Nasopharyngeal cancer in non-endemic areas: Impact of treatment intensity within a large retrospective multicentre cohort

AIM

Recommendations for managing patients with nasopharyngeal carcinoma (NPC) in non-endemic areas are largely derived from studies conducted in endemic areas. We analysed the impact of treatment approaches on survival in non-endemic areas.

METHODS

In an international, multicentre, retrospective study, we analyse consecutive patients with NPC diagnosed between 2004 and 2017 in 36 hospitals from 11 countries. Treatment was categorised as non-intensive (NIT), including radiotherapy alone or concomitant chemoradiotherapy (cCRT), and intensive (IT) including cCRT preceded by and/or followed by chemotherapy (CT). The impact of IT on overall survival (OS) and disease-free survival (DFS) was adjusted for all the available potential confounders.

RESULTS

Overall, 1021 and 1113 patients were eligible for overall survival (OS) and disease-free survival (DFS) analyses, respectively; 501 and 554 with Epstein Barr-encoded RNA (EBER) status available. In the whole group, 5-year OS was 84% and DFS 65%. The use of NIT was associated with a risk of death or recurrence 1.37 times higher than patients receiving IT. Patients submitted to NIT and induction CT + concurrent concomitant chemo and three-dimensional Conformal Radiation Therapy (3DCRT) had a risk of death or recurrence 1.5 and 1.7 times higher than patients treated with induction CT + cCRT with intensity-modulated radiotherapy (IMRT), respectively. The IT had no impact on OS in neither patients with EBER+ nor in patients with EBER-; IT showed better DFS in EBER+ but not in patients with EBER-.

CONCLUSIONS

In low-incidence areas, patients with NPC treated with induction CT followed by concurrent IMRT cCRT achieved the highest DFS rate. The benefit of IT on DFS was restricted to patients with EBER+, suggesting that additional therapy offers no advantages in EBER- cases.

Radiotherapy in localized gastric cancer management: To be or not to be?

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Background: Gastric adenocarcinoma still have dismal outcome in spite of the progress made in systemic treatment in last 2 decades. In localized disease, treatment outcome still suboptimal, with up to 88% suffer from recurrence/metastasis. Hence, improvement in radical initial treatment is mandatory. Recent trials showed survival benefit of adding radiotherapy (preoperative or adjuvant) with favorable toxicity profile when using current advances radiation techniques. Methods: We retrospectively analyzed impact of radiotherapy in management of localized gastric cancer in Kuwait. 87 adult patients with newly diagnosed gastric cancers were treated and followed up at Kuwait Cancer Control Center (KCCC) between 2009-2015, 12 were excluded due to inoperability. 13 patients were excluded as they had early disease and underwent only surgery. Finally, 62 patients were submitted in study 48 patient received radiotherapy (RT group) as part of treatment (44 postoperative, 3 postoperative after induction Chemotherapy, 1 preoperative). 14 patients did not receive radiotherapy (NRT group); five received perioperative chemotherapy, nine received postoperative chemotherapy). Survival analysis was done using Kaplan-Meier, and comparison was done according to clinicopathological features. Results: The median age at diagnosis was 55 (range 25-70). Men represented 65.5%. Asian were 17 patients and Caucasian were 70 patients. 68.9% were nonsmoker while 31% were smoker. Median follow up was 45 months (1-89). 2 year Overall survival in the NRT group was 50% while in RT group was 79.1%. 3 year OAS was 42.8% and 64.5% in NRT group and RT group respectively. Median overall survival for NRT group was 82 months. While for the RT group median survival was not reached at time of analysis with p value (0.025). 2 year DFS in NRT group was 50% while in RT group was 66.6%. 3 year DFS was 42.8% and 54.1% in NRT group and RT group respectively. Median DFS not reached in both groups p value (0.04). On correlation of prognostic clinicopathological features with benefits of adding radiotherapy it was noticed that high grade, positive margins statistically benefit more from local radiotherapy and had better local control. Distal tumours behave badly whether received radiotherapy or not. Interestingly benefit of adding radiotherapy was not significantly affected by nodal status. Conclusions: Radiotherapy should be part of management in postoperative locally advanced gastric cancer especially with high grade tumours and positive margins. However still ongoing trials to clear the role of radiotherapy in preoperative setting.

