Concurrent chemoradiotherapy with or without cetuximab for stage II to IVb nasopharyngeal carcinoma: a case-control study

Advance in integrating platinum-based chemotherapy with radiotherapy for locally advanced nasopharyngeal carcinoma

Nasopharyngeal carcinoma (NPC) is a malignant tumor characterized by the malignant transformation of nasopharyngeal epithelial cells. It is highly sensitive to radiation therapy, making radiotherapy the primary treatment modality. However, 60-80% of patients are initially diagnosed with locally advanced NPC (LA-NPC), where radiotherapy alone often fails to achieve desirable outcomes. Therefore, combining radiotherapy with chemotherapy has emerged as an effective strategy to optimize treatment for LA-NPC patients. Among the various chemotherapy regimens, concurrent chemoradiotherapy (CCRT) using platinum-based drugs has been established as the most commonly utilized approach for LA-NPC patients. The extensive utilization of platinum drugs in clinical settings underscores their therapeutic potential and emphasizes ongoing efforts in the development of novel platinum-based complexes for anticancer therapy. The aim of this review is to elucidate the remarkable advances made in the field of platinum-based therapies for nasopharyngeal carcinoma, emphasizing their transformative impact on patient prognosis.

Concurrent chemoradiotherapy plus anlotinib vs. concurrent chemoradiotherapy alone in locally advanced nasopharyngeal carcinoma: An interim analysis of a multicenter randomized controlled trial

Despite the use of intensity-modulated radiation therapy (IMRT) and concurrent chemotherapy (CCRT), the treatment of locoregionally advanced nasopharyngeal carcinoma (LA-NPC) is not satisfactory. EGFR and VEGFR are highly expressed in 60-80% of patients with LA-NPC and this is associated with a poor prognosis, which suggests the potential effectiveness of an inhibitor targeting tumor angiogenesis for treating LA-NPC. The present study aimed to assess the safety and effectiveness of CCRT combined with anlotinib in patients with LA-NPC. The study involved patients with LA-NPC (stage III-IVA) from four institutions in Guangxi, China. Patients were randomized to receive CCRT + anlotinib (n=36) or CCRT alone (n=37). Acute toxicity and short-term efficacy were evaluated. The most common grade 3 or 4 adverse events were leucopenia [10 (27.7%) vs. 8 (21.6%)], neutropenia [6 (16.7%) vs. 5 (13.5%)] and mucositis [13 (36.1%) vs. 11 (29.7%)] in the CCRT + anlotinib vs. CCRT cohort but there were no significant differences between the two cohorts (P=0.54, P=0.70 and P=0.56, respectively). Two patients (5.6%) displayed grade 1/2 hemorrhage in the CCRT + anlotinib cohort. No patient displayed grade 3/4 hemorrhages or adverse event-associated deaths in any cohort. Complete response rates in the CCRT + anlotinib arm at 1 week and 3 and 6 months post-radiotherapy were 60.0, 91.4, and 97.1%, respectively, compared with 40.5, 81.1 and 91.9% in the CCRT arm but there was no significant difference (P=0.10, P=0.35 and P=0.65, respectively). This interim analysis of the ongoing trial showed that administration of CCRT + anlotinib has acceptable toxicity profiles, good compliance and promising results in patients with LA-NPC. A larger study cohort and a longer follow-up period are needed to confirm therapeutic effectiveness and late toxicity.

Machine learning explainability in nasopharyngeal cancer survival using LIME and SHAP

Nasopharyngeal cancer (NPC) has a unique histopathology compared with other head and neck cancers. Individual NPC patients may attain different outcomes. This study aims to build a prognostic system by combining a highly accurate machine learning model (ML) model with explainable artificial intelligence to stratify NPC patients into low and high chance of survival groups. Explainability is provided using Local Interpretable Model Agnostic Explanations (LIME) and SHapley Additive exPlanations (SHAP) techniques. A total of 1094 NPC patients were retrieved from the Surveillance, Epidemiology, and End Results (SEER) database for model training and internal validation. We combined five different ML algorithms to form a uniquely stacked algorithm. The predictive performance of the stacked algorithm was compared with a state-of-the-art algorithm-extreme gradient boosting (XGBoost) to stratify the NPC patients into chance of survival groups. We validated our model with temporal validation (n = 547) and geographic external validation (Helsinki University Hospital NPC cohort, n = 60). The developed stacked predictive ML model showed an accuracy of 85.9% while the XGBoost had 84.5% after the training and testing phases. This demonstrated that both XGBoost and the stacked model showed comparable performance. External geographic validation of XGBoost model showed a c-index of 0.74, accuracy of 76.7%, and area under curve of 0.76. The SHAP technique revealed that age of the patient at diagnosis, T-stage, ethnicity, M-stage, marital status, and grade were among the prominent input variables in decreasing order of significance for the overall survival of NPC patients. LIME showed the degree of reliability of the prediction made by the model. In addition, both techniques showed how each feature contributed to the prediction made by the model. LIME and SHAP techniques provided personalized protective and risk factors for each NPC patient and unraveled some novel non-linear relationships between input features and survival chance. The examined ML approach showed the ability to predict the chance of overall survival of NPC patients. This is important for effective treatment planning care and informed clinical decisions. To enhance outcome results, including survival in NPC, ML may aid in planning individualized therapy for this patient population.

