The best choice of induction chemotherapy for patients with locally advanced nasopharyngeal carcinoma: Bayesian network meta-analysis

The determination of the optimal induction chemotherapy (IC) regimen for patients with locally advanced nasopharyngeal carcinoma (NPC) remains controversial. Eligible trials included in this Bayesian network meta-analysis were judged by synthetically evaluating survival and safety outcomes. The analysis revealed that the combined IC regimen of gemcitabine plus cisplatin (GP) gained not only the most favorable overall survival (OS) benefit but also longer distant metastasis-free survival and manageable adverse events (AEs). Additionally, combination IC regimen of mitomycin, epirubicin, cisplatin, fluorouracil, and leucovorin had insufficient significant efficacy on complete response. Docetaxel combined with cisplatin and fluorouracil induction regimen provided the first exact probability of efficacy in term of local recurrence-free survival, ranking second in OS, but accompanied by the highest rates of grade 3 or above AEs. GP regimen appears to be currently the best choice of IC regimen for combined benefit of patients with locally advanced NPC.

Survival benefit of induction chemotherapy for locally advanced nasopharyngeal carcinoma: prognosis based on a new risk estimation model

BACKGROUND

Although the National Comprehensive Cancer Network (NCCN) Guidelines recommend CCRT+AC and IC + CCRT as level 2A evidence for treatment of the locoregionally advanced NPC (II-IVa), IC + CCRT+AC could also be an alternative but it is seldom used because of the low completion rates. This article aimed to compare the effectiveness of the three radiotherapy regimens using a large-scale retrospective study.

METHODS

This retrospective single center analysis enrolled 1812 diagnosed NPC patients at Nanfang Hospital from January 2005 to December 2015 and only 729 patients met the inclusion criteria and were analyzed. Patients without distant metastasis, age of 18-70 years, Karnofsky scores of at least 70,stage III-IVb, and adequate adequate bone marrow, liver and renal function. Were enrolled. Adverse events and other categorical variables were compared by Pearson chi-square test or Fishier exact test. Time-to-event data were described with the Kaplan-Meier curves, time-to-event intervals compared with the log-rank test. We did multivariable analyses with the Cox proportional hazards model to test the independent signifi cance of diff erent factors. Cox proportional hazards model was used to estimate the β regression coeffi cient, p value, and hazard ratio and its 95% CI for each of the selected risk predictors.

RESULTS

The median follow-up time was 47 months. Kaplan-Meier analyses revealed no significant differences among three groups in 3-year failure-free survival (FFS, P = 0.225), 3-year overall survival (OS, P = 0.992), 3-year locoregional failure-free survival (LFFS, P = 0.549), and 3-year distant failure-free survival (DFFS, P = 0.174). Stratified survival analysis based on the risk scoring model revealed no differences in FFS, OS, LFFS, and DFFS between IC + CCRT and CCRT+AC groups for low-risk patients, however, the 3-year OS (88.3% vs. 77.6%, P = 0.049) and 3-year DFFS (84.0% vs.66.8%, P = 0.032) were respectively significantly better in IC + CCRT group compared with CCRT+AC group for high-risk patients.

CONCLUSIONS

Compared with CCRT+AC, IC + CCRT lowers distant metastasis rate and improves OS among patients with locally advanced NPC in high risk group.

An interpretable machine learning prognostic system for locoregionally advanced nasopharyngeal carcinoma based on tumor burden features

OBJECTIVES

We aimed to build a survival system by combining a highly-accurate machine learning (ML) model with explainable artificial intelligence (AI) techniques to predict distant metastasis in locoregionally advanced nasopharyngeal carcinoma (NPC) patients using magnetic resonance imaging (MRI)-based tumor burden features.

MATERIALS AND METHODS

1643 patients from three hospitals were enrolled according to set criteria. We employed ML to develop a survival model based on tumor burden signatures and all clinical factors. Shapley Additive exPlanations (SHAP) was utilized to explain prediction results and interpret the complex non-linear relationship among features and distant metastasis. We also constructed other models based on routinely used cancer stages, Epstein-Barr virus (EBV) DNA, or other clinical features for comparison. Concordance index (C-index), receiver operating curve (ROC) analysis and decision curve analysis (DCA) were executed to assess the effectiveness of the models.

