The role of chemotherapy in the management of nasopharyngeal carcinoma

Nasopharyngeal carcinoma: current views on the tumor microenvironment's impact on drug resistance and clinical outcomes

The incidence of nasopharyngeal carcinoma (NPC) exhibits significant variations across different ethnic groups and geographical regions, with Southeast Asia and North Africa being endemic areas. Of note, Epstein-Barr virus (EBV) infection is closely associated with almost all of the undifferentiated NPC cases. Over the past three decades, radiation therapy and chemotherapy have formed the cornerstone of NPC treatment. However, recent advancements in immunotherapy have introduced a range of promising approaches for managing NPC. In light of these developments, it has become evident that a deeper understanding of the tumor microenvironment (TME) is crucial. The TME serves a dual function, acting as a promoter of tumorigenesis while also orchestrating immunosuppression, thereby facilitating cancer progression and enabling immune evasion. Consequently, a comprehensive comprehension of the TME and its intricate involvement in the initiation, progression, and metastasis of NPC is imperative for the development of effective anticancer drugs. Moreover, given the complexity of TME and the inter-patient heterogeneity, personalized treatment should be designed to maximize therapeutic efficacy and circumvent drug resistance. This review aims to provide an in-depth exploration of the TME within the context of EBV-induced NPC, with a particular emphasis on its pivotal role in regulating intercellular communication and shaping treatment responses. Additionally, the review offers a concise summary of drug resistance mechanisms and potential strategies for their reversal, specifically in relation to chemoradiation therapy, targeted therapy, and immunotherapy. Furthermore, recent advances in clinical trials pertaining to NPC are also discussed.

Pembrolizumab monotherapy versus chemotherapy in platinum-pretreated, recurrent or metastatic nasopharyngeal cancer (KEYNOTE-122): an open-label, randomized, phase III trial

BACKGROUND

Pembrolizumab previously demonstrated robust antitumor activity and manageable safety in a phase Ib study of patients with heavily pretreated, programmed death ligand 1 (PD-L1)-positive, recurrent or metastatic nasopharyngeal carcinoma (NPC). The phase III KEYNOTE-122 study was conducted to further evaluate pembrolizumab versus chemotherapy in patients with platinum-pretreated, recurrent and/or metastatic NPC. Final analysis results are presented.

PATIENTS AND METHODS

KEYNOTE-122 was an open-label, randomized study conducted at 29 sites, globally. Participants with platinum-pretreated recurrent and/or metastatic NPC were randomly assigned (1 : 1) to pembrolizumab or chemotherapy with capecitabine, gemcitabine, or docetaxel. Randomization was stratified by liver metastasis (present versus absent). The primary endpoint was overall survival (OS), analyzed in the intention-to-treat population using the stratified log-rank test (superiority threshold, one-sided P = 0.0187). Safety was assessed in the as-treated population.

RESULTS

Between 5 May 2016 and 28 May 2018, 233 participants were randomly assigned to treatment (pembrolizumab, n = 117; chemotherapy, n = 116); Most participants (86.7%) received study treatment in the second-line or later setting. Median time from randomization to data cut-off (30 November 2020) was 45.1 months (interquartile range, 39.0-48.8 months). Median OS was 17.2 months [95% confidence interval (CI) 11.7-22.9 months] with pembrolizumab and 15.3 months (95% CI 10.9-18.1 months) with chemotherapy [hazard ratio, 0.90 (95% CI 0.67-1.19; P = 0.2262)]. Grade 3-5 treatment-related adverse events occurred in 12 of 116 participants (10.3%) with pembrolizumab and 49 of 112 participants (43.8%) with chemotherapy. Three treatment-related deaths occurred: 1 participant (0.9%) with pembrolizumab (pneumonitis) and 2 (1.8%) with chemotherapy (pneumonia, intracranial hemorrhage).

CONCLUSION

Pembrolizumab did not significantly improve OS compared with chemotherapy in participants with platinum-pretreated recurrent and/or metastatic NPC but did have manageable safety and a lower incidence of treatment-related adverse events.

Stereotactic body radiotherapy extends the clinical benefit of PD-1 inhibitors in refractory recurrent/metastatic nasopharyngeal carcinoma

Purpose

Emerging evidence shows that immune checkpoint inhibitors lead to durable responses in a variety of cancers, including nasopharyngeal carcinoma (NPC), however, combination approaches (i.e., stereotactic body radiation therapy, SBRT) are required to extend this benefit beyond a subset of patients. This study retrospectively evaluated eight recurrent/metastatic NPC patients, to investigate how radiation could potentiate PD-1 checkpoint inhibition therapy.

Methods

Between September 2016 and July 2017, eight consecutive cases with histologically confirmed PDL1-positive status, for which prior standard therapy had been ineffective (five patients), were treated at our institution and Macao Clinics and two patients had disease progression within 6 months of completion of definitive chemoradiation, or one patient refused to receive chemoradiotherapy. All received PD-1 inhibitors first, seven of them accepted SBRT with an unmodified PD-1 inhibitors regimen after first evaluation as they were unresponsive to PD-1 inhibitors alone. Treatment was discontinued as long as patients were experiencing a clinical benefit in the opinion of the physicians and at least five cycles were given before stoppage.

Results

Median follow-up time was 56.7 months. The confirmed objective response rate based on RECIST-v1.1 at first evaluation was 12.5% (1/8). For the seven cases who received SBRT, six of them experience an objective response (6/7, 85.7%) after SBRT. Only one patient showed rapid progress and die within 95 days after the initiation of SBRT intervention. Three patients who did not have all lesions exposed to irradiation were available to evaluate the incidence of an abscopal effect, however, it did not occur as expected. Median PFS and OS for the seven patients were 8.0 and 30.8 months after SBRT intervention, respectively. Two-year OS as indicated was 71.0%.

Conclusions

PD-1 inhibitors combined with SBRT demonstrated promising antitumor activity in patients with PD-L1 positive RM-NPC. Patients may benefit from continue immunotherapy beyond disease progression when SBRT was introduced.

Nimotuzumab plus platinum-based chemotherapy versus platinum-based chemotherapy alone in patients with recurrent or metastatic nasopharyngeal carcinoma

Background

Palliative chemotherapy has been the mainstay treatment for patients with recurrent or metastatic nasopharyngeal carcinoma (R/M-NPC). However, little is known about the efficacy and toxicity of nimotuzumab (NTZ) - a monoclonal antibody drug targeting epidermal growth factor receptor - plus chemotherapy (CT) versus CT alone for these patients.

Methods

The database at Cancer Hospital of Chinese Academy of Medical Sciences was queried for patients diagnosed with NPC who received CT with or without NTZ between 2004 and 2018. Treatment compliance, survival outcomes, and adverse effects were compared among these groups.

