Could the Addition of Cetuximab to Conventional Radiation Therapy Improve Organ Preservation in Those Patients With Locally Advanced Larynx Cancer Who Respond to Induction Chemotherapy? An Organ Preservation Spanish Head and Neck Cancer Cooperative Group Phase 2 Study

PURPOSE

To evaluate the efficacy and safety of induction chemotherapy (IC) followed by bioradiotherapy (BRT) to achieve functional larynx preservation in the setting of locally advanced head and neck tumors.

METHODS AND MATERIALS

This was a phase 2, open-label, multicenter study of patients with stage III and IVA laryngeal carcinoma who were candidates for total laryngectomy. The primary endpoint was the rate of survival with functional larynx (SFL) at 3 years, with a critical value to consider the study positive of SFL >59%. Patients received 3 cycles of IC with TPF (docetaxel, cisplatin, and 5-fluorouracil), and those who responded received conventional BRT with cetuximab. In patients with residual nodal disease after BRT, neck dissection was planned 2 months after BRT. Patients who did not respond to IC underwent total laryngectomy plus neck dissection and radiation therapy.

RESULTS

A total of 93 patients started TPF. Responses to IC on larynx target lesion were as follows: 37 patients (40%) showed a complete response; 38 patients (41%) showed a partial response; 8 patients (9%) showed stabilization; 2 patients (2%) showed progressive disease, and 8 patients (9%) were not evaluated (2 deaths, 5 adverse events, and 1 lost to follow-up). Seventy-three patients (78%) received BRT: 72 as per protocol, but 1 with only stable disease. Median follow-up was 53.7 months. Three-year actuarial rates were as follows: SFL: 70% (95% confidence interval [CI] 60%-79%); laryngectomy-free survival: 72% (95% CI 61%-81%); overall survival: 78% (95% CI: 63%-82%). The acute toxicity observed during both IC and BRT was as expected, with only 1 toxicity-related death (local bleeding) during BRT.

CONCLUSIONS

According to this protocol, the SFL rate was clearly higher than the critical value, with acceptable levels of toxicity. The use of cetuximab added to radiation therapy in patients with stage III and IVA laryngeal cancer who respond to TPF could improve functional larynx preservation. A phase 3 trial is warranted.

A genetic view of laryngeal cancer heterogeneity

During the recent decades significant improvements in the understanding of laryngeal molecular biology allowed a better characterization of the tumor. However, despite increased molecular knowledge and clinical efforts, survival of patients with laryngeal cancer remains the same as 30 years ago. Although this result may not make major conclusions as preservation approaches were not broadly used until the time of database collection, it seems to be clear that there is still window for improvement. Although the cornerstone for laryngeal cancer eradication is to implement smoking cessation programs, survival progresses will be hopefully seen in the future. Introducing molecular biomarkers as predictive factors to determine which patients will benefit of preservation treatments may become one of the next steps to improve survival. Furthermore, the development of new therapeutic modalities joint to biomarkers to selectively apply such new therapy in these patients may help to define new modalities with improved survival. New inhibitors against Notch pathway, EGFR, VRK1 or DNA damage repair may become gold standard if we are able to identify patients that may benefit from them, either on survival or functional larynx preservation. It is the moment for an inflexion point on the way laryngeal cancer is clinically managed.

SEOM clinical guidelines for the treatment of head and neck cancer (HNC) 2013

Head and neck cancer represents 5 % of oncologic cases in adults. Early stage treatments are local with surgery and/or radiotherapy. For locally advanced stages, treatment requires radiotherapy combined with platinum-based drugs or cetuximab. Induction chemotherapy should be considered for selected cases. In the case of metastatic disease, adjuvant or palliative treatment is based on platinum agents and cetuximab.

Larynx preservation: what is the standard treatment?

Locally advanced laryngeal and hypo-pharyngeal cancers have a rather poor prognosis. Up until the early 1990s, standard treatment was total laryngectomy, with dramatic functional and social outcome. The introduction of cisplatin based chemotherapy made concurrent chemo-radiotherapy (CCRT) the standard treatment for selected patients, fit for an organ preservation strategy. Over two decades of improvement in nonsurgical management of locally advanced laryngeal cancer is reviewed, including the most recent improvements with the introduction of taxanes and anti-EGFR targeted therapy.

