Induction chemotherapy for locally advanced nasopharyngeal carcinoma treated with concurrent chemoradiation: A systematic review and meta-analysis

Cisplatin-docetaxel induction chemotherapy for patients with nasopharyngeal carcinoma in a non-endemic cohort

This is the report on our clinic's 15 years of experience (2004-2018) on nasopharyngeal carcinoma (NPC), treated with induction chemotherapy (IC) and subsequent concomitant chemoradiotherapy (CCRT), comprising population characteristics and treatment outcomes of 203 patients with non-metastatic NPC. IC comprised docetaxel (75 mg/m2) and cisplatin (75 mg/m2) combination (TP). Concurrent cisplatin (P) was applied either weekly (40 mg/m2, 32 cases) or every-3-week (100 mg/m2, 171 cases). The median follow-up duration was 85 months (range, 5-204 months). Overall and distant failure rates were observed in 27.1% (n = 55) and 13.8% (n = 28) patients, respectively. The 5-year locoregional recurrence-free survival (LRRFS), distant metastasis-free survival (DMFS), disease-free survival (DFS), and overall survival (OS) rates were 84.1%, 86.4%, 75%, and 78.7% respectively. The overall stage was an independent prognostic factor for the LRRFS, DMFS, DFS, and OS. The WHO histological type was a prognostic factor for the LRRFS, DFS, and OS. Age was a prognostic factor for the DMFS, DFS, and OS. Concurrent P schedule was independent prognostic only the LRRFS.

Reducing Target Volumes of Intensity Modulated Radiation Therapy After Induction Chemotherapy in Locoregionally Advanced Nasopharyngeal Carcinoma: Long-Term Results of a Prospective, Multicenter, Randomized Trial

PURPOSE

The objective of this study was to estimate the long-term survival, late toxicity profile, and quality of life of patients with locoregionally advanced nasopharyngeal carcinoma (NPC) treated with combined induction chemotherapy (IC) and concurrent chemoradiotherapy from a clinical trial focused on reducing the target volume of intensity modulated radiation therapy (IMRT).

METHODS AND MATERIALS

This prospective, randomized clinical trial was conducted across 6 Chinese hospitals and included 212 patients with stage III-IVB NPC who were randomly allocated to a pre-IC or post-IC group. Eligible patients were treated with 2 cycles of IC + CCRT. All patients underwent radical IMRT. Gross tumor volumes of the nasopharynx were delineated according to pre-IC and post-IC tumor extent in the pre-IC and post-IC groups, respectively.

RESULTS

After a median follow-up of 98.4 months, 32 of 97 (32.9%) and 33 of 115 (28.7%) patients experienced treatment failure or died in the pre-IC and post-IC groups, respectively. None of the patients developed grade 4 late toxicity. Late radiation-induced toxicity predominantly manifested as grade 1 to 2 subcutaneous fibrosis, hearing loss, tinnitus, and xerostomia, whereas grade 3 late toxicity included xerostomia and hearing loss. The 5-year estimated overall, progression-free, locoregional recurrence-free, and distant metastasis-free survival rates in the pre-IC and post-IC groups were 78.2% versus 83.3%, 72.0% versus 78.1%, 90.2% versus 93.5%, and 78.1% versus 82.1%, respectively. The pre-IC group had a significantly higher incidence of xerostomia and hearing damage than the post-IC group. In terms of quality of life, compared with the pre-IC group, the post-IC group showed significant improvement in cognitive function (P = .045) and symptoms including dry mouth (P = .004), sticky saliva (P = .047), and feeling ill (P = .041).

CONCLUSIONS

After long-term follow-up, we confirmed that reducing the target volumes of IMRT after IC in locoregionally advanced NPC showed no inferiority in terms of the risk of locoregional relapse and potentially improved quality of life and alleviated late toxicity.

Age is a significant biomarker for the selection of neoadjuvant chemotherapy plus radiotherapy versus concurrent chemoradiotherapy in patients with advanced nasopharyngeal carcinoma

BACKGROUND

The optimal timing of combined chemotherapy with radiotherapy for locally advanced nasopharyngeal carcinoma (LA-NPC) is undetermined.

OBJECTIVE

This study aimed to compare the therapeutic efficacy of neoadjuvant chemotherapy (NACT) followed by radiotherapy (RT) and concurrent chemoradiotherapy (CCRT).

METHODS

Five hundred and thirty-eight patients diagnosed with LA-NPC and treated with NACT + RT or CCRT alone were enrolled in the study. Restricted cubic spline regression (RCS) was used to determine the relationship between age and the hazard Ratio of death. A Kaplan-Meier analysis was performed to evaluate overall survival (OS) related to NACT + RT or CCRT alone. Cox proportional hazards models were used to adjust for potential confounding factors.

RESULTS

Compared with the CCRT alone regimen, the NACT + RT regimen showed a significantly better OS rate with a 62% decreased risk of death in a subgroup of patients aged ⩾ 45 years (hazard ratio, HR: 0.38; 95% confidence interval, CI: 0.24-0.61). In patients aged < 45 years, the risk of death was significantly increased when NACT + RT was chosen compared with CCRT (HR: 4.10; 95% CI: 2.09-8.07).

CONCLUSIONS

Age is a significant biomarker when selecting NACT + RT or CCRT alone in patients with advanced NPC.

Impact of induction chemotherapy with concurrent chemoradiotherapy on nasopharyngeal carcinoma: A meta-analysis of randomized controlled trials

Purpose

Induction chemotherapy followed by concurrent chemoradiotherapy (IC-CCRT) may be beneficial for nasopharyngeal carcinoma. However, the evidence on medium- and long-term effects of IC-CCRT is limited, and new randomized controlled trials (RCTs) have been published after 2018. Therefore, this systematic review and meta-analysis compared survival rates between patients with nasopharyngeal carcinoma receiving IC-CCRT or concurrent chemoradiotherapy (CCRT).

Methods

Four databases were searched for RCTs on this topic. Two authors independently selected studies, assessed evidence, and extracted data on progression-free survival, overall survival, metastasis-free survival, and local recurrence-free survival. Available data were pooled in a random-effects model and mainly presented in hazard ratio (HR). Heterogeneity and small study effects were also evaluated.

Results

Eleven RCTs (n = 3345) were deemed eligible. Pooled results revealed that patients receiving IC-CCRT had significantly improved progression-free survival (HR = 0.66, P &lt; 0.05), overall survival (HR = 0.64, P &lt; 0.05), metastasis-free survival (HR = 0.58, P &lt; 0.05), and local recurrence-free survival (HR = 0.69, P &lt; 0.05) at 3 years, but no significant difference in 5-year overall survival was noted between IC-CCRT and CCRT (HR = 0.84, P &gt; 0.05). Most findings had low heterogeneity.

Conclusion

IC-CCRT may benefit patients with nasopharyngeal carcinoma in the medium term, although no significant difference was observed in 5-year survival compared with CCRT. All outcomes had decreased survival rate from the 3-years to 5-year follow-up. Differences in patient ethnicities and regimens of IC-CCRT may be sources of heterogeneity.

Induction chemotherapy with paclitaxel, carboplatin and cetuximab for locoregionally advanced nasopharyngeal carcinoma: A single-center, retrospective study

Background

The addition of induction chemotherapy (IC) before chemoradiotherapy (CRT) has improved survival over CRT alone in locoregionally advanced nasopharyngeal cancer (LA-NPC). Nevertheless, this population would benefit from further development of a novel IC regimen with satisfactory efficacy and a more favorable safety profile.

Methods

We retrospectively assessed 29 LA-NPC patients who received the combination of paclitaxel (PTX), carboplatin (CBDCA), and cetuximab (Cmab) (PCE) as IC (IC-PCE) at the National Cancer Center Hospital East between March 2017 and April 2021. IC-PCE consisted of CBDCA area under the plasma concentration-time curve (AUC) = 1.5, PTX 80 mg/m², and Cmab with an initial dose of 400 mg/m² followed by 250 mg/m² administered weekly for a maximum of eight weeks.

Results

Patient characteristics were as follows: median age, 59 years (range 24–75); 0, 1 performance status (PS), 25, 4 patients; and clinical stage III/IVA/IVB, 6/10/13. The median number of PCE cycles was 8(1-8). After IC-PCE, 26 patients received concurrent cisplatin and radiotherapy (CDDP-RT), one received concurrent carboplatin/5-fluorouracil and radiotherapy (CBDCA/5-FU-RT), and two received RT alone. The % completion of CDDP-RT was 88.5%. The response rate was 75.9% by IC and 100% at completion of CRT. The 3-year recurrence-free survival, locoregional failure-free survival, distant recurrence-free survival, and overall survival were 75.9%, 79.3%, 84.3%, and 96.3%, respectively. The incidence of adverse events of grade 3/4 was 34.5% during IC and 44.8% during CRT.

Conclusion

IC-PCE is feasible and effective for LA-NPC and may be a treatment option for this disease.

Induction chemotherapy in nasopharyngeal carcinoma- A systematic review of phase III clinical trials

BACKGROUND

Induction Chemotherapy (IC) has the potential advantage of resulting in early eradication of micro metastasis thereby reducing distant failure in Nasopharyngeal Carcinoma (NPC). This study is to evaluate the effectiveness of induction chemotherapy in NPC based on published phase III Randomized Controlled Trials (RCT) METHODS: : We searched PubMed, SCOPUS, EMBASE and COCHRANE databases for phase III trials evaluating the role of IC in NPC using the following key words: nasopharyngeal carcinoma, locally advanced, locoregionally advanced, induction chemotherapy, and concurrent chemoradiation. We included phase 3 RCTs of NPC in which intervention patients received induction chemotherapy plus concurrent chemoradiation (CCRT) and the control patients received CCRT alone.

