Sequential chemotherapy and radiation therapy of buccal mucosa carcinoma in South India. Methods and preliminary results

Batoclimab as induction and maintenance therapy in patients with myasthenia gravis: rationale and study design of a phase 3 clinical trial

Introduction

Batoclimab, a fully human monoclonal antibody that inhibits the neonatal fragment crystallisable receptor, has shown promising phase 2 clinical trial results in patients with generalised myasthenia gravis (gMG).

Methods and analysis

In this phase 3, randomised, quadruple-blind, placebo-controlled study, adults with gMG will be randomised 1:1:1 to induction therapy with batoclimab 680 mg, batoclimab 340 mg, or placebo, administered once weekly (QW) for 12 weeks as a subcutaneous injection. The primary endpoint is the change from baseline to week 12 on the Myasthenia Gravis Activities of Daily Living (MG-ADL) score. Batoclimab-treated patients achieving a ≥2-point improvement from baseline on MG-ADL at week 10 or week 12 will be re-randomised to maintenance treatment with batoclimab 340 mg QW, batoclimab 340 mg every other week (Q2W), or placebo for 12 weeks; batoclimab-treated patients with a <2-point improvement at week 10 and week 12 will be switched to placebo for the maintenance period and discontinued thereafter. Placebo-treated patients from the induction period will be re-randomised to batoclimab 340 mg QW or Q2W in the maintenance period. All patients who complete the maintenance period and achieve a ≥2-point improvement from baseline in MG-ADL during ≥1 of the final 2 visits of the induction and/or maintenance periods will continue their current batoclimab dose (or switch to batoclimab 340 mg QW for those on placebo) for a 52-week long-term extension (LTE-1). Patients who complete LTE-1 may enter a second, optional 52-week LTE (LTE-2).

Ethics and dissemination

This trial is being conducted in accordance with the International Council for Harmonisation Guideline for Good Clinical Practice, the Declaration of Helsinki, and each site's Institutional Review Board/Independent Ethics Committee. All patients must provide written informed consent. Results from this study will be published in peer-reviewed journals and presented at national and global conferences.

Trial registration number

NCT05403541.

Neoadjuvant chemotherapy in breast cancer

BACKGROUND

Neoadjuvant chemotherapy for breast cancer was originally used in locally advanced inoperable disease in order to achieve surgical resection. It was then extended to operable breast cancer with a view to downstaging tumours to facilitate breast-conserving surgery. Increasingly, it is being considered as a treatment for earlier-stage disease.

METHODS

A Medline literature search was performed to identify articles relating to neoadjuvant chemotherapy in breast cancer published in the English language between 1960 and 2004. Secondary references were obtained from key articles. Search words included 'neoadjuvant chemotherapy', 'breast cancer', 'tumour biology', 'tumour markers' and 'sentinel lymph node biopsy'.

RESULTS

Long-term results from randomized studies have shown no difference in disease-free or overall survival between neoadjuvant and adjuvant chemotherapy. The main benefit of neoadjuvant chemotherapy is its ability to downstage large tumours with a view to treatment by breast-conserving surgery, although there is a non-significant increase in the local recurrence rate. Initial results of neoadjuvant chemotherapy trials using newer agents such as taxanes have demonstrated a greater pathological complete response. Whether this will translate into better long-term survival remains to be seen.

[Chemoradiotherapy of carcinomas of the upper aerodigestive tract]

