This document summarizes key points from an NACT workshop. It discusses how NACT can improve outcomes for locally advanced nasopharyngeal carcinoma and help preserve organs for cancers of the hypopharynx, larynx, and oral cavity. The document also covers appropriate patient selection, choosing effective NACT regimens, managing toxicities like neutropenic enterocolitis, assessing patient response to NACT, surgery after NACT, and managing radiation therapy after NACT. The overall goals of NACT are to improve survival, make tumors more operable, and help preserve organs and functions.

1. NACT WORKSHOP
Take away points
Dr. K. K. Mukherjee
Dr. Rajib
Bhattacharjee
Dept. of Medical Oncology

2. Indication of NACT
 Locally Advanced Nasopharyngeal Carcinoma-
improves OS.
 Hypopharynx and Larynx- organ preservation.
Oral Cavity-mandibular preservation.
Rare tumors are not necessity Chemo resistant.

3. Surgeon’s Viewpoint
 Borderline operable tumors
 Downstage tumor for resection
 Downstage tumor for organ preservation
 Select Responders and Non Responders

4. How to choose eligible patients
 Patient Factors – Age, PS, Co-morbidities
 Lab works – CBC,KFT, LFT, Biochemistry & Serology
Cardiac Evaluation –ECG, ECHO and MUGA Scan
 Audiometry
 DPD Testing

5. Selection of Appropriate Regimen
 3 Drug Regimen better than 2 Drug Regimen
 Survival
 Resectibility, Organ Preservation
 Taxane –Platinum is valid alternative (
Resectibility, Organ Preservation)
 Docetaxel is slightly better than Paclitaxel
 Cituximab has been disappointing
 Immunotherapy- fun time ahead

6. Delivery of TPF & DCF
 Pre & Post Hydration
 Antiemetics
 Mg Supplementation
Mannitol only when Cisplatin dose > 100
mg/m2
 G-CSF
 Adequate Nutrition

7. 5 FU Induced Cardio Toxicity
 About 10% of all patients
 Mortality - 5%
 Monitor Patient during Infusion
 Tegafur –Uracil may be useful in this scenario.

8. Neutropenic Enterocolitis
 Incidence – 5% ( Probably more in India)
 High Mortality
 Not to take Fever , Pain & Diarrohea lightly
 CT Abdomen to check for bowel thickening and
Perforation
 Antibiotics to be started ASAP
 Surgery is indicated in case of Bleeding , Perforation
and Abscess.

9. Reponse Assessment to NACT
Exact Measurements , Diagram, Photographs
 At regular interval- may modify plan of
treatment
 Radiological Response Assessment to be done
by a Radiologist experienced in Radio Oncology
 PET may help to detect responders
 Separate Response Assessment for
Immunotherapy
 Joint Clinic decision making.

10. Surgery after NACT
 Resection as per post NACT disease volume.
 Reduction in tumor volume predicts overall
survival
 Tumor regression is non-uniform and
heterogeneous
Micro vascular free flap reconstruction allows
more aggressive resection
Increased risk of flap failure post NACT
NACT leads to decreased PNI status

11. Radiation Post NACT
• Increased toxicity is an issue
• De-escalation of therapy possible in certain cases
• NACT may help in prevention of xerostomia
• Accelerated repopulation is an issue
• Concurrent Cisplatin post TPF lead to increased
toxicities (Cetuximab and Carboplatin are
alternatives)

12. “Don’t just add days to life but
life to those days”