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Hypoxia Imaging -Guided Radiotherapy of Nasopharyngeal Carcinoma

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ClinicalTrials.gov Identifier: NCT02089204
Recruitment Status : Unknown
Verified March 2014 by Longzhen Zhang, Xuzhou Medical University.
Recruitment status was:  Enrolling by invitation
First Posted : March 17, 2014
Last Update Posted : March 17, 2014
Sponsor:
Collaborator:
University of North Carolina, Chapel Hill
Information provided by (Responsible Party):
Longzhen Zhang, Xuzhou Medical University

Brief Summary:

Nasopharyngeal carcinoma (NPC) differs from other head and neck malignancies in terms of its epidemiology, pathology, and treatment outcome . It is endemic in China and is one of the major public health problems. Concurrent radiotherapy and chemotherapy is the primary treatment for patients with NPC. Despite such aggressive treatment, many patients with locally advanced NPC still develop locally recurrent disease. Since local control is directly related to patient morbidity and mortality in NPC, there is a strong need to identify methods to further improve treatment outcome for NPC.

One strategy to improve local control is to escalate the dose of radiotherapy. This is because local control has been shown to be directly related to the radiotherapy dose. Several different techniques, including brachytherapy, stereotactic radiosurgery, and dose-painting intensity modulated radiotherapy (IMRT), have been used to increase radiotherapy dose. However, due to the large number of critical anatomic structures near the nasopharynx, dose-escalation in NPC can also lead to increased toxicities. One technique that has achieved dose-escalation with minimal increase in toxicity is simultaneous modulated accelerated radiation therapy (SMART). The main challenge for such treatment is to identify the appropriate tumor volume to receive the high-dose radiotherapy. Conventional dose-escalation is conducted using computed tomography (CT) to identify the gross tumor volume (GTV). However, recent progress with F-18 fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT) in treatment planning allows more accurate tumor volume delineation. We hypothesize that the use of PET/CT in treatment planning can improve dose-escalation radiotherapy for NPC which in turn can improve therapeutic efficacy while reducing toxicity. PET/CT imaging of tissue hypoxia using [F-18]fluoromisonidazole (FMISO), the most widely used nitroimidazole imaging agent.Given that there has been no clinical trials directly comparing conventional chemoradiotherapy to CT-guided dose-escalation chemoradiotherapy or PET/CT guided dose-escalation chemoradiotherapy in locally advanced NPC.This was a study to evaluate the role of FMISO-PET hypoxia imaging for predicting survival in NPC,our study aims to compare the local control, overall survival and toxicities of the three treatment regimens..


Condition or disease Intervention/treatment
Nasopharyngeal Carcinoma Radiation: FMISO-PET/CT Radiation: FDG-PET/CT Radiation: contrast-enhanced CT

Detailed Description:

Study Design Patients with previously untreated Stages III~IVA (AJCC 6th Edition) of locally advanced NPC, Karnofsky performance status≥70, and good bone marrow, liver and kidney functions (white blood count ≥ 4.0×109/L, platelets ≥ 100×109/L, albumin ≥30 g/L , creatinine ≤100μmol/L) were enrolled on this study. Patients younger than 18, those with a prior (within 5 years) or synchronous malignancy were excluded. Pretreatment evaluations consisted of a history and physical, dental and laboratory studies. The clinical stage was determined based on all information provided by examinations including contrast enhanced CT and magnetic resonance imaging (MRI) of head and neck, Chest X-ray, liver sonography, bone scan, and 18F-FDG-PET. All tumors were histologically confirmed except those of distant sites.

Patients who met the eligibility criteria were randomized 1:1:1 into the three treatment arms: conventional chemoradiotherapy (group A), FDG PET/CT -guided dose escalation chemoradiotherapy (group B) and FMISO PET/CT -guided dose escalation chemoradiotherapy (group C). All patients were given concurrent chemoradiotherapy within two weeks of diagnosis. Radiotherapy was delivered using the simultaneous modulated accelerated radiation therapy (SMART) IMRT technique in the dose-escalation treatment arms. Concurrent chemotherapy consisted of cisplatin (20mg / m2 ,iv, d1- 4) and docetaxel (75mg / m2, d1, d8) administered on the 1st and 4th week of treatment. All patients received adjuvant chemotherapy that ranged from 2 to 4 cycles.

Follow-up and statistical analysis Planned patient assessment included physical examination and fiberoptic nasopharyngoscopy every 3 months to 3 years starting at 4 weeks post-treatment. A contrast-enhanced CT or MRI of the head and neck is also obtained at each follow up. After 3 years, the patients were followed yearly thereafter. Suspected recurrences were histologically proven. To assess for distant metastasis, CT of the chest and bone scan were obtained every half a year. During every follow-up visit, treatment toxicity were assessed. Radiotherapy-related toxicities were graded according to the Acute and the Late Radiation Morbidity Scoring Criteria of the Radiation Therapy Oncology Group (RTOG) and the European Organization for Research and Treatment of Cancer (EORTC). Chemotherapy-related toxicities (except nausea or alopecia) were graded by the criteria of the WHO.