Results

Records of 70 patients with R/M-NPC were reviewed: 21 (30%) received NTZ plus CT (NTZ+CT) and 49 (70%) received CT. CT regimens included gemcitabine plus platinum, taxane plus platinum (TP), and fluorouracil plus platinum. Comparing the CT group with NTZ+CT group, the median follow up was 62 months (range = 3-133) versus 59 months (range = 9-117); median progression free survival was 7.5 [95% confidence interval (CI) 6.552-8.381] months versus 8.5 (95% CI 6.091-10.976) months, p = 0.424; median overall survival (OS) was 25.6 (95% CI 18.888-32.379) months versus 48.6 (95% CI 35.619-61.581) months, p = 0.017, respectively. Multivariable analysis established treatment group (CT versus NTZ+CT) as an independent prognostic factor for OS (hazard ratio, 0.5; 95% CI 0.255-0.979; p = 0.043). No significant difference with regard to toxicities was observed between the two groups. Among them, a subgroup analysis was performed in 53 (75.7%) patients who received TP with or without NTZ, which showed similar results.

Conclusion

Our findings suggested that NTZ+CT provides a novel treatment option and prolongs survival significantly for R/M-NPC.

Palliative chemotherapy with or without anti-EGFR therapy for de novo metastatic nasopharyngeal carcinoma: a propensity score-matching study

Objective

We aimed to investigate the efficacy and safety of cetuximab (CTX) or nimotuzumab (NTZ) on the addition of palliative chemotherapy (PCT) in patients with de novo metastatic nasopharyngeal carcinoma (NPC).

Materials and methods

From 2007 to 2016, 451 eligible patients with de novo metastatic NPC were enrolled in the study. With propensity score matching technique, we created a well-balanced cohort by matching patients who received CTX/NTZ plus PCT (62 patients) with those receiving PCT alone (248 patients) in a ratio of 1:4. The primary endpoint was overall survival (OS). All potential prognostic factors were involved in the multivariate analysis with the Cox regression hazards model. Kaplan-Meier curves were used to compare the survival status, and log-rank test to measure the significance.

Results

The median follow-up time was 27.7 months (range, 1-126 months). No significant difference in survival was observed between the CTX/NTZ plus PCT group and PCT group. (3-year OS: 63.0% vs 58.1%; P=0.485). The administration of CTX/NTZ was not found to be an independent prognostic factor in multivariate analysis. With regard to toxicity, the development of a G3-4 skin reaction and mucositis was more common in patients receiving CTX plus PCT. Interaction effects analysis did not show any significant interaction effects on OS between the treatment regimen and prognostic factors (P>0.05).

Conclusion

The efficacy of CTX/NTZ and PCT is comparable to single PCT treatment in terms of survival outcomes among de novo metastatic NPC patients. Moreover, the application of CTX exacerbated skin reactions and mucositis.

Role of zoledronic acid in nasopharyngeal carcinoma patients with bone-only metastasis at diagnosis

OBJECTIVE

We aimed to investigate whether zoledronic acid (ZA) can prevent skeletal-related events (SREs) and offer survival benefits for nasopharyngeal carcinoma (NPC) patients with bone-only metastasis at diagnosis.

MATERIALS AND METHODS

A total of 228 newly diagnosed NPC cases with bone-only metastasis were eligible for this retrospective study. Using the propensity score method (PSM) method, a well-balanced cohort was created for further analysis. Overall survival (OS) was the primary endpoint. The difference in survival was evaluated using the log-rank test. Hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause mortality were derived from a Cox regression model. Cumulative incidence competing risk analyses using Fine and Gray's method was used to test the cumulative incidence of SREs between the different treatment groups.

RESULT

In the PSM cohorts, patients in the platinum-based palliative chemotherapy (PCT) + ZA group and PCT alone group achieved similar 3-year OS (57.3% vs. 46.4%; log rank P = 0.188). Multivariate analysis indicated that ZA administration was not an independent prognostic factor (HR, 0.783; 95% CI, 0.267-2.300; P = 0.657). There was no significant difference in acute treatment toxicity between the 2 treatment groups, although the cumulative incidence of bone-related events (SREs) was significantly lower in the PCT + ZA group (Fine-Gray P = 0.026).

CONCLUSION

ZA combined with PCT could not improve OS in NPC patients with bone-only metastasis at diagnosis. However, the incidence of SREs could be effectively prevented via ZA application.

Which nasopharyngeal cancer patients need adaptive radiotherapy?

Background

Adaptive radiotherapy (ART) has potential benefits in patients with nasopharyngeal cancer (NPC). This retrospective study aimed to identify the factors favoring ART.

Materials and methods

Forty NPC patients were retrospectively included in this study. All patients received two-phase, volumetric modulated arc radiotherapy (VMAT) and underwent a second computed tomography (CT) for the phase II ART. We generated phantom, non-ART plans by a hybrid method for comparison with ART plans. A paired t-test was used to evaluate the dose differences between these two plans. A subgroup analysis through a paired t-test was used to evaluate the factors favoring ART.

Results

The second CT images were captured at the median 22 fractions. The median total dose of the planning target volume-one (PTV-1) was 72 Gy, and the phase II dose was 16 Gy. The volumes of the ipsilateral parotid gland (23.2 vs. 19.2 ml, p <  0.000), contralateral parotid gland (23.0 vs. 18.4 ml, p <  0.000), clinical target volume-1 (CTV-1, 32.2 vs. 20.9 ml, p <  0.000), and PTV-1 (125.8 vs. 107.3 ml, p <  0.000) all shrunk significantly between these two CT simulation procedures. Among the nearby critical organs, only the ipsilateral parotid gland displayed significant dose reduction by the ART plan (5.3 vs. 6.0 Gy, p = 0.004). Compared to the phantom plan, the ART could significantly improve the PTV-1 target volume coverage of D₉₈ (15.4 vs. 12.3 Gy, p < 0.000). Based on the D₉₈ of PTV-1, the factors of a large initial weight (> 60 kg, p < 0.000), large body mass index (BMI) (> 21.5, p < 0.000), obvious weight loss (> 2.8 kg, p < 0.000), concurrent chemoradiotherapy (p < 0.000), and stages III–IV (p < 0.000) favored the use of ART.

Conclusions

ART could significantly reduce the mean dose to the ipsilateral parotid gland. ART has dosimetrical benefit for patients with a heavy initial weight, large BMI, obvious weight loss, concurrent chemoradiotherapy, and cancer in stages III–IV.

