IAEA-HypoX. A randomized multicenter study of the hypoxic radiosensitizer nimorazole concomitant with accelerated radiotherapy in head and neck squamous cell carcinoma.
OBJECTIVE
To test the hypothesis that radiotherapy (RT) of head and neck squamous cell carcinoma (HNSCC) can be improved by hypoxic modification using nimorazole (NIM) in association with accelerated fractionation.


METHODS
The protocol was activated in March 2012 as an international multicenter randomized trial in patients with HNSCC. Tumors were treated to a dose of 66-70Gy, 33-35 fractions, 6 fractions per week. NIM was administered in a dose of 1.2gperm(2), 90min before the first daily RT fraction. The primary endpoint was loco-regional failure. The trial was closed prematurely by June 2014 due to poor recruitment. An associated quality assurance program was performed to ensure the consistency of RT with the protocol guidelines.


RESULTS
The trial was dimensioned to include 600 patients in 3years, but only 104 patients were randomized between March 2012 and May 2014 due to the inability to involve three major centers and the insufficient recruitment rate from the other participating centers. Twenty patients from two centers had to be excluded from the analysis due to the unavailability of the follow-up data. Among the remaining 84 patients, 82 patients were evaluable (39 and 43 patients in the RT+NIM and the RT-alone arms, respectively). The treatment compliance was good with only six patients not completing the full planned RT course, and 31 patients (79%) out of 39 allocated for NIM, achieving at least 90% of the prescribed drug dose. At the time of evaluation, 40 patients had failed to achieve persistent loco-regional tumor control, and a total of 45 patients had died. The use of NIM improved the loco-regional tumor control with an 18month post-randomization cumulative failure rate of 33% versus 51% in the control arm, yielding a risk difference of 18% (CI -3% to 39%; P=0.10). The corresponding values for overall death was 43% versus 62%, yielding a risk difference of 19% (CI -3% to 42%; P=0.10). Sixteen patients, out of 55 patients analyzed for hypoxic gene expression, were classified as having more hypoxic tumors. Such patients, if treated with RT alone, had a higher loco-regional tumor failure rate as compared to the rest of the patients with known hypoxic status (P=0.05).


CONCLUSIONS
Although the trial was incomplete and suffered from a small number of patients, the results suggested an improvement in loco-regional tumor control and overall survival in patients with advanced HNSCC given the hypoxic modifier NIM in addition to accelerated fractionation RT. However, the trial also revealed that conducting multicenter and multinational study combining drug and RT in developing countries may suffer from uncontrolled and unsolvable problems.
Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark. Electronic address: hassan@oncology.dk.
Mohamed A
MA
Hassan Metwally
Oncology Department, Nuclear Medicine, Oncology & Radiotherapy Institute, Islamabad, Pakistan.
Rubina
R
Ali
Radiation Oncology Center, North Estonia Medical Center, Tallinn, Estonia.
Maire
M
Kuddu
Radiation Oncology Department, National Cancer Institute, Cairo, Egypt.
Tarek
T
Shouman
Department of Radiation Oncology, Institute of Oncology, Ljubljana, Slovenia.
Primoz
P
Strojan
Oncology Department, Nuclear Medicine, Oncology & Radiotherapy Institute, Islamabad, Pakistan.
Kashif
K
Iqbal
Applied Radiation Biology and Radiotherapy Section, International Atomic Energy Agency, Vienna, Austria.
Rajiv
R
Prasad
Department of Oncology, Aarhus University Hospital, Denmark.
Cai
C
Grau
Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark.
Jens
J
Overgaard
D000328:Adult; D000368:Aged; D002294:Carcinoma, Squamous Cell / Q000235:genetics / Q000473:pathology / Q000532:radiotherapy*; D019583:Dose Fractionation, Radiation; D005260:Female; D015972:Gene Expression Regulation, Neoplastic; D006258:Head and Neck Neoplasms / Q000235:genetics / Q000473:pathology / Q000532:radiotherapy*; D006801:Humans; D000860:Hypoxia / Q000235:genetics; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D009554:Nimorazole / Q000627:therapeutic use*; D010349:Patient Compliance; D011838:Radiation-Sensitizing Agents / Q000627:therapeutic use*; D000077195:Squamous Cell Carcinoma of Head and Neck
D011838:Radiation-Sensitizing Agents; D009554:Nimorazole
Accelerated radiotherapy; Clinical trials; HNSCC; Hypoxia; Hypoxic radiosensitization; Nimorazole