The objective of this study was to review randomized trials which evaluated the effect of the radio-chemotherapy in head and neck carcinoma, and which compared radiotherapy alone vs the same local treatment plus chemotherapy. Over 40 such randomized trials have been performed, which generally showed no statistical difference between both arms. However few trials showed a benefit which is almost always in favor of the CT arm. Indeed, some trials of concomitant chemoradiotherapy have shown a statistically significant benefit in favor of the combined treatment. On the contrary, neoadjuvant chemotherapy generally leads to no detectable benefit compared to radiotherapy alone. These results have been reinforced by those of four randomized trials comparing neoadjuvant chemoradiotherapy and the same chemotherapy but given concomitantly with radiotherapy. The global effect of chemotherapy on survival of patients with head & neck squamous cell carcinoma has been recently evaluated by a meta-analysis based on individual patient data which included more than 10,000 patients from 63 randomized trials. The absolute survival rate benefit at 5 years is 4%, but is more pronounced in the concomitant combinations (8% at 5 years). In tumors classified as "T3" of the pharyngo-larynx, neoadjuvant chemotherapy followed by radiotherapy in good responders can avoid a total laryngectomy without significantly compromised survival. In the nasopharynx carcinoma, a few randomized studies have been performed, suggesting a benefit in favor of chemoradiotherapy. Finally, future randomized trials will determine what are the optimal chemoradiotherapy schedules, as well as determining what is the best radiotherapy (accelerated, hyperfractionated) to use in combination with chemotherapy.

Induction (neo-adjuvant) chemotherapy: systemic and arterial delivery techniques and their clinical applications

Induction chemotherapy is a well tried method of improving the cure prospects of locally advanced or aggressive primary cancers. It is most simply administered by systemic (intravenous) delivery but for some cases a greater chemotherapy impact is both desirable and achievable with the use of a more concentrated regional delivery technique. Any advantage of regional chemotherapy will depend upon the type of tumour to be treated, its site and blood supply, the most effective doses, concentrations and exposure periods of the preferred agents to be used and the relative risks of systemic and regional toxicity and the techniques of delivery. In general, systemic chemotherapy is most appropriate in treating tumours without a single artery of supply; when certain agents which are inactive until modified in body tissues (such as cyclophosphamide or DTIC) are to be used; when satisfactory responses can be achieved more easily by systemic delivery; when technical skills and facilities for regional delivery are not available; or when the patient's general health, co-operation or long-term prognosis precludes the additional complexity of regional delivery. Intra-arterial infusion may have advantages in treating head and neck, gastric, liver, some locally advanced breast, limb, pelvic and possibly pancreatic malignancies. More complex techniques to achieve short-term highly concentrated chemotherapy include closed circuit perfusion; chemofiltration infusion and 'stop flow' perfusion; and regional limb infusion. These should remain the subject of ongoing studies in highly specialized units which treat tumours such as melanoma or pancreatic cancer which respond poorly to lower chemotherapy concentrations.

An overview of randomised controlled trials of adjuvant chemotherapy in head and neck cancer

Meta-analysis of the published results from 54 randomised controlled trials of adjuvant chemotherapy in head and neck cancer suggests that chemotherapy might increase absolute survival by 6.5% (95% confidence interval 3.1-9.9%). The odds ratio in favour of chemotherapy is 1.37 (95% confidence interval 1.24-1.5). Single-agent chemotherapy given synchronously with radiotherapy increased survival by 12.1% (95% confidence interval 5-19%). The benefit from neoadjuvant chemotherapy was less: a rate difference of 3.7% (95% confidence interval 0.9-6.5%). The results suggest that the investigation of optimal agents and scheduling for synchronous radiotherapy and chemotherapy might still be important in clinical trials in head and neck cancer.

Intraarterial induction chemotherapy in locally advanced stage III breast cancer

Five-year results are reported on 27 patients with locally advanced breast cancer treated by intraarterial induction chemotherapy followed by radiotherapy and/or surgery with subsequent adjuvant chemotherapy. The cyclic infusion chemotherapy regimen was given over 3 to 6 weeks using Adriamycin (doxorubicin), 5-fluorouracil (5-FU), vincristine, and methotrexate in daily rotation. Regional and systemic side effects were minimal and temporary except in two patients in whom some skin discoloration has remained. Local tumor control and 5-year cures depended on two important factors: whether follow-up mastectomy was used after initial local tumor regression; and whether the carcinoma was classified as "inflammatory" with pathologic evidence of tumor invasion of dermal lymphatics. Of 16 patients with noninflammatory carcinoma treated by chemotherapy, radiotherapy, and mastectomy local tumor eradication was achieved in 15 and 5-year apparent cure in 11. Of six patients with noninflammatory carcinoma treated with chemotherapy and radiotherapy but no mastectomy 5-year local control was achieved in only three and 5-year apparent cure in three. Of five patients with pathologic inflammatory carcinoma local tumor control was achieved in only one and only this one patient has been a 5-year survivor apparently tumor-free.

