Sequential chemoradiotherapy (SCRT) for larynx preservation (LP): Preliminary results of the randomized phase II TREMPLIN study

6010

Background: Induction chemotherapy (ICT) followed by irradiation (RT) and concurrent chemoradiotherapy (CRT) are validated options for LP. Docetaxel-based ICT, concurrent cetuximab and RT are new options and SCRT (ICT followed by CRT) has been reported as a potential new approach. However, to date there are no data assessing SCRT specifically for LP. Methods: Previously untreated patients (pts) with larynx or hypopharynx squamous cell carcinoma and candidates for a total laryngectomy were eligible for this randomized phase II study. Eligible pts received 3 cycles of ICT (docetaxel and cisplatin both 75 mg/m2 on day 1 and 5-FU 750 mg/m2/day on days 1–5). In case of response ≥ 50 % pts were randomized to receive either in arm A: RT (70 Gy) with cisplatin (100 mg/m2 on days 1, 22 and 43 of RT) or in arm B: Cetuximab (400 mg/m2 loading dose before RT and 250 mg/m2 on the first day of the 7 weeks of RT. Pts with response < 50% had salvage surgery. Primary endpoint was LP 3 months after treatment, secondary endpoints were larynx function preservation at 18 months, quality of function and tolerance to treatment. Results: From March 2006 to April 2008 (end of accrual), 153 pts with stage III-IV larynx/hypopharynx cancer were enrolled in the study and could start ICT. Of them 74 % could receive the planned ICT while the others had either reduced dosages or less than 3 cycles. Toxic deaths occurred in 3 pts (2%). Of the 147 evaluable pts after ICT, 22 were non-responders (15%), 4 pts were withdrawn from the study, 6 responding pts with ICT-related toxicity precluding any further cisplatin could not be randomized and finally 115 pts could be randomized (59 in arm A and 56 in arm B). 3 months after treatment there was no significant difference in LP (93% in arm A and 96% in arm B). In arm A, 45 % of pts could receive the full CRT protocol vs 71 % in arm B. In arm A 50% of pts had cisplatin-related toxicity (definitive in 52% the cases) while in arm B 26 % of patients had cetuximab-related toxicity (definitive in only 1 case). There was no CRT treatment-related death. Conclusions: SCRT is considered for LP. ICT followed by RT with concurrent cetuximab appeared better tolerated than with concurrent cisplatin with the same LP rate 3 months after treatment.

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Compliance and toxicity profiles of the CARISSA trial of postoperative cisplatin-based chemoradiation ± gefitinib in head and neck cancer

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Background: Concurrent cisplatin and postoperative irradiation (PORT) is the standard treatment for resected poor-risk squamous cell carcinoma of the head and neck (HNSCC) . However, a substantial number of patients fail to respond. Anti-EGFR agents, such as gefitinib, may improve outcomes and molecular markers might predict treatment efficacy. This was the basis for the CARISSA trial. There was some concern after hemorrhagic events occurred in a large independent trial of recurrent unresectable HNSCC. This caused a temporary interruption and safety profile analysis of CARISSA, which resumed after security reports showed no excess of hemorrhagic events. Methods: The CARISSA multicenter blinded randomized phase II trial compares PORT and cisplatin alone (arm A) or in combination with the EGFR Inhibitor ZD1839 gefitinib (arm B) in HNSCC and analyses EGFR-binding, gene polymorphisms, Western Blotting and immunohistochemistry. Patients are followed weekly. Toxicities are graded according to the NCI/CTCv.3 scale. Results: Thirty-eight patients have been included. Compliance to cisplatin was 56% in arm A and 44% in arm B (NS). Compliance to gefitinib was 60% with half cases interrupting treatment for toxicity. There were 18 and 20 grade (G) 3/4 non-hematological toxicities, 12 and 6 hematological G3/4 toxicities in arms A and B, respectively. Mucositis was the most common toxicity. G3 mucositis occurred in 4 and 5 cases in arms A and B, dermatitis in three cases in each arm and diarrhea in one case in each arm (NS). There were 7 cancer- related deaths and 3 of other causes. One tumor-bleeding event occurred in the arm without gefitinib. Full-dose radiotherapy was delivered in all but one case in each arm. Mean doses were 63.9 ± 1.9 (arm A) and 65.5 ± 0.9 Gy (arm B) or 64.7 ± 0.9 (arm A) and 65 ± 0.9 Gy (arm B) in groups where RT was uninterrupted or temporarily interrupted, respectively (NS). The two patients who did not receive full dose received 60 Gy. Conclusions: Compliance to PORT was similar with cisplatin alone or cisplatin + gefitinib. While there was no excess of hemorrhagic morbidity postoperatively (no gross disease), accrual continues with particular caution.

