Simultaneous radiochemotherapy versus radiotherapy alone in advanced head and neck cancer: a randomized multicenter study

Phase I/II Study of Concurrent Chemoradiotherapy for Localized Nasal Natural Killer/T-Cell Lymphoma: Japan Clinical Oncology Group Study JCOG0211

Purpose

To explore a more effective treatment for localized nasal natural killer (NK)/T-cell lymphoma, we conducted a phase I/II study of concurrent chemoradiotherapy.

Patients and Methods

Treatments comprised concurrent radiotherapy (50 Gy) and 3 courses of dexamethasone, etoposide, ifosfamide, and carboplatin (DeVIC). Patients with a newly diagnosed stage IE or contiguous IIE disease with cervical node involvement and a performance status (PS) of 0 to 2 were eligible for enrollment. The primary end point of the phase II portion was a 2-year overall survival in patients treated with the recommended dose.

Results

Of the 33 patients enrolled, 10 patients were enrolled in the phase I portion and a two thirds dose of DeVIC was established as the recommended dose. Twenty-seven patients (range, 21 to 68; median, 56 years) treated with the recommended dose showed the following clinical features: male:female, 17:10; stage IE, 18; stage IIE, 9; B symptoms present, 10; elevated serum lactate dehydrogenase, 5; and PS 2, 2. With a median follow-up of 32 months, the 2-year overall survival was 78% (95% CI, 57% to 89%). This compared favorably with the historical control of radiotherapy alone (45%). Of the 26 patients assessable for a response, 20 (77%) achieved a complete response, with one partial response. The overall response rate was 81%. The most common grade 3 nonhematologic toxicity was mucositis related to radiation (30%). No treatment-related deaths were observed.

Conclusion

Concurrent chemoradiotherapy using multidrug resistance-nonrelated agents and etoposide is a safe and effective treatment for localized nasal NK/T-cell lymphoma and warrants further investigation.

Temporal trends in the incidence and survival of cancers of the upper aerodigestive tract in Ontario and the United States

The Ontario Cancer Registry (OCR) and the Surveillance, Epidemiology and End Results (SEER) databases were used to describe temporal trends in the incidence and survival of squamous cancers of the upper aerodigestive tract (UADT) in Ontario and the US between 1984 and 2001. Between the 1984-86 and 1999-01 periods, the age-adjusted incidence rate of all first primary cancers of the UADT decreased from 11.6 (11.2-12.0) to 8.8 (8.5-9.1) in Ontario and 13.0 (12.7-13.3) to 10.2 (10.0-10.4) in the US. Significant decreases in incidence were observed in many UADT sites but there was no significant change in the incidence of cancer of the oropharynx in either the US or Canada. Over the same period, the 5-year relative survival for all UADT cancers increased from 49.2% (47.2-51.2%) to 57.1%(55.0-59.1%) in Ontario and from 48.1% (46.9-49.3%) to 52.4% (51.2-53.6%) in the US. This significant improvement in the outcome of UADT cancer was largely due to a dramatic increase in the 5-year relative survival for cancers of the oropharynx from 31.1% (27.1-35.1%) to 53.6% (49.3-57.9%) in Ontario and from 35.3% (32.9-37.8%) to 51.0% (48.7-53.3%) in the US. Smaller increases in survival were observed in cancers of the oral cavity, nasopharynx, and hypopharynx, but there was no evidence of any increase in survival for cancer of the larynx. These results are consistent with the hypothesis that there has been a major change in the etiology of cancer of the oropharynx in Canada and the US and a concomitant change in its response to therapy.

Neoadjuvant chemotherapy for locally advanced squamous cancers of the head and neck: current status and future prospects

PURPOSE OF REVIEW

To assess the role of neoadjuvant chemotherapy for locally advanced squamous head and neck cancer.

RECENT FINDINGS

Several phase III clinical trials in locally advanced squamous head and neck cancer show promising results for neoadjuvant platinum, taxane, and fluorouracil chemotherapy prior to definitive radiation or concurrent chemoradiation.