All events were measured from the date of randomization. OS was defined as the time from the date of radiotherapy to death or the latest date known to be alive. Durations were calculated from the end of treatment. The Kaplan-Meier method was used to calculate the actuarial rates of local control, DFS and OS. The χ2 test was used for comparing incidence rates and categorical variables and Student's t-test was used for comparing the means of continuous variables.

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Study Type : Observational
Estimated Enrollment : 300 participants
Observational Model: Case-Control
Time Perspective: Prospective
Official Title: Clinical Feasibility Study of Hypoxia Imaging -Guided IMRT on the Individualized Radiotherapy of Nasopharyngeal Carcinoma
Study Start Date : June 2010
Actual Primary Completion Date : February 2014
Estimated Study Completion Date : December 2015

Resource links provided by the National Library of Medicine

Drug Information available for: Fluorine

Group/Cohort Intervention/treatment
FMISO-PET/CT
18F-MISO PET/CT -guided dose escalation chemoradiotherapy. All patients were given concurrent chemoradiotherapy within two weeks of diagnosis. Radiotherapy was delivered using the simultaneous modulated accelerated radiation therapy (SMART) IMRT technique in the dose-escalation treatment arms. Concurrent chemotherapy consisted of cisplatin (20mg / m2 ,iv, d1- 4) and docetaxel (75mg / m2, d1, d8) administered on the 1st and 4th week of treatment. All patients received adjuvant chemotherapy that ranged from 2 to 4 cycles.
Radiation: FMISO-PET/CT
Fluorine-18-labeled fluoromisonidazole PET/CT-guided dose escalation chemoradiotherapy (group C). Radiotherapy was delivered using the simultaneous modulated accelerated radiation therapy (SMART) technique in the dose-escalation treatment arms. Patients received concurrent and adjuvant chemotherapy.
Other Name: fluorine-18-labeled fluoromisonidazole

Radiation: contrast-enhanced CT
contrast-enhanced CT -guided dose escalation chemoradiotherapy. Radiotherapy was delivered using the simultaneous modulated accelerated radiation therapy (SMART) technique in the dose-escalation treatment arms. Patients received concurrent and adjuvant chemotherapy

FDG-PET/CT
18F-FDG PET/CT -guided dose escalation chemoradiotherapy. All patients were given concurrent chemoradiotherapy within two weeks of diagnosis. Radiotherapy was delivered using the simultaneous modulated accelerated radiation therapy (SMART) IMRT technique in the dose-escalation treatment arms. Concurrent chemotherapy consisted of cisplatin (20mg / m2 ,iv, d1- 4) and docetaxel (75mg / m2, d1, d8) administered on the 1st and 4th week of treatment. All patients received adjuvant chemotherapy that ranged from 2 to 4 cycles.
Radiation: FDG-PET/CT
18F-FDG PET/CT -guided dose escalation chemoradiotherapy. Radiotherapy was delivered using the simultaneous modulated accelerated radiation therapy (SMART) technique in the dose-escalation treatment arms. Patients received concurrent and adjuvant chemotherapy.
Other Name: fluorine-18 deoxyglucose

Radiation: contrast-enhanced CT
contrast-enhanced CT -guided dose escalation chemoradiotherapy. Radiotherapy was delivered using the simultaneous modulated accelerated radiation therapy (SMART) technique in the dose-escalation treatment arms. Patients received concurrent and adjuvant chemotherapy

contrast-enhanced CT
contrast-enhanced CT -guided dose escalation chemoradiotherapy . GTVs were delineated based on fusing diagnostic CT images with simulation CT images.All patients were given concurrent chemoradiotherapy within two weeks of diagnosis. Radiotherapy was delivered using the simultaneous modulated accelerated radiation therapy (SMART) IMRT technique in the dose-escalation treatment arms. Concurrent chemotherapy consisted of cisplatin (20mg / m2 ,iv, d1- 4) and docetaxel (75mg / m2, d1, d8) administered on the 1st and 4th week of treatment. All patients received adjuvant chemotherapy that ranged from 2 to 4 cycles.
Radiation: contrast-enhanced CT
contrast-enhanced CT -guided dose escalation chemoradiotherapy. Radiotherapy was delivered using the simultaneous modulated accelerated radiation therapy (SMART) technique in the dose-escalation treatment arms. Patients received concurrent and adjuvant chemotherapy




Primary Outcome Measures :
  1. local progression-free (LPF) survival rates [ Time Frame: 5 years ]
    LPF was defined as the time from the date of radiotherapy to local progression in the five years after treatment.Durations were calculated from the end of treatment.


