Advanced non-Sq Non-small Cell Lung Cancer Research Articles

Abstract CT553: Tislelizumab (TIS) versus docetaxel (D) in patients with previously treated advanced non-squamous (non-sq) non-small-cell lung cancer (NSCLC): Subanalysis from the RATIONALE-303 phase 3 randomized clinical study

Abstract Background: At a predefined interim analysis (IA), RATIONALE-303 (NCT03358875) demonstrated improved overall survival (OS) for TIS vs D in the intent-to-treat (ITT), with a manageable safety profile. Disease characteristics, standard of care and treatment/prognosis differ between histologic types of NSCLC. Here, we report on the non-sq population. Methods: 805 patients with histologically confirmed, advanced NSCLC with progressive disease during or after ≥ 1 platinum (Pt)-containing chemotherapy regimen were randomized (2:1) to TIS 200 mg or D 75 mg/m2 every 3 weeks until disease progression, intolerable toxicity, or withdrawal. Histology (sq vs non-sq) was a randomization stratification factor. Dual primary endpoints were OS in the ITT and PD-L1 ≥ 25% populations. A prespecified IA was conducted after ~426 deaths (76% of planned events). Efficacy and safety were assessed in 435 randomized patients with non-sq histology. Results: Baseline characteristics of non-sq patients were balanced between treatment arms and similar to the ITT population. As of August 10, 2020, at median follow-up of 20 and 17 months (mo), respectively, median (95% CI) OS was longer with TIS (18.6 mo [15.41, 23.16]) vs D (13.8 mo [9.43, 17.94]) in the non-sq ITT population, and objective response rate (ORR) and duration of response (DoR) were also improved for TIS vs D (Table). 95.5% (TIS) and 97.9% (D) of patients had ≥ 1 treatment-emergent adverse event (TEAE) and 39.0% (TIS) and 70.9% (D) of patients had ≥ Grade 3 TEAEs. The most common TEAEs were anemia, aspartate aminotransferase increased and alanine aminotransferase increased (TIS arm), and alopecia, anemia and neutrophil count decreased (D arm). Conclusions: TIS prolonged OS, consistent with the overall ITT population, with a favorable safety profile in patients with advanced non-sq NSCLC who progressed after a Pt-containing regimen. Table Efficacy* TIS (n=287) D (n=148) Median OS, mo (95% CI) 18.6 (15.41, 23.16) 13.8 (9.43, 17.94) OS HR (95% CI)† 0.71 (0.538, 0.929) P=0.0064‡,§ Median PFS, mo (95% CI) 2.5 (2.14, 4.01) 3.6 (2.17, 4.14) PFS HR (95% CI)† 0.84 (0.660, 1.062) P=0.0686‡,§ ORR, n (%) 60 (20.9) 14 (9.5) Median DoR, mo (95% CI) 11.7 (6.80, 14.65) 6.2 (2.10, 7.16) Safety** TIS (n=287) D (n=141) TEAEs ≥ 15% of patients in either arm, n (%) All grades ≥ Grade 3 All grades ≥ Grade 3 Anemia 76 (26.5) 11 (3.8) 56 (39.7) 6 (4.3) AST increased 64 (22.3) 5 (1.7) 18 (12.8) 0 (0.0) ALT increased 63 (22.0) 4 (1.4) 24 (17.0) 0 (0.0) Cough 59 (20.6) 4 (1.4) 25 (17.7) 0 (0.0) Weight decreased 44 (15.3) 2 (0.7) 13 (9.2) 0 (0.0) Decreased appetite 41 (14.3) 3 (1.0) 26 (18.4) 0 (0.0) Hypoalbuminemia 37 (12.9) 0 (0.0) 23 (16.3) 0 (0.0) Nausea 37 (12.9) 0 (0.0) 22 (15.6) 0 (0.0) Constipation 31 (10.8) 0 (0.0) 22 (15.6) 0 (0.0) Asthenia 29 (10.1) 1 (0.3) 29 (20.6) 8 (5.7) Neutrophil count decreased 8 (2.8) 1 (0.3) 53 (37.6) 36 (25.5) White blood cell count decreased 8 (2.8) 0 (0.0) 42 (29.8) 26 (18.4) Neutropenia 7 (2.4) 3 (1.0) 44 (31.2) 38 (27.0) Leukopenia 6 (2.1) 0 (0.0) 38 (27.0) 22 (15.6) Alopecia 0 (0.0) 0 (0.0) 70 (49.6) 2 (1.4) *Efficacy analysis set - non-sq patients; †Stratified; ‡One-sided stratified log-rank test; §Descriptive P-value; **Safety analysis set - non-squamous patients ALT, alanine aminotransferase; AST, aspartate aminotransferase; CI; confidence interval; DoR, duration of response; HR, hazard ratio; mo, months; NE, not evaluable; ORR, objective response rate; PFS, progression-free survival; TEAE, treatment-emergent adverse event Data cut-off: August 10, 2020 Citation Format: Ying Cheng, Dingzhi Huang, Zhiyong Ma, Yun Fan, Jie Wang, Xinmin Yu, Mikhail Dvorkin, Gareth Rivalland, Yiyuan Ma, Yan Wang, Yan Ma, Caicun Zhou. Tislelizumab (TIS) versus docetaxel (D) in patients with previously treated advanced non-squamous (non-sq) non-small-cell lung cancer (NSCLC): Subanalysis from the RATIONALE-303 phase 3 randomized clinical study [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr CT553.