SUMMARY

Clinical trials comparing cisplatin and 5-fluorouracil with or without a taxane followed by radiation or concurrent chemoradiation show that the three-drug induction chemotherapy may improve survival particularly for unresectable tumors. Clinical trials comparing chemoradiation with and without induction three-drug chemotherapy are ongoing. Molecular and clinical considerations for using neoadjuvant chemotherapy in the treatment of locally advanced head and neck cancers are being explored.

[Radiotherapy, chemotherapy and target therapy for treatment of head and neck cancer : new developments]

Approximately 60% of patients initially treated for squamous cell cancer of the upper gastrointestinal tract suffer from advanced tumor disease (UICC stages III and IV). Multimodal strategies lead to overall survival rates of up to 50%. Recent studies show indications that the risk of distant metastases after induction chemotherapy (CT) is less than after primary radiotherapy (RT) or radiochemotherapy (RCT). Hyperfractionation or accelerated radiation with concomitant boost shows superior results compared to classic RT. Intensity-modulated radiotherapy (IMRT) is a new method for better adjusted dose distribution. Targeted therapy with specific antibodies against biological targets, such as epidermal growth factor receptor (EGFR), showed superiority over RT but the comparison to classic RCT is still pending. Targeted therapy against vascular endothelial growth factor (VEGR) showed antiangiogenetic effects on tumors. In cases of non-resectability or distant metastases, palliative CT and target therapy are recommended. Reirradiation or IMRT offer increased locoregional tumor control at the expense of higher toxicity. Overall, advances in research on tumor biology offer increasingly more prognostic factors and markers for customized individual targeted therapy and CT.

Nodal control and surgical salvage after primary radiotherapy in 1782 patients with laryngeal and pharyngeal carcinoma

The purpose of this study was to evaluate the ultimate neck control after primary radiotherapy and surgical salvage in laryngeal and pharyngeal cancer patients. Some 1782 consecutive patients with squamous cell carcinoma were treated by radiotherapy. At presentation 26% of the patients had metastatic lymph nodes. A total of 298 primary or secondary nodal recurrences were seen, 159 were treated, and 53 (53/298 approximately 18%) were controlled. Isolated N-recurrence was fatal in 2.7% (36/1324) of the N0 patients. Univariate actuarial analysis of nodal control demonstrated that the region of origin, T-classification, T-size, N-classification, tumor stage, differentiation, hemoglobin, and radiation time were significant prognostic factors. In a Cox analysis the independent significant parameters were gender, region of origin, N-classification, and differentiation. The conclusions were that in patients with nodal recurrence a little over half were treated and of these a third of the nodal recurrences were controlled. Significant prognostic factors in multivariate analysis were gender, region of origin, N-classification, and tumor differentiation.

Impact of the prophylactic gastrostomy for unresectable squamous cell head and neck carcinomas treated with radio-chemotherapy on quality of life: Prospective randomized trial

BACKGROUND AND PURPOSE

Concomitant radio-chemotherapy is the gold standard treatment for unresectable head and neck carcinomas. Placement of prophylactic gastrostomy has been proposed to provide adequate nutrition during the therapeutic sequence. The objectives of this study were to assess the impact of prophylactic gastrostomy on the 6-month quality of life, and to determine the factors related to this quality of life.

MATERIALS AND METHODS

Design. randomized, controlled, open study ("systematic percutaneous gastrostomy" versus "no systematic gastrostomy"). Patients. squamous cell head and neck carcinoma (stages III and IV, UICC 1997). Setting. oncological departments of French university teaching hospitals. Treatment. optimal concomitant radio-chemotherapy. Evaluations. T0 baseline evaluation, T1 during the treatment, T2 end of the treatment, and T3 6-month post-inclusion. Primary endpoint. 6-month quality of life (Qol) assessed using SF36, EORTC QLQ-C30, EORTC QLQ H&N35 questionnaires.