Treatment Protocols in the Efficacy and Safety of Anti-EGFR Medicines in Combination with Standard Therapy for Patients with Nasopharyngeal Cancer: A Meta-Analysis

Objective

This study was conducted to compare the efficacy of standard therapy (radiotherapy/RT/CT) with that of antiepidermal growth factor receptor (anti-EGFR) monoclonal antibody (NPC) therapy in patients with advanced nasopharyngeal cancer.

Methods

A meta-analysis was performed to meet the objective of this study. The English databases PubMed, Cochrane Library, and Web of Science were searched. The literature review compared anti-EGFR-targeted therapy with conventional therapy practices. The main outcome measure was overall survival (OS). Secondary goals were progression-free survival (PFS), locoregional recurrence-free survival (LRRFS), distant metastasis-free survival (DMFS), and adverse events (grade 3).

Results

The database search resulted in 11 studies, with a total of 4219 participants. It was found that combining an anti-EGFR regimen with conventional therapy did not enhance OS (hazard ratio [HR] = 1.18; 95%confidence interval [CI] = 0.51-2.40; p = 0.70) or PFS appreciably (HR = 0.95; 95%CI = 0.51-1.48; p = 0.88) in patients with nasopharyngeal carcinoma. While LRRFS increased considerably (HR = 0.70; 95%CI = 0.67-1.00; p = 0.01), the combined regimen did not improve DMFS (HR = 0.86; 95%CI = 0.61-1.12; p = 0.36). Treatment-related adverse events included haematological toxicity (RR = 0.2; 95%CI = 0.08-0.45; p = 0.01), cutaneous reactions (RR = 7.05; 95%CI = 2.15-23.09; p = 0.01), and mucositis (RR = 1.96; 95%CI = 1.58-2.09; p = 0.01).

Conclusions

Individuals who have nasopharyngeal cancer do not have an increased chance of surviving until a local recurrence of their disease if they get normal therapy in addition to an anti-EGFR regimen. However, this combination does not enhance overall survival. On the other hand, this factor adds to an increase in the number of adverse effects.

Real-world evidence of cisplatin versus carboplatin in patients with locally advanced nasopharyngeal carcinoma receiving concurrent chemoradiotherapy: A multicenter analysis

BACKGROUND

Though concurrent chemoradiotherapy (CCRT) with cisplatin remains a standard of care for patients with locally advanced nasopharyngeal carcinoma (LA-NPC), carboplatin has alternatively been used without sufficient supportive evidences. Thus, we evaluated an efficacy and tolerability of carboplatin CCRT compared with cisplatin in LA-NPC patients.

METHODS

Patients with LA-NPC treated with CCRT were identified through the Thai multicenter head and neck cancer database. Patient tolerability and survival were analyzed and compared between regimens. Survivals were calculated by using the Kaplan-Meier method, and compared by the log-rank test. A p-value of <0.05 was considered statistically significant.

RESULTS

A total of 135 of 980 patients (13.8%) were treated with carboplatin. Patients treated with carboplatin were significantly associated with older age (p < 0.001), smoking (p = 0.003), more comorbidity (p = 0.014), kidney disease (p = 0.016), and lower baseline creatinine clearance (p < 0.001). Intensity-modulated radiation therapy was used significantly more in the cisplatin group than carboplatin group (p < 0.001). Patients who received carboplatin were associated with delay (p = 0.049) and hospitalization (p = 0.006), whereas cisplatin CCRT had more dose reduction (p = 0.001). Patients treated with cisplatin had CCRT interruption from grade 3-4 mucositis (p = 0.019) more than carboplatin, whereas carboplatin had more grade 3-4 thrombocytopenia (p < 0.001). The 5-year overall survival (OS) of patients treated with cisplatin and carboplatin was 59% and 49%, respectively (p = 0.128). Cisplatin or carboplatin CCRT was not a significant predictor for OS and locoregional recurrence-free survival in multivariate analysis.

CONCLUSIONS

Carboplatin CCRT provided acceptable efficacy and tolerability profiles in real-world practice. Carboplatin should be considered as an alternative regimen, particularly in cisplatin-ineligible patients with LA-NPC treated with CCRT.