Prognostic and predictive significance of p53, EGFr, Ki-67 in larynx preservation treatment

BACKGROUND

The optimal management of advanced laryngeal and hypopharyngeal cancers (L&HC) must involve consideration of both survival and functional effect of the given treatment approach. Despite over two decades of investigations of several treatment options, including surgery, radiotherapy, chemotherapy or some combinations thereof, little consensus exists as to which treatment offers the best survival, together with functional speech and swallowing.

AIM

To determine predictive and prognostic value of p53, EGFr, Ki-67 in patients with advanced laryngeal and hypopharyngeal cancer, treated with larynx preservation intent.

MATERIALS AND METHODS

Thirty-three patients received 2-3 cycles of induction chemotherapy (ICHT) consisting of cisplatin and fluoruracil and underwent subsequent radical radiotherapy. Immunohistochemical analyzes of p53, EGFr and Ki-67 were performed.

RESULTS

Response to ICHT was obtained in 24 patients (75%). Better response to ICHT was correlated only with EGFr expression (p = 0.04, RR = 1.91). The 5-year loco-regional control (LRC) and disease-specific survival (DSS) rates were 48% and 57%, respectively. The 5-year larynx preservation rate was 68% in responders to ICHT compared to 21% in non-responders (p = 0.02). It was also higher in patients without EGFr expression (but not significantly, p = 0.43).

CONCLUSION

Lack of EGFr expression is a favorable predictive factor for response to ICHT. Neither p53 nor Ki-67 have predictive and prognostic value in larynx preservation treatment.

Surgery for Laryngopharyngeal SCC in the Era of Organ Preservation

Over the past decades, randomized clinical trials have assessed and validated the concept of larynx preservation. This new concept has obviously modified the treatment algorithm for laryngopharyngeal squamous cell carcinoma. However surgery for larynx and hypopharynx cancer remains indicated in many cases. Initial partial surgery is indicated for early diseases. This surgery may be performed endoscopically or openly. The results are excellent in terms of local control and function. Transoral robotic surgery is under evaluation. Initial radical surgery is indicated for advanced diseases in case of very infiltrative tumor, in case of cartilage destruction or when tolerance and/or compliance to chemotherapy-based approached is questionable. Larynx preservation is to be discussed between these two situations. In randomized trials evaluating the different larynx preservation strategies, a substantial number of larynxes could be preserved without compromising disease control or survival. The best approach in terms of quality of function preservation, overall acute and late toxicity, disease control and survival is still a matter of clinical research. It must be stressed that salvage surgery is a definite part of these larynx preservation protocols in order to maintain the ultimate disease control. This discussion underscored the need of a multidisciplinary decision making and the need of a coordinated clinical research.

Integrating biologically targeted therapy in head and neck squamous cell carcinomas

The integration of targeted therapies such as cetuximab to radiation therapy has revolutionized the management of head and neck cancers in the last decade. However, the use of targeted therapies raised several clinically relevant questions that have yet to be answered. These questions include the optimal patient and tumor profile for biologically targeted therapy, the optimal radiation fractionation to use with targeted therapies, how to integrate them into standard or new chemoradiation regimens, their schedule and duration of administration, their toxicity, and which direction to consider for novel targeted treatment. In this review, we highlight several of these important issues, discuss the clinical trials that are designed to address these issues, and introduce some novel targeted therapies that may contribute to the improvement of the therapeutic ratio for head and neck cancer therapy.