RESULTS

The Qol changes from baseline included a decline (T1 and T2) followed by an improvement (T3). Qol at 6 months was significantly higher in the group receiving systematic prophylactic gastrostomy (p=10(-3)). Higher initial BMI and lower initial Karnofsky index were significant factors related to a higher 6-month Qol.

CONCLUSIONS

The study results suggest that prophylactic gastrostomy improves post-treatment quality of life for unresectable head and neck cancer patients, after adjusting for other potential predictive quality of life factors.

Neoadjuvant chemotherapy followed by concurrent hyperfractionated radiation therapy and sensitizing chemotherapy for locally advanced (T3-T4) oropharyngeal squamous cell carcinoma

BACKGROUND

Radiation therapy (RT) is commonly used in the management of patients with advanced (T3-T4) oropharyngeal squamous cell carcinomas. In recent years, based upon the meta-analyses of randomized trials, chemotherapy administered concurrently with RT (chemoradiotherapy) has become the standard of care. Twice-a-day hyperfractionated or accelerated-fractionated RT regimens have been shown in a number of randomized trials to significantly improve the rate of local control compared with conventional once-a-day fractionation. Concurrent chemotherapy administered along with hyperfractionated or accelerated RT has been shown to add significant additional benefit over hyperfractionated or accelerated RT alone. Neoadjuvant chemotherapy (usually consisting of cisplatin and fluorouracil) also produces favorable responses in most patients (approximately 75% partial or complete response rates) with advanced head and neck cancer, but its role remains controversial.

METHODS

The results of treatment of 23 patients with T3 or T4 oropharyngeal squamous cell carcinomas who received neoadjuvant chemotherapy, followed by hyperfractionated RT (120 cGy twice-a-day to 74.4-76.8 Gy) were retrospectively reviewed. The 14 patients who were most recently treated also received concurrent sensitizing doses of single agent chemotherapy, usually cisplatin. No patient was seen with distant metastasis, and all were treated with curative intent. Ten patients had T3 and 13 patients had T4 primary tumors. Three patients (13%) had stage III disease and 20 patients (87%) had stage IV disease. Ten patients had base of tongue primaries, 12 had tonsillar primaries, and 1 had an oropharyngeal wall primary. Eighteen patients (78%) had clinically involved neck nodes.

RESULTS

Seventy-four percent of patients had partial (>50%) or complete response at the primary site following neoadjuvant chemotherapy. One patient died of cardiorespiratory arrest after the first cycle. Thirteen percent of patients had unplanned interruptions of their RT courses secondary to severe mucositis. Local control at the primary site (minimum 2 years follow-up) was achieved in 17 of 19 (89%) patients. Two- and 5-year absolute survival rates were 71% and 55%, respectively. No patient was gastrostomy dependent beyond 18 months. Four patients developed neck failure after RT alone and none was successfully salvaged.

CONCLUSION

This study is noteworthy in that it uses both neoadjuvant and concurrent sensitizing chemotherapy along with hyperfractionated RT. There is little information in the literature on this approach. Although the regimen is somewhat toxic, it is less so than many other regimens, which combined full-dose multiagent chemotherapy during the course of RT. The latter regimens also have a significant incidence of permanent dysphagia, gastrostomy dependence, and/or aspiration, complications that were not encountered in this group. The local control rate was high (89%). We continue to recommend this regimen for patients with locally advanced head and neck squamous cell carcinomas.

Outcome and histopathologic regression in oral squamous cell carcinoma after preoperative radiochemotherapy

BACKGROUND AND PURPOSE

Preoperative radiochemotherapy has been reported to enhance tumor response and to improve long-term survival in advanced squamous cell carcinoma of the head and neck. This retrospective study evaluates regression rate and long-term survival in 228 patients with primary oral squamous cell carcinoma treated by neoadjuvant radiochemotherapy and radical surgery.

