A phase II trial of cisplatin and vinorelbine in patients with recurrent or metastatic squamous cell carcinoma of the head and neck

Efficacy and safety of vinorelbine in heavily pretreated recurrent/metastatic head and neck squamous cell carcinoma patients

The aim of this study was to evaluate the efficacy and tolerance of vinorelbine as a single agent in the treatment of recurrent/metastatic head and neck squamous cell carcinoma. Patients were treated with oral or intravenous vinorelbine according to the pluridisciplinary tumor board's decision. Efficacy and safety outcomes were analyzed retrospectively. Twenty-three patients were included in the study. Sixteen patients (69%) had received at least two previous lines of chemotherapy. The disease control rate was 19%. The median progression-free survival was 2.6 months and the median overall survival was 3.4 months. The rate of grade 3-4 side effects was low (13%). Only one patient discontinued treatment because of side effects. Vinorelbine seems to be a well-tolerated regimen in heavily pretreated patients. However, this regimen does not seem to be efficient enough to be recommended.

Chemotherapy for Late-Stage Cancer Patients: Meta-Analysis of Complete Response Rates

Complete response (CR) rates reported for cytotoxic chemotherapy for late-stage cancer patients are generally low, with few exceptions, regardless of the solid cancer type or drug regimen. We investigated CR rates reported in the literature for clinical trials using chemotherapy alone, across a wide range of tumour types and chemotherapeutic regimens, to determine an overall CR rate for late-stage cancers. A total of 141 reports were located using the PubMed database. A meta-analysis was performed of reported CR from 68 chemotherapy trials (total 2732 patients) using standard agents across late-stage solid cancers—a binomial model with random effects was adopted. Mean CR rates were compared for different cancer types, and for chemotherapeutic agents with different mechanisms of action, using a logistic regression. Our results showed that the CR rates for chemotherapy treatment of late-stage cancer were generally low at 7.4%, regardless of the cancer type or drug regimen used. We found no evidence that CR rates differed between different chemotherapy drug types, but amongst different cancer types small CR differences were evident, although none exceeded a mean CR rate of 11%. This remarkable concordance of CR rates regardless of cancer or therapy type remains currently unexplained, and motivates further investigation.

Induction of NKT cell-specific immune responses in cancer tissues after NKT cell-targeted adoptive immunotherapy

Vα24 natural killer T (NKT) cells have potent anti-tumor activity. We performed a phase II clinical study in patients with head and neck squamous cell carcinoma (HNSCC) using ex vivo expanded Vα24 NKT cells and α-galactosylceramide (αGalCer; KRN7000)-pulsed antigen-presenting cells (APCs) to investigate the efficacy and induction of NKT cell-specific immune responses. The subjects were 10 patients with locally recurrent and operable HNSCC. One course of nasal submucosal administration of αGalCer-pulsed APCs and intra-arterial infusion of activated NKT cells via tumor-feeding arteries was given before salvage surgery. Anti-tumor effects, NKT cell-specific immune responses in extirpated cancer tissue and peripheral blood, safety, and pathological effects were evaluated. Five cases achieved objective tumor regression. The number of NKT cells increased in cancer tissues in 7 cases and was associated with tumor regression. The combination therapy induced NKT cell-specific immune responses in cancer tissues that were associated with beneficial clinical effects.

MASPIN's prognostic role in patients with advanced head and neck carcinoma treated with primary chemotherapy (carboplatin plus vinorelbine) and radiotherapy: preliminary evidence

CONCLUSIONS

Our very preliminary results support the hypothesis that MASPIN expression in primary head and neck squamous cell carcinoma (HNSCC) may be a valuable parameter for predicting patients' responses to a treatment based on carboplatin plus vinorelbine combined with radiotherapy.

OBJECTIVES

The roles of induction chemotherapy and combined chemoradiotherapy in the treatment of locally advanced unresectable HNSCCs have evolved rapidly. MASPIN has a unique tumour-suppressing activity. Experimental evidence has shown that MASPIN suppresses tumour growth, angiogenesis, invasion and metastasis. We investigated the potential prognostic roles of MASPIN and p53 in a series of HNSCCs treated with carboplatin plus vinorelbine combined with radiotherapy.

PATIENTS AND METHODS

Nineteen consecutive stage III or IV HNSCC patients were recruited. The treatment plan consisted of the administration of carboplatin on day 1 and vinorelbine on days 1 and 8. Four weeks later, carboplatin was administered concomitantly with radiation therapy. Expression of MASPIN and p53 was determined immunohistochemically in HNSCC diagnostic biopsies.

RESULTS

A significant inverse relation was found between MASPIN expression and cN staging (p = 0.003). From a prognostic viewpoint, MASPIN expression was directly correlated with chemoradiotherapy response (p = 0.041). Moreover, the log-rank test showed a significant relationship between higher MASPIN expression and longer disease-free survival (p = 0.03), overall survival (p = 0.006) and disease-specific survival (p = 0.007).