RESULTS

Six phase III RCTs have reported the data on effectiveness of IC in NPC so far. All except one study found statistically significant improvement in the primary outcome. One study demonstrated improved relapse free survival (RFS) with IC (stratified HR for recurrence or death 0.51; p=0.0001). Two studies reported improvement in disease free survival (DFS) with IC [adjusted HR 0.739 (p=0.0264) in one study; HR for 3-year and stratified HR for 5-year DFS 0.67 (p=0.028) and 0.66 (p=007) respectively in the other study]. One study demonstrated improvement in failure free survival (FFS) with IC [HR for 3-year and 5-year FFS 0.68 (p=0.034) and 0.67 (p=0.019) respectively] and another study reported improved progression free survival (PFS) [HR 0.44; p=0.042)]. Grade 3-4 acute adverse events were higher among patients who received IC.

CONCLUSION

IC followed by CCRT showed superior clinical outcomes in NPC compared to CCRT alone. Conflicting results were found with regard to overall survival.

Neoadjuvant chemotherapy plus intensity-modulated radiotherapy versus neoadjuvant chemotherapy plus concurrent chemoradiotherapy for ascending or descending types of nasopharyngeal carcinoma: A retrospective study

PURPOSE

This study aimed to compare the efficacy between neoadjuvant chemotherapy (NACT) plus intensity-modulated radiotherapy (IMRT) and NACT plus concurrent chemoradiotherapy (CCRT) in patients with nasopharyngeal carcinoma (NPC).

MATERIALS AND METHODS

Data from 603 patients with ascending (T4 and N0-1) or descending (T1-2&N3) NPC who were treated at Sun Yat-sen University Cancer Center between October 2009 and February 2012 were retrospectively analyzed. These patients were divided into two groups: NACT+IMRT (n = 302) and NACT+CCRT (n = 301). The primary endpoint was overall survival (OS), which was analyzed using the Kaplan-Meier method, log-rank test, Cox proportional hazards model, and landmark analysis.

RESULTS

In univariate analysis, there was no significant difference in 5-year OS between the NACT+IMRT and NACT+CCRT groups (hazard ration [HR]: 0.69; 95% confidence interval [CI]: 0.47-1.01; P = 0.057). However, after adjustment for age (<45 years, ≥45 years), gender, histological stage (I/II, III), T stage (1/2, 3, 4), and N stage (0/1, 2/3), NACT+IMRT was more effective in improving OS, with a 33% decrease in the risk of death than NACT+CCRT (HR: 0.67; 95%CI: 0.45-0.99). Furthermore, landmark analysis indicated that patients in the NACT+IMRT group had higher OS rates within 24 months (HR: 1.83; 95%CI: 1.00-3.34), whereas those treated with NACT+CCRT had higher OS rates after 24 months (HR, 0.47; 95% CI, 0.29-0.77). We also found significant survival benefits of NACT+IMRT regimen in patients younger than 45 years old (HR: 0.27; 95%CI: 0.14-0.49), and in those at stage T3 (HR: 0.50; 95%CI: 0.27-0.93) and stage N2/3 (HR: 0.52; 95%CI: 0.32-0.83).

CONCLUSION

Patients with ascending or descending NPC who are treated with NACT+IMRT may have better long-term survival outcomes than those treated with NACT+CCRT, especially the patients younger than 45 years old or in stage T3/N2/N3. Additionally, NACT+IMRT may be a better option than NACT+CCRT in patients within the first 24 months.

Meta-analysis of chemotherapy in nasopharynx carcinoma (MAC-NPC): An update on 26 trials and 7080 patients

Purpose

Chemotherapy, when added to radiotherapy, improves survival in locally advanced nasopharyngeal carcinoma (NPC). This article presents the second update of the Meta-Analysis of Chemotherapy in NPC.

Methods

Published or unpublished randomized trials assessing radiotherapy (±a second chemotherapy timing) with/without chemotherapy in non-metastatic NPC patients were identified. Updated data were sought for studies included in the previous rounds of the meta-analysis. The primary endpoint was overall survival. All trials were analyzed following the intent-to-treat principle using a fixed-effects model. Treatments were classified in five subsets according to chemotherapy timing. The statistical analysis plan was pre-specified.

Results

Eighteen new trials were identified. Individual patient data were available for seven. In total, the meta-analysis now included 26 trials and 7,080 patients. The addition of chemotherapy reduced the risk of death, with a hazard ratio (HR) of 0.79 (95% confidence interval (CI) [0.73; 0.85]), and an absolute survival increase at 5 and 10 years of 6.1% [+3.9; +8.3] and + 8.4% [+5.7; +11.1], respectively. The largest effect was observed for concomitant + adjuvant, induction (with concomitant in both arms) and concomitant chemotherapy, with respective HR [95%CI] of 0.68 [0.59; 0.79] (absolute survival increase at 5 years: 12.3% (7.0%;17.6%)), 0.73 [0.63; 0.86] (6.0% (2.5%;9.5%)) and 0.81 [0.70; 0.92] (5.2% (0.8%;9.6%)). The benefit of chemotherapy was also demonstrated by improvement in progression-free survival, cancer mortality, locoregional control and distant control. There was a significant interaction between patient age and chemotherapy effect.

Conclusion

This updated meta-analysis confirms the benefit of concomitant chemotherapy and concomitant + adjuvant chemotherapy, and suggests that addition of induction or adjuvant chemotherapy to concomitant chemotherapy improves tumor control and survival. The benefit of chemotherapy decreases with increasing patient age.

Efficacy and Safety of Concurrent Chemoradiotherapy Combined With Induction Chemotherapy or Adjuvant Chemotherapy in Patients With Stage II-IVA Nasopharyngeal Carcinoma: A Propensity Score Matching Analysis and Meta-Analysis

Purpose

To evaluate the efficacy and safety of induction chemotherapy (IC) combined with concurrent chemoradiotherapy (CCRT) versus CCRT combined with adjuvant chemotherapy (AC) in patients with stage II-IVA nasopharyngeal carcinoma (NPC), we conducted a retrospective study and a meta-analysis combining the results of our studies.

Patients and Methods

We used the propensity score matching (PSM) to balance variables. A total of 168 patients were chosen by one-to-two PSM, including 101 patients with IC + CCRT and 67 cases with CCRT + AC. We used the Kaplan-Meier curve to compare survival outcomes and also used Cox regression analysis to determine independent prognostic factors. For meta-analysis, we determined the related studies by searching the PubMed database. We used STATA v12 software to perform meta-analysis of the extracted data and calculate pooled hazard ratios, 95% confidence intervals of survival outcomes, and risk ratios for the toxicities.

Results

In this retrospective study, there was no significant difference in 5-year overall survival (76.9% vs. 79.0%, P = 0.966), progression-free survival (71.3% vs. 68.5%, P = 0.332), distant metastasis-free survival (80.5% vs. 74.2%, P = 0.140), and locoregional relapse-free survival (91.5% vs. 91.8%, P = 0.894) among patients with NPC with IC + CCRT versus CCRT + AC after PSM. For meta-analysis, six articles (including our study) reporting 1,052 cases of IC + CCRT and 883 cases of CCRT + AC were included in the meta-analysis. There was no difference of OS (pooled HR = 0.90, 95% CI: 0.63-1.29, P = 0.561), PFS (pooled HR = 1.07, 95% CI: 0.87-1.33, P = 0.633), DMFS (pooled HR= 0.98, 95% CI: 0.76-1.25, P=0.861), and LRRFS (pooled HR = 1.06, 95% CI: 0.76-1.48, P = 0.724).

Conclusion

The efficacy of IC + CCRT and CCRT + AC was comparable in patients with stage II-IVA NPC. In terms of compliance and acute adverse reactions, IC + CCRT may be a potential therapeutic strategy.

Risk of Stroke in Nasopharyngeal Cancer Survivors: A National Registry-Based Population Cohort Study

BackgroundWe aim to determine the risk of stroke and death within 30 days post stroke in nasopharyngeal cancer (NPC) survivors.MethodsWe conducted a population-based cohort study of patients diagnosed with NPC from Jan 1, 2005 to Dec 31, 2017. Using the cancer and stroke disease registries and the Singapore general population as the reference population, we report the age-standardized incidence rate differences (SIRDs) ratios (SIRs) and the cumulative incidence of stroke and the standardized mortality rate differences (SMRDs) and ratios (SMRs) for all causes of death within 30 days post stroke for NPC survivors.FindingsAt a median follow up of 48.4 months (IQR 19.8 - 92.9) for 3849 patients diagnosed with NPC, 96 patients developed stroke. The overall SIRD and SIR for stroke was 3.12 (95% CI 2.09 - 4.15) and 2.54 (95% CI 2.08 - 3.10) respectively. The SIRD was highest for the age group 70 - 79 years old (8.84 cases per 1000 person-years (PY); 0.46 - 17.21) while the SIR was highest for the age group 30 - 39 years old (16.41; 6.01 - 35.82). The SIRD and SIR for stage 1 disease was (6.96 cases per 1000 PY; 2.16 - 11.77) and (4.15; 2.46 - 7.00) respectively. The SMRD and SMR for all cause deaths within 30 days of stroke was (3.20 cases per 100 persons; -3.87 - 10.28) and (1.34; 0.76 - 2.37) respectively.InterpretationThe overall risk of stroke was markedly elevated in survivors of NPC, especially in Stage 1 disease when compared to the general population. The risk of death within 30 days of stroke was not significantly higher for NPC survivors.Classification of EvidenceThis study provides Class II evidence of the increased risk of stroke in survivors of nasopharyngeal cancer compared to general population.

