JOURNAL READING

Survival Without Adjuvant Chemotherapy for Selected Patients

With Stage II and III Nasopharygeal Carsinoma After Concurrent
Chemoradiotherapy Alone

ADVISER :
dr. Agus Sudarwi, Sp. THT–KL
dr. Afif Zjauhari, Sp. THT-KL

KEPANITERAAN KLINIK ILMU THT

BY :
RSUD DR. LOEKMONO HADI KUDUS
2018 Mega Puspita S (30101306991)
Andini Rizky Budiati (30101407134)
JOURNAL IDENTITY

▰ Tittle : Survival Without Adjuvant

Chemotherapy for Selected Patients With
Stage II and III Nasopharygeal Carsinoma
After Concurrent Chemoradiotherapy Alone
▰ Authors : Jia-Shing Wu MD, Yu-Chen Tsai MD,
James Jer-Min Jian MD, Hsin-Hsuan Chen
MD, Cheng-Fang Horng MS, Skye Hung-Chun
Cheng MD
▰ The Rise : March 16, 2018
▰ Publication by : Skye Hung-Chun Cheng,
Department of Radiation Oncology, Koo
Foundation Sun Yat-Sen Cancer Center,
Taipei, Taiwan.
2
ABSTRACT
• Between April 1998 and December 2008, 263 patients
with stage II AJCC 1997 T2aN0, T1-T2aN1; AJCC 2010
T1N1) NPC or stage III (AJCC 1997 T1-T2aN2; AJCC
2010 T1N2) NPC were enrolled.

• Patients received standard concurrent CRT with

01 Background cisplatin and 5-fluorouracil (5-FU) but without adjuvant
chemotherapy.

• The role of adjuvant chemotherapy after concurrent

chemoradiotherapy (CRT) for nasopharyngeal carcinoma
(NPC) is controversial.
Methods 02
• We report our phase II prospective study of withholding
adjuvant chemotherapy in a subgroup of patients with
American Joint Committee on Cancer (AJCC) stage II and III
NPC with
low risk for metastasis.
3
ABSTRACT

• It is safe to withhold adjuvant chemotherapy for

selected patients with stage II and III NPC.

03 Result

Conclusion04
• With a median follow-up of 107 months, the 5-year overall
survival (OS), disease-free survival (DFS), and distant
metastasis-free survival (DMFS) were 92.4%, 84.4%, and
90.7% for all patients; 94.1%, 85.9%, and 92.9% for patients
with stage II NPC; and 90.9%, 83.2%, and 88.9% for patients
with stage III NPC, respectively.
4
 INTRODUCTION
PREVIOUS STUDY
"Concurrent Chemoradiotherapy (CRT) +
Adjuvant Chemotherapy is SUPERIOR to
Radiotheraphy Alone in treatment of
advanced stage nasopharyngeal
carsinoma (NPC)”
The Contribution of adjuvant chemotherapy and advocated concurrent CRT Alone?
LAST GUIDELINE NOWDAYS
“CRT + Adjuvant “ 3 earlier Randomized Trial  Adjuvant
Chemoradiotherapy for patient Chemotherapy to Radiotherapy did not
with stage II NPC” improved survival”
Significant to toxicity
5
 THE GOAL
“In this phase II prospective study tested the hypothesis that
these selected patients could be treated with concurrent CRT
only and still archieved >90% of 5-year distant metastasis free
survival (DMFS)”
6
 MATERIALS AND METHODS
RADIATION TECHNIQUE :

1. 3D Conformal
Radiotherapy (3D
Conformal RT)
 Time : April 1998 – Stage II
December 2008 (T2aN0, T1-T2aN1) 2. Intensity Modulated
AJCC1997 Radiotherapy (IMRT)
 Place : Sun Yat-Sen
Cancer Center, Taipei, Stage III
Taiwan (T2aN0, T1-T2aN2) CHEMOTHERAPY TECHNIQUE :

1. Cis Diamine
Dichloroplatinum (CDDP,
Cisplatin)
Follow up :
• Disease Control 2. 5-Fuorouracil (5 FU)
• Complication
• Survival
• Follow up examination : Fiber
7
optic endoscopy and MRI
MATERIALS AND METHODS

8
 MATERIALS AND METHODS

Radiography
INCLUSION EXCLUSION PRETREATMENT
EVALUATION 6. Bone
1. Biopsy proven NPC 1. Underwent excisional biopsy of Scintigraphy
cervical lymph node 1. Complite
2. AJCC 1997 stage II or medical history 7. USG Liver
stage III 2. Had previous chemo or 2. Physical 8. Complete blood
radiotherapy to the head and neck examination count
3. Normal Renal Function region
3. Fiberopic 9. Serum chemical
endoscopic evaluation
4. Informed consent 3. Had distant metastasis or other
malighnant disease examination
4. MRI
9
5. Chest
MATERIALS AND METHODS

10
 MATERIALS AND METHODS

Survival estimates were

calculated using the Kaplan-
5 years Distant Meier method
Metastasis Free
Primary End Point Survival (DMFS) Sub group analysis, survival
STATISTIC was compared using the log
CONSIDERATION rank test and hazard ratio was
• 5 years overal
Secondary End Point survival (OS) estimated by Cox regression
• Disease free
SAS for Windows was used for
survival
all analysis

11
RESULT (Failure pattern and outcome)

12
RESULT (Prognostic factors)

13
RESULT

14
RESULT

15
RESULT

16
RESULT

ALL PATIENT
5-YEARS OS : 92,4% DFS : 84,4% DMFS : 90,7%

STAGE II NPC
5-YEARS OS : 94,1% DFS : 85,9% DMFS : 92,9%

STAGE III NPC

5-YEARS OS : 90,9% DFS : 83,2% DMFS : 88,9%
17
DISCUSSION

18
DISCUSSION

▰ Potential bias : The use of MRI routine for staging

▰ Limitation of the study is extremely favorable characteristic
of the population
▰ Some low risk patient with AJCC 1997 stage II and III NPC
have a very low risk of distant metastasis and excellent
survival with concurrent CRT alone.

19
Conclusion

“It is safe to withhold adjuvant chemotherapy for

selected patients with AJCC 1997 stage II and III NPC.
We propose to reclassify patients with T1-2aN2 disease
(T1N2 in AJCC 2010 staging) to stage II because of
their excellent prognosis without adjuvant
chemotherapy.”
THANKS!
Any questions?

21