Curative and organ-preserving treatment with intra-arterial carboplatin induction followed by surgery and/or radiotherapy for advanced head and neck cancer: single-center five-year results

Efficacy and Safety of Intro-Arterial Chemotherapy Combined with Radiotherapy on Head and Neck Cancer: A Systematic Review and Meta-Analysis

Objectives: Intro-arterial chemotherapy combined with radiotherapy (IACRT) for the treatment of head and neck cancer (HNC) underwent a revival in recent years. Although many clinical trials have reported favorable outcomes, the effect of IACRT for HNC is still controversial. Therefore, this study was designed to evaluate the efficacy and safety of IACRT for HNC.

Methods: The relevant articles published before August 2019 were searched from PubMed, Embase, Cochrane Library, Web of Science and PMC databases. Data were extracted and the combined complete response (CR), overall survival (OS) and toxicity incidence with 95% credible interval (CI) were examined from eligible studies.

Results: Thirty-four studies comprising 1890 patients were included. IACRT achieved high CR (0.81, 95% CI: 0.76-0.86, P < 0.001), 3-year OS (0.75, 95% CI: 0.68-0.82, P < 0.001) and 5-year OS (0.68, 95% CI: 0.61-0.75, P < 0.001). The 3-year OS rate of stage III cancer (0.75, 95% CI: 0.53-0.97, P< 0.001) was higher than stage IV (0.52, 95% CI: 0.37-0.66, P = 0.025). Meanwhile, the 5-year OS of T3 cancer (0.87, 95% CI: 0.73-1.01, P = 0.028) was higher than T4 (0.53, 95% CI: 0.42-0.63, P = 0.286). Additionally, oral diseases, mucositis, leukopenia and dermatitis were the major toxicities of IACRT, which were all reversible.

Conclusion: IACRT is an efficient and safe modality for HNC, which could achieve favorable cancer response and higher survival rate with acceptable toxicities, even for advanced HNC.

Structure and kinetics of lipid-nucleic acid complexes

The structure and function of lipid-based complexes (lipoplexes) have been widely investigated as cellular delivery vehicles for nucleic acids-DNA and siRNA. Transfection efficiency in applications such as gene therapy and gene silencing has been clearly linked to the local, nano-scale organization of the nucleic acid in the vehicle, as well as to the global properties (e.g. size) of the carriers. This review focuses on both the structure of DNA and siRNA complexes with cationic lipids, and the kinetics of structure evolution during complex formation. The local organization of the lipoplexes is largely set by thermodynamic, equilibrium forces, dominated by the lipid preferred phase. As a result, complexation of linear lambda-phage DNA, circular plasmid DNA, or siRNA with lamellae-favoring lipids (or lipid mixtures) forms multi-lamellar L(α)(C) liquid crystalline arrays. Complexes created with lipids that have bulky tail groups may form inverted hexagonal HII(C) phases, or bicontinuous cubic Q(II)(C) phases. The kinetics of complex formation dominates the large-scale, global structure and the properties of lipoplexes. Furthermore, the time-scales required for the evolution of the equilibrium structure may be much longer than expected. In general, the process may be divided into three distinct stages: An initial binding, or adsorption step, where the nucleic acid binds onto the surface of the cationic vesicles. This step is relatively rapid, occurring on time scales of order of milliseconds, and largely insensitive to system parameters. In the second step, vesicles carrying adsorbed nucleic acid aggregate to form larger complexes. This step is sensitive to the lipid characteristics, in particular the bilayer rigidity and propensity to rupture, and to the lipid to nucleic acid (L/D) charge ratio, and is characterized by time scales of order seconds. The last and final step is that of internal rearrangement, where the overall global structure remains constant while local adjustment of the nucleic acid/lipid organization takes place. This step may occur on unusually long time scales of order hours or longer. This rate, as well, is highly sensitive to lipid characteristics, including membrane fluidity and rigidity. While the three step process is consistent with many experimental observations to date, improving the performance of these non-viral vectors requires better understanding of the correlations between the parameters that influence lipoplexes' formation and stability and the specific rate constants i.e., the timescales required to obtain the equilibrium structures. Moreover, new types of cellular delivery agents are now emerging, such as antimicrobial peptide complexes with anionic lipids, and other proteins and small-molecule lipid carriers, suggesting that better understanding of lipoplex kinetics would apply to a variety of new systems in biotechnology and nanomedicine.