Nasopharyngeal carcinoma: an evolving paradigm

The past three decades have borne witness to many advances in the understanding of the molecular biology and treatment of nasopharyngeal carcinoma (NPC), an Epstein-Barr virus (EBV)-associated cancer endemic to southern China, southeast Asia and north Africa. In this Review, we provide a comprehensive, interdisciplinary overview of key research findings regarding NPC pathogenesis, treatment, screening and biomarker development. We describe how technological advances have led to the advent of proton therapy and other contemporary radiotherapy approaches, and emphasize the relentless efforts to identify the optimal sequencing of chemotherapy with radiotherapy through decades of clinical trials. Basic research into the pathogenic role of EBV and the genomic, epigenomic and immune landscape of NPC has laid the foundations of translational research. The latter, in turn, has led to the development of new biomarkers and therapeutic targets and of improved approaches for individualizing immunotherapy and targeted therapies for patients with NPC. We provide historical context to illustrate the effect of these advances on treatment outcomes at present. We describe current preclinical and clinical challenges and controversies in the hope of providing insights for future investigation.

Epidemiological Profile and Clinicopathological, Therapeutic, and Prognostic Characteristics of Nasopharyngeal Carcinoma in Northern Morocco

Background

Nasopharyngeal carcinoma is a multifactorial disease mainly affecting the Asian and North African populations including Morocco. This study aimed to determine the epidemiological profile of nasopharyngeal carcinoma in Northern Morocco as well as its clinicopathological, therapeutic, and prognostic characteristics.

Methods

129 patients with nasopharyngeal carcinoma followed at the regional center of oncology of Tangier in the period between April 2017 and July 2019, and diagnosed elsewhere from March 2000 to February 2019, were included in this study. Statistical analysis of the data was realized using Statistical Package for the Social Sciences (SPSS) software.

Results

Nasopharyngeal carcinoma (NPC) represented 5% of all cases with a median age of 50. The most affected age group was 40–54 years (41.1%). Of all patients, 65.9% were men and 34.1% were women with a sex ratio of 1.93 (Male/Female). Undifferentiated nasopharyngeal carcinomas were the most common histological type affecting 96.12% of patients. At diagnosis, the majority of patients (82.2%) had an advanced stage of NPC (III, VIa, b, c) including 5.4% of metastatic cases (IVc). Most cases (86%) had lymph node involvement with cervical mass being the most common clinical presentation. 81.4% of patients received radiotherapy combined with chemotherapy. Among these patients, 54.3% had concurrent radiochemotherapy preceded by induction chemotherapy. The 5-year overall survival (OS) was 86.8% for all patients. It represented 91.3% for early stages, 87.9% for locally advanced stages, and 57.1% for the metastatic stage significantly. The disease-free survival (DFS) at 5 years was 87.6% knowing that relapse occurred in 16 cases.

Conclusions

Nasopharyngeal carcinoma is a particular disease with a late declaration. It is common in Morocco as is the case in other endemic areas with a high prevalence. Patients’ survival is significantly influenced by disease staging.

CT-Based Radiomics Nomogram for Prediction of Progression-Free Survival in Locoregionally Advanced Nasopharyngeal Carcinoma

Purpose

We aimed to construct of a nomogram to predict progression-free survival (PFS) in locoregionally advanced nasopharyngeal carcinoma (LA-NPC) with risk stratification using computed tomography (CT) radiomics features and clinical factors.

Patients and Methods

A total of 311 patients diagnosed with LA-NPC (stage III–IVa) at our hospital between 2010 and 2014 were included. The region of interest (ROI) of the primary nasopharyngeal mass was manually outlined. Independent sample t-test and LASSO-logistic regression were used for selecting the most predictive radiomics features of PFS, and to generate a radiomics signature. A nomogram was built with clinical factors and radiomics features, and the risk stratification model was tested accordingly.

Results

In total, 20 radiomics features most associated with prognosis were selected. The radiomics nomogram, which integrated the radiomics signature and significant clinical factors, showed excellent performance in predicting PFS, with C-index of 0.873 (95% CI: 0.803~0.943), which was better than that of the clinical nomogram (C-index, 0.729, 95% CI: 0.620~0.838) as well as of the TNM staging system (C-index, 0.689, 95% CI: 0.592–0.787) in validation cohort. The calibration curves and the decision curve analysis (DCA) plot obtained suggested satisfying accuracy and clinical utility of the model. The risk stratification tool was able to predict differences in prognosis of patients in different risk categories (p<0.001).

Conclusion

CT-based radiomics features, an in particular, radiomics nomograms, have the potential to become an accurate and reliable tool for assisting with prognosis prediction of LA-NPC.

Survival benefit of induction chemotherapy in treatment for stage III or IV locally advanced nasopharyngeal carcinoma - An updated meta-analysis and systematic review

PURPOSE

The purpose of this study was to investigate whether combined Induction chemotherapy (IC) with concurrent chemoradiotherapy (CCRT) for stage III or IV locally advanced nasopharyngeal carcinoma (LA-NPC) could achieve better survival benefits than CCRT alone.

MATERIALS AND METHODS

Only randomized controlled trials were included in this study. There were two treatment regiments (IC + CCRT and CCRT alone) recruited for analysis. The end points of this meta-analysis were overall survival (OS), locoregional recurrence-free survival (LRFS), and distant metastases-free survival (DMFS). Then we performed a traditional meta-analysis.

RESULTS

Seven studies were included, including 2628 patients. Compared with using CCRT alone, IC + CCRT has better effects on overall survival (OS) [HR = 0.75, 95% CI = 0.63-0.89], locoregional recurrence-free survival (LRFS) [HR = 0.70, 95% CI = 0.56-0.86] and distant metastasis-free survival (DMFS) [HR = 0.65, 95% CI = 0.54-0.78]. Of note, the addition of IC also increases the incidence of toxic reactions and patient discomfort.

CONCLUSION

IC + CCRT provided better survival benefits than CCRT alone. However, patients also had a higher incidence of toxic reactions with combination therapy.

The safety and efficacy of gemcitabine and cisplatin (GP)-based induction chemotherapy plus concurrent chemoradiotherapy in locoregionally advanced nasopharyngeal carcinoma: a meta-analysis

OBJECTIVE

To assess the safety and efficacy of gemcitabine and cisplatin (GP)-based induction chemotherapy (IC) plus concurrent chemoradiotherapy (CCRT) for patients with locoregionally advanced nasopharyngeal carcinoma (LA-NPC).

METHODS

We systematically searched the PubMed, Web of Science, Embase, and Cochrane Library databases. The endpoints included overall survival (OS), progression-free survival (PFS), distant failure-free survival (DMFS), locoregional failure-free survival (LRFFS) and treatment-related adverse events (AEs).

RESULTS

A total of seven studies were included in this meta-analysis. When GP-based IC was compared with double-drug-based or triple-drug-based IC, there were no significant differences in OS (HR 0.64, P = 0.08), PFS (HR 0.71, P = 0.09), DMFS (HR 0.87, P = 0.49) or LRFFS (HR 0.88, P = 0.66). Furthermore, subgroup analysis revealed that GP IC led to an improvement in OS compared with triple-drug-based IC (P < 0.0001). Regarding safety, compared to triple-drug-based IC, GP-based IC was related to a decreased risk of leucopenia (P = 0.007) and neutropenia (P = 0.02) but was associated with an increased risk of thrombocytopenia (P = 0.01). Compared to double-drug-based IC, the prevalence of grade 3 or above thrombocytopenia was higher in the GP group (P = 0.007). No significant difference in the incidence of other AEs was observed.

CONCLUSION

Based on efficacy and safety, our meta-analysis demonstrated that, compared to double-drug-based or triple-drug-based IC, IC with a GP regimen does not appear to improve OS, PFS, DMFS or LRFFS and mainly led to an increased risk of grade3/4 thrombocytopenia. Notably, our subgroup analysis data show that GP-based IC may bring improved trends in OS as compared to triple-drug-based IC. For the optimal IC regimen has not been established, which IC regimen will benefit most LA-NPC patients should be further explored.

Concurrent chemoradiotherapy with additional chemotherapy for nasopharyngeal carcinoma: A pooled analysis of propensity score-matching studies

OBJECTIVE

To determine the benefits of adding induction chemotherapy (IC) and adjuvant chemotherapy (AC) to concurrent chemoradiotherapy (CCRT) for nasopharyngeal carcinoma (NPC) based on propensity score-matching (PSM) studies.

METHODS

Eligible PSM studies were searched in the PubMed, Web of Science, and Embase databases from inception to September 1, 2020. The primary endpoints included overall survival (OS), distant metastasis-free survival (DMFS), and locoregional recurrence-free survival (LRFS).

RESULTS

A total of 14 trials consisting of 4086 participants were included. Significant benefits were observed between IC + CCRT and CCRT for OS (hazard ratio [HR], 0.76; 95% confidence interval [CI]: 0.64-0.91) and DMFS (HR, 0.77; 95% CI: 0.64-0.94) with the exception of LRFS (HR, 1.14; 95% CI: 0.90-1.43). However, CCRT + AC did not achieve significant improvements.

CONCLUSIONS

IC with CCRT yields significant survival benefits in terms of OS and DMFS, whereas CCRT with AC fails to achieve any additional benefit in all endpoints.

