Evolving Strategies for Combined‐Modality Therapy for Locally Advanced Head and Neck Cancer

Systemic therapy for squamous cell carcinoma of the head and neck

The use of systemic therapy as part of curative treatment and palliation is an evolving paradigm for squamous cell cancer of the head and neck (SCCHN), which historically has been treated with local modalities. At present, the treatment armamentarium includes traditional cytotoxic therapy, targeted biological agents, and emerging immunotherapeutics. This article discusses the use of all of these systemic approaches for the curative and palliative treatment of SCCHN.

Chemoselection: a paradigm for optimization of organ preservation in locally advanced larynx cancer

Definitive chemoradiation (CRT) and laryngectomy followed by postoperative radiotherapy (RT) are both considered standard-of-care options for the management of advanced laryngeal cancer. While organ preservation with chemoradiotherapy is often the preferred up-front approach for appropriately selected candidates, the functional benefits of organ preservation must be carefully balanced against the considerable morbidity of salvage laryngectomy in patients who fail primary chemoradiation. Up-front identification of patients who are likely to require surgical salvage, therefore, is an important aim of any organ preserving approach in order to minimize morbidity while maximizing organ preservation. To this end, a strategy of 'chemoselection', using the primary tumor's response after 1 cycle of induction chemotherapy as an in vivo method of selecting responders for definitive chemoradiation while reserving primary surgical management for non-responders, has been employed extensively at our institution. The rationale, treatment results and future directions of this approach are discussed.

Survival following non surgical treatments for oral cancer: a single institutional result

AIM

To report the results of radiotherapy with or without chemotherapy in the patients with oral cancer.

METHODS

Over the 2003-2009 periods, a total number of 69 patients with squamous cell carcinoma of the oral cavity that refused surgery or had unresectable tumor were enrolled in this study. A total dose of 60 to 70 Gy (2 Gy per day) was given to the primary tumor and clinically positive nodes. In the patients with locoregionally advanced disease (57 patients with T3, T4 lesions and/ or N+) induction chemotherapy following by concomitant chemoradiation was used. Induction chemotherapy consisted of 3 cycles of Cisplatin and 5-Flourouracil with or without Docetaxel. Weekly cisplatin was used in concomitant protocol. Kaplan-Meier method was used to calculate overall survival. Log-rank test and Cox regression model were used for comparison purposes.

RESULTS

Median follow-up was 32 months. The mean age of the patients was 59.2 years. The overall response rate after induction chemotherapy was 68.4%. Actuarial overall survival rates after 2 and 3 years were 38% and 26%, respectively. Clinical stage emerged as the only independent predictor of survival.

CONCLUSION

Outcome of the patients with oral cancer is poor. Presenting with an advanced stage lesion contributed to this result. The role of chemotherapy in advanced cases remains to be defined.

Induction chemotherapy for locoregionally advanced head and neck cancer: past, present, future?

The treatment of patients with locoregionally advanced squamous cell cancer of the head and neck is still evolving. Induction chemotherapy (IC) is widely used in this patient population and it is unclear how to best incorporate IC into multimodality treatment. Recently, the results of two randomized clinical trials were presented (the PARADIGM and Docetaxel Based Chemotherapy Plus or Minus Induction Chemotherapy to Decrease Events in Head and Neck Cancer trials), which showed no demonstrable benefit of IC followed by concurrent chemoradiation over concurrent chemoradiotherapy alone. However, a lower rate of distant metastatic disease was noted, suggesting that patients who are at high risk for metastatic disease may benefit from IC. This review summarizes how IC has evolved over the years, provides an update of recent developments, and discusses how IC may develop in the future.

PET/CT of cancer patients: part 2, deformable registration imaging before and after chemotherapy for radiation treatment planning in head and neck cancer

OBJECTIVE

The purpose of this perspective is to discuss the use of deformable registration as a tool for image fusion to integrate information from PET/CT scans obtained before and after chemotherapy to assist definition of radiation targets in the management of head and neck cancer.

CONCLUSION

The consistent method for target delineation described capitalizes on the capability of deformable registration to compensate for changes in position and accurately represent evolving spatial relationships between normal anatomy and areas at risk of disease.

Role of paclitaxel and platinum-based adjuvant chemotherapy in high-risk penile cancer

Aim:

To study the efficacy and safety of paclitaxel and platinum doublet chemotherapy in penile cancer patients with high-risk features of local failure.

Materials and Methods:

Retrospective analysis was done of patients with 19 carcinoma of the penis who were offered adjuvant chemotherapy with paclitaxel and platinum combination. The data regarding the surgical details, high-risk features for which chemotherapy was offered, chemotherapy toxicity details (in accordance with CTCAE vs 3), failure pattern, and survival data were noted. SPSS version 16 was used for statistical analysis. Descriptive and Kaplan–Meier survival analysis was performed.