PATIENTS AND METHODS

All patients with biopsy-proven, resectable oral squamous cell carcinoma - TNM stages II-IV without distant metastasis - received preoperative treatment consisting of fractioned irradiation of the primary and the regional lymph nodes with a total dose of 40 Gy and additional cisplatin (n = 160) or carboplatin (n = 68) during the 1st week of treatment. Radical surgery and neck dissection followed after a delay of 10-14 days. The study only included cases with histologically negative resection margins.

RESULTS

After a median follow-up of 5.2 years, 53 patients (23.2%) had experienced local-regional recurrence. The median 2-year disease-specific survival (DSS) rate was 86.2%. 5-year DSS and 10-year DSS were 76.3% and 66.7%, respectively. Complete histological local tumor regression after surgery (ypT0) was observed in 50 patients (21.9%) and was independent of pretreatment tumor classification. Uni- and multivariate survival analysis revealed that ypT- and ypN-stage were the most decisive predictors for DSS.

CONCLUSION

Preoperative radiochemotherapy with cisplatin/carboplatin followed by radical surgery attains favorable long-term survival rates. This applies especially to cases with complete histological tumor regression after radiochemotherapy, which can be assumed for one of five patients.

Concurrent chemoradiation with carboplatin-5-fluorouracil versus cisplatin in locally advanced oropharyngeal cancers: is more always better?

PURPOSE

The optimal chemotherapy regimen remains undefined in the treatment of locally advanced oropharyngeal cancer by concomitant chemoradiation. This article compares two platinum-based chemotherapy regimens.

METHODS AND MATERIALS

In this retrospective study, we reviewed all consecutive patients treated for Stage III or IVA-B oropharyngeal cancer using either a combination of carboplatin and 5-fluorouracil (5FU) every 3 weeks or high-dose cisplatin every 3 weeks concomitant with definitive radiation therapy.

RESULTS

A total of 200 patients were treated with carboplatin-5FU and 53 patients with cisplatin. Median potential follow-up was 43 months. The 3-year overall survival rates for carboplatin-5FU and cisplatin respectively were 79.1% and 74.9% (p = 0.628), the 3-year disease-free survival rates were 76.0% and 71.3% (p = 0.799), and the 3-year locoregional control rates were 88.4% and 94.2% (p = 0.244).

CONCLUSIONS

We could not demonstrate differences between these two regimens, which both proved efficacious. Polychemotherapy and monochemotherapy therefore seem comparable in this retrospective analysis.

Weekly low-dose docetaxel-based chemoradiotherapy for locally advanced oropharyngeal or hypopharyngeal carcinoma: a retrospective, single-institution study

PURPOSE

To retrospectively assess the efficacy, toxicity, and prognostic factors of weekly low-dose docetaxel-based chemoradiotherapy for Stage III/IV oropharyngeal or hypopharyngeal carcinoma.

METHODS AND MATERIALS

Between 2001 and 2005, 72 consecutive patients with locally advanced oropharyngeal or hypopharyngeal carcinoma were treated with concurrent chemoradiotherapy (CCR; radiation at 60 Gy plus weekly docetaxel [10 mg/m(2)]). Thirty of these patients also received neoadjuvant chemotherapy (NAC; docetaxel, cisplatin, and 5-fluorouracil) before concurrent chemoradiotherapy. Survival was calculated according to the Kaplan-Meier method. The prognostic factors were evaluated by univariate and multivariate analyses.

RESULTS

The median follow-up was 33 months, with overall survival, disease-free survival, and locoregional control rates at 3 years of 59%, 45%, and 52%, respectively. Thirty-six patients (50%) experienced more than one Grade 3 to 4 acute toxicity. Grade 3 mucositis occurred in 32 patients (44%), Grade 4 laryngeal edema in 1 (1%). Grade > or =3 severe hematologic toxicity was observed in only 2 patients (3%). Grade 3 dysphagia occurred as a late complication in 2 patients (3%). Multivariate analyses identified age, T stage, hemoglobin level, and completion of weekly docetaxel, but not NAC, as significant factors determining disease-free survival.