The utility of transbronchial rebiopsy for peripheral pulmonary lesions in patients with advanced non-squamous non-small cell lung cancer

BackgroundPatients treated for non-squamous (non-Sq) non-small cell lung cancer (NSCLC) often require repeat biopsies to determine the optimal subsequent treatment. However, the differences between rebiopsy and initial biopsy in terms of their diagnostic yields and their ability to test the molecular profiles using bronchoscopy with radial endobronchial ultrasound guidance in patients with advanced NSCLC remain unclear. Hence, we aimed to compare the diagnostic yields and ability for molecular analyses of rebiopsies with those of initial biopsies.MethodsWe investigated 301 patients with advanced non-Sq NSCLC who underwent radial endobronchial ultrasound-guided transbronchial biopsy (TBB) for peripheral pulmonary lesions (PPLs) between August 2014 and July 2017. Patients were divided into the rebiopsy and initial biopsy groups: the latter referred to the biopsy that determined the definitive diagnosis. The diagnostic yields and ability for molecular analyses were compared between the two groups, and the factors affecting the TBB diagnostic yield were identified using univariate and multivariate analyses.ResultsThe diagnostic yields of the rebiopsy and initial biopsy groups were comparable (86.8 and 90.8%, respectively; p = 0.287). Furthermore, 93.0 and 94.0% of the patients in the rebiopsy and initial biopsy groups, respectively, had adequate specimens for gene profiling and mutational analysis (p = 0.765). The factors that increased the diagnostic yield were a positive bronchus sign (p < 0.001) and tumour location within the internal two-thirds of the lungs (p = 0.026).ConclusionsThe PPL diagnostic yield of the rebiopsy group was as high as that of the initial biopsy group. Hence, TBB for PPLs is feasible for patients requiring rebiopsy as well as for those with initial diagnoses. Adequate, high-quality biopsy specimens can be obtained by transbronchial rebiopsy for molecular testing.

Comparative effectiveness of carboplatin-pemetrexed (Carbo-Pem) with vs. without bevacizumab (Bev) in patients with advanced non-squamous (Sq) non-small cell lung cancer (NSCLC).

9073Background: The majority of patients with advanced non-sq NSCLC do not have high programmed death ligand 1 (PD-L1) expression or a targetable genetic alteration. Carbo-pem-bev is commonly used ...

Prognostic Impact of TTF-1 Expression in Non-Squamous Non-Small-Cell Lung Cancer: A Meta-Analysis.

