to demonstrate improved outcome
in anemic patients.
• But…, patients with low Hb do not have more hypoxic tumors.

35. ARCON in anemic patients - Conclusions
• ARCON is the first treatment modality to demonstrate improved outcome
in anemic patients.
• But…, patients with low Hb do not have more hypoxic tumors.
• Suggested mechanism:
- shorter O2 diffusion distances in tumors of anemic patients.
- no compensatory increase of tumor cord thickness with ARCON.

36. ARCON in anemic patients - Conclusions
• ARCON is the first treatment modality to demonstrate improved outcome
in anemic patients.
• But…, patients with low Hb do not have more hypoxic tumors.
• Suggested mechanism:
- shorter O2 diffusion distances in tumors of anemic patients.
- no compensatory increase of tumor cord thickness with ARCON.
• Other potential mechanisms:
- increased plasma flow with low hematocrit (increased effect of
carbogen, glycolytic switch).
- different effect of ARCON on red blood cell 2,3-DPG and
subsequent O2 unloading in anemic patients.
- carboxyhemoglobin deblocking by carbogen in smokers.

37. Translational studies….

38. High EGFR-expression correlates with
poor treatment outcome
Ang KK et al. Cancer Res 2002;62:7350-7356

39. EGFR-expression in larynx carcinoma
no expression intermediate high

40. EGFR-expression: intensity vs fraction
Median EGFR fraction: 0.43
(0.003 – 0.93)
180
160
140
120
100
80
60
40
0.0 0.2 0.4 0.6 0.8 1.0
EGFR fraction

41. Accelerated radiotherapy can improve outcome
of high EGFR expressing tumors
Bentzen SM et al. Journal of Clinical Oncology 2005

42. Accelerated radiotherapy can improve outcome
of high EGFR expressing tumors
Accelerated arm of larynx study
100
75
50
25
EGFR low
EGFR high
0
0 12 24 36 48 60
months
Bentzen SM et al. Journal of Clinical Oncology 2005

43. ARCON can improve outcome
of low EGFR expressing tumors
100
75
AR arm 50
25
EGFR low
EGFR high
0
0 12 24 36 48 60
months
100
75
ARCON arm 50
25
EGFR low
p = 0.02 EGFR high
0
0 12 24 36 48 60
months

44. ARCON can improve LRC and DFS
of low EGFR expressing tumors
100 100
75 75
50 50
25 25
EGFR low EGFR low
p = 0.02 EGFR high p = 0.05 EGFR high
0 0
0 12 24 36 48 60 0 12 24 36 48 60
months months

45. ARCON can improve LRC and DFS
of low EGFR expressing tumors
100 100
75 75
50 50
25 25
EGFR low EGFR low
p = 0.02 EGFR high p = 0.05 EGFR high
0 0
0 12 24 36 48 60 0 12 24 36 48 60
months months
Independent prognostic factor in MV analysis (age, sex, T, N, subsite, grade, Hb, EGFR)
HR 2.43 (1.01 – 5.87), p = 0.05.

46. ARCON can improve LRC and DSS
of low EGFR expressing tumors
100 100
75 75
50 50
25 25
EGFR low EGFR low
p = 0.02 EGFR high p = 0.05 EGFR high
0 0
0 12 24 36 48 60 0 12 24 36 48 60
months months
Independent prognostic factor in MV analysis (age, sex, T, N, subsite, grade, Hb, EGFR)
HR 2.43 (1.01 – 5.87), p = 0.05.
Why are high expressing EGFR tumors resistant to ARCON?
•better defense mechanisms after “O2-shock” and simultaneous radiotherapy?
•induction of HIF-1 pathway by EGFR through hypoxia-independent mechanisms?
•more rapid activation of DNA-repair processes?

47. Acknowledgements
• Nijmegen UMC St. Radboud • Groningen UMC
G. Janssens H. Bijl
S. Rademakers
• Maastro Clinic
I. Hoogsteen
P. van den Ende
P. Span
J. Bussink • Leiden UMC
• Utrecht UMC A. Chin
Ch. Terhaard • London Mt Vernon
• Amsterdam VUMC M. Saunders
P. Doornaert
R. De Bree
Financial support:
Dutch Cooperative Head and Neck
Oncology Group