Induction chemotherapy in head and neck cancer

Induction chemotherapy in head and neck cancer patients followed by concomitant docetaxel-based radiochemotherapy

Concurrent chemoradiotherapy has become the standard of care for patients with inoperable squamous cell head and neck carcinoma. More recently, induction chemotherapy has been adopted as an approach in the management of these patients. We report the results of a phase II trial associating induction chemotherapy and concomitant chemoradiotherapy in a series of patients with inoperable squamous cell head and neck cancer. Twenty-nine patients with advanced squamous cell carcinoma ineligible for surgery were enrolled. Induction chemotherapy with docetaxel 75 mg/m(2) and cisplatin 75 mg/m(2) every 21 days was administered for two cycles. Radiotherapy followed the induction phase. During radiotherapy, docetaxel was administered weekly at the dose of 33 mg/m(2) . Primary end point of the study was feasibility of treatment. Six (18%) patients failed to conclude the treatment schedule. Although response rates in evaluable patients were very high (disease control rate >90%), toxicities were a matter of concern. The reported treatment schedule proved infeasible. However, some modifications in ancillary therapies aimed at exploiting its efficacy could make it practicable.

A Phase I Study of Concurrent Chemoradiotherapy with S-1 for T2N0 Glottic Carcinoma

OBJECTIVE

Chemoradiation based on S-1, a novel oral antitumor agent of fluorinated pyrimidines, is the treatment for T2N0 glottic carcinoma; however, the optimal scheduling and dosing have still not been established. A phase I study was conducted to determine the maximum tolerated dose of S-1 with radiotherapy of 2 Gy/day for 5 days a week to a total dose of 60 Gy. Endpoints of this study were to examine the toxicity profile of this regimen and to determine the recommended dose of S-1.

METHODS

Concomitant administration with the above-mentioned radiotherapy of S-1 once a day for 2 weeks, beginning on the day therapy was started, followed by 2 weeks off the drug and 2 weeks on the drug with the dose escalating from S-1 60 mg/body (level 1) to 80 mg/body/day (level 2), and then to 100 mg/body/day (level 3).

RESULTS

Twenty-one patients were valid for safety. Eighteen patients were enrolled in the dose-escalation phase. In all patients, S-1 was administered. The maximum tolerated dose was determined to be 100 mg/body/day and the dose-limiting toxicity was indicated by the onset of grade 3 chemoradiation dermatitis. Therefore, the determined recommended dose of S-1 was 80 mg/body/day. Objective response according to Response Evaluation Criteria in Solid Tumors were observed in 20 of 21 patients who had measurable disease (95.2%).

CONCLUSION

Concurrent S-1 and radiotherapy was feasible and well tolerated, and was suggested to produce a worthwhile response in T2N0 glottic carcinoma. These results warrant further investigation, and a phase II has already been started.

Induction chemotherapy for squamous cancer of the head and neck

This paper reviews the efficacy and hazard of sequential combined treatment programs for squamous cell carcinoma of the head and neck. These regimens consist of initial systemic chemotherapy, known as neoadjuvant or induction chemotherapy, followed by radiation with or without concomitant chemotherapy.

Does induction chemotherapy have a role in the management of locoregionally advanced squamous cell head and neck cancer?

The use of systemic chemotherapy before definitive locoregional management, or induction chemotherapy, has been a theoretically attractive and well-studied approach in the management of squamous cell head and neck cancer. Although a decrease in distant metastases has frequently been observed, an improvement in survival from induction has been difficult to demonstrate. When chemotherapy and radiation are used concomitantly, however, an improvement in both survival and locoregional control can be identified, and this has led to the adoption of concurrent chemoradiotherapy as a standard of care for these patients. With this improvement in locoregional control, distant metastases have become a more frequently recognized cause of treatment failure, suggesting that an intervention, such as induction chemotherapy, directed at improving distant control might now be of some importance in improving overall treatment success. The recent development of taxane-containing, three-drug induction regimens that are capable of producing significantly better response rates than the older cisplatin and fluorouracil combination has also raised the possibility of a new and more important role for induction. The results of phase II investigations using this kind of a sequential schedule of induction chemotherapy followed by concurrent chemoradiotherapy have been encouraging, and phase III trials are now underway. This treatment approach remains investigational however, and these phase III studies are critical. The current randomized trials are reviewed and discussed.