Thyroid transcription factor-1 (TTF-1) is overexpressed in up to 95% of primary lung adenocarcinoma while negative for almost all squamous cell carcinomas. TTF-1 expression has been investigated as a prognostic factor in non-small-cell lung cancer (NSCLC) with conflicting results. We conducted this meta-analysis to gain a better insight into the prognostic role of TTF-1 in patients only with non-squamous (non-SQ) NSCLC. A systematic computerized search of the electronic databases including PubMed, PMC, EMBASE, Web of Science, and Cochrane Library was performed. From 21 studies, 6,451 patients were included in the combined analysis of hazard ratios (HRs) with 95% confidence intervals (CIs) for overall survival. Compared with patients with non-SQ NSCLC showing negative TTF-1 expression, those with tumors harboring TTF-1 overexpression had significantly better survival (HR = 0.49, 95% CI: 0.42-0.57, p < 0.00001). Subgroup analyses revealed that TTF-1 expression significantly correlated with a better prognosis in stage I (HR = 0.65, 95% CI: 0.50-0.84, p = 0.0008) as well as stage III-IV non-SQ NSCLC (HR = 0.38, 95% CI: 0.29-0.49, p < 0.00001). In conclusion, this meta-analysis demonstrates that TTF-1 overexpression is a favorable prognostic factor in patients with non-SQ NSCLC. The subgroup analyses indicate that TTF-1 is a good prognostic marker for survival not only in early-stage but also in advanced non-SQ NSCLC.

P3.02c-015 Phase II Trial of S-1/Cisplatin Combined with Bevacizumab for Advanced Non-Squamous Non-Small Cell Lung Cancer: TCOG LC-1202: Topic: Targeted Therapy

S-1 plus cisplatin is a standard chemotherapy regimen for advanced non-small cell lung cancer (NSCLC) (Ann. Oncol. 2015; 26:1401-8). The addition of bevacizumab significantly improved overall survival (OS) in patients with advanced non-squamous (non-SQ) NSCLC who received carboplatin plus paclitaxel but failed to show an OS advantage in patients who received cisplatin plus gemcitabine. Few studies of bevacizumab have evaluated quality of life (QOL) in patients with non-SQ NSCLC. Chemotherapy-naïve patients with stage IIIB, IV, or recurrent non-SQ NSCLC, Eastern Cooperative Oncology Group (ECOG) performance status (PS) 0–1, age 20–74 years, and measurable lesions were treated with a 3-week cycle of S-1 40 mg/m2 twice a day on days 1–14, cisplatin 60 mg/m2 on day 8, and bevacizumab 15 mg/kg on day 8, for 4–6 cycles. Patients without progressive disease received maintenance bevacizumab 15 mg/kg on day 1 with a 3-week cycle and S-1 40 mg/m2 twice a day every other day. The primary endpoint was progression-free survival (PFS). Secondary endpoints were objective response rate (ORR), OS, toxicity profile, and QOL. From June 2013 to January 2015, 39 evaluable patients were enrolled from 8 institutions: 10 women and 29 men; median age 65 (range, 38–74) years; epidermal growth factor receptor positive/anaplastic lymphoma kinase positive: two patients/two patients; performance status 0/1: 22/17; stage IIIB/IV/recurrence: 1/35/3; adeno/large cell/other: 35/1/3. Thirty one patients (80%) completed 4 cycles of induction chemotherapy, and 23 patients (59%) were started on maintenance chemotherapy. Median PFS, OS, and ORR were 7.3 months (95% confidence interval (CI): 5.9–8.7), 21.4 months (95% CI: 14.7–not reached), and 64%, respectively. The worst hematologic and non-hematologic adverse events were as follows (%): grade 3/4 leukopenia: 13/0; neutropenia: 18/5; thrombocytopenia: 0/0; anemia: 0/0; neutropenic fever: 3/0; and hypertension: 28/0; diarrhea: 3/0. QOL data will be presented at the meeting. S-1 plus cisplatin in combination with bevacizumab met the primary endpoint in patients with advanced non-SQ NSCLC in the present trial. Additionally, the response rate is anticipated to be high, and the regimen was well tolerated. Clinical trial information: UMIN000009476.

Impact of Reflex EGFR/ ALK Testing on Time to Treatment of Patients With Advanced Nonsquamous Non-Small-Cell Lung Cancer.

