Chemotherapy with gemcitabine-containing regimens for locally recurrent or metastatic nasopharyngeal carcinoma

Prevention of Hepatitis B Virus Reactivation in Patients With Nasopharyngeal Carcinoma With Lamivudine

PURPOSE

Although the mainstay of treatment of patients with nasopharyngeal carcinoma (NPC) had been radiotherapy, chemotherapy has increasingly been adopted in conjunction with radiation and in advanced disease. In parts of Asia where NPC is prevalent, it is also known that around 10% of the population has chronic hepatitis B virus (HBV) infection. Cancer patients who are HBV carriers are frequently complicated by HBV reactivation during chemotherapy. This may result in liver damage, which disrupts anticancer therapy and compromises the patients' prognosis. In its most severe form, fatal hepatic failure may occur. With the increasing use of chemotherapy in NPC, the occurrence of HBV reactivation is likely to increase further. Although recent reports have suggested that the antiviral agent lamivudine may reduce HBV reactivation and its associated morbidity, there has been no data on this aspect in NPC patients. This study assessed the role of lamivudine in preventing HBV reactivation and its associated morbidity in NPC patients who have chronic HBV infection and are undergoing chemotherapy.

MATERIALS AND METHODS

Two groups were studied. One group consisted of 16 patients who received prophylactic lamivudine prior to and until 8 weeks after discontinuing chemotherapy. The other comprised 21 historical control subjects who underwent chemotherapy without prophylactic lamivudine. The outcomes were compared.

RESULTS

With prophylactic lamivudine, there were significantly fewer incidences of hepatitis (6.7% vs 33.3%, P = 0.047) and HBV reactivation (0% vs 28.6%, P = 0.027), and less disruption of chemotherapy (18.8% vs 67.7%, P = 0.045).

CONCLUSION

Prophylactic lamivudine significantly reduces the incidence and morbidity of HBV reactivation in NPC patients undergoing chemotherapy.

A phase II study of docetaxel and cisplatin as first-line chemotherapy in patients with metastatic nasopharyngeal carcinoma

To evaluate the efficacy and safety of docetaxel and cisplatin as first-line chemotherapy in patients with metastatic nasopharyngeal carcinoma (NPC). Nineteen previously untreated metastatic NPC patients received one to six cycles of docetaxel and cisplatin. Fifteen patients received at least three cycles. The starting dose was 75 mg/m2 every three weeks for both drugs in 15 patients, and 60 mg/m2 for both drugs in four patients. All patients were included in toxicity and survival analysis, and 16 patients were evaluable for response. Median follow-up time was 11.6 months. Hematological toxicity was severe with Grade 4 neutropenia in 78.9% patients and 51.3% cycles. Febrile neutropenia occurred in 42% patients and 12.5% cycles, with two septic deaths in the population treated with 75 mg/m2. Patients treated with a dose subsequently reduced to 60 mg/m2 had a lower incidence of Grade 4 neutropenia and no incidence of neutropenic fever/sepsis. Overall response rate was 62.5%, with a 95% confidence interval of 35-85%. Partial and complete response rates were 56.3% and 6.3%, respectively. Median time to progression was 5.6 months and median survival was 12.4 months. Three patients (15.6%) survived >2 years following chemotherapy. The combination of docetaxel and cisplatin is active in metastatic NPC. The dose of 60 mg/m2 for both drugs without colony-stimulating factor support should be further evaluated as a high incidence of febrile neutropenia was observed with 75 mg/m2 dose.

State-of-the-art management of nasopharyngeal carcinoma: current and future directions

Nasopharyngeal carcinoma (NPC) is a distinct type of head and neck cancer. Approximately 70% of patients with newly diagnosed NPC present with locally advanced disease. Phase III clinical trials support the addition of chemotherapy to radiotherapy for the initial treatment of these patients. Once metastatic disease develops, practices become varied. Further experience needs to be gained with both targeted therapies and immunotherapy to gauge whether they will improve treatment outcomes in NPC.