Acute toxicity and preliminary clinical outcomes of concurrent radiation therapy and weekly docetaxel and daily cisplatin for head and neck cancer

OBJECTIVE

To examine the feasibility and efficacy of concurrent weekly docetaxel and radiation therapy as a definitive treatment for head and neck cancer (HNC).

METHODS

Thirty-two patients with primary HNC, who were treated with concurrent weekly docetaxel and radiation therapy, were analysed. The distribution of the disease stage was as follows: Stage II, 18 patients; Stage III, 3 patients; Stage IVA, 7 patients; Stage IVB, 3 patients; the patient of cervical lymph node metastasis with unknown primary tumor was not assessable. The average total dose of radiotherapy was 67.5 Gy. Docetaxel (10 mg/m(2), intravenously, once a week) was given to all patients up to four cycles, and cisplatin (6 mg/m(2), intravenously, five times a week) was also administered to all patients for up to 3 weeks from the beginning of the radiation therapy.

RESULTS

Only in two patients did the radiotherapy need to be temporarily interrupted due to the development of acute mucositis. Grade 3 toxicity was observed in six patients. Grade 4 acute mucositis was seen in one patient. The response rate was 100%, and complete response (CR) was observed in 30 patients (94%). At the time of the analysis, the 2 year local control and relapse-free rates in the 30 patients showing CR were 90 and 76%, respectively.

CONCLUSIONS

Concurrent weekly docetaxel and radiation therapy did not affect the compliance of the patients for the radiation therapy, indicating that the acute toxicities were within acceptable limits.

Induction chemotherapy in locally advanced squamous cell cancer of the head and neck: evolution of the sequential treatment approach

Cisplatin plus 5-fluorouracil (5-FU) (PF regimen) induction chemotherapy (IC) has been studied over the last two decades and has proven to be a durable and effective therapy for patients with locally advanced squamous cell cancer of the head and neck (SCCHN). Although randomized trials and meta-analyses have demonstrated that PF-based IC improves survival, reduces systemic metastases, and permits organ preservation, the effect on overall survival has been less robust than the results seen with cisplatin-based chemoradiotherapy (CRT) regimens. Differences in trial design, scheduling, and surgical interventions account for some of the variation in results. As studies have evolved, it has become evident that there are advantages to both approaches. This perception has led to the concept of sequential therapy (ST), the combination of IC, CRT, and surgery. ST programs are being studied intently in many centers. Phase II and III trials of ST regimens have reported unprecedented survival results in patients with locally advanced disease. In addition, the hypothesis that PF plus a taxane may result in an improved survival, compared to PF alone, for patients with locally advanced SCCHN on ST treatments is being tested in phase III trials. Although ST has not been compared head to head with CRT, early results support the use of this treatment paradigm in patients with poor prognosis SCCHN and should lead to definitive phase III trials in the near future. ST may represent the cutting edge of therapy for patients with curable, locally advanced SCCHN.

Systemic chemotherapy for squamous cell head and neck cancer

Squamous cell head and neck cancer is a relatively uncommon malignancy in North America. Nonetheless, it has been of considerable interest to medical oncologists because of its remarkable sensitivity to systemic chemotherapy. Even in patients with relapsed or metastatic disease, meaningful tumour shrinkage can be achieved with systemic therapy. This has led to the performance of carefully conducted clinical trials exploring the role of systemic chemotherapy, not only in the palliative setting, but as part of definitive multi-modality treatment. Chemotherapy has been used as the initial (or induction) treatment, as an adjuvant treatment after definitive surgery and/or radiation, and concurrent with both definitive and adjuvant radiation therapy. Evidence-based conclusions have been drawn from these clinical trials and have led to significant changes in the current standards of care for this disease. In this article, the available data supporting the use of systemic chemotherapy as palliative treatment, and as part of the definitive management for this disease will be reviewed.