The Clinical Outcomes and Toxicities of Induction Chemotherapy Followed by Concurrent Chemoradiotherapy Plus Adjuvant Chemotherapy in Locoregionally Advanced Nasopharyngeal Carcinoma

Purpose

To analyze the outcomes and toxicities of induction chemotherapy (ICT) followed by concurrent chemoradiotherapy (CCRT) plus adjuvant chemotherapy (ACT) in patients with locoregionally advanced nasopharyngeal carcinoma (LA-NPC).

Methods

Retrospective analysis of 163 patients with LA-NPC referred from August 2015 to December 2018 was carried out. All patients underwent platinum-based ICT followed by CCRT plus ACT.

Results

The median follow-up time was 40 months, ranging from 5 to 69 months. The 3-year disease-free survival (DFS), overall survival (OS), locoregional recurrence-free survival (LRRFS), and distant metastasis-free survival (DMFS) rates were 80.8, 90.0, 91.6, and 87.4%, respectively. The most frequent acute grade 3/4 adverse events were leukopenia (66.8%), neutropenia (55.8%), mucositis (41.1%), thrombocytopenia (27.0%), and anemia (14.7%).

Conclusion

ICT followed by CCRT plus ACT did not seemingly enhance DFS and OS in LA-NPC patients compared to the addition of ICT to CCRT (historical controls). In contrast, ICT followed by CCRT plus ACT had more acute adverse events than ICT followed by CCRT. Longer-term clinical studies are required to examine the treatment outcomes and late toxicities.

Grading Soft Tissue Involvement in Nasopharyngeal Carcinoma Using Network and Survival Analyses: A Two-Center Retrospective Study

BACKGROUND

Soft tissue involvement (STI) indicates poor prognosis in nasopharyngeal carcinoma (NPC). However, only a few studies have systematically assessed this extension using network analysis.

PURPOSE

To investigate the prognostic value of STI and to propose an improved STI grading system for NPC therapy.

STUDY TYPE

Retrospective study.

POPULATION

A total of 1225 consecutive patients with pathologically confirmed NPC treated with intensive-modulated radiotherapy from January 2010 to March 2014 were enrolled from two centers.

FIELD STRENGTH/SEQUENCE

T1- and T2-weighted imaging and enhanced T1-weighted imaging with fast spin echo sequence at 1.5 or 3.0 T.

ASSESSMENT

The levator veli palatini and tensor veli palatini involvement were graded "mild," prevertebral muscle involvement, "moderate," medial pterygoid, lateral pterygoid, and the infratemporal fossa involvement, "severe" STI. The above STI sites were evaluated separately by three radiologists using MRI images and graded using network analysis. Overall survival (OS) and progression-free survival (PFS) were assessed.

STATISTICAL TESTS

Kaplan-Meier method, Cox's proportional hazards model, and concordance index (C-index) were used.

RESULTS

Five-year OS and PFS rates between mild and moderate groups (90.5% vs. 81.7%, P < 0.05 and 82.9% vs. 72.5%, P < 0.05, respectively) and between moderate and severe groups (81.7% vs. 70.4%, P < 0.05 and 72.5% vs. 61.2%, P < 0.05, respectively) revealed significant differences. The C-index of the nomogram with STI grading was higher compared with current T-classification (OS 0.641 vs. 0.604, P < 0.05 and PFS 0.605 vs. 0.581, P < 0.05, respectively). Significant OS differences were observed between patients with severe STI who underwent induction chemotherapy (IC) and those who did not (84.5% vs. 70.7%, P < 0.05).

DATA CONCLUSION

STI grading was an independent prognostic factor for OS and PFS in NPC patients and it may be help to improve the accuracy in predicting survival outcomes. Patients with severe STI might benefit from IC to improve OS.

LEVEL OF EVIDENCE

4 TECHNICAL EFFICACY: Stage 2.

Which treatment is better than concurrent chemoradiotherapy about survival for stage III or IV locally advanced nasopharyngeal carcinoma? An updated Bayesian network meta-analysis of randomized controlled trials

OBJECTIVE

To speculate whether induction chemotherapy (IC) or adjuvant chemotherapy (AC) with concurrent chemoradiotherapy (CCRT) could obtain better survival benefit for stage III or IV locally advanced nasopharyngeal carcinoma (LA-NPC).

METHODS

Only randomized controlled trials were incorporated. There were five treatments (CCRT, IC + CCRT, CCRT + AC, IC + RT and RT alone) recruited for analysis. Overall survival (OS), locoregional recurrence-free survival (LRFS) and distant metastasis-free survival (DMFS) with a hazard ratio (HR) were selected as endpoints. First of all, we performed a traditional meta-analysis and subsequently conducted network meta-analysis based on the Bayesian method.

RESULTS

Totally, 15 studies, including 6182 patients, were incorporated for analysis. There was a statistically significant benefits in favor of IC + CCRT, compared with CCRT alone, for OS [HR = 0.75, 95% CI = 0.63-0.89], LRFS [HR = 0.70, 95% CI = 0.56-0.86], and DMFS [HR = 0.65, 95% CI = 0.54-0.78]. What's more, we did not observed any significant differences between CCRT + AC and CCRT alone for all the endpoints. Unsurprisingly, it was RT alone that demonstrate the poorest survival benefit. Strange to say, survival benefit, between IC + CCRT and IC + RT, or between IC + CCRT and CCRT + AC, did not significantly exist.

CONCLUSION

Induction chemotherapy IC + CCRT provided better survival benefit than CCRT alone. CCRT + AC failed to increase survival benefit significantly compared to CCRT alone. More research about comparing IC + CCRT with IC + RT or CCRT + AC are needed.

Pretreatment Plasma EBV-DNA Load Guides Induction Chemotherapy Followed by Concurrent Chemoradiotherapy in Locoregionally Advanced Nasopharyngeal Cancer: A Meta-Analysis

Background

The efficacy of induction chemotherapy (IC) followed by concurrent chemoradiotherapy (CCRT) in locoregionally advanced nasopharyngeal cancer (LA-NPC) is controversial. In this paper, we conduct a meta-analysis based on relevant studies to provide strong evidence for clinical strategies.

Materials and Methods

We searched the MEDLINE, Embase, Cochrane, PubMed, and Web of Science databases for studies that stratified patients based on a high or low plasma Epstein–Barr virus deoxyribonucleic acid (EBV-DNA) load before treatment and compared the clinical efficacy of IC+CCRT vs. CCRT alone in LA-NPC. We tested for heterogeneity of studies and conducted sensitivity analysis. Subgroup analysis was performed for overall survival (OS), progression-free survival (PFS), distant metastasis-free survival (DMFS), and locoregional relapse-free survival (LRFS).

Results

Seven studies with a total of 5289 cases were finally included in the meta-analysis. The heterogeneity test revealed the homogeneity of OS (I² = 0.0%, p=0.794), PFS (I² = 0.0%, p=0.778), DMFS (I² = 0.0%, p=0.997), and LRFS (I² = 0.0%, p=0.697) in patients with EBV-DNA loads of ≥4000 copies/ml in both the IC+CCRT and CCRT groups. The results reveal that IC+CCRT significantly extended the OS (HR 0.70 [95% CI 0.58-0.83], p=0.000), PFS (HR 0.83 [95% CI 0.70-0.99], p=0.033), and DMFS (HR 0.79 [95% CI 0.69-0.9], p=0.000) of patients compared with the CCRT group, but there were no beneficial effects on LRFS (HR 1.07 [95% CI 0.80-1.42], p=0.647). The heterogeneity test found that there was no significant heterogeneity of PFS (I² = 0.0%, p=0.564), DMFS (I² = 0.0%, p=0.648), LRFS (I² = 22.3%, p=0.257), and OS (I² = 44.6%, p=0.164) in patients with EBV-DNA loads of <4000 copies/ml. The results show that IC+CCRT prolonged DMFS (HR 0.57 [95% CI 0.39-0.85], p=0.006) of patients without significant improvements in OS (HR 0.88 [95% CI 0.55-1.26], p=0.240), PFS (HR 0.98 [95% CI 0.74-1.31], p=0.908), and LRFS (HR 0.98 [95% CI 0.54-1.77], p=0.943).

Conclusions

Pretreatment plasma EBV-DNA can be considered a promising effective marker for the use of IC in LA-NPC patients. The addition of IC could improve the OS and PFS of patients with EBV-DNA load ≥4000 copies/ml, but we saw no efficacy in patients with EBV-DNA load <4000 copies/ml. Moreover, regardless of the EBV-DNA load, IC could improve DMFS, but there was no effect on LRFS.

Induction chemotherapy plus concomitant chemoradiotherapy in nasopharyngeal carcinoma: An updated network meta-analysis

BACKGROUND

Induction chemotherapy (IC) added to concurrent chemoradiotherapy (CCRT) appears to be superior to CCRT alone for locally-advanced nasopharyngeal carcinoma (NPC). The main objective of this network meta-analysis (NMA) was to assess the impact of different IC regimens on patient outcome.

PATIENTS AND METHODS

We systematically searched and extracted data from randomized, controlled trials involving stage III-IV NPC patients randomly assigned to receive IC + CCRT vs. CCRT alone. Overall survival (OS), locoregional recurrence-free survival (LRFS) and distant metastasis-free survival (DMFS) in the two arms were compared using hazard ratios (HRs).

RESULTS

Eight clinical trials were identified including 2362 patients. OS-benefit from doublet IC regimens, in particular platinum-docetaxel and platinum-gemcitabine regimens, was seen. With regard to LRFS, docetaxel-platinum-5FU regimen showed a greater impact than the others. An indirect comparison between taxane- and gemcitabine-based IC regimens showed a benefit of the latter in terms of OS and DMFS.

