Pilot study of concurrent chemotherapy and radiotherapy for stage IV nasopharyngeal cancer

Advance in integrating platinum-based chemotherapy with radiotherapy for locally advanced nasopharyngeal carcinoma

Nasopharyngeal carcinoma (NPC) is a malignant tumor characterized by the malignant transformation of nasopharyngeal epithelial cells. It is highly sensitive to radiation therapy, making radiotherapy the primary treatment modality. However, 60-80% of patients are initially diagnosed with locally advanced NPC (LA-NPC), where radiotherapy alone often fails to achieve desirable outcomes. Therefore, combining radiotherapy with chemotherapy has emerged as an effective strategy to optimize treatment for LA-NPC patients. Among the various chemotherapy regimens, concurrent chemoradiotherapy (CCRT) using platinum-based drugs has been established as the most commonly utilized approach for LA-NPC patients. The extensive utilization of platinum drugs in clinical settings underscores their therapeutic potential and emphasizes ongoing efforts in the development of novel platinum-based complexes for anticancer therapy. The aim of this review is to elucidate the remarkable advances made in the field of platinum-based therapies for nasopharyngeal carcinoma, emphasizing their transformative impact on patient prognosis.

Concurrent chemoradiotherapy in locally advanced nasopharyngeal carcinoma: a treatment paradigm also applicable to patients in Southeast Asia

The majority of nasopharyngeal carcinoma (NPC) patients present at locally advanced stage. The poor prognosis has led to increasing interests in exploring the use of chemotherapy (CT). Intergroup-0099 trial was the first randomized trial comparing concurrent chemoradiotherapy (CCRT) with radiotherapy (RT) alone. Its outcome established the treatment standard in the United States as standard of care for locally advanced NPC. However, criticism has been arisen, particularly about its reproducibility and applicability in Southeast Asia where NPC is an endemic disease. Subsequently, new evidence has been provided by a large number of publications from various centers. In this article, through comprehensively analyzing recent meta-analyses and randomized controlled trials performed in Asian centers, we conclude that CCRT as a treatment paradigm is also applicable to patients in Southeast Asia and should be standard of practice in locally advanced disease. However, the CT regimen varied markedly among those trials, and the optimal regimen and scheduling remains to be determined. Moreover, a number of patients experienced toxicities and the treatment compliance was generally poor. With the emergence of new RT techniques such as intensity-modulated radiotherapy (IMRT) and image-guided radiotherapy (IGRT), the role of concurrent CT with these new techniques needs to be tested. New chemotherapeutics have been investigated in the recurrent or metastatic disease. However, their effectiveness in previously untreated NPC is unclear. Previous efforts have been made for immunotherapy and targeted therapy in palliative setting. Their role in newly diagnosed NPC should be evaluated, particularly when they are combined with CT or RT.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Concurrent chemo-radiotherapy for nasopharyngeal carcinoma

OBJECTIVE

Because of the low incidence of nasopharyngeal carcinoma (NPC) in Japan, few studies have reported on the use of concurrent chemo-radiotherapy (CCRT) for treatment of this disease. The present study investigated the efficacy and toxicity of CCRT with Carboplatin (CBDCA) and UFT for NPC.

PATIENTS AND METHODS

CCRT with injection of CBDCA and oral administration of UFT was given to 21 patients in our institution during 1996-2000. We compared the patients treated with CCRT with those treated with RT alone from 1976 to 1995 or those treated with RT after chemotherapy (Pre-RT chemotherapy) from 1985 to 1995. Overall survival rate (OS), progression free survival rate (PFS) and cause specific survival (CSS) rate were analyzed.

RESULTS

The actual 2-year OS, PFS, and CSS of CCRT were 85.7, 66.7 and 90%, respectively. The rates were improved compared to RT alone (37.9, 31.0, and 56.6%) and Pre-RT chemotherapy (58.8, 41.2, and 64.7%). The most frequent and severe acute toxicities were leukopenia (42.9%) and mucositis with grade 3-4 (28.6%), both of which eventually resolved.

CONCLUSION

CCRT with CBDCA and UFT is considered to be an effective, convenient, and tolerable treatment, which improves survival rates for NPC patients. Therefore, we recommend this CCRT method for the treatment of NPC.

Nasopharyngeal carcinoma with skull base invasion: a necessity of staging subdivision

PURPOSE

To investigate prognostic values of nasopharyngeal carcinoma (NPC) with skull base invasion for optimal management, according to its extent of involvement.

METHODS

From January 1985 through December 2000, 119 patients with histologically proven NPC were analyzed retrospectively with review of their computed tomography/magnetic resonance imaging and medical records. All patients underwent sequential chemoradiotherapy except 2 cases, which were treated concurrently. The mean duration of follow-up was 61 months (range 8-179). Potential prognostic factors were evaluated by univariate and multivariate analyses by the Kaplan-Meier method and the Cox model, with a particular emphasis on the extent of skull base invasion.