Developments in surgical oncology: induction (neoadjuvant) chemotherapy--the state of the art

The three established modalities for treatment of cancer are operative surgery, radiotherapy and chemotherapy. In the past, patients have been referred to clinics where experts in the appropriate discipline have usually advised management by one or other of the three modalities. In recent years it has become apparent that for some cancers in which good results have not been forthcoming by one therapeutic modality alone, improvements may well be made by integrating management using two or three forms of treatment, in a planned approach. Management of localized cancers in which a surgical operation is likely to play a major part has traditionally been carried out by surgeons. However, operative surgery alone may not provide optimal care so that surgical oncology has developed as a discipline often embracing combined treatment with either chemotherapy or radiotherapy or both. In managing advanced but localized cancers for which a surgical operation alone is unlikely to produce tumour eradication (or for which tumour eradication can only be achieved with a mutilating operation such as amputation) it has become increasingly recognized that reduction of tumour size and viability by using chemotherapy first may render many tumours more susceptible to total eradication by subsequent radiotherapy and/or surgical operation. Such treatment is often referred to as 'induction' or 'neo-adjuvant' chemotherapy. This paper summarizes the principles of use of induction chemotherapy with integrated follow-up radiotherapy and/or surgical operation.

Evaluation of the role of radiotherapy in the management of carcinoma of the buccal mucosa

Carcinoma of the buccal mucosa is the commonest intraoral malignancy in south India. This article concerns the results of radiotherapy in cancer of the buccal mucosa. Radiotherapy was used as the first line of management in this series and surgery was reserved for failures even though very few patients opted for salvage surgery. Of the 234 evaluable patients, 42% survived disease-free at the end of 3 years with radiotherapy alone. Eighty-five percent of the patients with Stage I, 63% with Stage II, 41% with Stage III, and 15% with Stage IV disease survived disease-free at 3 years. With radium implant and small-volume beam-directed external radiotherapy, the survival rates were similar (62% versus 64%). The results of external radiation in advanced disease were dismal. Persistent disease after radiotherapy was a serious problem in advanced stages, especially in view of nonacceptance of salvage surgery by a significant proportion of patients. The most effective way of improving cure rates in cancer of the buccal mucosa seems to be early detection.

Bleomycin, methotrexate and vincristine before irradiation of stage III and IV laryngeal and pharyngeal squamous cell carcinoma. A study initiated by the Danish Society of Head and Neck Cancer

Primary treatment with bleomycin, methotrexate and vincristine for two weeks followed by curatively intended 60Co irradiation was administered to 153 patients consecutively referred to the three main treatment centres in Denmark over more than a two-year period. Seventy-one laryngeal and 82 pharyngeal squamous cell carcinomas were evaluated. According to the TNM classification (UICC) 76 patients had stage III and 77 patients stage IV disease. The immediate response (complete + partial) to chemotherapy was 20 per cent. Judging from frequency of local recurrence, metastases as well as survival the treatment results were not obviously improved. A high frequency of complications was observed after this combination of chemotherapy and irradiation, and it was often impossible to fulfil the irradiation to the planned dose in appropriate time.

Cisplatin sensitization to radiotherapy of squamous cell carcinomas of the head and neck

A combined modality of treatment utilizing cisplatin as a radiosensitizing agent concomitantly with full-course radical irradiation has been studied in 14 patients. Cisplatin at a dose of 15 mg/M2 body surface area was given intravenously on days 1 through 5 and 21 through 25 of the radiation therapy course. Among the 14 patients so treated, 11 patients had evidence of complete clinical regression of their tumors. Most remained in remission without evidence of recurrent disease for as long as 18 months. Recurrence in the field of treatment was even more rare. Symptomatic improvement was very encouraging in these patients. Most of them have had a significant improvement in their tolerance of pain and in the ability to swallow foods and maintain weight without a nasogastric feeding tube. Decannulation of the tracheostomy is usual. Problems included four patients with renal toxicity, one of whom died with renal failure. No patient required interruption of therapy due to mocositis or dysphagia. Nausea was rare. This encouraging data in our pilot study of a new therapeutic regimen justifies a full-scale clinical trial.