RESULTS

Our proposed system consistently demonstrated promising performance across independent cohorts. The concordance indexes were 0.773, 0.766 and 0.760 in the training, internal validation and external validation sets. SHAP provided personalized protective and risk factors for each NPC patient and uncovered some novel non-linear relationships between features and distant metastasis. Furthermore, high-risk patients who received induction chemotherapy (ICT) and concurrent chemoradiotherapy (CCRT) had better 5-year distant metastasis-free survival (DMFS) than those who only received CCRT, whereas ICT + CCRT and CCRT had similar DMFS in low-risk patients.

CONCLUSIONS

The interpretable machine learning system demonstrated superior performance in predicting metastasis in locoregionally advanced NPC. High-risk patients might benefit from ICT.

Prognostic and Treatment Guiding Significance of MRI-Based Tumor Burden Features and Nodal Necrosis in Nasopharyngeal Carcinoma

We aimed to develop a nomogram integrating MRI-based tumor burden features (MTBF), nodal necrosis, and some clinical factors to forecast the distant metastasis-free survival (DMFS) of patients suffering from non-metastatic nasopharyngeal carcinoma (NPC). A total of 1640 patients treated at Sun Yat-sen University Cancer Center (Guangzhou, China) from 2011 to 2016 were enrolled, among which 1148 and 492 patients were randomized to a training cohort and an internal validation cohort, respectively. Additionally, 200 and 257 patients were enrolled in the Foshan and Dongguan validation cohorts, respectively, which served as independent external validation cohorts. The MTBF were developed from the stepwise regression of six multidimensional tumor burden variables, based on which we developed a nomogram also integrating nodal necrosis and clinical features. This model divided the patients into high- and low-risk groups by an optimal cutoff. Compared with those of patients in the low-risk group, the DMFS [hazard ratio (HR): 4.76, 95% confidence interval (CI): 3.39–6.69; p < 0.0001], and progression-free survival (PFS; HR: 4.11, 95% CI: 3.13–5.39; p < 0.0001) of patients in the high-risk group were relatively poor. Furthermore, in the training cohort, the 3-year DMFS of high-risk patients who received induction chemotherapy (ICT) combined with concurrent chemoradiotherapy (CCRT) was better than that of those who were treated with CCRT alone (p = 0.0340), whereas low-risk patients who received ICT + CCRT had a similar DMFS to those who only received CCRT. The outcomes we obtained were all verified in the three validation cohorts. The survival model can be used as a reliable prognostic tool for NPC patients and is helpful to determine patients who will benefit from ICT.

Neoadjuvant chemotherapy followed by concurrent chemoradiotherapy versus concurrent chemoradiotherapy alone in locoregionally advanced nasopharyngeal carcinoma: A phase III multicentre randomised controlled trial

BACKGROUND

The role of neoadjuvant chemotherapy (NACT) for locoregionally advanced nasopharyngeal carcinoma (NPC) is unclear. We aimed to evaluate the feasibility and efficacy of NACT followed by concurrent chemoradiotherapy (CCRT) versus CCRT alone in locoregionally advanced NPC.

METHODS

Patients with stage III-IVB (excluding T3N0-1) NPC were randomly assigned to receive NACT followed by CCRT (investigational arm) or CCRT alone (control arm). Both arms were treated with 80 mg/m² cisplatin every 3 weeks concurrently with radiotherapy. The investigational arm received cisplatin (80 mg/m² d1) and fluorouracil (800 mg/m² civ d1-5) every 3 weeks for two cycles before CCRT. The primary end-point was disease-free survival (DFS) and distant metastasis-free survival (DMFS). Secondary end-point was overall survival (OS). Survival curves for the time-to-event endpoints were analyzed by the Kaplan-Meier method and compared using the log-rank test. The P value was calculated using the 5-year endpoints.

RESULTS

Four hundred seventy six patients were randomly assigned to the investigational (n = 238) and control arms (n = 238). The investigational arm achieved higher 3-year DFS rate (82.0%, 95% CI = 0.77-0.87) than the control arm (74.1%, 95% CI = 0.68-0.80, P = 0.028). The 3-year DMFS rate was 86.0% for the investigational arm versus 82.0% for the control arm, with marginal statistical significance (P = 0.056). However, there were no statistically significant differences in OS or locoregional relapse-free survival (LRRFS) rates between two arms (OS: 88.2% versus 88.5%, P = 0.815; LRRFS: 94.3% versus 90.8%, P = 0.430). The most common grade 3-4 toxicity during NACT was neutropenia (16.0%). During CCRT, the investigational arm experienced statistically significantly more grade 3-4 toxicities (P < 0.001).

CONCLUSION

NACT improved tumour control compared with CCRT alone in locoregionally advanced NPC, particularly at distant sites. However, there was no early gain in OS. Longer follow-up is needed to determine the eventual therapeutic efficacy.