CONCLUSIONS

Docetaxel is an active agent used in both concurrent and sequential chemoradiotherapy regimens. Mucositis was the major acute toxicity, but this was well tolerated in most subjects. Anemia was the most significant prognostic factor determining survival. Further studies are warranted to investigate the optimal protocol for integrating docetaxel into first-line chemoradiotherapy regimens, as well as the potential additive impact of NAC.

Current concepts of management in radiotherapy for head and neck squamous-cell cancer

Radiotherapy plays a key role in the management of early stage and locally advanced head and neck squamous-cell carcinomas (HNSCC) either alone or, more frequently combined with surgery and/or chemotherapy. Several approaches have been developed to improve its efficacy while maintaining acceptable toxicities, such as altered fractionated radiotherapy or concomitant chemoradiotherapy which have both improved the anti-tumor efficacy of radiotherapy. Of particular interest is concomitant chemoradiotherapy (CT-RT) which is the most commonly used approach in locally advanced disease. Taxanes and platinum-based induction chemotherapy could constitute an option in the treatment of locally advanced HNSCC and it's contribution before concomitant RT-CT is currently under investigation. More recently, epidermal growth factor receptor (EGFr) molecular targeting with cetuximab combined with radiotherapy has been successfully tested in a large randomized trial and this combination constitutes a new option, especially for patients with medical co-morbidities. Finally management of treatment related acute or late toxicity remains an important issue and in the last decade major achievements have been obtained in this field especially using intensity modulated radiotherapy (IMRT).

Molecular markers predict outcome in squamous cell carcinoma of the head and neck after concomitant cisplatin-based chemoradiation

Not all patients with squamous cell carcinomas of the head and neck (HNSCC) benefit from concurrent cisplatin-based chemoradiation, but reliable predictive markers for outcome after chemoradiation are scarce. We have investigated potential prognostic biomarkers for outcome in a large group of patients. Ninety-one tumor biopsies taken from consecutive HNSCC patients were evaluated for protein expression on a tissue microarray. Using immunohistochemistry, 18 biomarkers, involved in various cellular pathways were investigated. Univariable and multivariable proportional hazard analyses were performed to investigate associations between each individual marker and outcome. In addition, the global test was used to test all variables simultaneously and selected combinations of markers for an overall association with local control. Univariable analysis showed statistically significant increased relative risks of RB, P16 and MRP2 for local control and MDR1 and HIF-1alpha for overall survival. MRP2, MDR1 and P16 levels were positively associated with outcome whereas RB and HIF-1alpha had a negative relationship. Using Goeman's global testing no combination of markers was identified that was associated with local control. Grouping the markers according to their function revealed an association between a combination of 3 markers (P16, P21 and P27) and outcome (p = 0.05) was found. In the multivariable analysis, MRP2 and RB remained significant independent predictive markers for local control. This study describes the prognostic value of biomarkers for the outcome in patients uniformly treated with concurrent chemoradiation. MRP2 and RB were found to be associated with outcome in patients treated with concurrent chemoradiation.

Current state-of-the-art for concurrent chemoradiation

Throughout the last 2 decades, great strides have been made in managing patients with locally advanced head and neck squamous cell carcinoma. In many clinical settings, they translated to significant advances in treatment efficacy and improvements in disease prognosis. To achieve this, most strategies, ranging from induction to postoperative treatments, are essentially based on multidisciplinary approaches. Nowadays, the indication and sequencing of surgery, radiotherapy, and systemic treatments are carefully weighted in the function of risk levels, efficacy results, and quality of life. Along this track, the coadministration of chemotherapy and radiotherapy was shown, as definitive or adjuvant treatment, to improve the results of conventional radiotherapy alone. However, recent prospective trials showed that the compliance of patients to aggressive approaches is more of a concern for poor tolerability and reduced compliance inevitably impact on treatment dose intensity, leading to the delivery of suboptimal regimens. Therefore, further efforts to tailor novel, multidisciplinary approaches based on drug-radiation interactions have been put forth to optimize treatment outcomes in terms of both disease control and quality of life. Because therapy is becoming more intense, a careful recording and reporting of treatment-related morbidity is also a crucial element in estimating the therapeutic gain from competing strategies.