CONCLUSIONS

Although CCRT with cisplatin has been the gold standard of treatment in NPC for several years. Docetaxel + cisplatin-IC and cisplatin + gemcitabine-IC regimens have a positive impact on survival in locally-advanced NPC and should be considered the new standard option.

Chemotherapy in Combination With Radiotherapy for Definitive-Intent Treatment of Stage II-IVA Nasopharyngeal Carcinoma: CSCO and ASCO Guideline

PURPOSE

The aim of this joint guideline is to provide evidence-based recommendations to practicing physicians and other healthcare providers on definitive-intent chemoradiotherapy for patients with stage II-IVA nasopharyngeal carcinoma (NPC).

METHODS

The Chinese Society of Clinical Oncology (CSCO) and ASCO convened an expert panel of radiation oncology, medical oncology, surgery, and advocacy representatives. The literature search included systematic reviews, meta-analyses, and randomized controlled trials published from 1990 through 2020. Outcomes of interest included survival, distant and locoregional disease control, and quality of life. Expert panel members used this evidence and informal consensus to develop evidence-based guideline recommendations.

RESULTS

The literature search identified 108 relevant studies to inform the evidence base for this guideline. Five overarching clinical questions were addressed, which included subquestions on radiotherapy (RT), chemotherapy sequence, and concurrent, induction, and adjuvant chemotherapy options.

RECOMMENDATIONS

Evidence-based recommendations were developed to address aspects of care related to chemotherapy in combination with RT for the definitive-intent treatment of stage II to IVA NPC.Additional information is available at www.asco.org/head-neck-cancer-guidelines.

Comparison of Induction Chemotherapy Plus Concurrent Chemoradiotherapy and Concurrent Chemoradiotherapy Alone in Locally Advanced Nasopharyngeal Carcinoma

PURPOSE

Induction chemotherapy plus concurrent chemoradiotherapy and concurrent chemoradiotherapy alone are both standard treatment regimens for managing locally advanced nasopharyngeal carcinoma. However, the results of comparisons between them in clinical trials vary. Therefore, we designed this meta-analysis to illustrate their advantages and disadvantages in patients with locally advanced nasopharyngeal carcinoma.

METHODS

We thoroughly searched the PubMed, EMBASE, and Cochrane Library databases and then merged the effect indicators of hazard ratios and risk ratios using RevMan 5.1.

RESULTS

Seven randomized controlled trials totaling 2,319 patients were included in our research. The synthesized results showed that induction chemotherapy plus concurrent chemoradiotherapy improved overall survival (HR = 0.75, 95% CI: 0.63-0.89, P = 0.001), progression-free survival (HR = 0.69, 95% CI: 0.60-0.80, P < 0.001), distant metastasis-free survival (HR = 0.65, 95% CI: 0.53-0.80, P < 0.001) and locoregional recurrence-free survival (HR = 0.68 95%, CI: 0.54-0.86, P = 0.001) versus concurrent chemoradiotherapy alone. It also increased the risk of anemia, thrombocytopenia, and neutropenia during concurrent chemoradiotherapy. However, the incidence of leukopenia and mucositis was similar in induction chemotherapy and induction chemotherapy plus concurrent chemoradiotherapy. Furthermore, the subgroup analysis showed better survival outcomes with induction chemotherapy plus concurrent chemoradiotherapy than with concurrent chemoradiotherapy alone in the triweekly cisplatin subgroup (all P < 0.01), whereas induction chemotherapy plus concurrent chemoradiotherapy could only improve progression-free survival and locoregional recurrence-free survival in the weekly cisplatin subgroup (HR = 0.78, P = 0.02; and HR = 0.66, P = 0.03, respectively).

CONCLUSIONS

Induction chemotherapy plus concurrent chemoradiotherapy improved survival outcomes in patients with locally advanced nasopharyngeal carcinoma versus concurrent chemoradiotherapy. For the weekly cisplatin regimen subgroup, it did not improve remote control or overall survival versus concurrent chemoradiotherapy alone, warranting further clarification.

Phase II study of induction chemotherapy followed by concurrent chemoradiotherapy with raltitrexed and cisplatin in locally advanced nasopharyngeal carcinoma

Objective

For locally advanced nasopharyngeal carcinoma (LA-NPC) patients, high incidences of distant metastases and severe treatment related toxicities are the main obstacles needed to be overcome. Raltitrexed, a specific thymidylate synthase inhibitor with a convenient administration schedule, has an acceptable and manageable toxicity, and possesses radio-sensitizing properties. To investigate the efficacy and safety of raltitrexed and cisplatin induction chemotherapy and concurrent chemoradiotherapy (IC+CCRT) in patients with LA-NPC, a phase II clinical study was conducted.

Methods

Sixty eligible patients with LA-NPC were enrolled into this study. A raltitrexed-cisplatin combination was used as part of an IC+CCRT regimen. Raltitrexed-cisplatin IC was given once every 3 weeks (q3w) for two cycles, followed by raltitrexed-cisplatin based CCRT q3w for two cycles. Intensity-modulated radiotherapy (IMRT) was given for all enrolled patients.

Results

All patients were included in survival analysis according to the intent-to-treat principle. The objective response rate (ORR) 3 months after treatment was 98%. The 2-year overall survival (OS) rate was 92%. The median relapse-free survival (RFS) time was 30.5 [95% confidence interval (95% CI), 28.4−32.3] months. The 2-year RFS rate was 85%. The 2-year local failure-free survival (LFFS) rate was 97% and the 2-year distant metastasis-free survival (DMFS) rate was 88%. Acute toxicities were mostly grade 2 and 3 reactions in bone marrow suppression, gastrointestinal side effect and oropharyngeal mucositis. Only two patients occurred grade 4 acute toxicities, one was bone marrow suppression and the other was dermatitis radiation.

Conclusions

The combination of raltitrexed and cisplatin has a comparable efficacy to those in standard first-line therapy.

Applying the ASCO and European Society for Medical Oncology Value Frameworks to Nasopharyngeal Cancer Treatments: Is Adding Induction Chemotherapy or Adjuvant Chemotherapy to Concurrent Chemoradiotherapy Worthwhile?

PURPOSE

To determine and compare the incremental clinical benefit (ICB) and costs of induction chemotherapy (IC) when added to concurrent chemoradiotherapy (CCRT), concurrent chemotherapy (CC) when added to radiotherapy (RT), and CC plus adjuvant chemotherapy (AC) when added to RT for locally advanced nasopharyngeal cancer (LA-NPC).

MATERIALS AND METHODS

We searched phase III randomized controlled trials (RCTs) that reported overall survival benefit with the use of IC, CC, and CC + AC in LA-NPC. We quantified the ICB using the ASCO and European Society for Medical Oncology (ESMO) value frameworks. We calculated the incremental drug costs in US dollars using the lowest average wholesale price reported in the Lexicomp drug database.

RESULTS

We identified three RCTs on IC, three RCTs on CC, and four RCTs on CC + AC. The ICB was judged to be grade A based on the ESMO framework. The ASCO Net Health Benefit score ranged from 17.43 to 57.39. The incremental drug costs ranged from $133.46 to $626.14. There were no statistically significant differences in the mean Net Health Benefit scores (39.37 for IC v 37.61 for CC v 33.98 for CC + AC; P = .89) and costs ($383 for IC v $253 for CC v $460 for CC + AC; P = .27) between the three approaches. There was no statistically significant correlation between ICB and costs.

CONCLUSION

The magnitudes of ICB and incremental drug costs of adding of IC to CCRT, CC to RT, and CC + AC to RT for LA-NPC are not significantly different.

Short-term outcomes of induction chemotherapy with docetaxel, cisplatin, and fluorouracil (TPF) in locally advanced nasopharyngeal carcinoma

There is an unmet need for improving survival outcomes of locally advanced nasopharyngeal carcinoma, for example, T4/ N3 stage disease. To this end, we administered induction chemotherapy (IC) with TPF (docetaxel, cisplatin, and fluorouracil) because this stage of disease is associated with a high risk of recurrence and is difficult to control with standard treatments, such as chemoradiotherapy (CRT) alone or CRT followed by adjuvant chemotherapy. The aim of this retrospective single-center study was to clarify the short-term outcomes of locally far-advanced nasopharyngeal carcinoma patients treated with IC-TPF, followed by CRT with cisplatin. Data from 11 patients were extracted from our database, indicating that the overall response rate to IC-TPF, clinical complete response rate after CRT, 1-year progression-free survival, and 1-year overall survival were 73%, 91%, 68%, and 89%, respectively. Hematological toxicity was the most common adverse event reported during IC-TPF with 64% of patients suffering grade 3 or 4 neutropenia, 55% grade 3 or 4 leucopenia and 9% febrile neutropenia. Despite the small number of patients, these data are important because there is a limited number of studies investigating IC-TPF followed by CRT in Japanese patients. This pilot study provides some indication of the short-term effectiveness and toxicity of this therapeutic approach, which may be superior to standard treatments. Long-term follow-up is warranted to assess the effectiveness of IC-TPF in terms of clinical outcome and late-phase toxicity.

Meta-Analysis on Induction Chemotherapy in Locally Advanced Nasopharyngeal Carcinoma

Purpose

Concurrent chemo radiotherapy (CCRT) has been the standard of care in locally advanced nasopharyngeal carcinoma (LA‐NPC) for many years. The role of induction chemotherapy (ICT) has always been controversial. This systematic review and meta‐analysis investigates the value of adding ICT to CCRT in LA‐NPC.