Primary Squamous Cell Carcinoma of the Trachea: Two Cases Report

Tracheal squamous cell carcinoma is the most common pathology in smokers while ACC is more prevalent among non-smokers. These tumors tend also to be diagnosed late on account of delayed specific symptoms as hemoptysis, dyspnea, cough, hoarseness, and stridor being the most common. Management of tracheal tumors is essentially multidisciplinary. It includes interventional endoscopy, surgery, radiotherapy, and/or end luminal brachytherapy. Extensive segmental resection of the trachea is the potentially curative treatment of choice for primary lesion. The sleeve trachea resection is one of the optimal surgical modalities. The other options are: partial tracheal wall resection and immediate tracheal reconstruction, total laryngectomy plus partial resection of trachea and primary reconstruction, laryngeo-tracheal resection, cervico-mediastinal exenteration, or carinal resection and reconstruction. Trachea anastomosis is suitable for small defects. The platysma myocutaneous flap combined with the facial flap of the sternohyoid muscle, sternocleidomastoid myoperiosteal flap and the pectoralis major musculocutaneous flap are applied to reconstruct the defects of cervical trachea. Post-operative radiation therapy, in many cases, is considered a fundamental part of treatment. Contraindications to surgery include: metastatic disease, invasion of adjacent organs, involvement of airway greater than could be safely resected (i.e. >50% of trachea), involvement of airway that would leave grossly positive margins after resection, spinal kyphosis, or poor medical condition of the patient. Patients in the current report tolerated therapy well with the use of modern RT techniques and dose delivery to 60 to 64 Gy to a large extent of the central airway. Additional data and meta-analysis are required to validate the efficacy of chemoradiation in comparison to primary RT alone for unresectable cases and subsequently identify improved systemic therapies. Further investigation into the potential role of additional therapies, such as adjuvant chemotherapy or immunotherapy, may be worth exploring. Our initial findings suggest the use of concurrent chemotherapy in addition to RT in patients with locally advanced tracheal SCC.

Phase II/III Randomized Controlled Trial of Concomitant Hyperfractionated Radiotherapy plus Cetuximab (Anti-EGFR Antibody) or Chemotherapy in Locally Advanced Head and Neck Cancer

INTRODUCTION

Globally, there is marked variation in overall incidence and presentation of head and neck cancers, these cancers account for 11.5 per 100,000 population in G.C.C states. Concomitant chemotherapy and external beam radiotherapy (EBRT) is indicated in such cancers with aim of organ preservation, control and possible cure. Hyper fractionated radiotherapy with concomitant chemotherapy or cetuximab is a lesser explored option. In this study we wish to assess the tolerability and efficacy of cetuximab with altered fractionation and compare this with the chemotherapy (cisplatin).

MATERIALS AND METHODS

This is a randomized controlled study from a single institute in Kuwait. Locally advanced head and neck cancer cases excluding cancer nasopharynx are enrolled for the study. Stage III or stage IV-A cases were enrolled with histopathology squamous cell carcinoma. Patients were randomized into 2 arms. Arm A: to receive platinum-based CT i.e. cisplatin in a dose of 100 mg/m2 3-weekly or 40 mg/m2 weekly during radiation; Arm B: received cetuximab with a loading dose 400 mg/m², one week before radiation followed by weekly dose of 250 mg/m² during radiation. Radiotherapy was delivered using intensity modulated radiotherapy (IMRT) or 3D-conformal radiotherapy (CRT). The primary objective was to evaluate whether the use of cetuximab with concurrent hyperfractionated radiation regimen will have loco regional control rates (LC) and Disease-free survival (DFS) that are comparable to concurrent cisplatin in patients with LAHNC. The secondary endpoints were to compare the impact of using concurrent cetuximab vs chemotherapy regimen on Overall Survival of patients (OS) and acute and late adverse events.

RESULTS

From November 2012 to November 2017, 40 patients were randomized. The median age of was 51 years (range 27-72 years). Thirty-five patients are male and remaining was female. 14 patients have their primaries in larynx, 11 in oropharynx, 8 in oral cavity, and 5 has tumor in hypopharynx. Two patients had disease in nasal sinus or overlapping subsides. 50% has T4 lesions while 35% has T3 lesions, Nodal status was (N0-1) in 20 patients and (N2-3) in 20 patients. Overall staging showed a majority to have stage IV disease (63%). HPV was negative in 2 cases in Arm 1 and positive in 2 cases in Arm 2. 22 patients were randomly allocated in Arm A (platinum-based) while 18 were in Arm B (cetuximab). CR was achieved in 59% in arm A vs 50% in Arm B, while PR was 27.3% and 27.8% respectively. Disease progressed in 2 patients in Arm B only. Out of these 40 patients, 14 patients failed (6 and 8 in arm A and B respectively). Locoregional failure was documented in 6 (27.3%) vs 7 (38.9%) of arm A and B respectively, which was statistically not significant possibly related with lower number of cases. 2 years DFS was 56.5% vs 77.3% in cisplatin vs cetuximab arm (denoting nonsignificant increase of relapse rate in cisplatin arm). However, 2 years OS was 80.7% vs 57.3% in cisplatin and cetuximab arm respectively (p value=0.04).

