Carboplatin plus Taxol is an Effective Third-line Regimen in Recurrent Undifferentiated Nasopharyngeal Carcinoma

Stereotactic body radiotherapy extends the clinical benefit of PD-1 inhibitors in refractory recurrent/metastatic nasopharyngeal carcinoma

Purpose

Emerging evidence shows that immune checkpoint inhibitors lead to durable responses in a variety of cancers, including nasopharyngeal carcinoma (NPC), however, combination approaches (i.e., stereotactic body radiation therapy, SBRT) are required to extend this benefit beyond a subset of patients. This study retrospectively evaluated eight recurrent/metastatic NPC patients, to investigate how radiation could potentiate PD-1 checkpoint inhibition therapy.

Methods

Between September 2016 and July 2017, eight consecutive cases with histologically confirmed PDL1-positive status, for which prior standard therapy had been ineffective (five patients), were treated at our institution and Macao Clinics and two patients had disease progression within 6 months of completion of definitive chemoradiation, or one patient refused to receive chemoradiotherapy. All received PD-1 inhibitors first, seven of them accepted SBRT with an unmodified PD-1 inhibitors regimen after first evaluation as they were unresponsive to PD-1 inhibitors alone. Treatment was discontinued as long as patients were experiencing a clinical benefit in the opinion of the physicians and at least five cycles were given before stoppage.

Results

Median follow-up time was 56.7 months. The confirmed objective response rate based on RECIST-v1.1 at first evaluation was 12.5% (1/8). For the seven cases who received SBRT, six of them experience an objective response (6/7, 85.7%) after SBRT. Only one patient showed rapid progress and die within 95 days after the initiation of SBRT intervention. Three patients who did not have all lesions exposed to irradiation were available to evaluate the incidence of an abscopal effect, however, it did not occur as expected. Median PFS and OS for the seven patients were 8.0 and 30.8 months after SBRT intervention, respectively. Two-year OS as indicated was 71.0%.

Conclusions

PD-1 inhibitors combined with SBRT demonstrated promising antitumor activity in patients with PD-L1 positive RM-NPC. Patients may benefit from continue immunotherapy beyond disease progression when SBRT was introduced.

Copy number loss in granzyme genes confers resistance to immune checkpoint inhibitor in nasopharyngeal carcinoma

Background

Anti-programmed death (PD)-1 therapy has recently been used in recurrent or metastatic (R/M) nasopharyngeal carcinoma (NPC). The long-term survival and its biomarkers responding to anti-PD-1 treatment in patients with R/M NPC remain unclear.

Methods

Patients with R/M NPC were enrolled between March 2016 and January 2018 from two phase I clinical trials. The median follow-up period was 24.7 months. Eligible patients progressed on standard chemotherapy had measurable disease by Response Evaluation Criteria in Solid Tumor V.1.1. Non-obligatory contemporaneous tumor samples were collected for whole-exome sequencing. The primary outcome was objective response rate (ORR). Duration of response (DOR), progression-free survival (PFS), and overall survival (OS) were secondary outcomes assessed in all patients.

Results

Among 124 evaluable patients, anti-PD-1 therapy achieved an ORR of 29.8% and a durable clinical benefit rate of 60.5%. The median OS (mOS) was 17.1 months (95% CI 14.2 to 24.7), median PFS (mPFS) was 3.8 months (95% CI 3.4 to 6.0), and median DOR was 9.5 months. Significant OS benefit from treatment was observed in patients without liver metastasis (23.8 vs 13.3 months, p=0.006). Copy number deletion in genes encoding granzyme B or granzyme H (GZMB/H) was associated with poor treatment outcome (mPFS altered vs wildtype: 1.7 vs 3.6 months, p=0.03; mOS altered vs wildtype: 10.1 vs 18 months, p=0.012).

Conclusions

Anti-PD-1 treatment provided promising clinical benefit in pretreated patients with R/M NPC. Copy number loss in either GZMB or GZMH genes was associated with reduced survival.

Systemic therapies for recurrent or metastatic nasopharyngeal carcinoma: a systematic review

BACKGROUND

The majority of published studies in recurrent or metastatic nasopharyngeal carcinoma (RM-NPC) are single-arm trials. Reliable modelling of progression-free survival (PFS) and overall survival (OS) outcomes, therefore, is difficult. This study aim to analyse existent literature to estimate the relative efficacy of available systemic regimens in RM-NPC, as well as provide estimates of aggregate OS and PFS.