Optimal first-line systemic therapy for patients with advanced nonsquamous (nonsq) non-small-cell lung cancer (NSCLC) requires confirmation of EGFR/ ALK status, which can delay treatment. We evaluated the impact of reflex testing, defined as pathologists initiating EGFR/ ALK testing at the time of diagnosis of nonsq NSCLC, on time to treatment (TTT). We conducted a retrospective review of patients with nonsq NSCLC with medical oncology consultation at Sunnybrook Odette Cancer Centre between March 18, 2010 and April 30, 2014. Data were compared during routine and reflex testing. TTT was defined as the interval between the first medical oncology visit with advanced NSCLC and the initiation of systemic therapy. A total of 306 patients were included (n = 232 for routine testing, n = 74 for reflex testing). There was a trend to improvement in median TTT with reflex testing (36 days [interquartile range {IQR}, 16 to 71 days v 26 days [IQR, 8 to 41 days], P = .071). Omitting patients with intentional delays in systemic therapy for low-volume disease, poor performance status, comorbidity management, and/or radiation therapy, median TTT improved (34 days [IQR, 15 to 67 days] v 22 days [IQR, 8 to 42 days], P = .049). Time to optimal first-line systemic therapy according to published guidelines improved (median, 36 days [IQR, 16 to 91 days] v 24 days [IQR, 8 to 43 days], P = .036). There was no impact on receipt of any first-line systemic therapy (55% v 59%, P = .66). The quality of biomarker testing improved, with fewer unsuccessful tests ( EGFR, 14% v 4%, P = .039; and ALK, 17% v 3%, P = .037). Reflex testing of EGFR/ ALK improved the time to optimal systemic therapy and the quality of biomarker testing for patients with advanced nonsq NSCLC.

O3-9-1 - Weekly Paclitaxel in Combination with Bevacizumab in Patients with Non-Sq Nsclc Who Have Failed Previous Treatments

Backgrounds: Bevacizumab (BEV) in combination with paclitaxel (PTX) and carboplatin (Cb) has provided survival benefit for advanced non-small cell lung cancer (NSCLC) as first-line treatment. However, tri-weekly PTX therapy induce severe peripheral neuropathy frequently, and may deteriorate quality of life. Because of this toxicity, platinum plus pemetrexed regimen may be preferred as first-line treatment over Cb/PTX/BEV regimen. Weekly paclitaxel (w-PTX) regimen has proved to be effective and safe in a large number of clinical trials for advanced solid tumors. However, few clinical studies have focused on the comparison between w-PTX and tri-weekly PTX in advanced NSCLC. We previously reported that fractionated administration of paclitaxel may be less toxic and more active against advanced NSCLC in clinical trials. Furthermore, several studies have reported that combination chemotherapy of w-PTX and BEV proved survival benefit in patients with advanced breast cancer. Therefore, we conducted a phase II trial to evaluate the efficacy and toxicity for the combination chemotherapy of w-PTX and BEV in patients with advanced non-squamous (non-Sq) NSCLC who have failed previous treatment.Methods: Eligibility required ECOG performance status 0-2 and prior cytotoxic chemotherapy. The primary end point of the phase II study was the progression free survival (PFS). PTX was infused on days 1, 8 and 15, and BEV (15 mg/kg) was administered on day 1 of a 4-week cycle until PD. Toxicity evaluations were based on CTCAE (version 4).Results: Between September 2011 and January 2014 a total of 30 eligible patients were enrolled onto the study.Conclusions: This combination of w-PTX and BEV is both feasible and active in the treatment of patients with advanced non-Sq NSCLC. We will soon start a phase II study evaluating this combination as first-line treatment.

P1–066 - Clinical Investigation of Cisplatine/Pemetrexed in Patients with Advanced Non-Squamous Non-Small-Cell Lung Cancer

Background: Randomized phase 3 trial of cisplatine/pemetrexed (CDDP/PEM) combination chemotherapy for non-small cell lung cancer (NSCLC) comparing with cisplatine/gemcitabine (CDDP/GEM) combination chemotherapy revealed to be non-inferiority for efficacy with less toxicity. Also, in the subgroup analysis for non-squamous cell carcinoma (non-SQ), the CDDP/PEM group was significantly better for response rate and overall survival in comparison to the CDDP/GEM group. Currently, CDDP/PEM combination chemotherapy is one of the standard chemotherapy for advanced non-SQ NSCLC.