Intensity-modulated chemoradiation for treatment of stage III and IV oropharyngeal carcinoma: the University of California-San Francisco experience

BACKGROUND

Treatment outcomes for stage III and IV oropharyngeal carcinoma treated with intensity-modulated radiotherapy (IMRT) and concurrent chemotherapy without prior surgical resection were reviewed.

METHODS

Between April 2000 and September 2004, 71 patients underwent IMRT concurrent with chemotherapy without prior surgical resection for stage III and IV oropharyngeal carcinoma. Chemotherapy was platinum based. The gross tumor volume (GTV) received 70 Gy in 2.12 Gy per fraction. The high-risk clinical tumor volume (CTV) received 59.4 Gy in 1.80 Gy per fraction, and the low-risk CTV received 54 Gy in 1.64 Gy per fraction.

RESULTS

With a median follow-up of 33 months, the 3-year local, regional, and locoregional progression-free probabilities were 94%, 94%, and 90%, respectively. The 3-year overall survival estimate was 83%. Locoregional failures occurred in the GTV in 7 patients. Acute grade 3 or 4 toxicity developed in 35 patients. A feeding gastrostomy was placed in 25 patients. Late xerostomia was grade 0 in 16 patients, grade 1 in 31 patients, and grade 2 in 24 patients at last follow-up. No patients experienced grade 3 or 4 late toxicity, except for 1 who developed osteoradionecrosis of the mandible.

CONCLUSIONS

Excellent local and regional control was achieved with IMRT and concurrent chemotherapy without prior surgical resection in the treatment of stage III and IV oropharyngeal carcinoma. Significant sparing of the parotid glands and other critical normal tissues was possible using IMRT with moderate acute toxicities and minimal severe late effects.

Current concepts for the management of head and neck cancer: chemotherapy

Chemotherapy can be administered in patients with locoregionally advanced (LA) squamous cell carcinoma of the head and neck (SCCHN) either concurrently with irradiation or as induction chemotherapy prior to local treatment or as palliative therapy in patients with recurrent and/or metastatic disease. Cisplatin-based chemoradiation is still the standard for LA-SCCHN. TPF has emerged as the new standard regimen when induction chemotherapy is indicated. Areas of active investigation in LA-SCCHN are the sequential administration of induction chemotherapy followed by chemoradiation and the integration of targeted therapies. None of the combination chemotherapy regimens demonstrated an overall survival benefit when compared to single agent methotrexate, cisplatin or 5-fluorouracil in recurrent/metastatic disease. Combination chemotherapy in this setting is preferably used in younger patients with a good performance status and with symptomatic disease who require prompt symptom relief. However, a survival benefit was observed when cetuximab was combined with platinum-5-fluorouracil.

Impact of adding concomitant chemotherapy to hyperfractionated accelerated radiotherapy for advanced head-and-neck squamous cell carcinoma

PURPOSE

To evaluate the feasibility and efficacy of a hyperfractionated accelerated radiotherapy (RT) schedule combined with concomitant chemotherapy (Cx) in patients with locally advanced head-and-neck squamous cell carcinoma.

METHODS AND MATERIALS

Between 2004 and 2007, a total of 90 patients with locoregionally advanced head-and-neck squamous cell carcinoma underwent irradiation according to a hybrid fractionation schedule consisting of 20 fractions of 2 Gy (once daily) followed by 20 fractions of 1.6 Gy (twice daily) to a total dose of 72 Gy. Concomitant Cx (cisplatinum 100 mg/m(2)) was administered at the start of Weeks 1 and 4. Treatment outcome and toxicity were retrospectively compared with a previous patient group (n = 73) treated with the same schedule, but without concomitant Cx, between 2001 and 2004.