Concurrent chemoradiotherapy combined with nimotuzumab in stage III–IVa nasopharyngeal carcinoma: a retrospective analysis

PURPOSE

The efficacy and safety of nimotuzumab (NTZ) added to concurrent chemoradiotherapy (CCRT) were investigated in patients with stage III-IVa nasopharyngeal carcinoma (NPC).

METHODS

Patients with stage III-IVa NPC treated with CCRT, with or without NTZ, were screened between January 2015 and December 2017. We compared patients' overall survival (OS), progression-free survival (PFS), locoregional recurrence-free survival (LRFS), and distant metastasis-free survival (DMFS) between different therapeutic regimens. Propensity score matching (PSM) was applied to reduce the selection bias. Nomogram models were developed to predict the survival of CCRT with or without NTZ.

RESULTS

Four hundred and twenty-six patients were included after PSM, with 213 patients in each regimen. Compared with NPC patients receiving CCRT alone, patients who received NTZ plus CCRT treatment had significantly better OS (5 year OS, 76.1 vs. 72.3%, P = 0.004), PFS (5 year PFS, 73.2 vs. 69.0%, P = 0.002), and LRFS (5 year LRFS, 73.2 vs. 69.0%, P = 0.028). A multivariate Cox regression analysis demonstrated that, compared with receiving CCRT alone, NTZ plus CCRT was an independently positive factor for OS, PFS, and LRFS. No significant difference was observed in the major toxicities between the two treatments (all P > 0.05). In addition, the nomogram presented good accuracy for predicting the prognosis of NPC patients.

CONCLUSION

CCRT combined with NTZ presented favorable clinical outcomes for stage III-IVa NPC patients with good tolerance and similar toxicity compared to CCRT alone. A prospective, randomized clinical trial is essential to validate the current findings.

Efficacy of Cetuximab in Nasopharyngeal Carcinoma Patients Receiving Concurrent Cisplatin-Radiotherapy: A Meta-Analysis

Background

Nasopharyngeal carcinoma (NPC) is a malignant neoplasm of the nasopharyngeal epithelium. Concurrent chemoradiotherapy has been established as a standard treatment for locoregional NPC, and cisplatin is a common agent in NPC treatment. Cetuximab is a monoclonal antibody against epidermal growth factor receptor. This meta-analysis was performed to evaluate the curative effectiveness and survival outcomes of cetuximab in NPC patients who received concurrent cisplatin-radiotherapy.

Methods

PubMed, Cochrane Library, EMBASE, China National Knowledge Infrastructure (CNKI), Wan Fang, and China Biology Medicine disc (CBM) were used to search publications studying on concurrent chemoradiotherapy and/or cetuximab in NPC. The qualities of included RCTs were assessed by the Newcastle-Ottawa Scale. STATA 14.0 was used to conduct the statistical analysis.

Results

In total, 17 trials with 2066 patients were included in this meta-analysis. The results from this study show that cetuximab improved the therapy efficacy in NPC patients who received concurrent cisplatin-radiotherapy. Cetuximab cotreatment improved the complete response (RR = 1.92, 95% CI [1.61, 2.30]), and reduced stable disease (RR = 0.67, 95% CI [0.51, 0.88]) as well as progression disease (RR = 0.24, 95% CI [0.15, 0.40]). Besides, it also improved the overall survival (RR = 1.10, 95% CI [1.02, 1.18]), disease-free survival (RR = 1.09, 95% CI [1.03, 1.15]), metastasis-free survival (RR = 1.06, 95% CI [1.01, 1.11]), and relapse-free survival (RR = 1.04, 95% CI [1.01, 1.07]) in NPC patients.

Conclusions

Cetuximab could improve the curative efficacy and survival outcomes of NPC patients who underwent concurrent cisplatin-radiotherapy. However, all the trials included were conducted in China; thus, the quality of the trials in this study remains doubtful. More high-quality RCTs should be included in further relevant studies.

Revealing the crosstalk between nasopharyngeal carcinoma and immune cells in the tumor microenvironment

Nasopharyngeal carcinoma (NPC) arises from the epithelial cells located in the nasopharynx and has a distinct geographic distribution. Chronic Epstein-Barr virus (EBV) infection, as its most common causative agents, can be detected in 100% of NPC types. In-depth studies of the cellular and molecular events leading to immunosuppression in NPC have revealed new therapeutic targets and diverse combinations that promise to benefit patients with highly refractory, advanced and metastatic NPC. This paper reviews the mechanisms by which NPC cells to circumvent immune surveillance and approaches being attempted to restore immunity. We integrate existing insights into anti-NPC immunity and molecular signaling pathways as well as targeting therapies in anticipation of broader applicability and effectiveness in advanced metastatic NPC.