Results:

Median age of patients was 48 years. Fifteen patients received paclitaxel in combination with cisplatin and four received paclitaxel with carboplatin in view of their low serum creatinine clearance. The treatment was completed by 12 patients (63.2%). Of 79 planned cycles, 50 were taken. The treatment was well tolerated with grade 3-4 gastrointestinal toxicity was seen in 1 patient, grade 3 neurological toxicity in one and grade 5 neutropenia in one patient. Treatment related death occured in one patient. The median follow-up was 15.33 months and 6 loco-regional relapsed had taken place. The estimated median DFS was 16.2 months and the estimated median OS was not reached. The estimated DFS for treatment completed patients was 23.13 months as against 2.16 months for patients not completing treatment.

Conclusion:

The platinum and taxane doublet chemotherapy was found to be safe and effective.

Sequential chemoradiotherapy in advanced laryngeal cancer: an institutional experience

AIM

The objective of this study was to determine the efficacy of sequential chemoradiation for larynx preservation.

METHODS

Between October 2002 and December 2007, 76 patients with T3, T4 and N+ laryngeal cancer who had refused a laryngectomy or had unresectable disease (medically or surgically) enrolled in this study. The chemotherapy consisted of three cycles of docetaxel (75 mg/m(2) on day 1), cisplatin (75 mg/m(2) on day 1) and 5-flurouracil (5-FU) (750 mg/m(2) by infusion on days 1-3). All patients were assigned to receive radiotherapy (70 Gy to primary site). The Kaplan-Meier method was used to obtain survival outcomes.

RESULTS

The median follow up was 36 months. A chemotherapy clinical response (complete and partial) was observed in 51 patients (67.1%). The 2-year laryngeal preservation rate was 75%. Actuarial progression-free survival rates of 71% and 67% were observed at 2 and 3 years, respectively. Actuarial overall survival rates were 83% and 71% at 2 and 3 years, respectively. Disease progression was seen in 26 patients (34.2%). Grade 3 and 4 neutropenia occurred in 39 (51.3%) patients.

CONCLUSION

Sequential chemotherapy with docetaxel, cisplatin and 5-flurouracil followed by radiation may be an alternative to a laryngectomy in patients with advanced laryngeal cancer.

Phase I trial of dose-escalated cisplatin with concomitant cetuximab and hyperfractionated-accelerated radiotherapy in locally advanced squamous cell carcinoma of the head and neck

BACKGROUND

Cetuximab is active in the treatment of squamous cell carcinoma of the head and neck (SCCHN), enhancing both radiotherapy and chemotherapy effects. This phase I study was designed to investigate the safety and tolerability of combining weekly cisplatin treatment with cetuximab and hyperfractionated-accelerated radiotherapy (HART) for locally advanced SCCHN.

PATIENTS AND METHODS

Patients with unresectable stage III or IVA/B SCCHN were treated with cetuximab, 400 mg/m² initial dose on day -7 of HART, followed by 250 mg/m² weekly during the administration of HART, which started with 2.0 Gy/day (5 days/week) for 3 weeks followed by 1.4 Gy/twice-daily (Monday to Friday) for another 3 weeks, resulting in a total dose of 70.6 Gy. Cisplatin was administered weekly starting on the first day of radiotherapy until week 6. Cisplatin was dose escalated of four dose levels from 20 to 40 mg/m² using a classical 3 + 3 dose escalation algorithm.

RESULTS

Eighteen patients were enrolled. Sixteen patients were eligible for toxicity, and 15 for response. No maximum tolerated dose was reached for cisplatin. One of six patients of dose level 4 had grade 4 neutropenia. This patient died 1 week after the end of the study treatment. The most common types of grade 3+ adverse events were mucositis (9 of 16 patients), in-field dermatitis (6 of 16 patients) and neutropenia (4 of 16 patients). Cetuximab-related hypersensitivity was observed in 1 out of 18 patients. Six weeks after the end of the study treatment, 5 complete responses, 8 partial responses and 1 progressive disease (at distant sites) were documented in a total of 15 patients (objective response rate 87%).

CONCLUSIONS

The combination of cisplatin with cetuximab and HART is active, well tolerated and merits additional investigation. The recommended weekly dose of cisplatin for phase II studies is 40 mg/m².

MMP9 but Not EGFR, MET, ERCC1, P16, and P-53 Is Associated with Response to Concomitant Radiotherapy, Cetuximab, and Weekly Cisplatin in Patients with Locally Advanced Head and Neck Cancer

Concomitant administration of radiotherapy with cisplatin or radiotherapy with cetuximab appear to be the treatment of choice for patients with locally advanced head and neck cancer. In the present retrospective analysis, we investigated the predictive role of several biomarkers in an unselected cohort of patients treated with concomitant radiotherapy, weekly cisplatin, and cetuximab (CCRT). We identified 37 patients treated with this approach, of which 13 (35%) achieved a complete response and 10 (27%) achieved a partial response. Severe side effects were mainly leucopenia, dysphagia, rash, and anemia. Tumor EGFR, MET, ERCC1, and p-53 protein and/or gene expression were not associated with treatment response. In contrast, high MMP9 mRNA expression was found to be significantly associated with objective response. In conclusion, CCRT is feasible and active. MMP9 was the only biomarker tested that appears to be of predictive value in cetuximab treated patients. However, this is a hypothesis generating study and the results should not be viewed as definitive evidence until they are validated in a larger cohort.