[Cancer chemotherapy of the upper aerodigestive tract]

Tumours of the upper aerodigestive tract represent the sixth most frequent kind of cancer in France and throughout the world. If the localised forms may be controlled in the long run in two thirds of cases by surgery or radiotherapy, only one third of locally advanced forms are accessible to a cure after association from radiotherapy and chemotherapy. Besides, with a median of survival less than six months, metastatic tumours present a catastrophic spontaneous prognosis among patients with a medical ground that is often heavily deteriorated by prolonged exposure to alcohol and tobacco. Thus, there is a necessity to implement adapted therapeutic strategies to each patient and based on satisfactory proof levels of effectiveness. Optimisation of existing chemotherapy protocols and development of new therapies, in particular of targeted therapies, remain an important objective in the hope to improve results of treatments in locally advanced and metastatic cancers of the oral cavity.

Standard, and novel cytotoxic and molecular-targeted, therapies for HNSCC: an evidence-based review

(1) Head and neck squamous cell carcinoma is the sixth most frequently occurring cancer worldwide.(2) Chemotherapy has shown some success as part of multimodal treatment schedules for locally advanced, nonmetastatic head and neck squamous cell carcinoma, and too a much lesser extent for metastatic head and neck squamous cell carcinoma.(3) A recent meta-analysis of 32 studies involving >10,000 patients concluded that chemotherapy added to radiotherapy produces a large survival advantage relative to radiotherapy alone.(4) Concurrent or alternate chemoradiotherapy, with a schedule based on cisplatin, has an established place in the management of locally advanced nonmetastatic head and neck squamous cell carcinoma.

A phase II study using vinorelbine and continuous 5-fluorouracil in patients with advanced head and neck cancer

Seventy patients with advanced head and neck cancer were treated with vinorelbine and continuous 5-FU administered in a central venous catheter. Over all response was 36% with 9% complete responses. The most common grade 3 and 4 toxicities were stomatitis (13), infection (5), pain related to vinorelbine infusion (4), skin toxicity (3). Thirty one patients had grade 3 or 4 leukopenia. Treatment was complicated by venous thrombosis in the central venous catheter in one case. A majority of patients experienced dose reduction of one or both drugs or treatment delays due to toxicity. Median time to progression was 4.7 months and overall median survival 6.6 months. We conclude that the regimen is feasible and tolerated with moderate toxicity. Response rates and time to progression are comparable to other studies with multi agent treatment.

Concurrent use of vinorelbine and gefitinib induces supra-additive effect in head and neck squamous cell carcinoma cell lines

PURPOSE

Squamous cell carcinoma of the head and neck (HNSCC) remains a clinical challenge because of the high rate of locoregional disease recurrence. Standard treatment includes surgery, radiation, chemoradiation or a combination of these approaches. New therapies are needed to achieve improved survival, quality of life and organ function in these patients. A novel molecular targeted therapy incorporated into our current treatment strategies may have a significant role in the treatment of HNSCC. The aim of this study was to evaluate the sensitivity of HNSCC cell lines to vinorelbine combined with gefitinib in vitro.

METHODS

Six recently established cell lines were used: UT-SCC-9, -11, -19A, -29 and -34 (laryngeal SCC) and UT-SCC-33 (oral cavity SCC). Chemosensitivity was tested using the 96-well plate clonogenic assay. The vinorelbine concentrations used varied between 0.4 and 1.0 nM and the gefitinib concentrations varied between 0.05 and 1.6 muM. Survival data were fitted to the LQ model, and the area under the curve (AUC) value was obtained with numerical integration. The type of interaction was determined by comparing the AUC ratio of the two drugs to the survival fraction (SF) of gefitinib alone.

RESULTS

In the current study the combination of vinorelbine and gefitinib had a clear supra-additive or additive cytotoxic effect on the HNSCC cell lines.

CONCLUSIONS

This finding is encouraging as a proof of the possible benefit of combing an EGFR targeting compound with a cell cycle specific drug and warrants further studies of available combinations in vitro.

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

The purpose of this review is to provide readers with guidance concerning treatment of patients with advanced, recurrent or metastatic squamous cell carcinoma of the head and neck (SCCHN) in the context of clinical trial data. We discuss issues surrounding the treatment of patients with SCCHN, with an emphasis on recommendations based on results from phase II and III clinical trials published since 1980. Many options exist for the treatment of patients with SCCHN. The most important decisions involve determining which patients are in need of treatment and which are most likely to benefit from treatment. Although many chemotherapy treatments have been shown to induce responses, survival improvement remains an unfulfilled goal. Definitive data do not exist on the effects of chemotherapy on quality of life or progression-free survival as measures of clinical benefit in this setting. Performance status, history of prior treatment, extent of tumor, and need for palliation are the most important factors in the decision to treat a patient with chemotherapy for incurable SCCHN. Single-agent treatment with conventional doses of methotrexate remains a standard for most patients with advanced, recurrent or metastatic SCCHN. Cisplatin plus fluorouracil, cisplatin plus a taxane, and single-agent taxane are the most widely studied alternatives. There is a need for further trials with end points other than overall survival or tumor response in this patient population. Guidelines for patient selection and treatment options are provided.