Nasopharyngeal Carcinoma: Clinical Achievements and Considerations Among Treatment Options

Nasopharyngeal carcinoma (NPC) is a severe malignancy arising from the nasopharyngeal epithelium and is southern China's third most common cancer. With the advancement of treatment methods, early-stage NPC patients usually have a better prognosis and more prolonged survival period than those with other malignant tumors. Most treatment failures are due to distant metastasis or a locally advanced stage of NPC in the initial diagnosis. In addition, approximately 10% of patients develop local recurrence, and 10%-20% of patients experience distant metastasis after treatment. These patients have a poor prognosis, with a median survival of only approximately 10-15 months. In the rapid development of treatment options, the efficacy and safety of some treatments have been validated and approved for first-line treatment, while those of other treatments remain unclear. The present study aims to provide a comprehensive overview of recent advances in NPC treatment and explain the various therapeutic possibilities in treating locally advanced, recurrent, and metastatic NPC patients.

S100A8/A9 Molecular Complexes Promote Cancer Migration and Invasion via the p38 MAPK Pathway in Nasopharyngeal Carcinoma

Nasopharyngeal carcinoma (NPC) is one type of malignancy associated with migration and invasion through a currently unclear mechanism. We previously discovered S100A8/A9 levels were roughly elevated in the plasma of NPC patients as the promising biomarkers. However, their expressions and underlying functions in NPC tissues are still unknown. In the present study, we analyzed 49 NPC tissues and 20 chronic pharyngitis (CP) tissues. Immunohistochemical staining was performed in different tissues and analyzed by the Mann-Whitney U test statistically. Transwell migration and invasion experiments were further performed to determine S100A8/A9 effects on NPC. Our results showed that S100A8/A9 in NPC tissues were significantly higher than those in CP tissues, closely associated with NPC clinical stages. Intriguingly, exogenous S100A8/A9 protein stimulation could dramatically enhance NPC migration and invasion abilities. In addition, p38 MAPK pathway blockade could diminish the migration and invasion of NPC cells stimulated by S100A8/A9 proteins. The downstream tumor invasion and migration associated proteins (e.g., MMP7) were also elevated in NPC tissues, consistent with S100A8/A9 overexpression. Taken together, our present findings suggest that the secreted soluble inflammatory factors S100A8/A9 might promote cancer migration and invasion via the p38 MAPK signaling pathway along with invasion/migration associated proteins overexpression in the tumor microenvironment of NPC. This may shed light on the mechanism understanding of NPC prognosis and provide more novel clues for NPC diagnosis and therapy.

Influence of CDK5 Regulatory Subunit-Associated Protein 1-Like 1 Expression on the Survival of Patients with Non-Metastatic Nasopharyngeal Carcinoma

Background

The aim of this study was to investigate the influence of CDK5 regulatory subunit-associated protein 1-like 1 (CDKAL1) expression on the survival of nasopharyngeal carcinoma (NPC) patients.

Methods

A total of 140 non-metastatic NPC patients were retrospectively analyzed. The expression of CDKAL1 was detected by immunohistochemistry.

Results

The CDKAL1-negative group exhibited better overall survival (OS) according to Kaplan–Meier curve analysis (p = 0.006), with 5-year OS rates for the CDKAL1-negative and -positive groups of 89.7% and 70.2%, respectively. The CDKAL1-negative group also exhibited a tendency toward a better progression-free survival (PFS) rate. Multivariate analysis showed that CDKAL1 expression was independently associated with both OS (p = 0.002) and PFS (p = 0.043).

Conclusion

CDKAL1 expression is an independent negative predictor of patient survival in non-metastatic NPC.

Subdivision of de-novo metastatic nasopharyngeal carcinoma based on tumor burden and pretreatment EBV DNA for therapeutic guidance of locoregional radiotherapy

BACKGROUND

Nasopharyngeal carcinoma (NPC) is a malignancy predominantly associated with infection by the Epstein-Barr virus (EBV). Approximately 12,900 new cases of NPC occur each year, with more than 70% of cases occurring in the east and southeast Asia. NPC is different from ordinary head and neck squamous cell carcinoma due to its particular biological properties and it is highly sensitive to radiotherapy. With the development of RT technology, the 3-year local control rate and survival rates of non-metastatic NPC reached 80-90% in the intensity-modulated RT (IMRT) era. However, whether distant metastatic NPC (de novo mNPC, dmNPC) should receive locoregional RT (LRRT) needs to be clarified.

RESULTS

Multivariate analysis identified three independent prognostic factors: Epstein-Barr virus (EBV) DNA, number of metastatic lesions, and number of metastatic organs. Through these factors, all patients were successfully divided into 3 subgroups: low-risk (single metastatic organ, EBV DNA ≤ 25,000 copies/ml, and ≤ 5 metastatic lesions), intermediate-risk (single metastatic organ, EBV DNA > 25,000 copies/ml, and ≤ 5 metastatic lesions), and high-risk (multiple metastatic organs or > 5 metastatic lesions or both). By comparing LRRT and non-LRRT groups, statistical differences were found in OS in the low-risk and intermediate-risk subgroups (p = 0.039 and p = 0.010, respectively) but no significant difference was found in OS in the high-risk subgroup (p = 0.076). Further multivariate analysis of different risk stratifications revealed that LRRT can improve OS of low- and intermediate-risk subgroups.