Swing of the pendulum: optimizing functional outcomes in larynx cancer

For years, total laryngectomy was the only treatment option for patients with intermediate to advanced laryngeal cancer. Over the past two decades, great progress has been made in the management of this disease, with multimodality approaches aimed at laryngeal preservation reshaping the treatment landscape. In the era of chemoradiation, greater focus and attention are now directed toward functional laryngeal preservation--not simply "organ preservation." The continued development and integration of new treatment approaches, including organ preservation surgery (eg, transoral minimally invasive surgery of the head and neck, supracricoid partial laryngectomy), intensity-modulated radiotherapy, and targeted molecular therapies, offer the potential to improve clinical outcomes, function, and quality of life. Incorporation of these new approaches advances the concept of personalized medicine, with treatment strategies tailored to the circumstances and future of each patient.

Immunotherapy for head and neck cancer

Head and neck cancer represents a challenging disease. Despite recent treatment advances, which have improved functional outcomes, the long-term survival of head and neck cancer patients has remained unchanged for the past 25 years. One of the goals of adjuvant cancer therapy is to eradicate local regional microscopic and micrometastatic disease with minimal toxicity to surrounding normal cells. In this respect, antigen-specific immunotherapy is an attractive therapeutic approach. With the advances in molecular genetics and fundamental immunology, antigen-specific immunotherapy is being actively explored using DNA, bacterial vector, viral vector, peptide, protein, dendritic cell, and tumor-cell based vaccines. Early phase clinical trials have demonstrated the safety and feasibility of these novel therapies and the emphasis is now shifting towards the development of strategies, which can increase the potency of these vaccines. As the field of immunotherapy matures and as our understanding of the complex interaction between tumor and host develops, we get closer to realizing the potential of immunotherapy as an adjunctive method to control head and neck cancer and improve long-term survival in this patient population.

Recent advances in head and neck cancer therapy: the role of new cytotoxic and molecular-targeted agents

PURPOSE OF REVIEW

To provide an update on novel compounds in head and neck cancer (HNC) therapy, with emphasis on biologic agents.

RECENT FINDINGS

Cisplatin-5-fluorouracil (5-FU) is the standard chemotherapeutic approach in HNC. Strategies to improve its activity include the substitution of 5-FU with oral fluoropyrimidines; the substitution of cisplatin with different analogs or formulations; and the use of additional or alternative compounds. Epidermal growth factor receptor (EGFR) is the most appealing target for novel therapies in HNC. Cetuximab, a chimeric anti-EGFR monoclonal antibody, has undergone evaluation in platinum-refractory recurrent or metastatic HNC with a satisfactory and consistent response rate (10-13%) across three different Phase II studies in association with platinum or as single agent. A recent Phase III placebo-controlled trial has shown better response rate for patients treated with cetuximab and cisplatin, with respect to those treated with cisplatin alone. EGFR tyrosine kinase inhibitors (TKIs) are under investigation in HNC, and efforts are made to understand which molecular features are associated with objective responses. One appealing way to use EGFR TKIs is in combination with other biologic compounds, such as anti-angiogenic agents.

SUMMARY

New molecular-targeted therapies are inducing consistent, small improvements in HNC management. The major challenge regards how to better combine them with the final aim of obtaining long-term stabilization of advanced disease.

Epidermal growth factor receptor directed therapy in head and neck cancer

Squamous cell head and neck cancer (SCCHN) is the seventh most common cause of cancer death worldwide and its incidence is rising rapidly in developing countries. Despite recent advances in managing locally advanced SCCHN, patients with recurrent and metastatic SCCHN have a poor prognosis and little progress has been made its management. Epidermal growth factor receptor (EGFR) has been implicated in the pathogenesis of SCCHN and is a marker of poor prognosis. Recent advances in targeted therapeutics against EGFR are being investigated clinically. In this article, we review the different modalities utilized to inhibit EGFR signaling in SCCHN, including small molecule tyrosine kinase inhibitors, monoclonal antibodies, anti-sense therapy and immunotoxin conjugates. Monotherapy with EGFR inhibitors has demonstrated response rates between 5 and 15% in advanced SCCHN. However, combining EGFR inhibitors with cytotoxic chemotherapy or radiation therapy appears to augment response rates and survival. With the foundation for the use of EGFR inhibitors laid in these studies, future studies will need to optimize the delivery of these agents in combination with conventional therapies.