Neoadjuvant chemotherapy followed by concurrent hyperfractionated radiation therapy and sensitizing chemotherapy for locally advanced (T3-T4) oropharyngeal squamous cell carcinoma

BACKGROUND

Radiation therapy (RT) is commonly used in the management of patients with advanced (T3-T4) oropharyngeal squamous cell carcinomas. In recent years, based upon the meta-analyses of randomized trials, chemotherapy administered concurrently with RT (chemoradiotherapy) has become the standard of care. Twice-a-day hyperfractionated or accelerated-fractionated RT regimens have been shown in a number of randomized trials to significantly improve the rate of local control compared with conventional once-a-day fractionation. Concurrent chemotherapy administered along with hyperfractionated or accelerated RT has been shown to add significant additional benefit over hyperfractionated or accelerated RT alone. Neoadjuvant chemotherapy (usually consisting of cisplatin and fluorouracil) also produces favorable responses in most patients (approximately 75% partial or complete response rates) with advanced head and neck cancer, but its role remains controversial.

METHODS

The results of treatment of 23 patients with T3 or T4 oropharyngeal squamous cell carcinomas who received neoadjuvant chemotherapy, followed by hyperfractionated RT (120 cGy twice-a-day to 74.4-76.8 Gy) were retrospectively reviewed. The 14 patients who were most recently treated also received concurrent sensitizing doses of single agent chemotherapy, usually cisplatin. No patient was seen with distant metastasis, and all were treated with curative intent. Ten patients had T3 and 13 patients had T4 primary tumors. Three patients (13%) had stage III disease and 20 patients (87%) had stage IV disease. Ten patients had base of tongue primaries, 12 had tonsillar primaries, and 1 had an oropharyngeal wall primary. Eighteen patients (78%) had clinically involved neck nodes.

RESULTS

Seventy-four percent of patients had partial (>50%) or complete response at the primary site following neoadjuvant chemotherapy. One patient died of cardiorespiratory arrest after the first cycle. Thirteen percent of patients had unplanned interruptions of their RT courses secondary to severe mucositis. Local control at the primary site (minimum 2 years follow-up) was achieved in 17 of 19 (89%) patients. Two- and 5-year absolute survival rates were 71% and 55%, respectively. No patient was gastrostomy dependent beyond 18 months. Four patients developed neck failure after RT alone and none was successfully salvaged.

CONCLUSION

This study is noteworthy in that it uses both neoadjuvant and concurrent sensitizing chemotherapy along with hyperfractionated RT. There is little information in the literature on this approach. Although the regimen is somewhat toxic, it is less so than many other regimens, which combined full-dose multiagent chemotherapy during the course of RT. The latter regimens also have a significant incidence of permanent dysphagia, gastrostomy dependence, and/or aspiration, complications that were not encountered in this group. The local control rate was high (89%). We continue to recommend this regimen for patients with locally advanced head and neck squamous cell carcinomas.

A phase I clinical study of VB4-845: weekly intratumoral administration of an anti-EpCAM recombinant fusion protein in patients with squamous cell carcinoma of the head and neck

VB4-845 is a scFv-Pseudomonas exotoxin A fusion construct that targets epithelial cell adhesion molecule (EpCAM). A phase I trial was conducted to determine the maximum tolerated dose (MTD) of VB4-845 when administered as weekly intratumoral (IT) injections to patients with squamous cell carcinoma of the head and neck (SCCHN). Secondary objectives included the evaluation of the safety, tolerability, pharmacokinetic profile, and immunogenicity, and a preliminary assessment of tumor response. Twenty patients with advanced, recurrent SCCHN were treated weekly for four weeks in ascending dose cohorts of 100, 200, 330, 500, 700, and 930 microg. The MTD was established as 930 microg with a dose limiting toxicity of elevated liver enzymes in two of five patients. VB4-845 therapy was well tolerated with common treatment-related adverse events of injection site reactions, fever, gastrointestinal disorders, and elevated liver enzyme levels. All patients developed antibodies to VB4-845 by the end of the study, but only seven patients had neutralizing antibodies. Preliminary efficacy data found 87.5% of EpCAM-positive patients had a positive response to VB4-845 therapy. Noninjected dermal metastases were also resolved in one patient. VB4-845 IT therapy is safe and feasible and warrants further clinical evaluation for the treatment of SCCHN.

Balancing risk and reward in target delineation for highly conformal radiotherapy in head and neck cancer

The therapeutic index of highly conformal radiotherapy (RT) depends on adequate selection and delineation of the gross tumor volumes, the clinical target volumes, and the tissues and organs whose sparing is likely to gain clinical benefit. Decisions about target and tissue selection and delineation affect the balance of reward and the risk of highly conformal RT. Some of these issues relating to head and neck cancer, including target delineation after tumor shrinkage by induction chemotherapy or at midradiotherapy, are discussed in this article.