No significant financial relationships to disclose.

No statistical impact of intra-tumoral overexpression of EGFR, VEGF and p53 on the overall survival in head and neck squamous cell cancer (HNSCC): Preliminary results of the GORTEC 99–02 randomized trial

6010

Background: Predictive and prognostic factors are warranted to improve the management of HNSCC patients. We designed a prospective study to analyze the p53 status, vascular endothelial growth factor (VEGF) and epidermal growth factor receptor (EGFR) tumoral overexpression of the patients included in the GORTEC 99–02 prospective phase III trial which compared conventional radiotherapy (RT) plus 5FU and carboplatin (FUP) vs RT with concomitant boost and FUP vs very accelerated RT Methods: This propective study has been designed to include 820 patients. We present here the results in a sub group of 219 patients for whom the immunohistochemical overexpression of EGFR, P53 and VEGF was analyzed. Association beetween these markers and TNM staging, age, sex,disease progression and survival was evaluated. Tumor overexpression was assessed by immunohistochemistry for EGFR (Dako EGFR pharmDx™ kit), VEGF (Santa Cruz Biotech), P53 (Dako). EGFR status was defined as positive or negative.If positive, we evaluated the percentage of cells presenting the same intensity of staining. Staining pattern was qualified as “diffuse” if more than 95% of cancer nests were stained with the same intensity, and as “mosaic” if the staining was heterogeneous Statistical analysis were performed using Spearman correlation coefficient, Kruskal-Wallis test for quantitative variables, chi2 and Fisher exact test for qualitative variables and Logrank test and cox model for survival analysis. Multivariate analysis of survival took into account T and N status, tumor localisation and the type of treatment. Results: Positive expression for P53, VEGF and EGFR were respectively found in 56.4%, 61.1% and 94%.Diffuse EGFR status was associated with higher T status (p=0.0141). VEGF(+) status was associated with increased EGFR staining (p=0.0017). Patients with p53+ status were younger than p53(-) (p=0.0362). P53,VEGF and EGFR expressions were not significatively related to survival Conclusions: These preliminary results don’t found any relationship between intra-tumoral markors and survival in HNSCC.Work supported by a french PHRC from the national Institute of Health

No significant financial relationships to disclose.

Patient-reported burden of mucosal injury (MUI): Comparison of clinician-rated MUI and patient-reported outcomes