CONCLUSION

Though cetuximab has lesser side effects but it is not indicated in treatment of LAHNC. Concurrent cisplatin is a trusted option for concomitant setting regardless of the HPV status and tumor location. However, in the context of cisplatin ineligible patients, cetuximab should be used only with hyper fractionation. This preliminary study could represent a good core of large international multicenter RCT.

Triple Negative Breast Cancer: 10-Year Survival Update of The Applied Treatment Strategy in Kuwait

BACKGROUND

Triple negative breast cancer (TNBC) is recognized as a distinct clinical and biological entity of poor outcome for almost two decades, yet its treatment strategy still needs to be better specified. The study aim is to update the 10-year survival data of our TNBC patients and to find its association with different treatment modalities.

PATIENTS AND METHODS

We updated the 10-year survival data of 359 women diagnosed with TNBC between 1999 and 2009 in the Kuwait Cancer Control Center (KCCC). The overall survival (OS), disease free survival (DFS), distant metastasis free survival (DMFS) and loco-regional recurrence free survival (LRFS) were estimated using Kaplan Meier method. Survival was correlated with different prognostic factors and treatment modalities. Statistical significance was calculated using the log-rank test and defined as p < 0.05. Cox regression is used for Multivariate analysis.

RESULTS

TNBC represented 12% of breast cancer in Kuwait with a median age of 48 years. The stage distribution was as follow: stage I, II, III, IV in 15%, 43%, 35% and 7% of patients respectively. Regarding surgery, 33% had Conservative surgery; 67% had mastectomy; 82% had axillary clearance. Chemotherapy was neoadjuvant in 25%, adjuvant in 56% and palliative in 5% of patients. Two-thirds of patients (67%) received adjuvant radiotherapy. After a median follow-up of 108 months, the 10-year OS, DFS, DMFS and LRFS were 66%, 59%, 72% and 77% respectively. The 10-year OS was 92%, 80%, 49% and 0% for Stage I, II, III and IV respectively (p =< 0.0001). OS was significantly worse with the presence of lymphovascular invasion (LVI) with p = 0.003. OS was not significantly affected by age, grade or treatment modality. In multivariate analysis, the clinical stage and LVI were still significant (P<0.0001 and 0.04 respectively).

CONCLUSION

In the absence of biological biomarkers, clinical stage and LVI seem to be the only significant prognostic factors for survival of TNBC patients in our study population. Timing of chemotherapy as well as the extent of surgery do not seem to affect the TNBC patients' outcome.

Clinicopathological Criteria and Prognostic Factors in Gastric Adenocarcinoma in Kuwait

Background: Gastric cancer is the 5th most common cancer in the world and 2nd leading cause of cancer deaths. It has marked geographic incidence variation. Most common in Japan, China, other East Asian countries, Eastern Europe and South America. There is sharp decrease in incidence in western countries over the past 60 years but incidence of GE junction and proximal gastric tumors is increasing. In state of Kuwait in 2012 ASR was 2.6/100,000 population (similar to other Gulf countries; apart from Oman). There are many known risk factors including eating smoked and salted food and H. pylori infection. Aim: The aim of this study is to analyze gastric cancer diagnosed cases from 2009 to 2015 in Kuwait and to analyze clinicopathological criteria and prognostic factors. Methods: A total of 145 adult patients with newly diagnosed gastric cancers were treated and followed-up at Kuwait Cancer Control Center (KCCC) between 2009-2015. Patients' data were examined retrospectively. In all cases: age, performance status, sex, ethnicity, smoking and dietary habit, tumor site, pathology, staging and type of treatment were identified. Survival analysis was done using Kaplan-Meier, and comparison was done using long-rank test. Results: The median age at diagnosis was 54 (29-94). Men represented 63.5%. 75.2% had adenocarcinoma, 14.5% gastric lymphoma, 6.2% GIST, 3.4% carcinoid and 1 case squamous cell carcinoma. For gastric adenocarcinoma, 22 were metastatic (20.2%). In spite of composing almost 25% of country population and expected high incidence in their home countries, only 19.5% of patients were Asian with known habit of spicy food intake. 31% of patients were smokers. Performance at diagnosis was ECOG 0-1 in majority. Median follow-up was 45 months (1-89) and median overall survival was 34 months (0.5-89). Almost half of tumors were poorly differentiated with signet-ring feature in 36.8%. 12.6% presented with clinically advanced tumor but after surgery the number upstaged to be 25.9% (Stage III). Tumor epicenter localization was almost equivalent with 43 (49.4%) localized proximally and 44 (50.6%) distally. Surgery was the main treatment in majority (85.1%) while radiation was used in 58.6% and chemotherapy in 74.4% (adjuvant, neoadjuvant or concomitant). 22 patients failed; 7 locoregionally, 15 had distant metastasis while 2 patients failed both locally and distantly. Close surgical margins, and proximal localization were poor prognostic factors. Age and ethnicity had no impact on outcomes in our cohort. Conclusion: Gastric adenocarcinoma in Kuwait has similar profile to that documented worldwide and regionally (apart from Oman). Proximal tumors represent a challenge and has poorer prognosis that may need more intensification of treatment. Current (neo)adjuvant treatment seem to be effective in our population. Molecular profiling and studies are needed for further understanding of this potentially curable disease.