Combined Chemo-Radiotherapy for Stage IV Undifferentiated Nasopharyngeal Carcinoma

Undifferentiated nasopharyngeal carcinoma is a chemosensitive lesion, but its role in the management of local advanced disease is under investigation. Twenty-seven untreated stage IV undifferentiated nasopharyngeal carcinoma patients were treated with radiotherapy (median dose, 66.6 Gy, 1.8 Gy/day) and concomitant cisplatin (100 mg/m2 days 1, 22 and 43). After 4 weeks, patients received, every 4 weeks, 3 cycles with cisplatin (80 mg/m2 day 1) + 5-fluorouracil (1000 mg/m2/day continuous infusion for 96 h). After radiotherapy, we observed 74% complete responses and 26% partial responses; after adjuvant chemotherapy 96% had a complete and 4% a partial response. After a median follow-up of 36 months, 81% of the patients were alive (70% with no evidence of disease). Four-year overall and disease-free survival was 70% and 60%, respectively. Concomitant chemotherapy plus radiotherapy was well tolerated, whereas adjuvant chemotherapy was more toxic. Long-term results were significantly better than those observed with radiotherapy alone.

Volumetric Analysis of Endoscopic and Maxillary Swing Surgical Approaches for Nasopharyngectomy

Objectives/Hypothesis  The endoscopic endonasal approach (EEA) for nasopharyngectomy is an alternative to the maxillary swing approach (MSA) for selected recurrent nasopharyngeal carcinomas (NPC). We compare the access between these approaches. Methods  Three cadaver specimens were used to compare access volumes of the EEA and MSA. Exposure volumes were calculated using image guidance registration to cone beam computed tomography and tracking of accessible tissue with volumetric quantification. The area of exposure to the carotid artery was measured. Results  The MSA provided higher volumes for access volume compared with the EEA (66.6 vs 39.1 cm ³ , p  = 0.009). The working area was larger in the MSA (80.2 vs 56.9 cm ² , p  = 0.06). The exposure to the carotid artery was higher in the MSA (1.88 vs 1.62 cm ² , p  = 0.04). The MSA provided larger volume of exposure for tumors of the parapharyngeal space with exposure below the palate. Conclusions  This study suggests that the MSA for nasopharyngectomy provides a larger volume of exposure. However, much of the increased exposure relates to exposure of the parapharyngeal space below the palate. The EEA provides adequate access to superior anatomical structures.

No association between TGF-β1 polymorphisms and risk of nasopharyngeal carcinoma in a large North African case-control study

Background

Genetic susceptibility plays a key role in the development of nasopharyngeal carcinoma (NPC) and in fact the disease presents with an unusually high incidence in certain regions of the world like North Africa. We investigated the association between polymorphism of the Transforming growth factor-β1 (TGF-β1) and risk of NPC in North Africa. TGF-β1 is a multifunctional cytokine that acts as both a tumor suppressor and a stimulator of cancer development; it has been shown to influence risk of numerous other carcinomas including lung, breast and prostate cancer.

Methods

TGF-β1 polymorphisms C-509T and T869C were studied in a large North African sample of 384 NPC cases and 361 controls, matched for age, sex and urban or rural residence in childhood. Genotypes were determined using polymerase chain reaction–restriction fragment length polymorphism.

Results

No association was observed between individual single nucleotide polymorphisms or their haplotypes and NPC susceptibility (for TGF-β1 C-509T: OR = 0.74; 95 % CI 0.46 − 1.18; for TGF-β1 T869C: OR = 0.86; 95 % CI 0.56 − 1.31), even when the samples were stratified by age, gender and TNM stage.

Conclusion

Contrary to what has been observed in Asian samples, in our North African sample, the TGF-β1 C-509T and T869C polymorphisms did not substantially influence NPC susceptibility.

Electronic supplementary material

The online version of this article (doi:10.1186/s12881-016-0337-8) contains supplementary material, which is available to authorized users.

Sequential Cytokine-Induced Killer Cell Immunotherapy Enhances the Efficacy of the Gemcitabine Plus Cisplatin Chemotherapy Regimen for Metastatic Nasopharyngeal Carcinoma

In this study, we investigated the efficacy of sequential cytokine-induced killer cell (CIK) immunotherapy with gemcitabine plus cisplatin (GC) regimen chemotherapy in metastatic nasopharyngeal carcinoma (NPC) patients. Between September 2006 and April 2010, 222 NPC patients with distant metastasis after radiotherapy completion were retrospectively analyzed: 112 patients received 4–6 cycles of GC chemotherapy at 4-week intervals, followed by at least 4 cycles of CIK immunotherapy at 2-week intervals (GC+CIK group); the remaining 110 patients received 4–6 cycles of GC chemotherapy alone (GC group). The evaluation of long-term efficacy showed that the progression-free survival (PFS) rate was significantly higher in the GC+CIK group (log-rank test; p = 0.009), as was the overall survival (OS) rate (p = 0.006). In conclusion, sequential CIK treatment may be effective in enhancing the therapeutic efficacy of GC chemotherapy for metastatic NPC patients. This study provides a basis for alternative therapeutic strategies for metastatic NPC.

Lymphoepithelioma-like carcinoma of the lung: an unusual case and literature review

We described a case of lymphoepithelioma-like carcinoma (LELC) of the lung of a 65-year-old man with initial symptoms of intermittent chest pain and mild shortness of breath for 2 weeks. A right-lung mass was noted on chest computed tomography (CT) scan and was proved histopathologically as LELC of lung after video-assisted thorascopic lobectomy. He was successfully treated with lobectomy with postoperative adjuvant chemotherapy and is alive without signs of recurrence for 36 months after the diagnosis. It is important for clinicians, pathologists, and radiologists to understand the clinical, pathological, and radiological presentations of this neoplasm to avoid improper clinical decision making and misdiagnosis.

Chitosan nanoparticles cause pre- and postimplantation embryo complications in mice

Embryo development is a complex and tightly controlled process. Nanoparticle injury can affect normal development and lead to malformation or miscarriage of the embryo. However, the risk that these nanoparticles may pose to reproduction is not clear. In this study, chitosan nanoparticles (CSNP) of near uniform size, in the range of 100 nm, were synthesized and confirmed by a particle size analyzer and transmission electron microscopy. Morulae-stage embryo exposure to CSNP during in vitro culture caused blastocyst complications that had either no cavity or a small cavity. Furthermore, CSNP-treated embryos showed lower expression of not only trophectoderm-associated genes but also pluripotent marker genes. When blastocysts developed in both media with and without CSNP were transferred to recipients, the percentage of blastocysts resulting in viable pups was significantly reduced. These detrimental effects are linked to the reduction of total cell numbers, enhanced apoptosis, and abnormal blastocoels forming at the blastocyst stage, indicating that CSNP treatment might have long-term adverse biological effects in view of pregnancy outcome.

