• 9/1/2007
  • Little Falls, NJ
  • Neil Osterweil
  • MedPageToday.com

A star chef with advanced squamous cell carcinoma of the oral tongue is undergoing aggressive chemoradiation hoping to avoid a resection that would cripple his sense of taste.

Grant Achatz, the nationally known chef, who is just 33, announced his condition a few weeks ago. He is owner of Alinea, a restaurant named as the best in the country by Gourmet.

According to Janet Adamy, a food writer in the Chicago bureau of the Wall Street Journal. Achatz is renowned for his meticulous plate preparations, audacious food pairings, and meals consisting of up to 30 tiny portions that can last up to seven hours and set diners back more than $200 each.

But when he was diagnosed with stage IVb squamous cell carcinoma of the oral tongue — a lesion most often treated by surgical resection, reconstruction, and irradiation, or in advanced cases palliative radiation alone — Achatz feared that he would lose his sense of taste. For an artist of the palate, it was unthinkable. Instead, Achatz pinned his hopes on an investigational protocol in phase II trials at the University of Chicago.

“We take an organ-preservation or primary non-surgical approach to treating these patients, because even if you’re not a chef who needs to preserve your taste, many patients want to preserve their ability to speak and swallow, for obvious reasons,” said Ezra Cohen, M.D., a member of the University of Chicago team treating Achatz.

Achatz is one of about 40 patients who are enrolled in a randomized trial of the targeted agent cetuximab (Erbitux), chemotherapy, and radiation.

Cetuximab is an epidermal growth factor receptor (EGFR_ inhibitor. Agents in this class, which include erlotinib (Tarceva) and gefitinib (Iressa), have shown promise in the treatment of head and neck cancers, both as single agents and in combination with radiation, Dr. Cohen said in an interview.

“We just completed a trial with a trial with a different EFGR inhibitor, Iressa,, in essentially the same regimen, and the data looked wonderful,” Dr. Cohen said. “We were getting survival rates higher than we had gotten in the past, the toxicity was lower because the EGFR agents tend to be well tolerated, and they don’t seem to exacerbate radiation toxicity, which is the main issue in treating these patients.”

Encouraging data emerging on the combination of cetuximab and radiation prompted the new trial, in which all patients are started on cetuximab added to paclitaxel and carboplatin as induction therapy.

Following induction, the patients are randomly assigned to one of two chemoradiation protocols:

Concurrent chemoradiation with cetuximab, 5-fluorouracil, hydroxyurea, and twice-daily radiation (the CetuxFHX protocol), or
Cetuximab, cisplatin, and accelerated radiation with concomitant boost (CetuxPX protocol).

But organ-preservation strategies are often less successful when used to treat the oral tongue compared with the base of the tongue, said Kevin S. Emerick, M.D., of the division of head and neck surgery and reconstruction at the Massachusetts Eye and Ear Infirmary in Boston, and Harvard.

“I think that the biology of squamous cell is quite diverse, and there are potentially some tumors that could respond to just chemotherapy,”. Dr. Emerick said in an interview. “However, we’re figuring which tumors those are.”

A more typical treatment approach to patients with stage IVb squamous cell carcinoma of the oral tongue, such as Achatz, would be a combination of a resection followed by radiation, with or without adjuvant chemotherapy, Dr. Emerick said.

“But as long as the patient understands that he’s receiving a unique protocol and the risks and benefits associated with it, then it may be worth a try,” he said.

According to the American Cancer Society, cancer of the tongue will occur in about 9,800 patients in the United States this year, and expected to cause 1,830 deaths.