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

A Nomogram Based on Tumor Response to Induction Chemotherapy and Plasma Epstein-Barr Virus DNA Level after Induction Chemotherapy to Explore Individualized Treatment of Patients with Locally Advanced Nasopharyngeal Carcinoma

Purpose

To explore the influence of Epstein-Barr virus (EBV) DNA levels before and after induction chemotherapy (IC), tumor response to IC, and baseline factors on overall survival (OS) in patients with locally advanced nasopharyngeal carcinoma (LA-NPC). A nomogram was subsequently constructed to explore the individualized optimal cumulative cisplatin dose (CCD) in concurrent chemoradiotherapy (CCRT).

Methods

A total of 581 LA-NPC patients were included, randomly divided into training and validation cohorts in a 7:3 ratio. In the training cohort, a nomogram was subsequently established based on multivariate Cox regression analysis and then validated. Subsequently, patients were classified into different risk groups based on the nomogram, and the impact of different levels of CCD on survival outcomes was evaluated.

Results

EBV DNA levels after IC, tumor response to IC, age, and LDH were independent prognostic factors of OS. Schoenfeld residual analysis indicated overall satisfaction of the proportional hazards assumption for the Cox regression model. The C-index of the nomogram was 0.758 (95% CI: 0.695-0.821) for the training cohort and 0.701 (95% CI: 0.589-0.813) for the validation cohort. Calibration curves demonstrated good correlation between the nomogram and actual survival outcomes. DCA confirmed the clinical utility enhancement of the nomogram over the TNM staging system. For OS, patients in the medium/high-risk group with a CCD > 200 mg/m² had better outcomes than those with CCD ≤ 200 mg/m², although the difference was not statistically significant (p = 0.097). No significant difference was observed in local relapse-free survival (LRFS), distant metastasis-free survival (DMFS), and progression-free survival (PFS) across various levels of CCD in different risk subgroups (p > 0.05).

Conclusion

The nomogram based on EBV DNA levels after IC, tumor response, LDH, and age effectively predicts OS in LA-NPC patients, aids in risk stratification, and may guide treatment decisions.

EBV-induced upregulation of CD55 reduces the efficacy of cetuximab treatment in nasopharyngeal carcinoma

Cetuximab, an anti-epidermal growth factor receptor (EGFR) antibody, has been shown to improve survival in nasopharyngeal carcinoma (NPC) patients. However, a correlation between the expression of EGFR and the response to cetuximab has not been observed, indicating that the mechanism underlying the effects of cetuximab needs to be further elucidated. The antitumour response involves immunotherapeutic mechanisms that target tumour-associated antigens, including complement-dependent cytotoxicity (CDC) and antibody-dependent cellular cytotoxicity (ADCC), act either alone or, more often, in combination. However, EBV infected NPC cells often develop resistance mechanisms that allow them to evade immune surveillance. Here, we found that overexpression of the complement-regulated protein CD55 in EBV-associated NPC cells mainly suppresses ADCC activity thus reduces the efficacy of cetuximab. Mechanistically, EBV latent membrane protein 1 (LMP1) mediated upregulation of CD55 through the NF-κB signalling pathway. The present study provides a rationale for the development of CD55 inhibitors to improve the clinical efficacy of cetuximab in NPC.

Cetuximab Plus Concurrent Radiotherapy in Patients With Nasopharyngeal Carcinoma

BACKGROUND/AIM

Several reports have evaluated the efficacy and safety of concurrent radiotherapy with cetuximab (BRT) in patients with nasopharyngeal carcinoma (NPC). Combination therapy with cetuximab can be a treatment option for NPC. Although clinical data regarding the efficacy and safety of BRT without induction chemotherapy (ICT) or adjuvant chemotherapy is essential for the development of new therapeutic strategies, such data are rarely reported.

PATIENTS AND METHODS

We retrospectively investigated a series of patients with NPC treated in our institution to evaluate the efficacy and safety of BRT. Eleven patients with newly diagnosed NPC were identified from an inpatient database from July 2015 to April 2018. Seven patients who received BRT were reviewed.

RESULTS

All patients completed BRT without cessation of treatment. Six (85.7%) patients achieved a complete response and one (14.3%) achieved stable disease. The response rate was 85.7%. All patients with ≤T3 disease achieved a complete response. Both patients with T3 disease developed local recurrence, and one of the four patients with T1-2 disease developed distant metastases. The 1- and 3-year overall survival rates were 85.7% and 47.6%, respectively. The most common adverse events (AEs) were pharyngeal mucositis (100%), radiation dermatitis (100%), anorexia (28.6%), weight loss (28.6%), acneiform rash (28.6%), and dry mouth (28.6%). Grade 3 AEs were pharyngeal mucositis (42.9%), radiation dermatitis (28.6%), and anorexia (14.3%). No grade 4/5 AEs were observed.