Significant improvement in superselective intra-arterial chemotherapy for advanced paranasal sinus cancer by using indocyanine green fluorescence

Recent advances in indocyanine green (ICG) fluorescence imaging have enabled the visualization of the blood supply to tissues. For advanced head and neck cancer, intra-arterial chemotherapy has been applied for improving the prognosis and organ preservation. To identify the tumor-feeding artery, CT angiography has been shown to be useful. However, the presence of dental metals sometimes disturbs the precise evaluation of paranasal sinus cancer patients by CT angiography. The objectives of the study were to assess the feasibility of the ICG fluorescence technique during intra-arterial chemotherapy for advanced maxillary cancer. Thirty-six patients with paranasal sinus cancer who were treated by intra-arterial chemotherapy were included. Conventional CT angiography followed by 5 mg of ICG injection was performed to confirm the areas in which the drug had dispersed. Intra-arterial chemotherapy was administered at 150 mg/m² of CDDP four times weekly. Additional information about the arteries feeding the tumors provided by ICG was evaluated. Out of 36 cases, in 17 (47%) the blood supply to the cancer was clearly detected by CT angiography. By adding the infrared ICG evaluation, the blood supply to the tumor was confirmed easily in all cases without radiation exposure. The information obtained from fluorescence imaging was helpful for making decisions concerning the administration of chemo-agents for paranasal sinus cancers in cases involving dental metal, or skin invasion. ICG fluorescence imaging combined with intra-arterial chemotherapy compensated for the deficiencies of CT angiography for paranasal sinus cancer. ICG fluorescence provided us clearer and more useful information about the feeders to cancers.

Neoadjuvant intra-arterial chemotherapy in advanced laryngeal and hypopharyngeal cancer

AIM

To investigate whether neoadjuvant intra-arterial chemotherapy down-stages the tumors and predicts ultimate outcome in patients with advanced laryngeal and hypopharyngeal cancer.

METHODS

Fifteen patients with stage III and IV cancers received two cycles of intra-arterial cisplatin (40 mg/m(2)) at days 1 and 15, infused super-selectively into superior thyroid artery. Interim evaluation using RECIST 1.1 and volumetry was done in all patients at day 25. Subsequently, the patients received concurrent chemoradiotherapy or surgery with radiotherapy. Final evaluation was done in 10 patients.

RESULTS

At interim evaluation, five patients qualified as responders. Partial response, stable disease and progressive disease rates were 40, 33 and 27%, respectively. At final evaluation, complete response was noted in all patients.

CONCLUSIONS

At interim evaluation, the response rates were lower compared to intravenous neoadjuvant chemotherapy and response to intra-arterial chemotherapy did not predict the ultimate outcome. Thus neoadjuvant intra-arterial chemotherapy offers no advantage over concurrent chemoradiotherapy.

Concurrent intra-arterial carboplatin administration and radiation therapy for the treatment of advanced head and neck squamous cell carcinoma: short term results

Background

The aim of the present study was to evaluate the survival, efficacy and safety of a modified RADPLAT-like protocol using carboplatin instead of cisplatin.

Methods

Fifty-six patients with primary head and neck squamous cell carcinoma received 4 cycles of intra-arterial carboplatin (350 mg/m² per cycle every 2 weeks), with concurrent three-dimensional conformal radiation therapy.

Results

Two major and 4 minor complications were observed. Forty-five of the 56 patients (80%) completed the protocol, while 11 (20%) patients had to discontinue the intra-arterial infusions due to the occurrence of severe haematological toxicity, but were able to complete radiotherapy.

Forty-four (98%) of the 45 patients who completed the protocol and 10 (91%) of the 11 who did not, were free of disease at the end of the treatment, for a comprehensive 96% of CR overall.

After a median 23.55 months (range: 2 to 58 months) of follow-up, 40 patients (71%) are alive and disease-free, 1 (2%) is alive but affected by disease and 15 (27%) have died of the disease or other causes.

Conclusion

Intra-arterial carboplatin administration with concurrent three-dimensional conformal radiation therapy seems to be a promising alternative to RADPLAT in the treatment of advanced head and neck tumours. Haematological and non-haematological toxicities are virtually similar, but carboplatin has the advantage in that it is not nephrotoxic and can be used at very high doses without any significant increase in the extent of side effects.