Oropharyngeal cancer: the role of chemotherapy

Successful management of squamous cell cancer of the oropharynx must address two, sometimes conflicting, treatment goals. The first goal is disease eradication, and the second is preservation of oropharyngeal function. For early cancers, definitive surgical excision often represents the most effective and least morbid approach. When surgery is likely to result in functional deficits of speech or swallowing, definitive radiation therapy can also be used successfully. Often the choice of treatment modality is based on institutional expertise and bias. However, for the more frequent patients with advanced disease, treatment choices become more complex. Historically, surgery and radiation therapy have been used together, often with suboptimal control of locoregional disease and significant long-term functional deficits, reflecting surgical excision, radiation-induced long-term toxicities, and any initial functional impairment resulting from the tumor. The addition of systemic chemotherapy to definitive radiation has now been demonstrated to produce a significant survival benefit for patients with advanced squamous cell head and neck cancer originating in the oropharynx and elsewhere. Although there are still specific indications for primary surgical resection, the use of chemotherapy and radiation has become a standard of care for the management of patients with this disease, with surgery often reserved for salvage of those who fail definitive nonoperative treatment. Debate continues as to the best tolerated and most successful combination of chemotherapy drugs, radiation fractionation schema, and coordination of treatment modalities; however, a reproducible survival benefit has been demonstrated only for the concomitant, platinum-based treatment schedules. The focus of future investigation must be on optimizing these multimodality approaches, minimizing toxicities and functional deficits while maximizing treatment success. It is hoped that the addition of the newer therapeutic approaches, including epidermal growth factor receptor inhibition and gene therapy, may further improve the results of more traditional treatment combinations. Continued enrollment of patients in well-designed and conducted clinical trials is of paramount importance.

Weekly carboplatin and paclitaxel followed by concomitant paclitaxel, fluorouracil, and hydroxyurea chemoradiotherapy: curative and organ-preserving therapy for advanced head and neck cancer

PURPOSE

The paclitaxel, fluorouracil, and hydroxyurea regimen of paclitaxel, infusional fluorouracil, hydroxyurea, and twice-daily radiation therapy (TFHX) administered every other week has resulted in 3-year survival rates of 60% of stage IV patients. Locoregional and distant failure rates were 13% and 23%, respectively. To reduce distant failure rates, we added a brief course of induction chemotherapy to TFHX.

PATIENTS AND METHODS

Sixty-nine patients received six weekly doses of carboplatin (AUC2) and paclitaxel (135 mg/m2) followed by five cycles of TFHX.

RESULTS

Ninety-six percent had stage IV disease. Response to induction chemotherapy was partial response 52% and complete response (CR) 35%. Symptomatically, there was a significant reduction in mouth and throat pain. The most common grade 3 or 4 toxicity was neutropenia (36%). Best response following completion of TFHX was CR in 83%. Toxicities of TFHX consisted of grade 3 or 4 mucositis (74% and 2%) and dermatitis (47% and 14%). At a median follow-up of 28 months, locoregional or systemic disease progression were each noted in five patients. The overall 3-year progression-free survival was 80% (95% confidence interval [CI], 71% to 90%), and the 2- and 3-year overall survival rates were 77% (95% CI, 66% to 87%) and 70% (95% CI, 59% to 82%), respectively. At 12 months, five patients were completely feeding-tube dependent.

CONCLUSION

Administration of carboplatin and paclitaxel before TFHX chemoradiotherapy results in high response activity and may decrease distant failure rates. Overall survival, progression, and organ preservation/functional outcome data support definitive evaluation of this approach.

An intergroup phase III comparison of standard radiation therapy and two schedules of concurrent chemoradiotherapy in patients with unresectable squamous cell head and neck cancer

PURPOSE

The Head and Neck Intergroup conducted a phase III randomized trial to test the benefit of adding chemotherapy to radiation in patients with unresectable squamous cell head and neck cancer.

PATIENTS AND METHODS

Eligible patients were randomly assigned between arm A (the control), single daily fractionated radiation (70 Gy at 2 Gy/d); arm B, identical radiation therapy with concurrent bolus cisplatin, given on days 1, 22, and 43; and arm C, a split course of single daily fractionated radiation and three cycles of concurrent infusional fluorouracil and bolus cisplatin chemotherapy, 30 Gy given with the first cycle and 30 to 40 Gy given with the third cycle. Surgical resection was encouraged if possible after the second chemotherapy cycle on arm C and, if necessary, as salvage therapy on all three treatment arms. Survival data were compared between each experimental arm and the control arm using a one-sided log-rank test.

RESULTS

Between 1992 and 1999, 295 patients were entered on this trial. This did not meet the accrual goal of 362 patients and resulted in premature study closure. Grade 3 or worse toxicity occurred in 52% of patients enrolled in arm A, compared with 89% enrolled in arm B (P <.0001) and 77% enrolled in arm C (P <.001). With a median follow-up of 41 months, the 3-year projected overall survival for patients enrolled in arm A is 23%, compared with 37% for arm B (P =.014) and 27% for arm C (P = not significant).