CONCLUSION

BRT for NPC was tolerable, but our findings suggest that BRT without induction chemotherapy or adjuvant chemotherapy is insufficient at least for ≥T3 disease.

PET/CT standardized uptake value and EGFR expression predicts treatment failure in nasopharyngeal carcinoma

OBJECTIVE

This study inventively combines epidermal growth factor receptor (EGFR) expression of the primary lesion and standardized uptake value (SUV) of positron emission tomography and computed tomography (PET/CT) to predict the prognosis of nasopharyngeal carcinoma (NPC). This study aimed to evaluate the predictive efficacy of maximum standard uptake value (SUVmax) and EGFR for treatment failure in patients with NPC.

METHODS

This retrospective study reviewed the results of EGFR expression and pretreatment ¹⁸F-FDG PET/CT of 313 patients with NPC. Time-dependent receiver operator characteristics was used for analyzing results and selecting the optimal cutoff values. Cox regression was used to screen out multiple risk factors. Cumulative survival rate was calculated by Kaplan-Meier.

RESULTS

The selected cutoff value of SUVmax-T was 8.5. The patients were categorized into four groups according to EGFR expression and SUVmax-T. There were significant differences in the 3-year local recurrence-free survival (LRFS) (p = 0.0083), locoregional relapse-free survival (LRRFS) (p = 0.0077), distant metastasis-free survival (DMFS) (p = 0.013), and progression-free survival (PFS) (p = 0.0018) among the four groups. Patients in the EGFR-positive and SUVmax-T > 8.5 group had the worst survival, while patients in the EGFR-negative and SUVmax-T ≤ 8.5 group had the best prognosis. Subsequently, patients with only positive EGFR expression or high SUVmax-T were classified as the middle-risk group. There were also a significant difference in 3-year overall survival among the three risk groups (p = 0.034). SUVmax-T was associated with regional recurrence-free survival and LRRFS in multivariate analysis, whereas EGFR was an independent prognostic factor for LRRFS, DMFS, and PFS.

CONCLUSION

The combination of SUVmax-T and EGFR expression can refine prognosis and indicate clinical therapy.

Meta-analysis of chemotherapy in nasopharynx carcinoma (MAC-NPC): An update on 26 trials and 7080 patients

Purpose

Chemotherapy, when added to radiotherapy, improves survival in locally advanced nasopharyngeal carcinoma (NPC). This article presents the second update of the Meta-Analysis of Chemotherapy in NPC.

Methods

Published or unpublished randomized trials assessing radiotherapy (±a second chemotherapy timing) with/without chemotherapy in non-metastatic NPC patients were identified. Updated data were sought for studies included in the previous rounds of the meta-analysis. The primary endpoint was overall survival. All trials were analyzed following the intent-to-treat principle using a fixed-effects model. Treatments were classified in five subsets according to chemotherapy timing. The statistical analysis plan was pre-specified.

Results

Eighteen new trials were identified. Individual patient data were available for seven. In total, the meta-analysis now included 26 trials and 7,080 patients. The addition of chemotherapy reduced the risk of death, with a hazard ratio (HR) of 0.79 (95% confidence interval (CI) [0.73; 0.85]), and an absolute survival increase at 5 and 10 years of 6.1% [+3.9; +8.3] and + 8.4% [+5.7; +11.1], respectively. The largest effect was observed for concomitant + adjuvant, induction (with concomitant in both arms) and concomitant chemotherapy, with respective HR [95%CI] of 0.68 [0.59; 0.79] (absolute survival increase at 5 years: 12.3% (7.0%;17.6%)), 0.73 [0.63; 0.86] (6.0% (2.5%;9.5%)) and 0.81 [0.70; 0.92] (5.2% (0.8%;9.6%)). The benefit of chemotherapy was also demonstrated by improvement in progression-free survival, cancer mortality, locoregional control and distant control. There was a significant interaction between patient age and chemotherapy effect.

Conclusion

This updated meta-analysis confirms the benefit of concomitant chemotherapy and concomitant + adjuvant chemotherapy, and suggests that addition of induction or adjuvant chemotherapy to concomitant chemotherapy improves tumor control and survival. The benefit of chemotherapy decreases with increasing patient age.