Materials and Methods

Two reviewers independently assessed the eligibility of randomized controlled trials (RCTs) comparing ICT followed by CCRT versus CCRT alone, including treatment‐naive adult patients with histologically proven nonmetastatic LA‐NPC.

Results

Eight RCTs with in total 2,384 randomized patients, of whom 69% had N2–N3 disease, were selected. ICT was the allocated treatment in 1,200 patients, of whom 1,161 actually received this. Treatment compliance varied, with a median rate of 92% (range, 86%–100%) of patients receiving all cycles of ICT. The percentage of patients completing radiotherapy was 96% and 95% [(Combined Risk difference(CRD)= 0.004; 95% Confidence Interval (CI) –0.001–0.01; p = 0.14)] in the ICT group and CCRT group, respectively, whereas chemotherapy during radiotherapy could be completed in only 28% of the ICT group versus 61% in the CCRT group (CRD, −0.243; 95% CI, −0.403 to −0.083; p = .003). Grade 3–4 acute toxicity was mostly hematologic during the ICT phase (496 events vs. 191 nonhematologic) and was predominant in the ICT group (1,596 events vs. 1,073 in the CCRT alone group) during the CCRT. Adding ICT to CCRT provided a significant benefit in overall survival (hazard ratio [HR], 0.680; 95% CI, 0.511–0.905; p = .001) and progression‐free survival (HR, 0.657; 95% CI, 0.568–0.760; p < .001).

Conclusion

Although ICT followed by CCRT is associated with more acute toxicity and a lower compliance of the chemotherapy during the CCRT phase, this association resulted in a clinically meaningful survival benefit. ICT should be considered as a standard option in patients with LA‐NPC, but further study on optimal patient selection for this treatment is warranted.

Implications for Practice

Locally advanced nasopharyngeal carcinoma (LA‐NPC) is a relatively common disease in some parts of the world, with a rather poor prognosis due to its high metastatic potential. The role of induction chemotherapy (ICT) has always been controversial. This meta‐analysis found that ICT followed by concurrent chemoradiotherapy (CCRT) in LA‐NPC is associated with a significant clinical improvement in both overall survival and progression‐free survival compared with CCRT alone. ICT should be considered as a standard option in patients with LA‐NPC.

This review reports on the role of induction chemotherapy in locally advanced nasopharyngeal carcinoma, focusing on the effect of adding induction chemotherapy to concurrent chemoradiotherapy on overall and progression‐free survival.

Anti-PD-1 antibody increases NK cell cytotoxicity towards nasopharyngeal carcinoma cells in the context of chemotherapy-induced upregulation of PD-1 and PD-L1

Background

Nasopharyngeal carcinoma (NPC) is a highly malignant epithelial cancer linked to Epstein–Barr virus (EBV) infection. Tumors are characterized by a lymphomononuclear infiltrate and the number of natural killer (NK) cells in tumors appears to be of prognostic significance. Standard treatment for NPC in adolescents and young adults consists of induction chemotherapy followed by radiochemotherapy. Though survival rates are above 80%, the majority of patients suffer from long-term side-effects, mainly related to radiotherapy. The addition of immunotherapy to induction chemotherapy could improve tumor response.

Methods

We have investigated the killing of NPC cells by NK cells in the context of chemotherapy, using a panel of three nasopharyngeal carcinoma cell lines and a patient-derived xenograft. Cytotoxicity was measured using the calcein-release assay, while the contribution of different checkpoints and signaling pathways to killing was studied by siRNA-mediated gene silencing and chemical inhibitors.

Results

Chemotherapeutics cisplatin, 5-fluorouracil and gemcitabine sensitized NPC cells to killing by NK cells. Chemotherapeutics led to upregulation of PD-1 in NK cells and PD-L1 in NPC cells via NF-κB. Inhibition of the PD-L1/PD-1 checkpoint by an anti-PD-1 antibody or siRNA increased NK-cell cytotoxicity towards NPC cells.

Conclusion

The addition of an anti-PD-1 antibody to chemotherapy in patients with NPC could increase the efficacy of induction chemotherapy. If confirmed in a clinical trial, more efficient induction therapy could allow the dose of radiotherapy to be reduced and thereby diminish severe late effects of such therapy.

Electronic supplementary material

The online version of this article (10.1007/s00262-020-02681-x) contains supplementary material, which is available to authorized users.

The evaluation of adding induction chemotherapy to concurrent chemoradiotherapy for locally advanced nasopharyngeal carcinoma: a meta-analysis

PURPOSE

We performed a meta-analysis to compare the efficacy and safety of induction chemotherapy (IC) followed by cisplatin-based concurrent chemoradiotherapy (CCRT) versus cisplatin-based CCRT for patients with locally advanced nasopharyngeal carcinoma (LA-NPC).

METHODS

We systematically searched PubMed, the Cochrane Library and Embase until February 29, 2020, for eligible randomized controlled trials (RCTs). The quality of the studies was assessed with the Cochrane Collaboration risk of bias tool. The following outcomes of interest were analyzed: 1) progression-free survival (PFS); 2) overall survival (OS); 3) distant metastasis-free survival (DMFS); 4) locoregional failure-free survival (LRFFS); and 5) any grade 3 or 4 treatment-related adverse events (AEs). The data were pooled with the use of hazard ratios (HRs) or odds ratios (ORs). Subgroup, heterogeneity and sensitivity analyses were performed.

RESULTS

After screening all studies selected from the initial search, seven trials with 2233 patients met the inclusion criteria. Compared to cisplatin-based CCRT alone, there was reliable evidence that IC significantly improved PFS (HR 0.65, 95% CI 0.55-0.75, P < 0.00001), OS (HR 0.61, 95% CI 0.45-0.83, P = 0.002), DMFS (HR 0.65, 95% CI 0.53-0.79, P < 0.0001) and LRFFS (HR 0.68, 95% CI 0.53-0.88, P = 0.003) and was associated with a markedly increased risk of AEs (grade 3/4) during the IC and CCRT phases. No significant difference in the incidence of late AEs (grade 3/4) was observed between different arms.

CONCLUSION

Compared to cisplatin-based CCRT alone, IC followed by cisplatin-based CCRT confers real and substantial favorable survival outcomes with controllable toxicities. Therefore, it is reasonable to define IC followed by cisplatin-based CCRT as one of the standard treatment strategies for patients with LA-NPC.

NPC-0501 trial on the value of changing chemoradiotherapy sequence, replacing 5-fluorouracil with capecitabine, and altering fractionation for patients with advanced nasopharyngeal carcinoma

BACKGROUND

A current recommendation for the treatment of patients with locoregionally advanced nasopharyngeal carcinoma (NPC) is conventional fractionated radiotherapy (RT) with concurrent cisplatin followed by adjuvant cisplatin and 5-fluorouracil (PF). This randomized NPC-0501 trial evaluated the therapeutic effect of changing to an induction-concurrent sequence or accelerated-fractionation sequence, and/or replacing 5-fluorouracil with capecitabine (X).

METHODS

Patients with American Joint Committee on Cancer/International Union Against Cancer stage III to stage IVB NPC initially were randomly allocated to 1 of 6 treatment arms (6-arm full-randomization cohort). The protocol was amended in 2009 to permit centers to opt out of randomization regarding fractionation (3-arm chemotherapy cohort).

RESULTS

A total of 803 patients were accrued (1 of whom was nonevaluable) from 2006 to 2012. Based on the overall comparisons, neither changing the chemotherapy sequence nor accelerated fractionation improved treatment outcome. However, secondary analyses demonstrated that when adjusted for RT parameters and other significant factors, the induction-concurrent sequence, especially the induction-PX regimen, achieved significant improvements in progression-free survival (PFS) and overall survival. Efficacy varied among different RT groups: although no impact was observed in the accelerated-fractionation group and the 3-arm chemotherapy cohort, a comparison of the induction-concurrent versus concurrent-adjuvant sequence in the conventional-fractionation group demonstrated a significant benefit in PFS (78% vs 62% at 5 years; P = .015) and a marginal benefit in overall survival (84% vs 72%; P = .042) after adjusting for multiple comparisons. Comparison of the induction-PX versus the adjuvant-PF regimen demonstrated better PFS (78% vs 62%; P = .027) without an increase in overall late toxicity.

CONCLUSIONS

For patients irradiated using conventional fractionation, changing the chemotherapy sequence from a concurrent-adjuvant to an induction-concurrent sequence, particularly using induction cisplatin and capecitabine, potentially could improve efficacy without an adverse impact on late toxicity. However, further validation is needed for confirmation of these findings.

Sleep in nasopharyngeal carcinoma patients before chemotherapy, after induction chemotherapy, and after concurrent chemoradiotherapy

Sleep disturbance is frequently observed in cancer patients before, during and after oncology treatment. We explored the sleep features of patients before treatment, after induction chemotherapy, and after concurrent chemoradiotherapy for nasopharyngeal carcinoma (NPC). Ninety eligible patients diagnosed with NPC (stages III to IVc) and treated with induction chemotherapy plus concurrent chemoradiotherapy were included. The Pittsburgh Sleep Quality Index (PSQI) was applied to assess sleep before treatment, after induction chemotherapy, and after concurrent chemoradiotherapy. The median global PSQI scores in patients with NPC before treatment, after induction chemotherapy, and after concurrent chemoradiotherapy were 5, 6, and 10, respectively. The median scores of daytime dysfunction, sleep disturbance and habitual sleep efficiency were statistically significant at the pretreatment, after induction chemotherapy and after concurrent chemoradiotherapy timepoints (P < 0.049, P < 0.001 and P < 0.001, respectively). However, minimal changes were observed in all subscores after induction chemotherapy. Patients with poor sleep quality after induction chemotherapy were more prone to suffer worse sleep after concurrent chemoradiotherapy (OR = 12.6, 95%; CI = 2.4-67.3). Induction chemotherapy had less effect on the quality of sleep in NPC patients. Patients experienced a significant increase in sleep disturbance after concurrent chemoradiotherapy, particularly those with bad sleep after induction chemotherapy.