METHODS

We conducted a systematic search of MEDLINE, EMBASE and the Cochrane Library to March 2015. Clinical trials (in English only) investigating cytotoxic and molecularly targeted agents in adult patients with RM-NPC were included. All relevant studies were assessed for quality using Downs and Blacks (DB) checklist (maximum quality score of 27). Aggregate data analysis and Student's t-test were performed for all identified studies (model A). For studies that published analysable Kaplan-Meier curves, survival data were extracted and marginal proportional hazards models were constructed (model B).

RESULTS

A total of 56 studies were identified and included in model A, 26 of which had analysable Kaplan-Meier curves and were included in model B. The 26 studies in model B had significantly higher mean DB scores than the remaining 30 (17.3 vs 13.7, P=0.002). For patients receiving first line chemotherapy, the estimated median OS was 15.7 months by model A (95% CI, 12.3-19.1), and 19.3 months by model B (95% CI, 17.6-21.1). For patients undergoing second line or higher therapies (2nd+), the estimated median OS was 11.5 months by model A (95% CI 10.1-12.9), and 12.5 months by model B (95% CI 11.9-13.4). PFS estimates for patients undergoing first-line chemotherapy by model A was 7.6 months (95% CI, 6.2-9.0), and 8.0 months by model B (95% CI, 7.6-8.8). For patients undergoing therapy in the 2nd+ setting, the estimated PFS by model A was 5.4 months (95% CI, 3.8-7.0), and 5.2 months by model B (95% CI, 4.7-5.6).

CONCLUSIONS

We present the first aggregate estimates of OS and PFS for RM-NPC patients receiving first and second-line or higher treatment settings, which could inform the design of future clinical trials in this disease setting.

Progresses and Challenges in Chemotherapy for Loco- Regionally Advanced Nasopharyngeal Carcinoma

Incidence rates of nasopharyngeal carcinoma are high in Indonesia, Singapore and South-Eastern China. Chemoradiotherapy has been the standard regimen for locally advanced nasopharyngeal carcinoma according to guidelines from the National Comprehensive Cancer Network. Recently, advances in the management of nasopharyngeal carcinoma have transferred into better treatment outcomes. Most phase III clinical trials support the addition of concurrent chemotherapy to radiotherapy for the initial treatment of these patients. Studies evaluating effects and toxicity of concurrent chemotherapy with different regimens have been reported. However, the status of adding adjuvant chemotherapy or induction chemotherapy remains controversial. Recent studies have shown that adjuvant chemotherapy with two or three cycles may improve survival for nasopharyngeal carcinoma with stage N2-3 disease or with persistently detectable plasma EBV DNA after radiotherapy. This review examines the pertinent issues and latest studies concerning the management of loco-regionally advanced NPC, regarding concurrent chemotherapy, adjuvant chemotherapy, and induction chemotherapy in decades.

Induction chemotherapy with carboplatin and taxol followed by radiotherapy and concurrent weekly carboplatin + taxol in locally advanced nasopharyngeal carcinoma

PURPOSE

Aim of this study was the clinical evaluation of carboplatin-taxol combination in a neoadjuvant and concomitant setting with conventional radiotherapy in loco-regionally advanced nasopharyngeal carcinoma (A-NPC).

METHODS

Thirty patients were treated with three cycles of carboplatin (AUC6) plus taxol (175 mg/m(2)) on day 1 every 3 weeks, followed by weekly carboplatin (AUC1) plus Taxol (60 mg/m2) and concomitant radiotherapy (70 Gy).

RESULTS

We observed the objective complete response rates of 33% (after chemotherapy) and 87% (after chemo-radiotherapy). Treatment tolerability and toxicity were controllable. Three- and five-year progression-free survival were 80 and 75%, respectively, and 3- and 5-year overall survival were 85 and 80% (follow-up 49.5 months). Five-year loco-regional control was 90.3%, and five-year distant metastases-free survival was 85%.

CONCLUSIONS

Neoadjuvant chemotherapy with such protocol represents a feasible, efficient treatment for patients with A-NPC, ensuring excellent loco-regional disease control and overall survival with low incidence of distant metastases.