Phase I dose escalation study of pemetrexed and carboplatin in chemotherapy-naive elderly patients with advanced nonsquamous non-small cell lung cancer.

e19137 Background: The subgroup analyses in several phase III trials have suggested that overall survival after platinum-doublet chemotherapy in elderly patients with non-small cell lung cancer (NSCLC) can be similar to those in younger patients. The combination of carboplatin (CBDCA) with pemetrexed (PEM) is expected as a suitable treatment for carefully selected elderly patients with advanced non-squamous (non-Sq) NSCLC. Methods: Patients with ≥75 years, PS of 0-1, chemotherapy-naïve advanced non-Sq NSCLC were enrolled in this study. They received escalated doses of CBDCA at AUC 4 (cohort 1) or AUC 5 (cohort 2) and PEM 500 mg/m2 every 3 weeks for six cycles. Dose escalation was decided by dose-limiting toxicity (DLT) occurred in the first cycle of chemotherapy. Study protocol stipulated that additional number of patients, up to maximum of 20 patients, was enrolled to receive the recommended dose of study treatment. The primary objectives were to evaluate feasibility and determine the recommended dose of this combination. Results: A total of 20 patients (6 patients in cohort 1, 14 patients in cohort 2) were enrolled in this study. Median age was 77 (range 75-83). No DLTs were observed in the patients with cohort 1 and the first 6 patients of cohort 2 during the first cycle of chemotherapy, thus the combination of PEM 500 mg/m2 plus CBDCA at AUC 5 was determined as the recommended dose. Median number of cycles was 4 (range 1-6). The major toxicities were neutropenia, thrombocytopenia, anemia. During the entire period of study, 2 and 5 patients needed to have platelet transfusion and RBC transfusion, respectively. Liver dysfunction, fatigue and anorexia were also common, but these were generally manageable. Six partial responses and 9 stable diseases were observed, giving an overall response rate of 30% and a disease control rate of 75%. Median progression-free survival time was 4.8 months (95% CI, 4.1 – 5.4 months). Conclusions: The combination of PEM 500 mg/m2 plus CBDCA at AUC 5 was determined as the recommended dose. This combination therapy is generally tolerable, and may have encouraging antitumor activity in chemotherapy-naïve elderly patients with advanced non-Sq NSCLC. Clinical trial information: UMIN000003231.

Feasibility study of pemetrexed (PEM) plus bevacizumab (BV) as the first-line treatment for elderly advanced or recurrent non-squamous (non-Sq) non-small cell lung cancer (NSCLC): TORG1015.

e19054 Background: The addition of BV to cytotoxic agent(s) prolonged survival for non-Sq NSCLC patients (pts). However, there is no definitive evidence for the cytotoxic agent(s) plus BV is superior to the cytotoxic agent(s) alone for elderly non-Sq NSCLC. We conducted the feasibility study of PEM plus BV as the first-line treatment for elderly advanced or recurrent non-Sq NSCLC. Methods: Major eligibility and exclusion criteria were followings; chemotherapy-naïve; unfit for bolus combination chemotherapy; stage III/IV or relapsed non-Sq NSCLC; age≥70; PS 0-1; no evidence of brain metastasis; no history of hemoptysis and irradiation for thorax. PEM (500 mg/m2) and BV (15 mg/kg) were administrated intravenously on day 1 every 3 weeks. The primary endpoint was toxicity and the secondary endpoints were objective response rate (ORR), progression-free survival (PFS), overall survival (OS), and the percentage of pts who completed more than 3 cycles. Results: From November 2010 to April 2012, total 12 pts were enrolled. Patients characteristics were following; male/female=6/6; Median age (range) 78 (72-81); histology was all adenocarcinoma; activating EGFR mutation no/yes/unknown=9/2/1; stage IIIB/IV/recurrence=2/8/2; ECOG PS 0/1=6/6; smoking history yes/no=6/6. Severe toxicities (Grade 3≥) were leukopenia (25%), neutropenia (25%), anemia (8%), thrombocytopenia (8%), febrile neutropenia (8%), anorexia (8%), hypertension (8%), fatigue (8%), nausea (8%), and perforation (colon) (8%). No dose-limiting toxicity and treatment-related death was occurred. Three patients achieved PR and the ORR was 25%. The median PFS and OS were 5.6 months (mo) (95% C.I. 1.1-7.9 mo) and 10.3 mo (95% C.I. 6.9-15.6 mo) in 11 evaluated pts, respectively. The 1-year survival rate was 49% (95% C.I. 12-79%). Seven of 12 pts (58%) received more than 3 cycles. Conclusions: PEM plus BV as first-line treatment for elderly non-Sq NSCLC was well tolerable and promising. Clinical trial information: UMIN000004263.