The efficacy and safety of induction chemotherapy combined with concurrent chemoradiotherapy versus concurrent chemoradiotherapy alone in nasopharyngeal carcinoma patients: a systematic review and meta-analysis

BACKGROUND

Induction chemotherapy (IC) combined with concurrent chemoradiotherapy (CCRT) has been recommended as the first-line therapy for locoregional nasopharyngeal carcinoma (NPC). Due to the different chemotherapeutic drugs used in the IC and CCRT, the results remain controversial.

METHODS

PubMed, EMBASE, Web of Science, and Cochrane Library databases were systematically retrieved to search potentially eligible clinical trials up to Sep 11, 2019. Eligible studies were registered and prospective randomized controlled clinical trials.

RESULTS

From 526 records, nine articles including seven randomized controlled clinical trials were eligible, with a total of 2311 locoregional advanced NPC patients. IC + CCRT had significantly lower risks of death (3-year hazard ratio [HR]: 0.70, 95% confidence interval [CI] 0.55-0.89, p = 0.003; 5-year HR: 0.77, 95% CI 0.62-0.94, p = 0.01), disease progression (3-year HR: 0.67, 95% CI 0.55-0.80, p < 0.001; 5-year HR: 0.70, 95% CI 0.58-0.83, p < 0.0001), distant metastasis (3-year HR: 0.58, 95% CI 0.45-0.74, p < 0.0001; 5-year HR: 0.69, 95% CI 0.55-0.87, p = 0.001) and locoregional relapse (3-year HR: 0.69, 95% CI 0.50-0.95, p = 0.02; 5-year HR: 0.66, 95% CI 0.51-0.86, p = 0.002) than CCRT. Compared with CCRT, IC + CCRT showed higher relative risks of grade 3 or more neutropenia, thrombocytopenia, nausea, vomiting and hepatotoxicity throughout the course of treatment, and higher relative risks of grade ≥ 3 thrombocytopenia and vomiting during CCRT.

CONCLUSION

IC combined with CCRT significantly improved the survival in locoregional advanced NPC patients. Moreover, toxicities were well tolerated during IC and CCRT. Further clinical trials are warranted to confirm the optimal induction chemotherapeutic regimen in the future.

Outcomes of Adding Induction Chemotherapy to Concurrent Chemotherapy for Nasopharyngeal Carcinoma Patients with Moderate-Risk in the Intensity-Modulated Radiotherapy Era

Background

The aim of this study was to evaluate the efficacy of induction chemotherapy (IC) in nasopharyngeal carcinoma (NPC) patients with moderate-risk treated with intensity-modulated radiotherapy (IMRT).

Methods

We retrospectively assessed 506 patients with T1-2N1M0 or T3-4N0-1M0 NPC (according to the 2010 UICC/AJCC staging system) who received concurrent chemoradiotherapy (CCRT) with or without IC at a single center in China between 2005 and 2010. Survival outcomes were compared between the IC + CCRT and CCRT groups using the Kaplan–Meier method, Log-rank test and a Cox regression model.

Results

Among the 506 patients, CCRT alone resulted in equivalent overall survival (86.8% vs 88.5%, p=0.661), progression-free survival (79.6% vs 79.6%, p=0.756), locoregional relapse-free survival (90.2% vs 87.0%, p=0.364) and distant metastasis-free survival (88.0% vs 89.8%, p=0.407) to IC plus CCRT. In multivariate analysis, IC did not lower the risk of death (HR 0.76, 95% CI 0.46–1.25, p=0.278), progression (HR 0.78, 95% CI 0.51–1.19, p=0.244), locoregional relapse (HR 1.06, 95% CI 0.81–1.42, p=0.651) or distant metastasis (HR 0.66, 95% CI 0.38–1.15, p=0.140) in the entire cohort; similar results were obtained in stratified analysis based on N category (N0 vs N1) and EBV DNA (< vs ≥4000 copies/mL).

Conclusion

Addition of IC to CCRT does not improve survival outcomes in moderate-risk NPC; the use of IC should be carefully considered in these patients, though additional prospective trials are warranted to confirm the conclusions of this study.

The efficacy and toxicity of induction chemotherapy plus concurrent chemoradiotherapy in locoregionally advanced nasopharyngeal carcinoma: A meta-analysis of randomized controlled trials

BACKGROUND

A systemic review and meta-analysis of randomized controlled trials (RCTs) was performed to compare the efficacy, toxicity and safety of concurrent chemoradiotherapy (CCRT) with or without induction chemotherapy (IC) for locoregionally advanced nasopharyngeal carcinoma (NPC).

METHODS

Research searching was performed in Web of Science, PubMed, The Cochrane Library, Embase, Chinese Biomedical Database, Chinese National Knowledge Infrastructure, Chongqing VIP Database for Chinese Technical Periodicals and Wanfang Database. RCTs including patients diagnosed with locoregionally advanced NPC without metastasis and randomly treated with IC plus CCRT and CCRT alone were included. Survival and outcome data were extracted and meta-analysis was performed using the Revman 5.3.0 software.

RESULTS

Ten RCTs (2280 patients) were selected and used for pooled meta-analysis. In comparison with CCRT, IC plus CCRT treatment significantly improved the overall survival (OS; HR = 0.70, 95%CI 0.56-0.87, P = .002), progression-free survival (PFS; HR = 0.75, 95%CI 0.65-0.87, P < .0001), distant metastasis failure-free survival (DMFS; HR = 0.71, 95%CI 0.58-0.85, P = .0003) and loco-regional failure-free survival (LFES; HR = 0.72, 95%CI 0.59-0.88, P = .002) of patients with locoregionally advanced NPC. Patients treated with IC and CCRT had higher incidence of grade 3-4 leucopenia and thrombocytopenia than patients treated with CCRT alone (P < .0001). No significant difference in other grade 3-4 adverse events and radiation toxicity was observed between the two groups. IC combined with CCRT improved the survival of patients with locoregionally advanced NPC.

CONCLUSIONS

Combined IC and CCRT therapy was an efficacy treatment regimen for locoregionally advanced NPC.

Current management of stage IV nasopharyngeal carcinoma without distant metastasis

Up to one in four patients with nasopharyngeal carcinoma present with non-metastatic stage IV disease (i.e. T4 or N3). Distinct failure patterns exist, despite the routine adoption of contemporary treatment modalities such as intensity modulated radiotherapy and systemic chemotherapy. Concurrent chemoradiotherapy (CCRT) followed by adjuvant chemotherapy or induction chemotherapy followed by CCRT are commonly employed in this setting, with the latter emerging as the preferred option. Additionally, emerging radiation technologies like proton therapy has become available offering new opportunities for prevention of radiation-induced side effects. This article reviews not only the current treatment strategies, but also discusses novel ways to tackle this challenging disease with respect to the patterns of failure.

Induction Chemotherapy Improved Long Term Outcomes in Stage IV Locoregional Advanced Nasopharyngeal Carcinoma

Purpose: We aimed to determine whether adding induction chemotherapy (IC) to concurrent chemoradiation (CCRT) improved outcomes in each stage of locally advanced nasopharyngeal carcinoma (LANPC). Methods: From 2007 to 2013, we retrospectively collected 259 histopathologically identified adult LANPC patients from two campuses in south Taiwan. Among the 238 eligibly treated cases, 156 patients received CCRT (CCRT group) upfront and 82 received IC followed by CCRT (IC group). Of these patients, 130 were stage III (92 patients that received CCRT and 38 that received IC adding CCRT) and 108 were stage IV (76 CCRT and 32 IC adding CCRT). Most chemotherapy regimens for IC are composed of cisplatin (P), 5-fluorouracil (F), and ifosfamide (I), while concurrent chemotherapy (CC) was essentially cisplatin-based. For CCRT as the upfront treatment, a P or PF regimen was usually used in CC. Survival outcomes were accessed with a Kaplan-Meier estimate and a p-value by log-rank test to compare the survival distributions of IC added to CCRT or CCRT as the upfront treatment in all LANPC stage III and LANPC IV patients. The failure free survival (FFS), overall survival (OS), local relapse free survival (LRFS), regional recurrence-free survival (RRFS), distant metastasis-free survival (DMFS), first failure site, and other prognostic factors were analyzed. Results: The median follow-up time of all treated LANPC patients was 59 months. For all LANPC patients, there was a significant difference only in the DMFS favoring IC group (91.5% vs 79.4%, p=0.013). In the subgroup study, for the stage III group, there was no significant difference between the groups for overall OS (IC group 71.3% vs CCRT group 78.7%), FFS (71.5% vs 62.4%) and RRFS (91.9% vs 90.9%). However, inferior LRLS (71.7% vs 91.5%; p = 0.03) was noted for the IC group. In contrast, for stage IV, there were significantly longer OS (75.8% vs 52.6%), FFS (66.8% vs 46.8%), and DMFS (86.0% vs 69.6%; p = 0.02, p = 0.04, and p = 0.03, respectively) rates in the IC group. Conclusion: Adding PIF-based IC to CCRT for the LANPC patients resulted in better outcomes for stage IV patients, but not for stage III patients. A future properly designed study should stratify enough LANPC cases under the structure of the AJCC stage grouping system to determine which subgroups truly benefit from adding IC to CCRT.

