Explore the Usefulness of Concurrent Chemotherapy in Stage II Nasopharyngeal Carcinoma: A Retrospective Study

Individualized Concurrent Chemotherapy for Patients with Stage III-IVa Nasopharyngeal Carcinoma Receiving Neoadjuvant Chemotherapy Combined with Definitive Intensity-Modulated Radiotherapy

PURPOSE

This retrospective study aimed to re-evaluate the effect of concurrent chemotherapy in patients with locally advanced nasopharyngeal carcinoma (NPC) in the era of intensity-modulated radiotherapy (IMRT).

MATERIALS AND METHODS

A total of 498 patients who received neoadjuvant chemotherapy (NCT) combined with concurrent chemoradiotherapy (CCRT) or IMRT were retrospectively reviewed. The distribution of baseline characteristics was balanced using propensity score matching. Additionally, the results of NCT+IMRT and NCT+CCRT were compared using Kaplan-Meier survival analysis, and differences in survival rates were analyzed using the log rank test.

RESULTS

There were no significant differences in overall survival (OS), progression-free survival (PFS), distant metastasis-free survival (DMFS), and local progression-free survival (LRFS) between the two groups. Patients were further categorized into risk subgroups based on pretreatment Epstein-Barr virus (EBV) DNA cutoff values using receiver operating characteristic curve analysis. There were no statistically significant differences in OS, PFS, DMFS, and LRFS between patients who received NCT+CCRT and NCT+IMRT in the high-risk group. In the low-risk group, although there were no differences between NCT+CCRT and NCT+IMRT in OS, PFS, and LRFS, patients who received NCT+CCRT had better DMFS than those who received NCT+IMRT.

CONCLUSION

Pretreatment EBV DNA level can be used to individualize concurrent chemotherapy for patients with locally advanced NPC. Patients with low pretreatment EBV DNA levels may benefit from concurrent chemotherapy, whereas those with high levels may not. Other treatment modalities need to be explored for high-risk patients to improve their prognosis.

Concurrent chemoradiotherapy versus radiotherapy alone for stage II nasopharyngeal carcinoma in the era of intensity-modulated radiotherapy

BACKGROUND

Concurrent chemoradiotherapy has long been a standardized therapy for localized advanced nasopharyngeal cancer. It is widely used in clinical applications. In contrast, NCCN guidelines highlight that the efficacy of concurrent chemoradiotherapy for stage II nasopharyngeal cancer in the new era of intensity-modulated radiotherapy has not been defined. Thus, we systematically reviewed the significance of concurrent chemoradiotherapy for stage II nasopharyngeal cancer.

METHODS

We searched the relevant literature in PubMed, EMBASE, and Cochrane, extracting relevant data from the searched literature. The main items extracted were hazard ratios (HRs), risk ratios (RRs) and 95% confidence intervals (CIs). When the HR could not be extracted from the literature, we used Engauge Digitizer software for extraction. Data analysis was accomplished using the Review Manager 5.4 tool.

RESULTS

Our study included seven articles involving 1633 cases of stage II nasopharyngeal cancer. The survival outcomes were overall survival (OS) (HR = 1.03, 95% CI (0.71-1.49), P = 0.87), progression-free survival (PFS) (HR = 0.91, 95% CI (0.59-1.39), P = 0.66), distant metastasis-free survival (DMFS) (HR = 1.05, 95% CI (0.57-1.93), P = 0.87), local recurrence-free survival (LRFS) (HR = 0.87, 95% CI (0.41-1.84), P = 0.71, P > 0.05), and locoregional failure-free survival (LFFS) (HR = 1.18, 95% CI (0.52-2.70), P = 0.69).

CONCLUSIONS

In the era of intensity-modulated radiotherapy, concurrent chemoradiotherapy and radiotherapy alone have the same survival benefits, and concurrent chemoradiotherapy increases acute hematological toxicity. Subgroup analysis showed that for people with N1 nasopharyngeal cancer at risk of distant metastases, concurrent chemoradiotherapy and radiotherapy alone also had equal survival benefits.

A Systematic Review and Meta-Analysis of Studies Comparing Concurrent Chemoradiotherapy With Radiotherapy Alone in the Treatment of Stage II Nasopharyngeal Carcinoma

Purpose

The role of concurrent chemoradiotherapy (CCRT) in stage II nasopharyngeal carcinoma (NPC) is still controversial. Our objective is to evaluate the value of concurrent chemotherapy in stage II NPC receiving radiotherapy (RT).

Methods

We searched the PubMed, Embase, and Scopus databases for studies comparing CCRT versus RT alone in stage II NPC with survival outcomes and toxicities, including locoregional recurrence-free survival (LRFS), metastasis-free survival (DMFS), progression-free survival (PFS), overall survival (OS), and grade 3–4 acute toxicities. The hazard ratios (HRs) of survival outcomes and risk ratios (RRs) of toxicities were extracted for meta-analysis. Subgroup analysis for stage N1 patients was performed to further explore whether these populations can earn benefits from concurrent chemotherapy.

Results

Nine eligible studies with a total of 4,092 patients were included. CCRT was associated with a better OS (HR = 0.61, 95% CI 0.44–0.82), LRFS (HR = 0.62, 95% CI 0.50–0.78), and PFS (HR = 0.65, 95% CI 0.54–0.79), but with similar DMFS (HR = 0.81, 95% CI = 0.46–1.45) compared with two-dimensional RT (2DRT) alone. However, CCRT showed no survival benefit in terms of OS (HR = 0.84, 95% CI 0.62–1.15), LRFS (HR = 0.85, 95% CI 0.54–1.34), DMFS (HR = 0.96, 95% CI 0.60–1.54), and PFS (HR = 0.96, 95% CI 0.66–1.37) compared with intensity-modulated RT (IMRT) alone. Subgroup analyses indicated that CCRT had similar OS (HR = 1.04, 95% CI 0.37–2.96), LRFS (HR = 0.70, 95% CI 0.34–1.45), DMFS (HR = 1.03, 95% CI 0.53–2.00), and PFS (HR = 1.04, 95% CI 0.58–1.88) in the stage N1 populations. Meanwhile, compared to RT alone, CCRT significantly increased the incidence of grade 3–4 leukopenia (RR = 4.00, 95% CI 2.29–6.97), mucositis (RR = 1.43, 95% CI 1.16–1.77), and gastrointestinal reactions (RR = 8.76, 95% CI 2.63–29.12). No significant differences of grade 3–4 toxicity in thrombocytopenia (RR = 3.45, 95% CI 0.85–13.94) was found between the two groups.

Conclusion

For unselected patients with stage II NPC, CCRT was superior to 2DRT alone with better LRFS, PFS, and OS, while adding concurrent chemotherapy to IMRT did not significantly improve survival but exacerbated acute toxicities.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022318253.