CONCLUSION

The addition of concurrent high-dose, single-agent cisplatin to conventional single daily fractionated radiation significantly improves survival, although it also increases toxicity. The loss of efficacy resulting from split-course radiation was not offset by either multiagent chemotherapy or the possibility of midcourse surgery.

Organ preservation trials for laryngeal cancer

Organ-preservation strategies include definitive radiation therapy alone, induction chemotherapy followed by radiotherapy, and concurrent chemoradiotherapy. Over the past decade, induction chemotherapy followed by radiotherapy has been the standard for the nonsurgical management of advanced laryngeal cancer. Over this same period, however, other nonsurgical strategies have been under evaluation. These approaches include radiotherapy with concurrent chemotherapy to take advantage of the radiosensitizing properties of most cytotoxic drugs with activity against squamous cell cancer, altered fractionation radiotherapy, and the incorporation of molecularly targeted therapeutics into multimodality treatment.

End points for new agents in induction chemotherapy for locally advanced head and neck cancers

More than 60% of patients diagnosed with squamous cell carcinoma of the head and neck present at a locally advanced stage. Although multimodality therapy has improved locoregional control, the 5-year survival rate of this population rarely exceeds 30%. In this review, we analyzed the impact of chemotherapy in the management of locally advanced head and neck cancer and we underline the potential benefit of induction chemotherapy. The Meta-Analysis of Chemotherapy in Head and Neck Cancer collaborative group has suggested a survival advantage of 5% at 5 years for platin-5-fluorouracil induction chemotherapy. We have analyzed cofactors that may affect the survival of head and neck patients and propose new end points for assessment of the efficacy of induction chemotherapy. The detrimental effect of second primary tumors on long-term results is stressed and we have suggested the use of overall 2-year survival as a surrogate end point for induction chemotherapy efficacy. Finally, we have examined the impact of new cytotoxic agents and present the promising results of new taxane-based combinations.

Maximizing local control and organ preservation in stage IV squamous cell head and neck cancer With hyperfractionated radiation and concurrent chemotherapy

PURPOSE

Results are reported from an aggressive chemoradiotherapy protocol for advanced squamous cell head and neck cancer.

PATIENTS AND METHODS

Patients with advanced squamous cell head and neck cancer were treated with hyperfractionated radiation therapy (72 Gy at 1.2 Gy twice per day) and two courses of concurrent chemotherapy with fluorouracil (1,000 mg/m(2)/d) and cisplatin (20 mg/m(2)/d), both given as 96-hour continuous intravenous infusions during weeks 1 and 4 of radiation therapy. Primary-site resection was reserved for residual or recurrent primary-site disease after chemoradiotherapy. Neck dissection was considered for N2 or greater disease, irrespective of clinical response, and for residual or recurrent neck disease after nonoperative treatment.

RESULTS

Forty-one patients with stage IV disease were treated. Toxicity was significant, with grade 3 to 4 mucositis in 98%, dysphagia in 88%, and skin reaction in 85%. Neutropenic fever requiring hospitalization occurred in 51%. Despite feeding tube placement in 35 patients (85%), the mean weight loss during chemoradiotherapy was 13.3% of initial body weight. One patient died during treatment as a result of a pulmonary embolus. At a median follow-up period of 30 months, the 3-year Kaplan-Meier projected overall survival was 59%, disease-specific survival 69%, likelihood of local control without surgical resection 91%, and local control with surgical resection 97%. The likelihood of distant disease control at 3 years was 74%, and distant metastases were present in eight of 13 patients who died.

CONCLUSION

This chemoradiotherapy schedule produces considerable but manageable toxicity. Survival and organ preservation are excellent for this poor-prognosis patient cohort. Distant metastases are the most common cause of treatment failure.

Laryngo-pharyngeal carcinoma in childhood

Laryngo-pharyngeal carcinoma is rare in children. We present two cases of squamous cell carcinoma of the laryngopharynx in children less than 15 years of age. Both patients presented with a prolonged history of symptoms and extensive disease at diagnosis. Early visualisation the vocal cords with flexible larygnoscopy is important in children presenting with symptoms suggestive of laryngeal pathology. Long-term complications of definitive local therapy for laryngopharyngeal carcinoma are important in young children. Evidence from studies in adult patients suggests that adjuvant chemotherapy may play a role in laryngeal preservation in a select group of patients.