Secondary Outcome Measures :
  1. disease-free survival (DFS) [ Time Frame: 5 years ]
    DFS was defined as the time from the date of radiotherapy to recurrence or local progression in the five years after treatment.Durations were calculated from the end of treatment.

  2. overall survival (OS) [ Time Frame: 5 years ]
    OS was defined as the time from the date of radiotherapy to death or the latest date known to be alive. Durations were calculated from the end of treatment.


Other Outcome Measures:
  1. acute toxicities [ Time Frame: from treatment start to 4 weeks post-treatment ]

    Acute toxicities were mucositis, nausea/vomiting, arrest of bone marrow, skin desquamation.

    Radiotherapy-related toxicities were graded according to the Acute and the Late Radiation Morbidity Scoring Criteria of the Radiation Therapy Oncology Group (RTOG) and the European Organization for Research and Treatment of Cancer (EORTC). Chemotherapy-related toxicities (except nausea or alopecia) were graded by the criteria of the WHO.


  2. Late toxicities [ Time Frame: from 4 weeks post-treatment to 5 years. ]

    Late toxicities were skin dystrophy, subcutaneous fibrosis, xerostomia, and hearing loss.

    Radiotherapy-related toxicities were graded according to the Acute and the Late Radiation Morbidity Scoring Criteria of the Radiation Therapy Oncology Group (RTOG) and the European Organization for Research and Treatment of Cancer (EORTC). Chemotherapy-related toxicities (except nausea or alopecia) were graded by the criteria of the WHO.




Information from the National Library of Medicine

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Ages Eligible for Study:   18 Years to 70 Years   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Sampling Method:   Probability Sample
Study Population
Between June 2010 to June 2015, patients from Department of Radiation Oncology, Affiliated Hospital of Xuzhou Medical College.
Criteria

Inclusion Criteria:

  • histologically confirmed NPC by biopsy,
  • no evidence of distant metastasis,
  • no previous treatment for NPC,
  • Stages III~IVA (AJCC 7th Edition) of locally advanced ,
  • adequate liver function (albumin ≥30 g/L),
  • adequate renal function (creatinine ≤100μmol/L) ,
  • adequate bone marrow function(white blood count ≥ 4.0×109/L, platelets ≥ 100×109/L),
  • Karnofsky performance status≥70,

Exclusion Criteria:

  • Patients younger than 18,
  • those with a prior (within 5 years) or synchronous malignancy were excluded.
  • presence of distant metastases,
  • pregnancy or lactation,
  • other concomitant malignant disease.

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT02089204


Sponsors and Collaborators
Xuzhou Medical University
University of North Carolina, Chapel Hill
Investigators
Layout table for investigator information
Study Chair: ZHANG Longzhen, MD Xuzhou Medical University
Study Director: Wang Andrew Z., MD and PHD University of North Carolina at Chapel Hill, USA
Principal Investigator: Wang Jianshe, M.M. Xuzhou Medical University
Principal Investigator: Xin Yong, M.M. Xuzhou Medical University
Principal Investigator: Xu Kai, MD Xuzhou Medical University
Principal Investigator: Tang Tianyou, M.M. Xuzhou Medical University
Principal Investigator: Ding Xin, M.M. Xuzhou Medical University
Publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):
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Responsible Party: Longzhen Zhang, MD,Professor, Xuzhou Medical University
ClinicalTrials.gov Identifier: NCT02089204    
Other Study ID Numbers: H201021
First Posted: March 17, 2014    Key Record Dates
Last Update Posted: March 17, 2014
Last Verified: March 2014
Keywords provided by Longzhen Zhang, Xuzhou Medical University:
Hypoxia Imaging -Guided Radiotherapy
PET/CT
simultaneous modulated accelerated radiation therapy (SMART)
Additional relevant MeSH terms:
Layout table for MeSH terms
Carcinoma
Nasopharyngeal Carcinoma
Hypoxia
Neoplasms, Glandular and Epithelial
Neoplasms by Histologic Type
Neoplasms
Signs and Symptoms, Respiratory
Nasopharyngeal Neoplasms
Pharyngeal Neoplasms
Otorhinolaryngologic Neoplasms
Head and Neck Neoplasms
Neoplasms by Site
Nasopharyngeal Diseases
Pharyngeal Diseases
Stomatognathic Diseases
Otorhinolaryngologic Diseases
Deoxyglucose
Fluorides
Cariostatic Agents
Protective Agents
Physiological Effects of Drugs
Antimetabolites
Molecular Mechanisms of Pharmacological Action
Antiviral Agents
Anti-Infective Agents