Treatment approaches to nasopharyngeal carcinoma: a review

Early-stage nasopharyngeal carcinoma (T1-2a;N0;M0) represents a small proportion of nasopharyngeal tumors. Radiotherapy alone is the current treatment approach for this tumor and the emerging role of new radiotherapy techniques will hopefully further improve the treatment outcome for these patients. The vast majority of patients with nasopharyngeal carcinoma is diagnosed with locally advanced disease. Concomitant chemoradiotherapy is now acknowledged as being a standard treatment option, even though it induces a considerable incidence of acute mucosal and hematologic toxicity. The issue of adding adjuvant chemotherapy is somewhat more controversial. Similarly, the role of neoadjuvant chemotherapy before concomitant chemoradiotherapy is a matter of interest. In patients with recurrent/metastatic nasopharyngeal carcinoma the prognosis is generally grim, as platinum-based chemotherapy results in a 50-70% response rate and in a median survival time of 11 months. Several trials have been performed on this subset of patients with both cytotoxic and biologic agents, but the results have not been particularly encouraging thus far. Epstein-Barr virus is associated with the vast majority of nasopharyngeal carcinoma. Concentrations of plasma Epstein-Barr virus DNA have been associated with treatment outcome in the clinic. Immunotherapy is generally well tolerated and can sometimes elicit significant immune response, which possibly induces clinical benefit in some patients.

Update on the management and therapeutic monitoring of advanced nasopharyngeal cancer

Despite being potentially curable at an early stage, more than 50% of patients who have nasopharyngeal carcinoma present with advanced locoregional disease, which results in a poor prognosis. This article discusses key advancements in the management of nasopharyngeal cancer, including the incorporation of concurrent chemoradiotherapy, new radiotherapy delivery techniques in the form of conformal and intensity-modulated radiotherapy, and salvage options for locoregional recurrence. New cytotoxic and targeted therapies that have resulted in improved survival in the metastatic setting are also described. The use of Epstein-Barr virus DNA for the prognostication and monitoring of nasopharyngeal cancer and the role of new diagnostic imaging techniques are also discussed.

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.

Advances in nasopharyngeal carcinoma

PURPOSE OF REVIEW

Nasopharyngeal carcinoma prognosis is related to its potential locoregional invasion and metastatic spread. Among prognostic factors, initial tumor-node-metastasis stage is the main one, besides other biological parameters. Worldwide development of positron emission tomography imaging is changing modalities of staging. Concomitant chemoradiotherapy represents one of the most recent advances in the treatment of nasopharyngeal carcinoma patients, besides intensity-modulated radiation therapy. This review updates these recent advances in diagnosis and treatment of nasopharyngeal carcinoma.

RECENT FINDINGS

Recent publications have shown the superiority of fused positron emission tomography/computed tomography over positron emission tomography alone and conventional imaging to do an accurate staging and to impact on patient management. Circulating Epstein-Barr virus DNA load may be a useful prognostic marker in endemic regions. Recent meta-analysis confirmed the superiority of concurrent chemoradiotherapy to radiotherapy alone. Previous publications have shown that induction chemotherapy with new agents might be promising. Data demonstrating targeted therapies efficacy in metastatic nasopharyngeal carcinoma are limited to date.

SUMMARY

Positron emission tomography-computed tomography is replacing conventional imaging in the initial M staging of nasopharyngeal carcinoma. Its usefulness in response evaluation after therapy and its place in the follow-up need to be prospectively evaluated. Cisplatin-based concomitant chemoradiotherapy is now the standard treatment for locally advanced patients. However, incidence of relapses remains high, and new multimodal therapy is needed.

Systemic treatment strategies and therapeutic monitoring for advanced nasopharyngeal carcinoma

Nasopharyngeal carcinoma (NPC) is endemic in Asia and is etiologically associated with the Epstein-Barr virus. Although radiotherapy can cure most patients with early-stage disease, those with advanced disease often develop recurrences following radiotherapy. The past decade has witnessed significant advances in the systemic treatment of advanced NPC. This article reviews the latest literature regarding: combined modality therapy for locoregionally advanced NPC; clinical trials of novel biologic and cytotoxic therapies for metastatic NPC; and disease monitoring with the plasma Epstein-Barr virus DNA assay.

Multicenter, phase II study of cetuximab in combination with carboplatin in patients with recurrent or metastatic nasopharyngeal carcinoma

PURPOSE

To evaluate efficacy and toxicity of cetuximab plus carboplatin in recurrent or metastatic nasopharyngeal carcinoma (NPC) resistant to platinum treatment.

PATIENTS AND METHODS

A multicenter, open-label, single-arm, phase II study in patients with epidermal growth factor receptor-expressing NPC who progressed on or within 12 months after termination of platinum-based chemotherapy for recurrent or metastatic disease. Cetuximab was administered at an initial dose of 400 mg/m2 followed by weekly doses of 250 mg/m2. Carboplatin area under the curve 5 was administered every 3 weeks up to a maximum of eight cycles.