CONCLUSIONS

The risk stratification of dmNPC may be used as a new prognostic factor to help clinicians organize individualized LRRT treatment to improve the survival outcomes of dmNPC patients.

Status of Treatment and Prophylaxis for Radiation-Induced Oral Mucositis in Patients With Head and Neck Cancer

Radiation-induced oral mucositis (RIOM) is one of the most frequent complications in head and neck cancer (HNC) patients undergoing radiotherapy (RT). It is a type of mucosal injury associated with severe pain, dysphagia, and other symptoms, which leads to the interruption of RT and other treatments. Factors affecting RIOM include individual characteristics of HNC patients, concurrent chemoradiation therapy, and RT regimen, among others. The pathogenesis of RIOM is not yet fully understood; however, the release of inflammatory transmitters plays an important role in the occurrence and development of RIOM. The five biological stages, including initiation, primary damage response, signal amplification, ulceration, and healing, are widely used to describe the pathophysiology of RIOM. Moreover, RIOM has a dismal outcome with limited treatment options. This review will discuss the epidemiology, pathogenesis, clinical appearance, symptomatic treatments, and preventive measures related to this disease. We hope to provide a reference for the clinical treatment and prevention of RIOM in HNC patients after RT.

Anti-EGFR therapies in nasopharyngeal carcinoma

Nasopharyngeal carcinoma (NPC) is a common malignant tumor in Southern China and South-East Asia. Regardless of initiative high response to radiotherapy, parts of patients still have relapses and metastases. It is reported that epidermal growth factor receptor (EGFR) is highly expressed in most of NPC and is a poor prognostic factor. Targeting EGFR therapies including monoclonal antibodies and EGFR tyrosine kinase inhibitors (EGFR-TKIs), offer different benefits and toxicities for patients with NPC. Herein, we summarize the clinical evidence of anti-EGFR therapies in the management of NPC and provide a direction for the treatment and research of NPC in the future.

Assessment of Nasopharyngeal Cancer in Young Patients Aged ≤ 30 Years

Purpose: This study assessed the prognosis of young patients with nasopharyngeal cancer (NPC), both domestic and foreign, using data from the Surveillance, Epidemiology and End Results (SEER) database, a population-based database, and departmental records.

Methods: Patients diagnosed with NPC from 2004 to 2016 in the SEER database were reviewed. Young patients aged ≤30 years when diagnosed, were compared with older patients. The medical records of patients with NPC aged ≤30 years in our own department were also reviewed. The prognostic effects of different variables, including age, sex, race, tumor stage, pathology, radiation, and chemotherapy were assessed by Kaplan–Meier and Cox analyses.

Results: A total of 212 foreign and 257 domestic patients, with mean ages of 21.5 and 22.9 years and median ages of 22 and 24 years, respectively, were included. In SEER database, younger NPC patients had a more advanced tumor stage (74.5% stage III/IV vs. 63.1% in older patients) and a worse pathological differentiation, but a better prognosis (P < 0.0001). Interestingly, the younger the patient, the better the prognosis. Younger patients received a higher proportion of chemotherapy. M stage, overall stage and radiation were the primary prognostic factors. Similar and more comprehensive results were found in our center. Patients with distant metastases, at a primary visit, had worse diagnoses. Intensity-modulated radiotherapy and three-dimensional conventional radiotherapy had minimal effects on survival in young patients in our center. Most patients from our department received chemotherapy, and different induction chemotherapy regimens resulted in similar survival prognoses.

Conclusions: Young patients with NPC usually present at an advanced stage, but have a better overall prognosis. How to treat patients with metastasis is critical for improving prognoses in young NPC patients.

A meta-analysis of cisplatin-based concurrent chemoradiotherapy with or without cetuximab for locoregionally advanced nasopharyngeal carcinoma

BACKGROUND

It is unclear whether cetuximab (CTX) plus cisplatin-based concurrent chemoradiotherapy (CCRT) delivers equivalent or improved results over standard CCRT in locoregionally advanced nasopharyngeal carcinoma (NPC).

METHODS

The strategy involved searching the PubMed, Embase, Cochrane Library, and Web of Science. Pooled hazard ratios (HRs) for overall survival (OS), distant metastasis-free survival (DMFS), locoregional relapse-free survival (LRFS), and disease-free survival (DFS), and pooled risk ratios for adverse events were meta-analyzed.