Long-Term Results of Concurrent Chemoradiotherapy for Advanced N2-3 Stage Nasopharyngeal Carcinoma

Background

N-stage is related to distant metastasis in nasopharyngeal carcinoma (NPC) patients. The purpose of this study was to evaluate the efficacy and toxicity of different nedaplatin-based chemotherapy regimens in advanced N2-3 stage NPC patients treated with intensity modulated radiation therapy (IMRT).

Patients and Methods

Between April 2005 and December 2009, a total of 128 patients with N2-3 advanced NPC were retrospectively analyzed. Patients were treated with IMRT concurrent with 2 cycles of chemotherapy consisting of either nedaplatin plus paclitaxel (NP group, n = 67) or nedaplatin plus fluorouracil and paclitaxel (NFP group, n = 61). Two to four cycles of adjuvant chemotherapy were then administered every 21 days following concurrent chemoradiotherapy.

Results

With a median follow-up of 60 months, the 5-year overall survival (OS), progression-free survival (PFS), local-regional recurrence-free survival (LRRFS), and distant metastasis-free survival (DMFS) for all patients were 81.4%, 71.5%, 87.8% and 82.0%, respectively. No significant difference in PFS (66.6% vs. 76.7%, P = 0.212) and LRRFS rates (89.0% vs. 86.3%, P = 0.664) was observed between the NP and NFP groups. The 5-year OS (75.4% vs. 88.5%, P = 0.046) and DMFS (75.1% vs. 89.0%, P = 0.042) rate were superior in the NFP group compared with the NP group. The NFP group had a higher incidence of grade 3–4 acute toxicities including bone marrow suppression (leukopenia: χ2 = 3.935, P = 0.047; anemia: χ2 = 9.760, P = 0.002; thrombocytopenia: χ2 = 8.821, P = 0.003), and both liver and renal dysfunction (χ² = 5.206, P = 0.023) compared with the NP group. Late toxicities were moderate and no difference was observed between the two groups.

Conclusion

IMRT concurrent with nedaplatin-based chemotherapy is an advocated regimen for patients with advanced N2-3 stage NPC. Patients with advanced N2-3 stage may be better candidates for the NFP regimen although this regimen was associated with a high acute toxicity rate.

Overexpression of CD147 contributes to the chemoresistance of head and neck squamous cell carcinoma cells

Head and neck cancer is the sixth most common cancer in the world and most of them are squamous cell carcinomas. High frequency of cisplatin resistance in head and neck squamous cell carcinoma (HNSCC) leads to tumor relapse and irresponsiveness to cisplatin-based chemotherapy. However, the mechanisms underlying cisplatin resistance is still largely unrevealed. In this study, we found that CD147 was overexpressed in cisplatin-resistant HNSCC cell lines. Based on the result, CD147 expression was down-regulated in the cisplatin-resistant cell line and we observed that the sensitivity to cisplatin increased, as showed in the results of MTT assay and PI-staining apoptotic detection. Meanwhile, transfection of CD147 expression vector promoted the occurrence of cisplatin resistance in the cisplatin-sensitive cell line. Simultaneously blocking of uPAR with neutralizing antibody would significantly prevent the occurrence of cisplatin resistance induced by CD147 overexpression. In conclusion, our study finds that CD147 is also involved in mediating cisplatin resistance in HNSCC and uPAR serves as a possible candidate that collaborates with CD147 in this process.

Is the combination of Cetuximab with chemo-radiotherapy regimens worthwhile in the treatment of locally advanced head and neck cancer? A review of current evidence

The administration of Cetuximab in combination with radiotherapy and chemotherapy has shown clear survival improvements within the locally advanced and the relapsed/metastatic settings respectively. These results have provided the clinical rational for the inclusion of Cetuximab into chemo-radiation regimens. Trials assessing the combination of Cetuximab with induction chemotherapy, concomitant chemo-radiotherapy or both are reviewed. Taken together, their results suggest that the addition of Cetuximab is promising in trials of induction chemotherapy, showing almost uniformly response rates higher than historical controls. In combination with concomitant hyperfractionated radiotherapy and Cisplatin the results of the RTOG 0522 trial do not suggest any benefit. However a positive effect cannot be excluded with other schedules. Although feasibility has been universally suggested, adding Cetuximab implies some toxicity enhancement. Single local and systemic toxicities are more frequent and supposedly the overall treatment intensity is increased. Moreover the drug-specific toxicities are potentially severe and deserve timely recognition and management.