Increased treatment-related mortality with additional cisplatin-based chemotherapy in patients with nasopharyngeal carcinoma treated with standard radiotherapy

BACKGROUND AND PURPOSES

We performed a meta-analysis of randomized controlled trials (RCTs) to determine the overall risk of treatment-related death associated with additional cisplatin-based chemotherapy in patients with nasopharyngeal carcinoma treated with standard radiotherapy.

MATERIAL AND METHODS

Eligible studies included RCTs in which cisplatin-based chemotherapy in combination with radiotherapy was compared with radiotherapy alone. Statistical analyses were conducted to calculate the summary incidence rates, relative risks (RRs), and 95% confidence intervals (CIs) using fixed- or random-effects models based on the heterogeneity of included studies.

RESULTS

A total of 2829 patients from 13 RCTs were included in this study. The overall incidence for treatment-related death in chemoradiotherapy and radiotherapy treated patients was 1.7% and 0.8%. Compared to radiotherapy alone, radiotherapy plus cisplatin-based chemotherapy significantly increased the risk of treatment-related mortality. On subgroup analyses, no difference was found in treatment-related mortality between different timings of chemotherapy and chemotherapeutic agents. Adding cisplatin-based chemotherapy was associated with higher incidences of severe acute toxicity.

CONCLUSIONS

Cisplatin-based chemotherapy plus radiotherapy increased the risk of treatment-related death and severe acute toxicity, compared with radiotherapy alone. Better management of treatment toxicity might improve the therapeutic gain in patients with nasopharyngeal carcinoma.

Open-label, single-arm phase II study of pemetrexed in the treatment of patients with recurrent or metastatic nasopharyngeal carcinoma who have had prior platinum-based chemotherapy

BACKGROUND

This study was designed to evaluate the anti-tumor activity and toxicity of single agent pemetrexed in the treatment of patients with recurrent or metastatic nasopharyngeal carcinoma (NPC) who had been treated with platinum-based chemotherapy.

PATIENTS AND METHODS

This is an open-label, single-arm phase II trial. All patients were treated with pemetrexed. Pemetrexed was given at the dosage of 500 mg/m(2) on day 1, with folic acid and vitamin B12 supplementation, each cycle repeated every 3 weeks. Treatment continued until patient had disease progression or unacceptable toxicities.

RESULTS

Thirty-five patients were enrolled in this trial. Thirty patients of total were suitable for tumor response assessment. One (2.9 %) patient achieved partial response (PR); 14 (40.0 %) patients, stable disease (SD); and 15 (42.9 %), progressed disease (PD). The progress-free survival (PFS) was 1.5 months (range, 1.5-14.4 months) and median overall survival (OS) was 13.3 months (95 % CI 8.2-18.4 months). Treatment was well tolerated in most patients. Only one patient (2.9 %) experienced grade 4 toxicity of thrombocytopenia and neutropenia. The most seen toxicities were neutropenia (37.1 %), aminotransferase increase (31.4 %), and rash (22.9 %).

CONCLUSIONS

Although pemetrexed induced a response in a patient, it has limited single-agent activity in advanced NPC patients pretreated with platinum-based chemotherapy.

Second malignant tumors after treatment of nasopharyngeal carcinoma: four case reports and literature review

The purpose of this study was to identify the histopathology, location, and latency interval for the development of second malignant tumors (SMT) after successful treatment for nasopharyngeal carcinoma (NPC). Of 55 patients, four developed SMT after successful treatment of NPC in a single institutional series for an incidence of 7%. An additional 31 patients with SMT after treatment for NPC were identified from the literature. At minimum, all patients were treated with radiotherapy to the primary site. The histopathology of SMT included sarcoma (69%), squamous cell carcinoma (17%), adenocarcinoma (6%), meningioma (6%), and lymphoma (3%). SMT occurred at various sites in the head and neck, but most (51%) arose in the sinonasal cavity. For the entire group, the mean latency interval between treatment for NPC and the development of SMT was 11.8 years. These findings indicate that the development of SMT in patients achieving long-term survival after treatment for NPC may be radiation induced. Long-term follow-up for these patients is important to assess for this potentially late complication.

Concurrent chemoradiotherapy with carboplatin followed by carboplatin and 5-fluorouracil in locally advanced nasopharyngeal carcinoma

Background

This study aimed to evaluate acute major toxicities, the response rate, 3-year overall survival and progression-free survival rate of locally advanced nasopharyngeal carcinoma patients on concurrent carboplatin chemoradiotherapy followed by carboplatin and 5-fluorouracil.

Methods

A prospective study of fifty patients diagnosed with locally advanced nasopharyngeal carcinoma received conventional radiation therapy with a total dose of 6600-7000 cGy in 6-7 weeks and concurrent chemotherapy of three cycles of carboplatin during radiotherapy, followed by adjuvant chemotherapy using carboplatin plus 5-fluorouracil for two cycles.

Results

Weight loss and mucositis were the two most common acute major grades 3-4 toxicities (42%). Myelosuppression occurred subsequently, including leukopenia (30%), neutropenia (20%), anemia (12%), and thrombocytopenia (6%). Only 8% of patients developed grades 3-4 nausea and vomiting. No patients had renal and electrolyte abnormalities. Regarding the response evaluation, 100% of patients achieved an objective response rate of the primary tumor (92% complete response, and 8% partial response). Similarly, all patients also achieved an objective response rate of the neck node (64% complete response and 36% partial response). The 3-year overall survival rate and progression-free survival rate were 89.7% and 72.7%, respectively.

Conclusions

Concurrent chemoradiotherapy with carboplatin followed by carboplatin and 5- fluorouracil could be considered as an alternative regimen for locally advanced nasopharyngeal carcinoma patients pertaining to a good overall response rate, 3-year overall survival and progression-free survival rate with good tolerability.

Indole-3-carbinol inhibits nasopharyngeal carcinoma

This study explored the effects of indole-3-carbinol on the proliferation of human nasopharyngeal carcinoma, both in vitro and in vivo, and the underlying mechanisms in inducing apoptosis of CNE1 cells. Proliferation, apoptosis, malondialdehyde, superoxide dismutase, glutathione peroxidase, expressions of caspase-9, and caspase-3 in human nasopharyngeal carcinoma cells CNE1 were examined. Indole-3-carbinol suppressed proliferation, induced apoptosis, decreased malondialdehyde level, increased the activity of superoxide dismutase and glutathione peroxidase, and up-regulated the expression of active fragments of caspase-9 and caspase-3 both in vitro and in vivo. It was concluded that indole-3-carbinol could inhibit proliferation and induce apoptosis of CNE1 cells and inhibit tumor growth in mice. Increased activity of superoxide dismutase and glutathione peroxidase and activated expression of caspase-9 and caspase-3 were also observed in indole-3-carbinol-treated tumors or tumor cells, suggesting that stress- and apoptosis-related molecules are involved in the indole-3-carbinol-induced apoptosis and inhibition of tumor growth.