Use of nimotuzumab combined with cisplatin in treatment of nasopharyngeal carcinoma and its effect on expressions of VEGF and MMP-2

PURPOSE

This paper aims to observe the expressions of VEGF and MMP-2 in patients with nasopharyngeal carcinoma treated by nimotuzumab combined with cisplatin.

METHODS

Altogether, 104 patients with nasopharyngeal carcinoma treated in our hospital from April 2014 to August 2016 were selected as research subjects. Among them, 50 patients treated with cisplatin were divided into a control group and 54 patients treated with nimotuzumab combined with cisplatin were divided into an observation group. The two groups of patients were compared in terms of efficacy after treatment and incidence of adverse reactions. Changes of serum VEGF and MMP-2 concentrations before and after treatment were detected using enzyme-linked immunosorbent assay (ELISA), and the 3-year overall survival (OS) of patients was observed.

RESULTS

Compared with the control group, patients in the observation group had significantly higher total remission rate (RR) (P < 0.05) and significantly lower incidence of adverse reactions (P < 0.05). Before treatment, there was no significant difference between the observation and control groups in the concentrations of VEGF and MMP-2 (P > 0.05). After treatment, the concentrations in the two groups were significantly lower than those before treatment (P < 0.05), and the concentrations in the observation group were significantly lower than those in the control group (P < 0.05). There was no significant difference in the 3-year OS between the observation and control groups (P > 0.05).

CONCLUSIONS

Nimotuzumab combined with cisplatin could improve the conditions of patients with nasopharyngeal carcinoma. After treatment, the expression of VEGF and MMP-2 decreased significantly. We speculated that it improves the survival rate of patients by reducing the expression of VEGF and MMP-2.

Advances in targeted therapy mainly based on signal pathways for nasopharyngeal carcinoma

Nasopharyngeal carcinoma (NPC) is a malignant epithelial carcinoma of the head and neck region which mainly distributes in southern China and Southeast Asia and has a crucial association with the Epstein-Barr virus. Based on epidemiological data, both incidence and mortality of NPC have significantly declined in recent decades grounded on the improvement of living standard and medical level in an endemic region, in particular, with the clinical use of individualized chemotherapy and intensity-modulated radiotherapy (IMRT) which profoundly contributes to the cure rate of NPC patients. To tackle the challenges including local recurrence and distant metastasis in the current NPC treatment, we discussed the implication of using targeted therapy against critical molecules in various signal pathways, and how they synergize with chemoradiotherapy in the NPC treatment. Combination treatment including targeted therapy and IMRT or concurrent chemoradiotherapy is presumably to be future options, which may reduce radiation or chemotherapy toxicities and open new avenues for the improvement of the expected functional outcome for patients with advanced NPC.

Combination Treatment With Paclitaxel, Carboplatin, and Cetuximab (PCE) as First-Line Treatment in Patients With Recurrent and/or Metastatic Nasopharyngeal Carcinoma

Background: Platinum-containing doublet chemotherapy regimens are generally considered the standard first-line systemic therapy for recurrent or metastatic (R/M) nasopharyngeal cancer (NPC). Gemcitabine (GEM) plus cisplatin (CDDP) has become a standard therapy based on a phase 3 study in several countries, yet this regimen sometimes affects quality of life due to nausea or appetite loss. Here, we present the manageable toxicity and promising activity of paclitaxel + carboplatin + cetuximab (PCE) therapy for R/M NPC. Materials and Methods: We conducted a retrospective review of patients with R/M NPC who were treated with PCE from 2013 to 2019 at the National Cancer Center East, Kashiwa, Japan. PCE consisted of PTX 100 mg/m2 on days 1 and 8; CBDCA area under the blood concentration-time curve (AUC) 2.5 on days 1 and 8, repeated every 3 weeks; and cetuximab at an initial dose of 400 mg/m2, followed by 250 mg/m2 weekly, as reported in the paper. Results: Fourteen patients were identified, consisting of 10 males and 4 females with a median age 59.6 years (range, 43-74). Among the 12 of 14 patients assessed for efficacy, overall response rate was 58.3%, with 2 complete responses and 5 partial responses. On median follow-up of 23.8 months, median overall survival was not reached with observed death events of 2. Median PFS was 4.1 months (95% CI, 2.6-5.6 months). Two patients experienced disease progression during cetuximab maintenance and restarted PCE treatment, then achieved partial response again. The most common grade 3 or 4 adverse events were neutropenia (21.4%) and skin reaction (14.3%). No treatment-related death was observed. Conclusion: Although the number of study population was small, our results suggest that PCE is feasible and potentially effective for R/M NPC, with a 58.3% response rate and 4.1-month PFS. Further prospective evaluation is warranted.

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.