O2-016 - Phase I Trial of Combination Chemotherapy of Pemetrexed (PEM) Plus Cisplatin (CDDP) and Concurrent Thoracic Radiotherapy (TRT) Followed by PEM Consolidation Therapy in Patients with Locally Advanced Non-Squamous (NON-SQ) Non-Small-Cell Lung Cancer (NSCLC): Post-Hoc Analysis for Progression-Free Survival (PFS) and Recurrent Sites

ABSTRACT Background Combination chemotherapy of PEM plus CDDP is established as a standard treatment of advanced non-Sq NSCLC. PEM has radiosensitizing potential when evaluated in vitro in combination with platinum-containing compounds and radiation. Our previous phase I trial demonstrated that combination chemotherapy of PEM plus CDDP with concurrent TRT at a total dose of 66 Gy was well tolerated in patients with locally advanced non-Sq NSCLC, and the response rate was 83% (The European Multidisciplinary Cancer Congress 2011, #9060). We conducted a post-hoc analysis of PFS and recurrent sites in those patients who were enrolled in the phase I trial. Methods Patients received PEM 500 mg/m2 plus CDDP 75 mg/m2 on day 1 of a 21-day interval for three cycles and concurrent TRT of 60 Gy (n = 6) or 66 Gy (n = 12) followed by consolidation PEM 500 mg/m2 of a 21-day interval for three cycles. We reviewed the medial records to collect data on progression, recurrent sites, late toxicity and survival. Results Between November 2008 and December 2010, 20 patients were enrolled in this study, and 18 patients received the protocol treatment. No late radiation morbidity was observed. Twelve patients had progressed, and recurrence included distant metastases (n = 7), local (n = 7) (in the radiation field (n = 6), out of the radiation field (n = 2) and both (n = 1)), and local plus distant sites (n = 2). Median PFS was 10.5 months (95% CI 8.7 to 12.3), and the 2-year PFS rate was 32%. The median follow-up time for censored cases was 21.8 months (range: 17.2–35.6 months). Conclusions Median PFS in our study was comparable with that in historical controls of chemoradiotherapy.

1215 - Phase I Trial of Combination Chemotherapy of Pemetrexed Plus Cisplatin and Concurrent Thoracic Radiotherapy in Patients with Locally Advanced Non-Squamous Non-Small-Cell Lung Cancer: Post-Hoc Analysis for Survival and Recurrent Sites

ABSTRACT Background Combination chemotherapy of pemetrexed (PEM) plus cisplatin (CDDP) is established as a standard treatment for advanced non-squamous (Non-Sq) non-small-cell lung cancer (NSCLC). PEM has radiosensitizing potential when evaluated in vitro in combination with platinum-containing compounds and radiation. Our previous phase I trial demonstrated that combination chemotherapy of PEM plus CDDP with concurrent thoracic radiotherapy (TRT) at a total dose of 66Gy was well tolerated in patients with locally advanced Non-Sq NSCLC, and the response rate was 83% (The European Multidisciplinary Cancer Congress 2011, #9060). We conducted a post-hoc analysis of progression-free survival (PFS) and recurrent sites in those patients who were enrolled in the phase I trial. Methods Patients received PEM 500mg/m2 plus CDDP 75mg/m2 on day 1 of a 21-day interval for 3 cycles and concurrent TRT of 60Gy (n = 6) or 66Gy (n = 12) followed by consolidation PEM 500mg/m2 of a 21-day interval for 3 cycles. We reviewed the medial records to collect data on progression, recurrent sites, late toxicity and survival. Results Between November 2008 and December 2010, 20 patients were enrolled in this study, and 18 patients received the protocol treatment. No late radiation morbidity was observed. 12 patients had progressed, and recurrence included distant metastases (n = 7), local (n = 7) (in the radiation field (n = 6), out of the radiation field (n = 2), and both (n = 1)), and local plus distant sites (n = 2). Median PFS was 10.5 months (95% confidence interval: 8.7-12.3), and 2-year PFS rate was 32%. Median follow-up time for censored cases was 21.8 months (range: 17.2-35.6 months). Overall survival data will be presented. Conclusions Median PFS in our study was comparable with that in historical controls of chemoradiotherapy. Disclosure All authors have declared no conflicts of interest.