Lymphoepithelioma-like carcinoma in the trachea: report of a case

Lymphoepithelioma-like carcinoma (LELC) is a non-nasopharyngeal undifferentiated carcinoma with prominent lymphoid infiltration. To our knowledge, only two cases of LELC in the trachea have ever been reported. This tumor has a strong association with the Epstein-Barr virus (EBV), which is especially prevalent in Asians and absent in Caucasians. We report a case of tracheal LELC with EBV-association in a 22-year-old man. The patient was treated with tracheal resection and anastomosis, followed later by adjuvant radiotherapy.

Phase II clinical study of gemcitabine in the treatment of patients with advanced nasopharyngeal carcinoma after the failure of platinum-based chemotherapy

PURPOSE

This study was designed to evaluate the anti-tumor activity and toxicity profile of gemcitabine in the treatment of patients with advanced nasopharyngeal carcinoma (NPC) who had been pretreated with platinum-based chemotherapy.

METHOD

This is an open label, single arm phase II trial. All patients were treated with single agent of gemcitabine. Gemcitabine was given in the dosage of 1.0 g/m(2) on days 1, 8, 15, each cycle repeated every 4 weeks. Gemcitabine was added to 100 ml normal saline infused over 30 min.

RESULT

About 32 patients were enrolled in this trial. Thirty patients were assessable for response to treatment. Fourteen patients had a partial response (PR), giving an overall response rate of 43.8% (14/32); 9 patients had stable disease (28.1%) and 7 progressed disease (21.9%). The median time to progression was 5.1 months and median survival time was 16 months, 1 year survival rate was 67%, 2 year overall survival rate was 12%. A total of 11 patients (34.4%) experienced grade 3 and 4 toxicity and the main toxicity was myelosuppression. the non-hematology toxicity was minimal.

CONCLUSION

The effectiveness of gemcitabine was higher and side effects were minimal in advanced NPC patients after platinum-based chemotherapy failed.

Treatment outcomes of patients with AJCC stage IVC nasopharyngeal carcinoma: benefits of primary radiotherapy

BACKGROUND

There is no agreement on the optimal management of patients initially presenting with metastatic nasopharyngeal carcinoma. This study was performed to investigate the treatment outcomes and to assess whether radiotherapy to the primary tumors has survival benefits.

METHODS

From 1993 to 2001, 806 consecutive patients with histology-proven nasopharyngeal carcinoma were registered at our department. Among them, 125 patients had distant metastases and fulfilled the criteria for stage IVC of the 1997 American Joint Committee on Cancer staging system. Tumor histology according to the World Health Organization classification was Type 2 in 67 patients and Type 3 in 58 patients. The most common site of initial metastasis was bone. A total of 28 patients refused any treatment, 39 received chemotherapy alone and 58 had radiotherapy to the primary tumor sites alone.

RESULTS

The 1 year overall survival rates were 25, 36 and 48% for patients with no treatment, chemotherapy and radiotherapy, respectively. In multivariate analysis, age of diagnosis and treatment modality were confirmed as independent prognostic factors for overall survival.

CONCLUSIONS

Based on our results, radiotherapy to the primary tumor sites could be considered for patients with stage IVC nasopharyngeal carcinoma. A combination of radiotherapy and chemotherapy might have potential survival benefits. Further randomized prospective study is necessary to explore the optimal treatment strategy.

Phase III Study Comparing Standard Radiotherapy With or Without Weekly Oxaliplatin in Treatment of Locoregionally Advanced Nasopharyngeal Carcinoma: Preliminary Results

Purpose

A prospective, randomized, phase III study was performed to evaluate the feasibility and efficacy of concurrent weekly oxaliplatin with radiotherapy in patients with locoregionally advanced nasopharyngeal carcinoma (NPC).

Patients and Methods

From January 2001 to January 2003, 115 patients with locoregionally advanced NPC were randomly assigned to either radiotherapy (RT) alone (56 patients) or concurrent chemoradiotherapy (CCRT; 59 patients). All patient characteristics were well balanced in both arms. CCRT with oxaliplatin 70 mg/m2 weekly was administered for six doses from the first day of RT.

Results

All patients were eligible for toxicity and response analysis. Compliance with the protocol treatment was excellent, with 97% of patients completing all planned doses of oxaliplatin, and a lack of high-grade toxicity was observed. After a median follow-up time of 24 months, there was a significant difference in overall survival (OS), relapse-free survival (RFS), and metastasis-free survival (MFS) in favor of the CCRT arm. The 2-year OS rates were 100% for the CCRT arm and 77% for the RT arm (P = .01). The 2-year MFS rates were 92% for the CCRT arm and 80% for the RT arm (P = .02). The 2-year RFS rates were 96% for the CCRT arm and 83% for the RT arm (P = .02).

Conclusion

CCRT with weekly oxaliplatin is feasible and improves OS, MFS, and RFS rates in patients with locoregionally advanced NPC. Therefore, further randomized trials including oxaliplatin are warranted.

Nasopharyngeal carcinoma in the pediatric age group: the northern Israel (Rambam) medical center experience, 1989-2004

Nasopharyngeal carcinoma (NPC) is rare in children, accounting for less than 1% of all malignancies. Radiation therapy has been the mainstay of treatment of many years, but to improve survival, the use of chemotherapy has been advocated. This is a retrospective analysis of 13 patients less than 20 years of age treated for NPC the Rambam Medical Center during 1989 to 2004. Eight boys and five girls with a median age of 14.5 years (range 10-19) were included. Median follow up (including patients who died) was 6.15 years (range 1-15 years). Duration of symptoms was 1 to 24 months (median 5 months). Of the 13 patients, one patient had stage I, 6 had stage III, 5 had stage IV-A, and 1 had stage IV-B disease. Ten patients (77%) had undifferentiated carcinoma (WHO type III) and three patients (23%) had nonkeratinizing carcinoma (WHO type II). Most of the children received two or three courses of neoadjuvant multiagent chemotherapy consisting of cisplatin and 5-FU, followed by radiotherapy with doses in excess of 60 Gy. One child received concomitant chemoradiation. Ten of the 13 patients (77%) are alive without disease 6 years after diagnosis (range 1-15 years). One patient developed local and distant metastases 1 year after diagnosis and is currently receiving combined radiochemotherapy. Two patients died. Overall survival was 84%; event-free survival was 77%. Nine patients (69%) developed moderate to severe long-term complications. Pediatric NPC is curable by combined radiation and chemotherapy, with doses of radiation in excess of 60 Gy. Long-term follow-up is important for early detection of second malignancies as well as for radiation-induced endocrinologic deficiencies and other normal tissue complications.