9117

Background: Patient (pt) reported outcome (PROs) tools identify MUI and its impact on functional and subjective outcomes. Among outpts, PRO tools are attractive because opportunities for direct assessment are limited, but agreement between PRO tools and objective MUI measures has not been uniform. We prospectively compared an objective MUI score and 3 previously validated PRO tools. Method: The Triad Burden of Illness study is an international, 41-center, prospective study of the risk and outcomes of radiation and chemotherapy-induced MUI. At baseline and during chemoradiation therapy (CRT), pts with larynx (L), hypopharynx (H), or non-small cell lung cancers (NSCLC) completed a daily MUI symptom tool (OMDQ) and 2 weekly PRO tools (FACT-E quality of life, FACIT- Fatigue). Clinicians examined pts twice weekly and scored MUI (WHO scale). In this interim analysis, we used random effects linear regression to compare clinician and pt ratings and t-tests to compare PRO scores in pts with and without severe MUI. Result: To date, 29 pts have completed =2 paired assessments; 23 (79%) had L or H cancers. Ulcerative MUI (WHO = 2) was more common among L/H than NSCLC pts (39% vs 17%). Pt-rated MUI predicted clinician-rated MUI (p = 0.001). FACT-E and FACIT-F scores were significantly lower (worse) among pts with clinician-rated ulcerative MUI than pts without and among pts with pt-rated severe MUI symptoms (OMDQ= 2) than pts without. Differences were largest in the subscales for physical and functional wellbeing and esophageal symptom special concerns. Conclusion: PRO tools estimate the burden of CRT-induced MUI in outpts with L/H or NCSL cancers. MUI appears to be associated with significantly poorer quality of life, functional status, and symptom scores. 1- 9 p <0.01; 10p = 0.06.

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Randomized phase III trial comparing induction chemotherapy using cisplatin (P) fluorouracil (F) with or without docetaxel (T) for organ preservation in hypopharynx and larynx cancer. Preliminary results of GORTEC 2000–01

5506

Background: Induction chemotherapy (CT) with PF followed by RT in case of objective response is an alternative to total laryngectomy (TL) for patients with locally advanced larynx (L) and hypopharynx (H) cancer. Data have suggested that T may add to the efficacy of PF. The objective of this trial was to determine whether the addition of T to PF could increase the L preservation rate. Methods: Patients with L and H cancer for whom surgical procedure required TL were randomized to receive PF or TPF. Inclusion criteria were: adequate organ function, WHO PS 0 or 1, age from 18 to 70, signed informed consent. Treatment arms were PF = P 100 mg/m2/d1 and F: 1000 mg/m2 continuous infusion (CI) d1 to 5, TPF = T: 75 mg/m2/d1, P: 75mg/m2/d1 and F: 750mg/m2 CI d1 to 5 for 3 cycles with 21 days interval. Patients with complete or partial response and who recovered normal L mobility received RT to 70 Gy. Non responders underwent TL followed by RT. The primary endpoint was 3-year larynx preservation rate. To detect an absolute difference of 15% the sample size was 210. Results: 220 patients were randomized (108 to PF, 112 to TPF). Patients characteristics (age, sex, PS, primary site, TN) were well balanced. The TPF arm showed greater grade 3–4 alopecia (19% vs 2%) and neutropenia (57% vs 35%) while the PF arm showed greater grade 3–4 mucositis (9% vs 4%) and febrile neutropenia (6% vs 2%).Compliance to CT was better in the TPF. The specified treatment was delivered in 81.2% of patients in the TPF vs 67.4%. The overall response rate (T and N) was 82.8% in the TPF vs 60.8% (p = 0.0013). 60.6% of patients achieved a complete endoscopic response vs 46.7%. L preservation was offered for 80% of patients in the TPF vs 57.6%. A high hemoglobin level (>14 gr/l) and a compliance to treatment >80% are associated with a better response rate. With a median follow up of 35 months the 3-year actuarial L preservation rate is 73% following TPF vs 63% using the PF regimen. Conclusion: In advanced L and H cancer, TPF demonstrated significantly superior overall response rate compared to the PF regimen. The TPF is better tolerated and preliminary results suggest that L preservation could be achieved for a higher proportion of patients.

No significant financial relationships to disclose.

Analysis of EGFr, VEGF and p53 in serum of head and neck squamous cell cancer (HNSCC) : Preliminary results of the GORTEC 99–02 randomized trial