RESULTS

In all, 1744 patients in 5 clinical trials were included in the analysis. Compared with CCRT group, CTX plus CCRT significantly improved DFS (HR = 0.59, 95% confidence interval [CI]: 0.41-0.86, P = .006) and distant metastasis failure-free survival (HR = 0.54, 95% CI: 0.38-0.76, P = .0004), rather than OS (HR = 0.70, 95% CI: 0.44-1.09, P = .12) and local-regional failure-free survival (HR = 0.82, 95% CI: 0.54-1.22, P = .33).

CONCLUSIONS

CTX plus CCRT might achieve higher DFS and DMFS with no significant difference in OS and LRFS. CTX plus CCRT group was associated with more grade 3-4 skin rash, mucositis and dermatitis. Large randomized trials were urgent to fully explore the usefulness of this treatment in the locally advanced NPC patients.

Cetuximab in the management of nasopharyngeal carcinoma - a narrative review

BACKGROUND

Concurrent chemotherapy with radiotherapy is the standard treatment for locoregionally advanced nasopharyngeal cancer. Cetuximab can be used in the treatment of head and neck squamous cell carcinoma. However, the randomised studies that led to approval for its use in this setting excluded nasopharyngeal cancer. In the context of limited data for the use of cetuximab in nasopharyngeal cancer in the medical literature, this review aimed to summarise the current evidence for its use in both primary and recurrent or metastatic disease.

METHOD

A literature search was performed using the keywords 'nasopharyngeal neoplasm', 'cetuximab' and 'Erbitux'.

RESULTS

Twenty studies were included. There were no randomised phase III trials, but there were nine phase II trials. The use of cetuximab in the treatment of nasopharyngeal carcinoma has been tested in various settings, including in combination with induction chemotherapy and concurrent chemoradiotherapy, and in the palliative setting.

CONCLUSION

There is no evidence of benefit from the addition of cetuximab to standard management protocols, and there is some evidence of increased toxicity. There is more promise for its use in metastatic or locally recurrent settings. This review draws together the existing evidence and could provide a focus for future studies.

Combination treatment with cetuximab in advanced nasopharyngeal carcinoma patients: a meta-analysis

Purpose

Cetuximab, an anti-epidermal growth factor receptor monoclonal antibody, carries the potential for combination treatment against nasopharyngeal carcinoma (NPC). We conducted a meta-analysis to assess the possible benefits and safety between the combination treatment with cetuximab and conventional treatment in NPC patients. Skin toxicity (ST) associated with additional cetuximab was evaluated as well.

Methods

We performed a systematic search (PubMed, Embase, Cochrane library, China National Knowledge Infrastructure, and WanFang Data) for studies comparing combination treatment with cetuximab versus conventional treatment in NPC patients. The selected studies included completely or partly reported clinical outcomes including survivals, complete and partial responses, and adverse reactions (ST). The pooled HR, relative risk (RR), and respective 95% CI were estimated by using fixed effects model or random effects model.

Results

A total of 23 relevant studies with available data were included in the final analysis. According to the pooled data, combination treatment with cetuximab showed improved efficacy on increased objective response rate (studies with cetuximab treatment: RR: 1.39, 95% CI: 1.29–1.50; concurrent chemoradiotherapy with or without cetuximab: RR: 1.39, 95% CI: 1.25–1.54) and prolonged survival (studies with cetuximab treatment: the pooled HR for OS was 0.70, 95% CI: 0.55–0.89; concurrent chemoradiotherapy with or without cetuximab: the pooled HR for OS was 0.64, 95% CI: 0.49–0.84) compared with conventional treatment. Moreover, the improved efficacy was invariably accompanied by an increased occurrence of ST (studies with cetuximab treatment: RR: 2.46, 95% CI: 1.81–3.34; concurrent chemoradiotherapy with or without cetuximab: RR: 1.84, 95% CI: 1.02–3.31). However, the majority of adverse reactions exhibited similar occurrence rates between the different treatments.

Conclusion

Patients with NPC receiving additional cetuximab treatment can benefit more from this systemic comprehensive therapy, while the efficiency of conventional treatment for NPC is limited. ST associated with cetuximab may be used as a potential on-treatment marker to guide treatment with cetuximab against NPC.

Apatinib monotherapy for advanced VEGFR-2-negative nasopharyngeal carcinoma: A case report

RATIONALE

Due to the anatomical and biological characteristics of nasopharyngeal carcinoma (NPC), radiotherapy is the standard treatment of choice. Recent advances in small molecule therapies targeting tumor angiogenesis also hold promise for the treatment of advanced NPC.

PATIENT CONCERNS

The patient's symptoms, including nasal obstruction, nasal bleeding, and headache, reappeared periodically and eventually became so severe that the patient's vision became impaired. In January 2016, the patient presented with blurred vision, diplopia, language impairment, left temporal paralysis, and bilateral eyelid ptosis.

