Case report: Down-staging locally advanced head and neck cancer in an HIV infected patient in a limited resource setting.

Introduction Head and neck cancers are a common group of malignancies. They rank sixth among the cancers, and accounting for 6% of all cancer cases globally1. In early stages the disease is highly curable with either radiotherapy or surgery, and these modalities offer equivalent survival outcomes. However, most patients up to 60% present with advanced disease which confers a poor prognosis2. The role of chemotherapy in head and neck cancers has evolved over time. The first big meta-analysis of chemotherapy in head and neck cancer (MACH-NC) involving over ten thousand patients failed to demonstrate benefit of neo-adjuvant chemotherapy in head and neck cancers, which was only demonstrated in concurrent chemo-radiation. The meta-analysis was largely looking for survival benefit. The Veteran approach of neo-adjuvant chemotherapy for laryngeal preservation was one of the first trials to report a positive role of neo-adjuvant chemotherapy but for laryngeal preservation other than survival benefit.3 Later, TAX trials demonstrated that induction chemotherapy with Cisplatin, 5Fluorouracil and Taxotere (TPF) regimen followed by concurrent chemo-radiation for patients with locally advanced head and neck cancer is more effective and tolerable4. The neo-adjuvant chemotherapy in this protocol demonstrated survival advantage. This is the recent standard of care for locally advanced head and neck cancers in good performance status patients. Palliative radiotherapy forms the main stay of treatment in locally advanced cases that are not fit for radical treatment. However, the management of HIV infected locally advanced head and neck cancer is not clearly established. HIV infected patients tolerate chemotherapy poorly, are more likely to suffer severe toxicity, with higher possibility of declining CD4 count, rebound in HIV viral load and septic complications5,6,7. Further challenges exist in areas where radiotherapy access is a major challenge. We report a case of a locally advanced head and neck cancer of squamous cell histology, HIV infected who was down-staged using non-TPF neo-adjuvant chemotherapy in a setting where there is no radiotherapy and achieved near complete response and enabled a potentially curative resection procedure be performed.