5509

Background: Predictive and prognostic markers are warranted in HNSCC. We designed a prospective study to analyze EGFr, VEGF and P53 both in the serum and in the tumor of HNSCC patients included in the GORTEC 99–02 prospective phase III trial which compared conventional radiotherapy (RT) plus 5FU and carboplatin (FUP) vs RT with a concomitant boost and FUP vs a very accelerated RT. Methods: This prospective study has been designed to include 820 patients, we present here the results in a sub group of 216 patients for whom the biological markers were analyzed. Association between these markers and TNM staging, age, sex, disease progression and survival was evaluated. Serum analysis was performed for serum EGFr (Oncogene Science), VEGF (R&D systems) and p53 serum-autoantibodies (Immunotech). Statistical analysis were performed using Spearman correlation coefficient, Kruskal-Wallis test for quantitative variables, chi2 and Fischer exact test for qualitative varaibles and Logrank test and cox model for survival analysis. Multivariate analysis of survival took into account T and N status, tumor localisation and the type of treatment. Results: No correlation was found between the serum levels of VEGF and EGFr, neither between EGFr and p53. There was a borderline significant association (p = 0.07) towards higher VEGF serum levels in p53 negative, compared to p53 positive patients. No correlation was found between age, sex, T and N staging and all the serum markers. The VEGF level was significantly higher in laryngeal and hypopharyngeal primaries and lower in oropharyngeal and buccal primaries (p = 0.04). The EGFr level seemed also associated with the tumor localisation (p = 0.055). The median follow up was 2 years. High levels of serum EGFR were associated with better overall survival in univariate and multivariate analysis (p < 0.01). Overall survival was not significantly higher in positive serum p53 patients than in negative p53 patients (p = 0.11 in multivariate analysis). VEGF was not associated with survival. Conclusions: These preliminary resulst suggest that high levels of serum EGFr was associated with a better outcome in this homogenous, prospective series of HNSCC. Work supported by a french PHRC from the National Institutes of Health.

No significant financial relationships to disclose.

Impact on the cosmetic outcome of concurrent administration of adjuvant chemotherapy and radiotherapy after breast-conservative surgery: Differences between patient’s and doctor’s views

8554

Purpose: A multicenter randomized study comparing after breast-conservative surgery, sequential versus concurrent adjuvant chemotherapy (CT) with radiation therapy (RT) was initiated (ARCOSEI). After a median follow-up of 6.7 (4.3–9) years, we assessed prospectively late effects and cosmesis satisfaction of these two strategies. Methods and material: After breast-conserving surgery, patients were treated either with sequential treatment with CT first followed by RT (arm A) or CT administered concurrently with the same normofractinnated breast RT (arm B).With structured questions, 214 patients (107 in each arm) rated their satisfaction considering cosmesis, the difference in overall appearance, and specific changes of the breast. Late toxicity (LENT/SOMA scale) and cosmesis were blinded to treatment and assessed by a radiation oncologist by a qualitative scale and another semi-qualitative and semi-quantitative evaluation. Results: Subcutaneous fibrosis (SF), telangectasia (T), skin pigmentation (SP), and breast atrophy (BA) were significantly increased in arm B. Patient’s cosmesis satisfaction was not statistically different between the two arms with 92.6% of good results in arm A and 86% in arm B (p=0.72); although patients have found more important differences in the treated breast in arm B than in arm A, with 28.8% vs 14.3% of bad results, respectively. Physician’s prospective assessment found less favorable cosmesis results with concomitant treatment than with sequential one, with 40% and 15% of unsatisfaction, respectively (p=0.0014) using a semi-quantitative and qualitative scale; The use of a subjective 5-point scale found also a worse physician’s cosmesis satisfaction in arm B than in arm A (p=0.0013) Conclusion: The concurrent use of CT with RT is significantly associated with an increase incidence of grade 2 or greater late side effects. Rating of cosmesis is also subjective. Patients’ satisfaction with cosmesis is greater than the doctors’ for concomitant radiochemotherapy in breast cancer, and is not only determined by radiation late effects. With two methods, physician found a worse cosmesis outcome for concomitant radiochemotherapeutic arm.

No significant financial relationships to disclose.

