Case presentation

59M, previously healthy. Heavy smoker, quit a couple of months ago.

6 weeks of progressive facial pain.

Seen by local doctors, given antibiotics for a presumed sinus infection.

Purulent drainage.

Dentures stopped fitting.

Face started to go numb.

Admitted, biopsied.

Nasopharyngeal SCC, nonkeratinizing, discharged home.

Case presentation

Exam

Swollen left eye

Numb left cheek and lips

Labs

mild anemia, mild leukocytosis, BMP and LFTs fine, really nothing interesting

Imaging

Similar case on Radiopaedia:

https://radiopaedia.org/cases/59258/studies/66600?lang=us

Questions

• What is induction? (What is the difference between induction and neoadjuvant therapy?)
• When is induction a good idea?
• When is it a bad idea?
• Why are the surgeons always asking us to induce new H&N diagnoses in-house?
• What regimens are available/have been studied?
• How do I select a regimen for a given patient and situation?

induction chemotherapy (ICT) through the ages

1960s

• MTX

1970s

• MTX vs cisplatin (response rate 14-41%)
• cisplatin+bleomycin
• cisplatin+bleomycin+[MTX vs vinca]
  • cisplatin+bleomycin+vincristine response rate 80%, CR 29%
• cisplatin+5-FU (PF)
  • response rate 88%, CR 19%
• PF with 120h of 5-FU
  • response rate 93%, Cr 38%
• PF with 120h of 5-FU and higher dose of cisplatin
  • no benefit, more tox

ICT through the ages

1980s

• 5x RCT w MTX - 4/5 -ve, 1/5 +ve only for stage II oral cavity disease (and used intra-arterial MTX)
• many other RCTs, no benefit (outside of limited stage oral cavity disease)

1990s

• Concurrent Cisplatin-based chemoRadioTherapy (CCRT)

ICT through the ages

2000s

• PF vs TPF
• European study (TAX323) had RT afterward, American Study (TAX324) had CCRT afterward.

ICT through the ages

2000s

• ICT + CCRT vs CCRT alone
• OS doesn’t increase, toxicity does
• nuanced (locoregional vs distant recurrence)
• later meta-analyses suggest perhaps TPF+CCRT has benefit over CCRT alone (fitter patients?)

ICT through the ages

2010s

Rise of the mods:

• modified TPF (dose reduced)
• weekly carbo-taxol followed by CCRT
• TPEx (cisplatin, docetaxel, cetuximab)

Our patient:

• docetaxel 75, cisplatin 75, q3wk x3 and reimage

ICT today

• larynx preservation
  • CCRT not clearly better than ICT in pts who qualify for total laryngectomy but not partial - SALTORL trial is comparing ICT and CCRT head-to-head
• treatment intensification
  • TPF+CCRT in the fittest patients?
• converting borderline resectable to resectable
  • ~30% conversion rate
• selecting HPV+ OPSCC pt for RT dose reduction
  • significant improvement in morbidity
• oligometastatic disease
  • shrink/eliminate distant sites, spot weld prn, then CCRT/surgery?
• neurologic and airway compromise

talking points that came up after the talk

• gem-cis ICT with CCRT, study out of China, good results (h/t Cody Lebeck Lee - also v good question about generalizability given high EBV burden in Asian populations)
• QUAD shot radiotherapy, highly targeted RT (h/t Dixon Dorand)
• dental procedures wrt timing of RT, may need to start ICT to bridge until dental procedures are done plus ~2wks (h/t Ronak Mistry)

Bibliography