Comparing the outcome of nasopharyngeal carcinoma in paediatrics and adolescents treated with neoadjuvant chemotherapy followed by radiotherapy versus concomitant chemoradiotherapy

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Background: The optimal treatment of pediatrics and young adolescents with nasopharyngeal carcinoma (NPC) is not clearly addressed in large clinical trials. Systemic failure remains the problem. Our aim is to analyze the profile and treatment outcome of NPC in this age group in Kuwait, and whether the change of practice from neoadjuvant to concomitant chemoradiotherapy (CRT) has an impact on outcome, particularly distant metastasis. Methods: Between 2002-2010, 7 NPC patients aged </=20 years (mean age 16.7 years, SD 3.5) were treated in our institution with concomitant CRT. They represented 4.5% of all NPC cases seen during that time. We analyzed the profile and treatment outcome of that patient cohort, and compared it to our previous results published in 2002, who were treated with neoadjuvant chemotherapy (CTH) followed by radiotherapy (RT). Results: 6 patients were females, and 1 male. All patients had locoregional advanced disease. The median follow-up was 81 ms (r = 25-125 ms). 6 patients (86%) were treated with upfront CRT. Only 1 patient had neoadjuvant CTH followed by CRT. 4 patients had hyperfractionated radiotherapy (RT). The median dose of RT was 70 Gy (r = 66-75.6 Gy). G 3 acute toxicity were as follows. Hematological and skin 29%, mucositis 71%. 57% of patients >10% weight loss. No G 4 acute toxicity was recorded. All patient developed delayed G 2 hypothyroidism, and most developed significant subcutaneous fibrosis. All patient achieved locoregional CR. The only patient that developed distant metastasis was the one who could not tolerate CTH even as adjuvant due to prolonged neutropenia. All patients were alive at time of analysis. Comparing these results to our previous report which included patients between 1991-2001, the general profile of the patients seems to be the same. However, in the former patient cohort, 50% died within the same follow-up period due to distant metastasis. Conclusions: It seems that adoption of concomitant rather than neoadjuvant CTH, and modern RT techniques rather than conventional methods may have an impact on reducing distant metastasis. However, large patient cohort is needed to validate such finding.

Is young age a poor prognostic factor in triple-negative breast cancer patients? Analysis of 363 patients from single institution registry

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Background: Young age is a known independent poor prognostic factor for breast cancer. Few data exist about validating such prognostic factor in triple negative subtype of breast cancer. In this study, we evaluate the prognostic value of young age presentation in triple negative breast cancer (TNBC) patients who were diagnosed in Kuwait Cancer Control Center. Methods: This is a retrospective analysis of 363 patients diagnosed with TNBC between July 1999 and June 2009. Of these, 27% were diagnosed at or below the age of 40. Chi-square test was used to correlate the age with other prognostic factors. Survival measurements were estimated using Kaplan-Meier analysis. Statistical significance was calculated using the log-rank test. Results: There was no correlation between young age at presentation and other prognostic factors including grade, T stage, lymph node status, lymphovascular invasion, and Ki67 positivity. Similarly, young age was not statistically associated with poorer 5-years overall survival (78% for patients < 40 years compared to 72% for those > 40 years; p = 0.13), disease free survival (66% vs. 61%; p = 0.5) or locoregional recurrence free survival (81% vs. 83%; p = 0.7). Conclusions: Young age does not seem to negatively impact the survival of TNBC patients nor associated with poor prognostic factors in our study population. Further studies are needed to define new prognostic factors, e.g. molecular markers, in this subtype of patients rather than the conventional clinicopathologic prognostic factors.