La chimiothérapie concomitante de la radiothérapie augmente la toxicité tardive après chirurgie conservatrice du cancer du sein

PURPOSE

In 1996, a multicenter randomized study comparing after breast-conservative surgery, sequential vs concurrent adjuvant chemotherapy (CT) with radiation therapy (RT) was initiated (ARCOSEIN study). Seven hundred sixteen patients were included in this trial. After a median follow-up of 6.7 (4.3-9) years, we decided to prospectively evaluate the late effects of these two strategies.

PATIENTS AND METHODS

A total of 297 patients were asked to follow-up from the five larger including institutions. Seventy-two percent (214 patients) were eligible for late toxicity. After breast-conserving surgery with axillary dissection, patients were treated either with sequential treatment with CT first followed by RT (arm A) or CT administered concurrently with RT (arm B). In all patients, CT regimen combined mitoxantrone (12 mg/m(2)), 5-FU (500 mg/m(2)), and cyclophosphamide (500 mg/m(2)), 6 cycles (day 1-day 21). In arm B, patients received concurrently the first 3 cycles of CT with RT. In arm A, RT started 3 to 5 weeks after the 6th cycle of CT. Conventional RT was delivered to the whole breast using a 2 Gy-fraction protocol to a total dose of 50 Gy (+/-boost to the primary tumour bed). The assessment of toxicity was blinded to treatment and was graded by the radiation oncologist according to the LENT-SOMA scale. Skin pigmentation was also evaluated using a personal 5-points scoring system (excellent, good, moderate, poor, very poor).

RESULTS

Among the 214 evaluated patients, 107 were treated in each arm. The two populations were homogeneous for patients', tumors' and treatment characteristics. Subcutaneous fibrosis (SF), telengectasia (T), skin pigmentation (SP), and breast atrophy (BA) were significantly increased in arm B. Twenty patients experienced grade superior or equal to 2 (SF) in arm B vs five in arm A (P=0.003). Twenty-five and seven patients showed grade superior or equal to 2 (T) in arm B and A, respectively (P=0.001). Forty-four and twenty patients showed grade superior or equal to 2 (BA) in arm B and A, respectively (P=0.0006). Thirty patients experienced grade superior or equal to 3 (SP) in arm B vs fifteen in arm A (P=0.02). No statistical difference was observed between the two arms concerning grade superior or equal to 2 pain, breast oedema, and lymphoedema. No deaths were caused by late toxicity.

CONCLUSION

Following breast conserving surgery, the concurrent use of CT with RT is significantly associated with an increase incidence of grade 2 or greater late side effects.

Proposition de sélection et délimitation des volumes cibles microscopiques péritumoraux dans les cancers de la cavité buccale et de l'oropharynx (aires ganglionnaires exclues)

This article reviews the concept of selectivity in peritumoral microscopic disease to be included in the Clinical Target Volume (CTV) for elective treatment for oral cavity and oropharyngeal squamous cell carcinoma, using the local tumoral spread. The objective of the present article is to present a procedure for the delineation of the target volumes, required for an appropriate application of 3-DCRT and IMRT for head and neck cancers. These propositions are for the delineation of microscopic peritumoral target volumes when external beam irradiation is required. CTVs are illustrated on CT sections.

La préservation laryngée, état de la question

Larynx preservation in advanced pharyngolaryngeal cancers has been a major challenge in clinical research over the past two decades. Subtotal surgery (endoscopic laser surgery, supracricoid partial laryngectomies and hemilaryngopharyngectomies) has allowed reducing the indications of the so-called "mutilating" surgery. On the other hand, the modification of fractionation has notably improved the results of definitive irradiation (but most probably for supraglottic tumors). The main clinical research has been carried out with either sequential or concurrent chemo-irradiation. Induction chemotherapy followed by irradiation in good responders or by surgery in poor responders allowed to preserve the larynx in around half the cases without deleterious impact on overall survival. Concurrent chemo-irradiation trials suggested that the larynx preservation rates could be increased but overall survival remained unchanged and mucositis was a notable side effect. The next step could be the combination of induction chemotherapy followed by concurrent chemo-irradiation in good responders. Finally, the place of new drugs (taxanes, targeted therapies) is to be explored in this context.