Inhibitors of Epidermoid Growth Factor Receptor Suppress Cell Growth and Enhance Chemosensitivity of Nasopharyngeal Cancer Cells in vitro

OBJECTIVE

Epidermoid growth factor receptor (EGFR, HER1) is overexpressed in a majority of head-and-neck cancers, including nasopharyngeal carcinoma (NPC). Although EGFR inhibitors appear to be effective for some head-and-neck cancers, their efficacy in NPC remains unclear.

METHODS

The effect of EGFR-specific tyrosine kinase inhibitors, including PD153035 and ZD1839, were studied in NPC-TW01, NPC-TW04, and HONE1 cell lines. The effect of combining EGFR inhibitors with cytotoxic agents was evaluated in NPC-TW04 cells.

RESULTS

All three NPC cell lines expressed EGFR. PD153035 and ZD1839 inhibited the growth of NPC cells with IC50s around 10 and 20 microM, respectively. These inhibitors, however, effectively suppressed ligand-stimulated EGFR activation in NPC cells with a much lower concentration (> or =0.1 microM). The growth-suppression activity of EGFR inhibitors was closely associated with suppression of AKT phosphorylation. LY294002, a phosphatidylinositol-3 kinase (P13K)/AKT inhibitor, did suppress the growth of NPC cells. Pretreatment of EGFR inhibitors by 24 h significantly enhanced the cytotoxic effect of doxorubicin, paclitaxel, cisplatin, and 5-fluororuacil in NPC-TW04 cells.

CONCLUSIONS

Our data indicate that inhibition of EGFR activation is not sufficient to induce growth inhibition in NPC cells in vitro. EGFR inhibitors may be useful adjuncts in treating NPC when combined with conventional anticancer drugs.

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.

Treatment outcomes and late complications of 849 patients with nasopharyngeal carcinoma treated with radiotherapy alone

PURPOSE

The objective of this study was to describe the treatment outcomes and treatment-related complications of nasopharyngeal carcinoma (NPC) patients treated with radiotherapy alone.

METHODS AND MATERIALS

Retrospective analysis was performed on 849 consecutive NPC patients treated between 1983 and 1998 in our institution. Potentially significant patient-related and treatment-related variables were analyzed. Radiation-related complications were recorded.

RESULTS

The 5-year overall and disease-free survival rates of these patients were 59% and 52%, respectively. Advanced parapharyngeal space (PPS) invasion showed stronger prognostic value than PPS invasion. Multiple neck lymph node (LN) involvement was demonstrated to be one of the most powerful independent prognostic factors among all LN-related parameters. External beam radiation dose more than 72 Gy was associated with significantly higher incidence of hearing impairment, trismus, and temporal lobe necrosis.

CONCLUSIONS

We recommend that the extent of PPS should be clarified and stratified. Multiple neck LN involvement could be integrated into the N-classification in further revisions of the American Joint Committee on Cancer stage. Boost irradiation is not suggested for node-negative necks. For node-positive necks, boost irradiation is indicated and a longer interval between initial and boost irradiation would reduce the incidence of neck fibrosis without compromising the neck control rate.

Validation of a new prognostic index score for disseminated nasopharyngeal carcinoma

Patients with metastatic nasopharyngeal carcinoma have variable survival outcomes. We previously designed a scoring system to better prognosticate these patients. Here, we report results on validation of this new prognostic index score in a separate cohort of patients. Clinical features and laboratory parameters were examined in 172 patients with univariate and multivariate analyses and a numerical score was derived for each independent prognostic variable. Significant independent prognostic variables and their scores assigned included poor performance status (score 5), haemoglobin < 12 g dl(-1) (score 4) and disease-free interval (DFI) (DFI < or = 6 months (score 10) or metastases at initial diagnosis (score 1)). Maximum score was 19 and patients stratified into three prognostic groups: good, 0-3; intermediate, 4-8; poor, > or = 9. When applied to a separate cohort of 120 patients, 59 patients were good, 43 intermediate and 18 poor prognosis, with median survivals of 19.6 (95% CI 16.1, 23.1), 14.3 (95% CI 12.3, 16.2) and 7.9 (95% CI 6.6, 9.2) months, respectively. (logrank test: P = 0.003). We have validated a new prognostic score with factors readily available in the clinics. This simple score will prove useful as a method to prognosticate and stratify patients as well as to promote consistent reporting among clinical trials.

Multicenter, phase II study of cetuximab in combination with carboplatin in patients with recurrent or metastatic nasopharyngeal carcinoma

PURPOSE

To evaluate efficacy and toxicity of cetuximab plus carboplatin in recurrent or metastatic nasopharyngeal carcinoma (NPC) resistant to platinum treatment.

PATIENTS AND METHODS

A multicenter, open-label, single-arm, phase II study in patients with epidermal growth factor receptor-expressing NPC who progressed on or within 12 months after termination of platinum-based chemotherapy for recurrent or metastatic disease. Cetuximab was administered at an initial dose of 400 mg/m2 followed by weekly doses of 250 mg/m2. Carboplatin area under the curve 5 was administered every 3 weeks up to a maximum of eight cycles.

RESULTS

Sixty patients were enrolled (46 males, 14 females; median age, 44.5 years; range, 23 to 64 years), and all patients were included in the intent-to-treat and safety analyses. Of the 59 patients assessable for efficacy, there were seven partial responses (11.7%), 29 patients (48.3%) with stable disease, and 23 patients (38.3%) with progressive disease, giving an overall response rate of 11.7% (95% CI, 4.8% to 22.6%). The median time to progression was 81 days in all patients and was longest in the group of patients with a confirmed response (173 days). The median overall survival time was 233 days in all patients. Six patients (10%) experienced serious treatment-related adverse events. Grade 3 or 4 toxicities occurred in 31 patients (51.7%); of these patients, only 19 (31.7%) were considered to have toxicity related to cetuximab.

CONCLUSION

Cetuximab in combination with carboplatin demonstrates clinical activity and an acceptable safety profile in heavily pretreated patients with recurrent or metastatic NPC who had previously experienced treatment failure with platinum-based therapy.

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.