New approaches to enhance chemotherapy in SCCHN

Chemotherapy is the standard approach to the treatment of patients with recurrent and metastatic squamous cell carcinoma of the head and neck (SCCHN) and is also now a common component of treatment for patients with locoregionally advanced, non-metastatic disease. Cisplatin has for many years been the agent of choice, alone or in combination with other agents, particularly 5-FU. The advent of the taxanes, which demonstrate good non-clinical activity against SCCHN, spawned a series of investigations aimed at integrating these agents into treatment regimens. Molecular targeted agents, which do not demonstrate overlapping toxicities with commonly used chemotherapy agents for SCCHN, represent a promising avenue of investigation. The epidermal growth factor receptor (EGFR) is expressed both widely and at high levels in SCCHN and is associated with poor prognosis. The EGFR-directed monoclonal antibody (MAb) cetuximab (Erbitux) in combination with chemotherapy has shown some activity in the treatment of recurrent/metastatic disease both as first-line therapy and following cisplatin failure, and preliminary results suggest single-agent activity in platinum-resistant disease. Promising activity has also been observed with a number of other EGFR inhibitors, both MAbs and tyrosine kinase inhibitors.

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.

Weekly cisplatin paclitaxel and continuous infusion fluorouracil in patients with recurrent and/or metastatic head and neck squamous cell carcinoma: a phase II study

BACKGROUND

Cisplatin, paclitaxel and 5-fluorouracil (5-FU) have demonstrated significant activity in patients with advanced squamous head and neck cancer (HNSCC) despite relevant toxicity. A weekly administration of cisplatin and paclitaxel with continuous infusion of 5-FU could offer a better toxicity profile without affecting dose intensity or treatment outcome. We evaluated the toxicity and the activity of weekly cisplatin/paclitaxel with continuous infusion 5-FU in patients with recurrent and/or metastatic HNSCC.

METHODS

A total of 44 patients were studied. Treatment consisted of two 6-week cycles with weekly cisplatin 20 mg/m2 and paclitaxel 60 mg/m2 and daily continuous infusion 5-FU 200 mg/m2 from day 1 to 42. Patients were evaluated for toxicity and response.

RESULTS

40 out of 44 patients were evaluable for response. After two cycles we observed seven complete responses (16%) and 12 partial responses (27%), with a 43% (95% CI 28-58%) overall response rate. Stable disease was seen in 13 patients (29%) and progressive disease in 12 patients (27%). Toxicity was mild in treated patients: we observed less than 10% of grade 3/4 hematological and gastroenteric toxicity.

CONCLUSIONS

A weekly schedule of cisplatin and paclitaxel associated with continuous infusion 5-FU showed low toxicity in the treatment of advanced HNSCC while significant activity was conserved.

New cytotoxic and molecular-targeted therapies of head and neck tumors

PURPOSE OF REVIEW

The purpose of this review is to provide an update on novel medical treatments for head and neck cancer.

RECENT FINDINGS

Despite the continuing introduction of new cytotoxic agents, such as antimetabolites (capecitabine, pemetrexed), and topoisomerase I inhibitors, the management of advanced head and neck cancer remains challenging. Epidermal growth factor receptor is an appealing target for novel therapies in head and neck cancer. Several rational approaches have been designed to abrogate epidermal growth factor receptor function, among which the development of small molecules, such as gefitinib or erlotinib, that inhibit tyrosine kinase activity, therefore abrogating the receptor's catalytic activity, autophosphorylation, and its engagement with signal transducers. The development of monoclonal antibodies, such as cetuximab, directed against the receptor's extracellular domain and competing for the binding of receptor ligands is another antireceptor strategy, because it induces epidermal growth factor receptor downregulation from the tumor cell surface. Gefitinib has been evaluated in a phase II study in head and neck cancer, at a dose of 500 mg/day. In this study, a 53% disease control rate was achieved, with a low toxicity. Currently, a phase II study at a dose of 250 mg/day is ongoing. A phase II study of erlotinib in advanced head and neck cancer has provided similar results to those of gefitinib, with a 46% control rate and an acceptable toxicity. Phase I studies of cetuximab have been carried out in advanced head and neck cancer, mainly combining the drug with chemotherapy or radiotherapy. Three phase II studies have evaluated the combination of cetuximab with platinum-based chemotherapy in pretreated patients with recurrent/metastatic head and neck cancer, with a control rate ranging from 29 to 66%. A phase III placebo-controlled trial has shown that the addition of cetuximab to cisplatin does not significantly improve median progression-free survival, despite a difference in the response rate between the two arms. Other molecular-targeted approaches in head and neck cancer include farnesyl transferase inhibitors, cell cycle regulators, and gene therapy.

SUMMARY

Novel targeted therapies are highly appealing in advanced head and neck cancer, and the most clever way to use them is a matter of intense investigation.