medical oncology perspective: neoadjuvant/induction … 2018/21 eylul... · 2019-01-16 ·...
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Medical Oncology Perspective: Neoadjuvant/Induction Chemotherapy
W/O Adjuvant Chemotherapy?
Amiran Matitashvili M.D.
Mardaleishvili Medical Centre Tbilisi, Georgia
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Cancer incidence In Georgia2015 -2016
Cancer incidence in both sex distributed according age in Georgia
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Cancer Incidence Distribution According Tumor Stage (%) 2015 -
2016
Stage I Stage II Stage III Stage IV
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Cancer incidence In Georgia2015
Tumor Type Number
Head & Neck Cancer(Oral cavity,oropharynx , hypopharynx, Glottic cancer, nasopharynx )
347 ( More than 80% of Head and Neck Cancer patients are treated at my Cancer Centre)
Breast Cancer 1885
GYO Cancers 1058
Thoracic malignancy 1192
GI tract maliganancy 1714
CNS Tumors 222
Soft tissue and bone tumors 60
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Survival Rate For Head and Neck Cancer
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Cancer Research Centre (Mardaleishvili Medical Centre)
Tbilisi, Georgia
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MTD Meetings
PATIENT
Pathologist
Radiation Oncologist
General Practitioner/Internist
Oncologist Dentist
Radiologist
Psychologist/psychiatrists
Medical Oncologist
Head and Neck Surgeon
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Clinical Practice Guidelines for Patients with Locoregionally Advanced SCCHN
Surgery followed by RT or CCRT
Level of evidence I Grade of recommendation A
Concomitant CT and RT Level of evidence I Grade of recommendation A
CCRT or ICT followed by RT for Organ preservation
Level of evidence II Grade of recommendation A
Cetuximab + RT Level of evidence II Grade of recommendation B
ICT followed by CCRT ( sequential Therapy)
Under evaluation
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CCRT Standard Nonsurgical Therapy
• Adding more cytotoxic chemotherapy (ICT)
• Adding Targeted Therapy
• Adding a hypoxic sensitizer to concurrent CRT
• Immunotherapy
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Role Of Induction Chemotherapy• ICT does not have a clear established frontline role
in the routine treatment of head and neck carcinomas of the major non-nasopharyngeal sites
• ICT RT has an established role for organ
Preservation in advanced and hypopharyngeal cancer
• ICT Cisplatin based CCRT reduced distant
metastatses but it does not increase OS and is more toxic than CCRTalone
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INDUCTION CHEMOTHERAPY
• TAX 324 : DCF vs PF
Did not include direct comparison to concurrent CRT
• PARADIGM
• DeCIDE
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Role Of Induction Chemotherapy
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RTOG 91 -11
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Toxicity Profile
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Questions ?
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Question: Induction…which chemotherapy?
GORTEC Trial
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Results
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Research Ares of Induction Chemotherapy for Treatment De-intensification
• Induction Chemotherapy can be used as a toll to stratify patients by treatment response
• Applicable for good prognosis HPV associated OPC
• Ongoing Trail : OPTIMA - very interesting Clinical trial
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OPTIMA Trial- Oropharynx Tumor Induction Response Stratified Therapy To Minimize Adverse Events
Radiologic Response
>50%
30-50%
<30%
Low Risk
1) Carboplatin AUC6,d1
2) 2) Nab –paclitaxel 100mg.m2
3) D1/d8/d15
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Results• Post-Treatment Biopsy/ND
Mean 7.3 weeks after RT/CRT(IQR 5.9-8.4)
Mean 26 nodes removed (IQR 18-33)
• Pathologic CR 91,5%
Low dose RT:94.7%(18/19)
Low dose CRT( CRT: 89,3%25/28)
Low risk patient :100% (6/6)
High Risk patient:86,4%(19/22)
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Optima Trial Results
OVERALL SURVIVAL
DISTATNT CONTROL
2-year OS :100%2-year PFS:93.8%
2.5 year OS: 85.7%2.5-year PFS: 93.8%
2-year DC: 91% 2-year LRC: 96.8%
2,5-year DC: 91%2,5- LRC 96.8%
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Optima Trial Results
Locoregional Control
Progression Free Survival 2-year PFS: 91%2-year OS: 97%
2.5 PFS 91%2.5-year OS 97%
2-year LRC: 100% 2-year DC 100%
2.5-year LRC 100%2 year DC 100%
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GSTTC Italian Study Group
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GSTTC Italian Study Group
• No Difference in toxicites, exept neutropenia, 8% IC-CCRT versus 1% CCRT; p=0.038)
• Compliance to concomitant treatments was not affected by TPF
IC arms better for
OS(p=0.031)
CRs(p=0.0028)
PFS(p=0.013)
LRC(p=0.036)
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ECOG 1308 Trial
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Results
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QUARTERBACK Trial
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ROLE OF INDUCTION CHEMOTHERAPYIn
NASOPHARYNGEAL CARCINOMA
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Clinical Case
• Patient: male 35 y old
• Patient was seen at our center in June 2018 when he admitted with complains on headace , nasal stiffnes, with some discharge , dizziness.
• Endoscopy and PET/CT scan was ordered
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Diagnosis
• Endoscopy confirmed mass lesion at posterior wall of nasopharynx
• Histology and Immunohistochemistry confirmed: nasopharyngeal carcinoma non keratinized Grade 3
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PET/CT Images
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Treatment
• Induction chemotherapy with DCF regimen :
Cisplatini 75mg/m2
Docetaxel 75mg/m2
5-FU 750mg /m2 -96 hour pump infusion
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CT Images after 3 cycles of IC treatemt
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Post IC Treatment
• Patient stared CRT with platinum based chemotherapy
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Induction Chemotherapy Role In Nasopharyngeal Carcinoma
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Results
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Induction Chemotherapy 2018
• Has established role in organ preservation strategies
• Decreases the occurrence of distant metastases
• TPF –chemotherapy regiment is most effective regimen
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THANK FOR YOUR ATTANTION