RESULTS

Skull base invasion was found in 46 (38.6%) of 119 patients. Cranial nerve palsy and intracranial extension was discovered in 34 (28.6%) and 23 (19.3%) of these patients, respectively. The sole erosion of the skull base was not found to be a poor prognostic factor. Patients with involvement of both anterior (I-VIII) and posterior (IX-XII) cranial nerves had a worse prognosis than those with involvement of either anterior or posterior cranial nerves (P = 0.0219). The presence of intracranial extension was the worst prognostic factor in NPC with skull base invasion (P = 0.0269). The advanced neck stage and histology did not affect the prognosis of NPC in the presence of skull base invasion.

CONCLUSION

Our results show that NPC with skull base invasion should be divided into the groups with, simple skull base erosion, minimal involvement of either anterior or posterior cranial nerves, multiple involvements of both cranial nerves, and intracranial extension.

Phase III study of concurrent chemoradiotherapy versus radiotherapy alone for advanced nasopharyngeal carcinoma: positive effect on overall and progression-free survival

PURPOSE

Nasopharyngeal carcinoma (NPC) is a radiosensitive and chemosensitive tumor. This randomized phase III trial compared concurrent chemoradiotherapy (CCRT) versus radiotherapy (RT) alone in patients with advanced NPC.

PATIENTS AND METHODS

From December 1993 to April 1999, 284 patients with 1992 American Joint Committee on Cancer stage III to IV (M0) NPC were randomly allocated into two arms. Similar dosage and fractionation of RT was administered in both arms. The investigational arm received two cycles of concurrent chemotherapy with cisplatin 20 mg/m(2)/d plus fluorouracil 400 mg/m(2)/d by 96-hour continuous infusion during the weeks 1 and 5 of RT. Survival analysis was estimated by the Kaplan-Meier method and compared by the log-rank test.

RESULTS

Baseline patient characteristics were comparable in both arms. After a median follow-up of 65 months, 26.2% (37 of 141) and 46.2% (66 of 143) of patients developed tumor relapse in the CCRT and RT-alone groups, respectively. The 5-year overall survival rates were 72.3% for the CCRT arm and 54.2% for the RT-only arm (P =.0022). The 5-year progression-free survival rates were 71.6% for the CCRT group compared with 53.0% for the RT-only group (P =.0012). Although significantly more toxicity was noted in the CCRT arm, including leukopenia and emesis, compliance with the combined treatment was good. The second cycle of concurrent chemotherapy was refused by nine patients and was delayed for > or = 1 week for another nine patients. There were no treatment-related deaths in either arm.

CONCLUSION

We conclude that CCRT is superior to RT alone for patients with advanced NPC in endemic areas.

Concurrent weekly carboplatin and radiotherapy for nasopharyngeal carcinoma: report of a joint phase II study

We report a phase I/II study of weekly concurrent carboplatin and radiotherapy in patients with nasopharyngeal carcinoma (M0 stage). Of 47 patients registered, 45 completed the treatment course. Twenty-six (55%) (95% CI, 41-69%) patients experienced > or =grade 3 acute toxicity (RTOG). Five (11%) (95% CI, 2-20%) patients experienced > or =grade 3 chronic toxicity. This regimen appears to have acceptable toxicity compared to the experimental arm of Phase III Intergroup Study 0099, but progression-free and overall survival are probably inferior. At present, there is no data to suggest that carboplatin can replace cisplatin for concurrent chemoradiation for NPC.

Locally advanced nasopharyngeal cancer: long-term outcomes of radiation therapy

PURPOSE

To investigate the clinical manifestations and treatment outcomes in patients with stage T4M0 nasopharyngeal carcinoma.

MATERIALS AND METHODS

Findings in 179 patients (age range, 13-78 years) with American Joint Committee on Cancer stage T4M0 nasopharyngeal carcinoma treated from January 1983 to February 1992 with a minimum follow-up of at least 5 years were reviewed. Of the 179 patients, 166 (92.7%) had World Health Organization type II or III disease. Forty-one patients (22.9%) had no lymph nodal involvement; 138 patients (77.1%) had metastatic nodal involvement in the neck. All patients underwent radiation therapy; 39 patients also received different forms of chemotherapy. The radiation therapy doses were usually 70-74 Gy administered to the primary tumor over 7 or 8 weeks, 70-74 Gy to the neck region in patients with nodal involvement, or 50-60 Gy administered to the neck region over 5 or 6 weeks in patients without neck nodal involvement.

RESULTS

In 100 patients, radiation therapy failed in the primary tumor alone (n = 28), neck nodes alone (n = 5), and distant metastases alone (n = 43) or at a combination of sites (n = 24). The cumulative failure rates for the primary tumor, neck metastases, and distant metastases were 25.1% (n = 45), 14.0% (n = 25), and 33.0% (n = 59), respectively. The 5-year primary disease-free, distant disease-free, and overall survival rates were 68.7%, 56.5%, and 28.6%, respectively. Results of salvage treatment for relapse were unsatisfactory.

CONCLUSION

In about three-tenths of patients, T4M0 nasopharyngeal carcinoma can be cured with conventional high-dose radiation therapy.