Pharmacokinetics of intra-arterial chemotherapy

Advanced or aggressive, but localised, malignancies can often be reduced to more curable proportions by the use of "basal chemotherapy", that is, using chemotherapy as the first mode of treatment, prior to definitive radiotherapy and/or surgical excision. In using anticancer agents, drug combinations, timing and methods of administration are employed which exploit differences between cancer cells and normal tissues and cells. One exploitable difference which is often overlooked is the fact that localised tumour is often supplied with blood by one artery; this can be cannulated so that the agents used can be delivered selectively in high concentration to the region containing the tumour. The advantage in delivering drugs regionally by intra-arterial infusion depends upon the size of the artery infused, the rate of excretion or detoxification of the agents used, the amount of the agent infused entering the tissues - especially from the first circulation, and especially the amount of agent entering the tissues which is biologically active against tumour cells. Taking all these factors into account, mathematical calculations indicated that under the worst possible circumstances infusion of anticancer agents intra-arterially should be at least 1.8 times more effective regionally than intravenous administration. In most situations and with most agents used the advantage would be significantly greater than this. These calculations are supported by evidence in the literature and by observations of a greater regional effect, albeit toxic, of intra-arterial administration of the agents. These effects include more pronounced loss of hair in the region of distribution of the artery infused, and increased skin and mucosal ulceration in the distribution of the artery infused. The disadvantage of using intra-arterial infusion delivery is the need for hospitalisation. Therefore, properly controlled, randomised clinical trials should be conducted to compare clinical results of intra-arterial and intravenous chemotherapy administration.

Advanced squamous cell carcinoma of the maxillary sinus. Results of combined regional infusion chemotherapy, radiation therapy and surgery

Sequential intraarterial chemotherapy using bleomycin and methotrexate followed by high dose radiation and surgery was evaluated in 10 patients with stage III and IV squamous carcinomas of the maxillary sinus. Seven of 10 patients had extensive tumor necrosis in the surgical specimen, and no evidence of residual tumor was found in 4 of these patients. After a median follow up period of 24 months, there has been only one local recurrence in resected patients. Three patients died from pulmonary metastases. Although many unanswered questions remain regarding the efficacy of triple therapy for maxillary sinus malignancy, these results are encouraging and establish that surgical resection and healing are not compromised by preoperative chemotherapy and radiation.

Chemotherapy of head and neck cancer

Chemotherapy has traditionally been relegated to a late palliative role in the management of head and neck cancer. For advanced disease in patients previously treated with surgery or radiation therapy, methotrexate, which has a response rate of approximately 50%, is the best single agent available. Other orally or systemically administered single agents--such as bleomycin, adriamycin, hydroxyurea, and cis-platinum--produce responses less frequently than methotrexate. Intraarterial chemotherapy with single-agent methotrexate or with combinations--including methotrexate, vinblastine sulfate (Velban), cyclophosphamide (Cytoxan), and 5-fluorouracil (5-FU)--can match the response rate of systemic methotrexate, but all require inpatient treatment and significant technical expertise. Programs utilizing chemotherapeutic combinations have not produced remission rates or durations of remission greater than those achieved with methotrexate alone. Chemotherapy has also been used in combination with other modalities. In two studies, chemotherapy combined with irradiation produced improvement in median or overall survival in comparison to irradiation alone. Many similar studies have been negative. Recent trials of chemotherapy used preoperatively in the treatment of head and neck cancer have not yielded decreased recurrence rates or increased overall survival rates in comparison to surgery alone, but they do appear to have prolonged the disease-free interval following definitive surgery.