DIAGNOSIS

Advanced NPC without metastasis in a 55-year-old man.

INTERVENTIONS

The patient refused treatment with radiotherapy or chemotherapy and was treated with Chinese herbal medicines. Following a worsening of symptoms, the patient was subsequently treated with apatinib monotherapy (0.25 g, once daily).

OUTCOMES

Symptom improvement, including decreased nasal bleeding and headache, was observed after 1 week of apatinib treatment. After 100 days of treatment, the patient was nearly asymptomatic with stable disease and improved quality of life.

LESSONS

For patients with advanced NPC who refuse standard radiotherapy and chemotherapy, apatinib monotherapy may be a suitable treatment option to improve symptoms and quality of life even in those with vascular endothelial growth factor receptor-negative tumors.

Nuclear Klf4 accumulation is associated with cetuximab drug-resistance and predicts poor prognosis of nasopharyngeal carcinoma

Background

The functions of the protein expressed in the nucleus and cytoplasm were different or opposite. The previous study found that oncogene Klf4 played a role of tumor suppressor in the nasopharyngeal cytoplasm. Cetuximab targeted epidermal growth factor receptor (EGFR) for the treatment of nasopharyngeal carcinoma.

Methods

A cohort of 231 cases of advanced nasopharyngeal carcinoma (7th AJCC III–IVa) samples was assessed by immunohistochemistry (IHC), of which, 63 cases were treated with basic treatment without cetuximab, the basic treatment include chemotherapy and radiotherapy, the regent of the chemotherapy include cisplatin and fluorouracil and 168 cases were treated with cetuximab in addition to the basic treatment. The expression of the KLF4 protein was detected in nucleus and cytoplasm, c-Met protein and nuclear EGFR protein (nEGFR) by IHC, and H-Ras and PI3K mutations by an arms-PCR method in vivo. KLF4 was found to specifically express in the cytoplasm by deleting the NES, while H-Ras and PI3K genes were mutated in the nasopharyngeal carcinoma 5–8F and HONE1cell line. The cetuximab resistance in differentially mutated 5–8F and HONE1 cells was analyzed.

Results

The expression of Klf4 in the nucleus was associated with prognosis in 168 patients with cetuximab-treated nasopharyngeal carcinoma, which was found by retrospective analysis. The KLF4 expression in the nucleus was not significantly correlated with the prognosis in 63 nasopharyngeal carcinoma patients treated with basic treatment (P = 0.261). The expression of Klf4 in the nucleus was correlated with mutations of H-Ras and PI3K in 168 cases of nasopharyngeal carcinoma with cetuximab treatment. In vitro experiments showed that Klf4 was specifically expressed in the nucleus of 5–8F and HONE1 cells as assessed by deleting nuclear export signal, which led to cetuximab resistance. H-Ras and PI3K mutations in 5–8F and HONE1 cells also led to the expression of Klf4 in the nucleus and resistance to cetuximab. In HONE1 cells, Klf4 was specifically localized in the cytoplasm by deleting the NES, and the H-Ras and PI3K mutations did not result in an increased expression of Klf4 in the nucleus and cetuximab resistance.

Conclusion

The prognosis of nasopharyngeal carcinoma was not significantly improved by cetuximab treatment when the Klf4 was highly expressed in the nucleus of nasopharyngeal carcinoma tissues. The expression of Klf4 in the nucleus can be used as a biomarker for predicting the effects of cetuximab treatment in nasopharyngeal carcinoma, which might be attributed to the H-RAS and PI3K mutations, leading to cetuximab resistance.

Anti-epidermal growth factor receptor therapy concurrently with induction chemotherapy in locoregionally advanced nasopharyngeal carcinoma

Little is known about the efficacy and toxicity of anti-epidermal growth factor receptor therapy concurrently with induction chemotherapy (IC) in locoregionally advanced nasopharyngeal carcinoma (LA-NPC). The present study aimed to address this question. We identified 2848 patients with newly diagnosed LA-NPC receiving IC between January 2012 and May 2015. The propensity score matching (PSM) method was used to balance various factors and to match patients. Survival outcomes and toxicities between different groups were compared. In total, 596 patients were selected at a 1:3 ratio, with 149 in the IC + CTX/NTZ group and 447 in the IC alone group. The 3-year disease-free survival, overall survival, distant metastasis-free survival and locoregional relapse-free survival rates for IC + CTX/NTZ vs IC alone were 84.3% vs 75.2% (P = .059), 94.0% vs 87.9% (P = .053), 88.0% vs 84.9% (P = .412) and 93.3% vs 88.2% (P = .242). Multivariate analysis established a treatment group (IC vs IC + CTX/NTZ) as a prognostic predictor for DFS (hazard ratio [HR], 1.497; 95% confidence interval [CI], 1.016-2.206; P = .041) and OS (HR, 1.984; 95%, CI, 1.023-3.848; P = .043). Grade 3-4 skin reaction (15.4% vs 0.4%, P < .001) and mucositis (10.1% vs 2.7%, P < .001) were more common in the IC + CTX/NTZ group than that in the IC alone group. Our findings suggested that CTX/NTZ in combination with IC may be a more effective and promising strategy for patients with LA-NPC treated with intensity-modulated radiotherapy.