Survival without concurrent chemotherapy for locoregionally advanced nasopharyngeal carcinoma treated with induction chemotherapy plus intensity-modulated radiotherapy: Single-center experience from an endemic area

Although induction chemotherapy (IC) combined with intensity-modulated radiotherapy (IMRT) plus concurrent chemotherapy (CC) is the new standard treatment option in locoregionally advanced nasopharyngeal carcinoma (NPC), many patients fail to receive CC. The aim of this study was to investigate long-term survival outcomes and toxicities in these patients who are treated with IC before IMRT without CC.We retrospectively reviewed 332 untreated, newly diagnosed locoregionally advanced NPC patients who received IC before IMRT alone at our institution from May 2008 through April 2014. The IC was administered every 3 weeks for 1 to 4 cycles. Acute and late radiation-related toxicities were graded according to the acute and late radiation morbidity scoring criteria of the radiation therapy oncology group. The accumulated survival was calculated according to the Kaplan-Meier method. The log-rank test was used to compare the difference in survival.With a median follow-up duration of 65 months (range: 8-110 months), the 5-year estimated locoregional relapse-free survival, distant metastasis-free survival, progression-free survival (PFS), and overall survival rates were 93.4%, 91.7%, 85.8%, and 82.5%, respectively. Older age and advanced T stage were adverse prognostic factors for overall survival, and the absence of comorbidity was a favorable prognostic factor for PFS. However, acceptable acute complications were observed in these patients.IC combined with IMRT alone provides promising long-term survival outcomes with manageable toxicities. Therefore, the omission of CC from the standard treatment did not affect survival outcomes.

Association of Chemoradiotherapy Regimens and Survival Among Patients With Nasopharyngeal Carcinoma: A Systematic Review and Meta-analysis

IMPORTANCE

The role of induction chemotherapy (IC) or adjuvant chemotherapy (AC) in the treatment of locoregionally advanced nasopharyngeal carcinoma (NPC) remains controversial.

OBJECTIVES

To update meta-analyses on the association of survival outcomes with IC and AC regimens in patients with locoregionally advanced NPC and assess whether the current evidence is conclusive by a trial sequential analysis (TSA) approach.

DATA SOURCES

PubMed, Embase, and Web of Science were searched for articles published from inception until June 1, 2019.

STUDY SELECTION

Randomized clinical trials that assessed the efficacy of radiotherapy with or without chemotherapy among previously untreated patients and patients with nondistant metastatic NPC.

DATA EXTRACTION AND SYNTHESIS

Data were extracted by 2 investigators from each trial independently and synthesized by the 2 investigators. All trial results were combined and analyzed by a fixed- or random-effects model.

MAIN OUTCOMES AND MEASURES

Overall survival (OS), progression-free survival (PFS), distant metastasis-free survival (DMFS), and locoregional recurrence-free survival (LRFS).

RESULTS

A total of 8036 patients (median age, 46.5 years; 5872 [73.1%] male) from 28 randomized clinical trials were included in the analysis. Pooled analyses revealed that concurrent chemoradiotherapy (CCRT) was significantly associated with improved OS, PFS, DMFS, and LRFS compared with radiotherapy across all subgroups. The TSA confirmed the treatment outcomes of CCRT compared with radiotherapy. The additional IC regimen was associated with an improvement in OS (hazard ratio [HR], 0.84; 95% CI, 0.74-0.95), PFS (HR, 0.73; 95% CI, 0.64-0.84), DMFS (HR, 0.67; 95% CI, 0.59-0.78), and LRFS (HR, 0.74; 95% CI, 0.64-0.85). These findings were consistent in subgroup analyses of multicenter trials with sample sizes greater than 250, years of survival rate of 5 or greater, median follow-up longer than 5 years, or low risk of bias. However, the additional AC regimen was not associated with a survival benefit in OS (HR, 0.98; 95% CI, 0.78-1.23), PFS (HR, 0.86; 95% CI, 0.70-1.07), DMFS (HR, 0.84; 95% CI, 0.64-1.10), or LRFS (HR, 0.80, 95% CI, 0.59-1.09). The TSA provided sound evidence on the additional benefit of IC but not AC.

CONCLUSIONS AND RELEVANCE

These data suggest a significant association of survival outcomes with CCRT in patients with locoregionally advanced NPC. The addition of IC instead of AC could achieve survival benefits. The potential therapeutic gain of AC should be explored in the future.

Prognosis of nasopharyngeal carcinoma with insufficient radical dose to the primary site in the intensity-modulated radiotherapy era

BACKGROUND

It was reported that reduced radiotherapy is feasible for children with nasopharyngeal carcinoma (NPC) and papilloma virus-positive oropharyngeal cancer. Therefore, we performed this study to explore the prognosis of reduced-dose radiation in adult with NPC.

METHODS

Between 2004 and 2013, we retrospectively analyzed 19 patients histologically diagnosed with NPC, who received <66 Gy radiation therapy. Ten patients receiving <54 Gy to the primary site were group A. Nine patients receiving ≥54 Gy were group B.

RESULTS

Thirteen patients received induction chemotherapy (IC) for two or three cycles. In group A, the 5-year overall survival (OS) was 50.0%. For group B, the 5-year OS, locoregional relapse-free survival, progression-free survival, and distant metastasis-free survival were 88.9%, 100.0%, 88.9%, and 88.9%. Group B had a better prognosis than group A on OS (88.9% vs 50.0%, P = .03).

CONCLUSION

Patients receiving ≥54 Gy but <66 Gy with IC achieved good local control and long-term survival.

A challenging presentation of invasive nasopharyngeal sarcomatoid carcinoma

Sarcomatoid carcinoma is a rare clinical entity, especially when presenting in the nasopharynx. We describe the first documented case of nasopharyngeal sarcomatoid carcinoma with intracranial extension in a 59-year-old Caucasian man presenting with severe bifrontal headache and diplopia, secondary to left abducens nerve palsy. We highlight some of the major diagnostic challenges and describe its unusual histological appearance. We outline the importance of a multidisciplinary approach to his management, which includes input from the medicine, neurosurgery, Ear, Nose and Throat (ENT), pathology, radiology, oncology and respiratory teams. In the context of limited evidence, we then describe the rationale to proceed with induction chemotherapy followed by concurrent chemoradiotherapy. Although there was a partial response to treatment, it was not sufficient enough to allow subsequent surgical clearance. The plan going forward is to palliate with chemotherapy as and when the disease progresses.

Less is more: role of additional chemotherapy to concurrent chemoradiotherapy in locoregionally advanced nasopharyngeal cancer management

Concurrent chemoradiation therapy (CCRT) has played the most important and central role in the definitive therapy for the patients with locoregionally advanced stage nasopharynx cancer. The addition of induction chemotherapy (IC) or adjuvant chemotherapy (AC) to CCRT have been widely accepted with the rationale of improving distant control in the clinical practices. This review article investigated the role of IC and AC based on 11 recent meta-analysis publications, and found that the clinical benefits obtained by the additional IC or AC to CCRT, at the cost of the increased risks of more frequent and more severe side effects, seemed not big enough. More intervention is not always better, however, less seems frequently good enough. The author would speculate that 'less is more' and would advocate CCRT alone as the current standard.

A Pairwise Meta-Analysis of Induction Chemotherapy in Nasopharyngeal Carcinoma

BACKGROUND

Locoregionally advanced nasopharyngeal carcinoma has high risk of distant metastasis and mortality. Induction chemotherapy is commonly administrated in clinical practice, but the efficacy was quite controversial in and out of randomized controlled trials. We thus conducted this pairwise meta-analysis.

MATERIALS AND METHODS

Trials that randomized patients to receive radiotherapy or concurrent chemoradiotherapy with or without induction chemotherapy were identified via searches of PubMed, MEDLINE, and ClinicalTrials.gov.

RESULTS

A total of ten trials (2,627 patients) were included. The pooled hazard ratios (HRs) based on fixed effect model were 0.68 (95% confidence interval [CI] 0.56-0.80, p < .001) for overall survival (OS) and 0.70 (95% CI 0.61-0.79, p < .001) for progression-free survival (PFS), which strongly favored the addition of induction chemotherapy. The absolute 5-year survival benefits were 8.47% in OS and 10.27% in PFS, respectively. In addition, based on the available data of eight trials, induction chemotherapy showed significant efficacy in reducing locoregional failure rate (risk ratio [RR] = 0.81, 95% CI 0.68-0.96, p = .017) and distant metastasis rate (RR = 0.69, 95% CI 0.58-0.82, p < .001).

CONCLUSION

This pairwise meta-analysis confirms the benefit in OS, PFS, and locoregional and distant controls associated with the addition of induction chemotherapy in nasopharyngeal carcinoma.

IMPLICATIONS FOR PRACTICE

According to the results of this meta-analysis of ten trials, induction chemotherapy can prolong overall survival and progression-free survival and improve locoregional and distant controls for nasopharyngeal carcinoma.

Current Role of Chemotherapy in Nonmetastatic Nasopharyngeal Cancer

Nasopharyngeal carcinoma is highly radio- and chemosensitive tumor with its unique clinical and biological behavior. Treatment of stage I disease is radical radiotherapy alone. For stage II disease treatment is radiotherapy with or without chemotherapy. The standard of care for locally advanced nasopharyngeal cancer (stages III-IVB) is concurrent chemoradiation. Optimum timing and sequence of chemotherapy are not yet well-defined. The role of adjuvant and induction chemotherapy is debatable. Here we are going to highlight the role of chemotherapy in nasopharyngeal carcinoma, its benefit, and controversies regarding timing and sequences.