RESULTS

Sixty patients were enrolled (46 males, 14 females; median age, 44.5 years; range, 23 to 64 years), and all patients were included in the intent-to-treat and safety analyses. Of the 59 patients assessable for efficacy, there were seven partial responses (11.7%), 29 patients (48.3%) with stable disease, and 23 patients (38.3%) with progressive disease, giving an overall response rate of 11.7% (95% CI, 4.8% to 22.6%). The median time to progression was 81 days in all patients and was longest in the group of patients with a confirmed response (173 days). The median overall survival time was 233 days in all patients. Six patients (10%) experienced serious treatment-related adverse events. Grade 3 or 4 toxicities occurred in 31 patients (51.7%); of these patients, only 19 (31.7%) were considered to have toxicity related to cetuximab.

CONCLUSION

Cetuximab in combination with carboplatin demonstrates clinical activity and an acceptable safety profile in heavily pretreated patients with recurrent or metastatic NPC who had previously experienced treatment failure with platinum-based therapy.

Recent perspectives in the role of chemotherapy in the management of advanced nasopharyngeal carcinoma

BACKGROUND

Recent advances in the treatment of nasopharyngeal carcinoma (NPC) have transpired into better treatment outcomes for patients with locoregionally advanced NPC, and have broadened the chemotherapeutic options for patients with metastatic disease.

METHODS

Data for this review were identified through searches of articles published in PubMed, MEDLINE, and abstracts from selected conference proceedings up to 2004.

RESULTS

The results of two meta-analyses and at least six randomized trials supported a survival benefit with the use of concurrent chemotherapy (e.g., platinum, tegafur-uracil [UFT)] and standard fractionated radiotherapy (with or without adjuvant chemotherapy) in the management of patients with locoregionally advanced NPC (nonmetastatic Stage III/IV disease, according to the staging system of the International Union Against Cancer). For those patients with metastatic NPC, platinum-based doublets using newer agents such as gemcitabine and the taxanes are reported to be better tolerated and can yield response rates comparable to those obtained with older, multidrug regimens.

CONCLUSIONS

The current study reviewed the latest literature and pertinent issues concerning the role of chemotherapy in the treatment of patients with metastatic and locoregionally advanced NPC.

A Phase II study of docetaxel and carboplatin as neoadjuvant therapy for nasopharyngeal carcinoma with early T status and advanced N status

BACKGROUND

Promising results from a Phase II trial of induction chemotherapy and sequential radiotherapy for advanced nasopharyngeal carcinoma (NPC) at The University of Texas M. D. Anderson Cancer Center (Houston, TX) and two retrospective reviews of the authors' historical experience with NPC demonstrated that distant failure was directly correlated with advanced lymph node status. Furthermore, local control was excellent for patients with T1-3 disease that was managed with radiation alone or with a sequential approach involving chemotherapy. Neoadjuvant chemotherapy (primarily with cisplatin + 5-fluorouracil) was associated with a significantly decreased risk of distant metastasis and with improved survival. Based on these findings, the authors evaluated a novel induction regimen involving docetaxel and carboplatin for patients with previously untreated T1-2N2-3M0 NPC.

METHODS

Docetaxel (80 mg/m2 on Day 1) and carboplatin (to an area under the time-concentration curve of 6 on Day 1) were administered every 21 days for 3 cycles, after which radiotherapy was administered. NPC was restaged with magnetic resonance imaging and nasopharyngoscopy 3 weeks after the completion of chemotherapy and 6 weeks after the completion of radiotherapy.

RESULTS

Over 5 years, 18 patients were enrolled in the study. Grade 4 neutropenia and Grade 2 fatigue were observed in 51% and 28% of chemotherapy courses, respectively. After chemotherapy, 2 patients had complete responses, 14 had partial responses, 1 had a minor response, and 1 had progressive disease. The latter two patients and one patient who had a partial response underwent off-study chemoradiotherapy. After radiotherapy or chemoradiotherapy, 12 patients had complete responses and 6 had partial responses. Seven patients had recurrent disease; two had local recurrences, and five had distant metastases.

CONCLUSIONS

Although unlikely to be superior to cisplatin + 5-fluorouracil, the trial regimen could be administered quickly in the outpatient setting, was logistically more convenient for the patient, and was devoid of serious nonhematologic toxic effects. We believe that the risk-based approach examined in the current study merits further investigation.