Anti-EGFR targeted therapy delivered before versus during radiotherapy in locoregionally advanced nasopharyngeal carcinoma: a big-data, intelligence platform-based analysis

BACKGROUND

Little is known about the prognostic difference of anti-EGFR therapy, cetuximab (CTX) or nimotuzumab (NTZ), concurrently with induction chemotherapy (IC, investigational arm) or RT (control arm) for patients with locoregionally advanced nasopharyngeal carcinoma (LA-NPC). We conducted this retrospective study to address this.

METHODS

We identified 296 patients with newly diagnosed LA-NPC at Sun Yat-Sen University Cancer Center between January 2012 and May 2015. Patients were treated by IC with CCRT or RT and CTX/NTZ was delivered during IC or radiotherapy. Survival outcomes and toxicities between different arms were compared.

RESULTS

In total, there were 149 patients in the investigational arm and 147 in control arm. The 3-year disease-free survival, overall survival, distant metastasis-free survival and locoregional relapse-free survival rates for investigational arm vs. control arm were 84.3% vs. 74.3% (P = 0.027), 94.0% vs. 92.1% (P = 0.673), 88.0% vs. 81.8% (P = 0.147) and 93.3% vs. 88.0% (P = 0.093). Multivariate analysis revealed patients in the control arm achieved significantly worse disease-free survival (HR, 1.497; 95% CI, 1.016-2.206; P = 0.026) compared with those in the investigational arm; however, no significant difference was identified for other endpoints. Patients in the investigational arm experienced more grade 3-4 skin reaction (15.4% vs. 2.0%, P <  0.001) and mucositis (10.1% vs. 3.4%, P = 0.022) during induction phase, but less skin reaction (5.4% vs. 25.9%, P <  0.001) and mucositis (24.8% vs. 36.7%, P = 0.026) during RT.

CONCLUSIONS

Our findings suggested that CTX/NTZ concurrently with IC may be a more effective and promising strategy for patients with LA-NPC receiving intensity-modulated radiotherapy.

Intensity-modulated radiotherapy plus nimotuzumab with or without concurrent chemotherapy for patients with locally advanced nasopharyngeal carcinoma

Objective

This study aimed to evaluate the safety and efficacy of intensity-modulated radiotherapy (IMRT) plus nimotuzumab with or without concurrent chemotherapy (CCT) for patients with locally advanced nasopharyngeal carcinoma (LA-NPC).

Patients and methods

A total of 50 newly diagnosed patients with LA-NPC treated at the Affiliated Hospital of Jiangnan University between November 2011 and January 2017 were retrospectively analyzed. All patients received the combined treatment modality of nimotuzumab plus IMRT. Nimotuzumab was administered concurrently with IMRT at a weekly dose of 200 mg. Neoadjuvant, concurrent or adjuvant chemotherapy with the doublet regimen of taxanes (docetaxel or paclitaxel) plus platinum (cisplatin or nedaplatin) were administered. Among the 50 patients, 43 (86.0%) received ≥6 cycles of nimotuzumab (median 7 cycles, range 2-14 cycles) and 29 (58.0%) received two cycles of CCT with docetaxel plus nedaplatin.

Results

With a median follow-up of 28.0 months, the 2-year progression-free survival (PFS) and overall survival were 83.29% (95% confidence interval [CI]: 67.93%-91.72%) and 97.67% (95% CI: 84.62%-99.67%), respectively. Both univariate and multivariate analyses revealed that cycles of nimotuzumab were significantly associated with PFS. Patients who received ≥6 cycles of nimotuzumab showed a better PFS than those receiving <6 cycles (P=0.006), whereas the addition of CCT failed to improve PFS. Oral mucositis was the most common adverse event, which was recorded as grade 3-4 in 18 (36.0%) patients. Besides, two (4.0%) patients experienced nimotuzumab-related anaphylaxis, and no skin rash was found in any patient. Subgroup analysis revealed that the patients who received CCT had more grade 3-4 adverse events as compared to those who did not receive CCT (62.1% vs 33.3%, P=0.045).

Conclusion

The regime of nimotuzumab plus IMRT for the treatment of LA-NPC was well tolerated, with encouraging survival data, and it could be an effective treatment alternative for patients with LA-NPC. Further clinical trials are needed to confirm these findings.