Preradiation chemotherapy with methotrexate, cisplatin, 5-fluorouracil, and leucovorin for pediatric nasopharyngeal carcinoma

BACKGROUND

Nasopharyngeal carcinoma (NPC) is rare in children, accounting for <1% of all cases. Treatment most commonly includes radiotherapy but long-term side effects of such treatment can produce devastating cosmetic and functional sequelae in children. Chemotherapy may help to decrease the radiotherapy dose and limit the side effects of local therapies. However, little is known regarding the chemosensitivity of NPC tumors in pediatric patients.

METHODS

Patients with American Joint Committee on Cancer (AJCC) Stage I/II disease (Stratum 01) received irradiation only. Patients with AJCC Stage III/IV disease (Stratum 02) received 4 courses of preradiation chemotherapy comprising methotrexate (120 mg/m2) on Day 1, with cisplatin (100 mg/m2) 24 hours later, 5-fluorouracil 1000 mg/m2 per day as a continuous infusion for 3 days, and leucovorin 25 mg/m2 every 6 hours for 6 doses. Irradiation was given after chemotherapy and consisted of 50.4 gray (Gy) to the upper neck and 45.0 Gy to the lower neck, with a boost to the primary tumor and positive lymph nodes for a total dose of 61.2 Gy.

RESULTS

One patient was enrolled in Stratum 01 and 16 evaluable patients were enrolled in Stratum 02. The median age of the patients was 13 years and 65% of the patients were black. All patients tested had evidence of Epstein-Barr virus infection. Two-thirds of the patients developed Grade 3-4 mucositis during chemotherapy. The overall response rate to induction chemotherapy was 93.7%. The overall 4-year event-free and overall survival rates (+/- the standard error) were 77%+/-12% and 75%+/-12%, respectively.

CONCLUSIONS

The current study demonstrated that childhood NPC was sensitive to chemotherapy and that chemotherapy before irradiation was feasible. Future trials should investigate equivalent efficacy with a reduced radiotherapy dose.

Lung metastasis alone in nasopharyngeal carcinoma: a relatively favorable prognostic group. A study by the Hong Kong Nasopharyngeal Carcinoma Study Group

BACKGROUND

The current study was conducted to examine the pattern and the predictive factors of distant metastases (DM) in patients with nasopharyngeal carcinoma (NPC) after primary radiotherapy treatment.

METHODS

Data from all five regional cancer centers in Hong Kong were collected retrospectively and pooled for the current study, which was coordinated by the Hong Kong Nasopharyngeal Carcinoma Study Group. The sample was comprised of all 2915 patients with NPC without DM at the time of presentation who were treated with radiotherapy in 1 of the 5 cancer centers during the period between January 1996 and December 2000.

RESULTS

DM was found to be the leading cause of NPC failure, with a 5-year actuarial rate of 14.9% in this patient cohort. Despite the poor overall survival (OS) of these patients, those with lung metastasis alone represented a distinctive group associated with a significantly better OS. International Union Against Cancer (UICC) N classification, UICC T classification, advanced age, and male gender were found to be significant and independent determinants for DM.

CONCLUSIONS

Long-term survival is possible in patients with distant metastatic NPC confined to the lung. An aggressive approach to treatment for this group of patients should be considered.

Nasopharyngeal carcinoma in childhood and adolescence: a single institution's experience with treatment modalities during the last 15 years

Pediatric nasopharyngeal carcinoma (NPC) represents a locally advanced undifferentiated tumor with widely varying epidemiological features and with a high cure rate when combined modality treatment is provided. Both local and systemic treatment is necessary, and additional treatment with biologic modifiers seems promising. In this study, clinical experience and therapeutic results of 10 children with newly diagnosed NPC, treated in a single pediatric hematology/oncology institution in Athens over a period of 15 years, are analyzed. Results from Greece on NPC in young patients are reported for the first time. Ten patients (6 male, 4 female) 7-14 years old (median = 12.5) with a nasopharyngeal tumor were retrospectively evaluated. Disease extent was staged according to the TNM system. EBV-DNA, EBERs, and LMP-1 from paraffin-embedded tissues were studied in 8 patients. All patients received both local and systemic treatment. All cases were classified as type WHO-3. The presence of EBV-DNA and expression of EBER 1-2 mRNAs was demonstrated in the 8 tumors examined, while LMP-1 protein was expressed in 4/8 of the studied cases. Disease stage was III in 4 and IV in 6 patients. Time from the onset of symptoms to diagnosis ranged from 4 to 24 weeks (mean 8 weeks). All patients received preradiation chemotherapy and radiotherapy, and 5/10 received postradiation chemotherapy due to either resistant or advanced disease. In 9/10 patients, complete locoregional control was achieved. In addition to chemotherapy and radiotherapy the latest patient of this series was treated with recombinant IFN-beta (10(5) IU/Kg i.v. 3 times a week) for 6 months and at 18 months remains in continuous complete remission. One patient was lost to follow-up 3 years after cessation of treatment while remaining in complete remission. Of the remaining 9 patients, 7 are alive for a median follow-up of 54 months (range 18-186); 5/7 are free of disease, and 2/7 are with disease but stable. The median time for first relapse was 17 months. The data confirm the good results of combined chemo-radiotherapy treatment for high-risk NPC in young patients. The documented EBV latency underlying this tumor, which possibly critically mediates its pathogenesis, justifies the use of biological modifiers with antiviral and immunoregulatory activity, like the IFNs, which may offer better therapeutic results in the future.

Timing of Chemoradiotherapy and Patient Selection for Locally Advanced Nasopharyngeal Carcinoma

AIMS

Predictors of outcome after radiotherapy alone for nasopharyngeal carcinoma (NPC) are now available from several retrospective studies. On the basis of these, it is theoretically possible to separate patients at risk of local failure from patients at risk of distant metastases (DM). According to classical principles of chemoradiotherapy timing, patients at risk of local failure would benefit mostly from concomitant chemoradiotherapy, whereas patients at risk distantly would benefit from sequential combinations.

MATERIALS AND METHODS

We reviewed the literature on combined chemoradiotherapy treatment for nasopharyngeal carcinoma to assess whether timing of combined treatment matches pattern of failure.

RESULTS

Available data show a significant overlap of activity, sequential treatments reducing local failure and concomitant treatments reducing DM. Therefore, in the individual patient, the strict adoption of traditional risk profiles in therapeutic decision-making may not fully exploit all the potential therapeutic effects derived from the maximal association of both sequential and concomitant therapies.

CONCLUSION

Whether such combination is clinically worthwhile in every patient with locoregionally advanced nasopharyngeal carcinoma needs prospective validation, because of the high toxicity of this modality.

A prospective study of pre-treatment cell kinetics and clinical outcome in nasopharyngeal carcinoma

BACKGROUND AND PURPOSE

To study pre-treatment cell kinetics and their clinical correlations in nasopharyngeal carcinoma (NPC).