Les carcinomes du nasopharynx : de la biologie à la clinique

Nasopharyngeal carcinomas (NPC) are very different from other head and neck cancers because of their specific multifactorial etiology and their geographic distribution. Epstein-Barr Virus (EBV) is implicated in oncogenesis of NPC in association with genetic alterations such as inactivation of the p16/Ink4, p19/ARF, RASSF1 or Blu genes. Tumoral tissues include a very abundant characteristic lymphoid infiltrate. Inflammatory cytokines are produced by both malignant and infiltrating cells. There is no efficient immune response against the tumor. On the opposite, infiltrating lymphocytes might play a role in tumor development. Serological methods and detection of circulating viral DNA are expected to become useful for early detection of relapse and on a longer term for primary screening. NPC are often diagnosed at a late stage because patients may remain asymptomatic for a long time. Computed tomography (CT scan) and magnetic resonance imaging (MRI) are complementary for the initial evaluation. Positron emission tomography (PET) is efficient for the evaluation of treatment efficiency and detection of relapses. Treatment is based on radiotherapy and chemotherapy. Their optimal use needs to be evaluated by phase III trials but positive results have been obtained by concomitant association of radiotherapy and chemotherapy. Targeted therapies are being studied with strategies based on disruption of viral latency, use of replicative adenoviruses or anti-tumor vaccination.

Recent perspectives in the role of chemotherapy in the management of advanced nasopharyngeal carcinoma

BACKGROUND

Recent advances in the treatment of nasopharyngeal carcinoma (NPC) have transpired into better treatment outcomes for patients with locoregionally advanced NPC, and have broadened the chemotherapeutic options for patients with metastatic disease.

METHODS

Data for this review were identified through searches of articles published in PubMed, MEDLINE, and abstracts from selected conference proceedings up to 2004.

RESULTS

The results of two meta-analyses and at least six randomized trials supported a survival benefit with the use of concurrent chemotherapy (e.g., platinum, tegafur-uracil [UFT)] and standard fractionated radiotherapy (with or without adjuvant chemotherapy) in the management of patients with locoregionally advanced NPC (nonmetastatic Stage III/IV disease, according to the staging system of the International Union Against Cancer). For those patients with metastatic NPC, platinum-based doublets using newer agents such as gemcitabine and the taxanes are reported to be better tolerated and can yield response rates comparable to those obtained with older, multidrug regimens.

CONCLUSIONS

The current study reviewed the latest literature and pertinent issues concerning the role of chemotherapy in the treatment of patients with metastatic and locoregionally advanced NPC.

Pathogenesis and treatment of nasopharyngeal carcinoma

Nasopharyngeal carcinoma (NPC), an endemic tumor in southern China, has three unique etiologic factors, including genetic susceptibility, chemical carcinogens, and association with Epstein-Barr virus (EBV) infection. Recent identification of critical genetic changes in this cancer has allowed the description of a multistep model for the pathogenesis of NPC. NPC is highly radiosensitive and chemosensitive. Attempts have been made to improve treatment results by integrating radiotherapy with some form of chemotherapy. Here, we review the current evidence available on the various chemotherapy-radiotherapy sequencing approaches and seek to define the optimal integration of radiotherapy and chemotherapy. Despite consistently high response rates to platinum-based neoadjuvant chemotherapy, none of six randomized studies of neoadjuvant and/or adjuvant chemotherapy showed any improvement in overall survival, although two did demonstrate significant improvement in local control rates and progression-free survival. However, three randomized studies of concurrent cisplatin-radiotherapy one with, and two without, adjuvant chemotherapy demonstrated significant improvement in progression-free survival and two of these have demonstrated improvement in overall survival. Preliminary data on the use of neoadjuvant chemotherapy followed by concurrent chemoradiation have been highly encouraging. Concurrent cisplatin-radiation with or without adjuvant chemotherapy should be considered as standard practice for locoregionally advanced NPC. The addition of neoadjuvant chemotherapy warrants further investigation and appears to be the most likely approach to further improve treatment results.

Chemotherapy for recurrent or metastatic squamous cell carcinoma of the head and neck

Recurrent and metastatic squamous cell carcinoma of the head and neck (SCCHN) are difficult problems and likely to become more challenging as concurrent chemotherapy and radiation are more widely used. Randomized studies reported in 1992 established the combination of cisplatin and infusional 5-fluorouracil (5-FU) as the reference regimen for chemotherapy-naive, good-performance status patients. Subsequently, a randomized study of 194 patients comparing cisplatin and 5-FU to cisplatin and paclitaxel found better tolerance, better pain relief, and improved quality of life with the newer regimen, but no survival differences (medians of 9 months) were detected. Phase II studies of a platinum/taxane combination with a third drug have reported response rates of greater than 50%, including 15% complete responses. A number of non-platinum-containing regimens are active in pretreated patients. Gefitinib has shown median survival times comparable to those achieved with cisplatin and paclitaxel, and appears especially promising for patients who recur after cytotoxic chemotherapy. Newer antifolates, agents that target or restore deficient p53, and other signal transduction inhibitors are under study.