"CRAB" chemotherapy. Curative, relieving, adjuvant, and basal

A selection of patients with a variety of tumors treated effectively by chemotherapy followed by radiotherapy or surgery or both is presented. The best success has been achieved with lesions not previously treated by radiotherapy or surgery and which have no fixed lymph node masses. Where possible, we prefer to administer chemotherapeutic agents by direct infusion into the regional artery supplying the tumor mass.

Synchronous VBM and radiotherapy in the treatment of squamous cell carcinoma of the head and neck

Since April 1974, 60 patients with squamous cell carcinoma of the head and neck region, of poor prognosis and generally in advanced stages, were treated with the combination of a cytotoxic regimen--VBM (Vincristine, Bleomycin and Methotrexate) and radical radiotherapy. The essential feature of the combination is the administration of pulses of VBM synchronous with a course of fractionated external radiotherapy in order to achieve potentiation of radiotherapy. On average 4-5 pulses of VBM were given during treatment, combined with radiotherapy on a Cobalt unit. The selection, preparation and management of the patients are described. Intense mucositis and intercurrent infection provide the main problems during treatment and close management is essential. Late complications have not been a serious problem. The crude actuarial survival rate at 24 months is 61%. The probability of survival without any recurrence to 24 months following initial treatment is 46%. Local control was achieved by the initial treatment in 43 patients. These results suggest that potentiation of radiotherapy and an increased therapeutic ratio has been obtained by the addition of VBM to radiotherapy and there is a possibility that the occurrence of distant metastases has been reduced or postponed.

Sequential multidrug chemotherapy and radiotherapy with possible surgery for locally advanced cancer

A preliminary report describes the use of both a single and a combined chemotherapeutic drug regime before radiotherapy for locally advanced and radioresistant cancers. Some tumours have been rendered operable with safety by this sequence. This method is suggested to replace the current practice of following surgery with radiotherapy and finally chemotherapy. In our experience, chemotherapy before radiotherapy is assisting in the effective control of locally advanced and hitherto radioresistant cancers of many types, and in converting inoperable cancers into cancers that can be resected sometimes with safety. Also, when chemotherapeutic drugs are given before radiotherapy, damage to normal adjacent tissue is less than that seen after radiotherapy alone.

"Crab" care and cancer chemotherapy

The letters CRAB indicate that there are four broad uses of chemotherapy in treating solid tumours: (i) curative, which is always the aim but as yet can rarely be reliably achieved with chemotherapy alone; (ii) relieving chemotherapy for widespread or incurable disease; (iii) adjuvant care to prevent peripheral occult disease developing after standard surgery or radiotherapy; and (iv) basal chemotherapy, to reduce the size, viability and especially the peripheral extent of large, localized tumour masses in preparation for definitive treatment usually by radiotherapy and/or extirpative surgery.

The role of chemotherapy in the management of cancer of the head and neck: a review

Although experience with drug therapy of advanced or recurrent squamous cell carcinoma of the head and neck is limited, several agents have produced convincing and reproducible tumor regression in these patients. Methotrexate has had the widest usage, and produces 30-50% response rates; bleomycin, hydroxyurea, and adriamycin appear to be somewhat less effective. Location of the malignancy and previous x-ray treatment appear to be important determinants of responsiveness to methotrexate, while degree of differentiation has not yet been shown to be an important factor for response to this drug. Attempts to improve the response rate and duration of chemotherapeutic response by utilizing combinations of drugs, or use of drugs to sensitize the tumor to x-ray treatment, or to reduce the bulk of tumor before x-ray treatment, are reviewed; they have been only moderately encouraging. Intra-arterial chemotherapy appears to have a therapeutic advantage over intravenous treatment; however, the morbidity associated with the former approach limits its usefulness for routine usage. The use of drugs as adjuncts following surgery and/or radiation therapy or immunotherapy are newer approaches that have not been investigated sufficiently, but are promising areas for investigation.

Current status of regional arterial infusion chemotherapy

The rationale for this method is that a prolonged, continuous exposure of tumor cells to an antimetabolite is required for effective antimetabolic activity to develop in the tumor cell population. Overall experience in selected sites such as head and neck, liver, and extremities is reviewed.