MATERIALS AND METHODS

Ninety newly diagnosed NPC patients were studied using in vivo Bromodeoxyuridine (BrdU) labeling and flow cytometric analysis. Immunohistochemical staining for BrdU and Ki 67 was also performed.

RESULTS

The median S-phase duration (Ts) was 6.2 h (range 3.5-18.7 h), median flow cytometric labeling index (FCM-LI) was 7.4% (1.3-37.6%), and median potential doubling time (Tpot) was 3.6 days (0.5-19.9 days). The median histologic labeling index (H-LI) was 12.4% (1.2-43.3%), and median histologic Tpot (H-Tpot) was 2.1 days (0.5-33.3 days). FCM-LI and H-LI were both positively correlated with Ki67 whereas Tpot and H-Tpot were both negatively correlated with Ki67 and N-stage. In univariate analysis, Tpot and H-Tpot showed a trend for progression free survival. Tpot was significantly associated with local relapse free survival, but lost its significance in multivariate analysis. N-stage was the only significant prognostic factor for all radiotherapy outcomes in both univariate and multivariate analyses.

CONCLUSIONS

Tpot was the only pre-treatment cell kinetic parameter for which some evidence was found for an association with survival in NPC patients. Future studies should aim to combine cell kinetic parameters together with other biological markers and clinical parameters to provide more useful prognostic information to guide individual patient's therapy.

Ceramide induces cell cycle arrest and upregulates p27kip in nasopharyngeal carcinoma cells

Ceramide mediates differentiation, growth arrest, apoptosis, proliferation, cytokine biosynthesis and secretion, and a variety of other cellular functions. However, little is known regarding ceramide signaling linked to the cell cycle. In the present study, the effect of ceramide on cell cycle in nasopharyngeal carcinoma cell line CNE2 was investigated. The results showed that ceramide inhibited cell proliferation and induced cell cycle arrest in G1 phase in CNE2 cells. Exposure of CNE2 cells to ceramide resulted in a dose-dependent up-regulation of the cyclin-dependent kinase inhibitor p27 and a decrease of phospho-Akt without reduced expression of total AKT protein. The activation of phosphatidylinositol-3-kinase (PI3K) and the protein expression of PTEN were unaffected following ceramide treatment. We concluded that ceramide induced cell cycle arrest in G1 phase in CNE2 cells and p27 up-regulation was involved in this process. In addition, up-regulation of p27 resulting from ceramide treatment may be due to the interruption of Akt, but decrease of phospho-Akt is independent of PI3K function or PTEN protein expression.

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

BACKGROUND

Results from Phase II trials conducted in Asia have shown that gemcitabine alone (GEM) or with cisplatin (GC) is active among patients with metastatic or locally recurrent nasopharyngeal carcinoma (NPC).

METHODS

At the Princess Margaret Hospital (PMH), Toronto, 32 patients with NPC were treated with GEM (n = 18) or GC (n = 14) from January 2000 to October 2001. Patients either received 1000 mg/m(2) GEM on Days 1, 8, and 15 every 28 days as a single agent, or with cisplatin (CG) given on day 2 at 70 mg/m(2).

RESULTS

Most patients (91%) were of Southeast Asian ancestry and 29 (91%) had Type 2 (World Health Organization 1991 classification) nonkeratinizing histology. Sixteen of the GEM (89%) and five (36%) of the GC patients had received chemotherapy before entering the study. Median follow-up was 32 weeks (range, 2-97 weeks) for both groups. In the GEM group, there were five (28%) partial responses (PR) and one (6%) complete response (CR), giving an overall response rate of 34% (95% confidence interval [CI], 13.59). In the GC group, there were two (14%) CRs and seven PRs (50%), giving an overall response of 64% (95% CI, 35-87). Hematologic toxicity was dose limiting but uncomplicated. Nonhematologic toxicity included one patient with reversible reactivation of hepatitis, one with Grade 3 cisplatin-related sensory neuropathy, and three with cardiovascular events that were possibly related to chemotherapy. The median duration of response for the GEM and GC patients was 17 and 24 weeks and the 1-year survival rate was 48% (95% CI, 18-78) and 69% (95% CI, 40-99), respectively. Median survival has not been reached.

CONCLUSIONS

Our study confirms that GEM is an active and tolerable drug for patients with NPC.

Treatment strategy and clinical experience

Nasopharyngeal carcinoma (NPC) is highly radiosensitive and patients presenting with early disease have a high cure rate after radiotherapy. For patients presenting with locoregionally advanced disease, despite a high initial control rate with radiotherapy, the subsequent failure rates are significant. Concurrent cisplatin-radiotherapy with or without adjuvant chemotherapy have been demonstrated to significantly improve survival and is currently the standard treatment strategy for patients with locoregionally advanced disease. Encouraging phase II trials have been reported on the use of neoadjuvant chemotherapy followed by concurrent chemotherapy-radiotherapy, which may provide the optimal way to deliver chemoradiation in NPC. Improved radiotherapy techniques using intensity modulated methods or three-dimensional conformal methods may further improve local control by reducing geographical misses while preserving normal organ functions.

Multimodality paradigms for a healthy multimodality society

The American Radium Society encourages the study of cancer in all its aspects, encourages liaison among the various medical specialists and allied scientists, and thereby champions multimodality oncologic care. Past and present membership rolls of the Society read like a "Who's Who" of cancer care and include distinguished physicians and allied scientists whose primary focus spans the spectrum of oncologic subspecialties; however, the current distribution of areas of expertise may not necessarily be optimal. Moreover, the practice of medicine constantly is changing, and we, as a society, should be prepared to evolve with it. For example, treatment of cancers arising in the head and neck region has changed dramatically during the past decade. The successful integration of concurrent chemotherapy with radiation therapy has created new paradigms for optimal care. These paradigms potentially decrease the risk of distant metastases, improve the local-regional control of disease, increase the likelihood of organ preservation, and reduce the risk posed by microscopic-sized unresected disease. Yet, much remains unknown, some of the available data appear contradictory, and much is left to do. Similar analysis persuasively argues that other groups that have specific expertise must also play a vital role in modern oncologic care, including radiation biologists, medical physicists, and molecular biologists. Yet, the current environment creates formidable obstacles to participation in the American Radium Society's mission. We must improve our understanding of these barriers and implement original solutions to ensure that our society remains in the forefront of progress in the fight against cancer. In particular, programs to increase the educational reach of the ARS need to be devised, implemented, and nurtured. The ARS has a long, proud history, but we should not seek to live in its past. We must seek continuously and welcome enthusiastically changes in the Society that will align the ARS with paradigms of cutting-edge oncologic care.