RESULTS

The locoregional control (LRC) rate was 70% after 2 years. Two-year overall and 2-year disease-free survival rates were 74% and 60%, respectively. In comparison with the RT-only group, an improvement of 15% in both LRC (p = 0.03) and overall survival (p = 0.09) was observed. All patients were treated to full radiation dose according to protocol, although the Cx schedule had to be adjusted in 12 patients. No acute Grade 4 or 5 toxicity was seen, but incidences of Grade 3 acute mucositis (74.5% vs. 50.7%; p = 0.002) and dysphagia (82.2% vs. 47.9%; p < 0.001) were significantly higher in the chemoradiotherapy group compared with patients treated with RT alone.

CONCLUSION

With this chemoradiotherapy regimen, excellent LRC and survival rates were achieved, with acceptable acute toxicity.

Current and emerging standards of concomitant chemoradiotherapy

Several different approaches have been tested in an effort to integrate chemotherapy into definitive non-operative management of squamous cell head and neck cancer. In phase III randomized trials and in meta-analyses, the concomitant use of chemotherapy and radiation has proven to be the most consistently successful, and to produce both locoregional control and survival benefits, when compared to radiation therapy alone. Large, multi-institutional and cooperative group studies have now established high-dose single-agent cisplatin and concurrent radiation therapy as the standard of care for patients with advanced nasopharynx cancer, for patients with unresectable head and neck tumors, and as a postoperative adjuvant for patients with high-risk pathologic features. This same treatment regimen also has been demonstrated to be the most effective multi-modality treatment strategy for larynx preservation. Future investigation will focus on optimizing the concomitant chemotherapy and radiotherapy schedules used, integrating targeted agents into these established treatment schedules, addressing the problem of distant metastases, minimizing both acute and late toxicities, and identifying the most appropriate patient populations for this kind of aggressive treatment.

Chemotherapy in the treatment of locally advanced head and neck cancer

Three decades of collaborative research have led to the integration of platinum-based chemotherapy into the curative management of squamous cell carcinoma of the head and neck and gains in local-regional control, organ preservation and survival endpoints. Concomitant cisplatin-based chemotherapy and radiotherapy is the strategy that has proven most effective for organ preservation for larynx and oropharynx cancers, the treatment of unresectable disease, nasopharyngeal cancer and the post-operative adjuvant treatment of patients at high risk of recurrence. The evolution of current indications for this multimodality approach is reviewed and current areas of investigation discussed. Nearly all patients with locally advanced head and neck cancer receive chemotherapy as part of initial curative treatment. The focus of future trials should be on survival improvement, toxicity reduction and risk stratification for treatment decision making.

Retrospective analysis of surgical resection after induction chemotherapy for patients with T4b squamous cell head and neck cancer

BACKGROUND

Standard treatment of patients with T4b squamous cell head and neck cancer (T4b-SCHNC) is concomitant chemo-radiotherapy (CT-RT). Recent Phase III trials with Taxane containing induction chemotherapy (IC) suggest that IC could also play a role in this setting. The value of resecting the residual mass after IC and before RT is not yet clear in this context.

METHODS

We present the results of a retrospective analysis.

RESULTS

Between 1984 and 2001, 113 patients (patients) with T4b-SCHNC were treated at our institution with IC. Four patients dead during IC and 57 patients achieved a complete or a >90% partial response at primary and proceeded to definitive RT (or concomitant CT/RT). Surgical resection was reconsidered after IC and before RT in the other 52 patients. Surgery was performed in 13 of them: in 7 patients resection was R1, all of them had loco-regional progression (2 also developed systemic metastases) and median OS after surgery was 21 months, with no patient alive at 48 months. In the other 6 patients a R0 resection was performed: 3 of these patients had loco-regional relapses (1 also developed systemic metastases) and the other 3 patients remain alive and disease free 56, 62 and 72 months after surgery. Considering the 52 patients that achieved less than a 90% partial response at primary with IC, overall survival was equivalent when no Resection or an R1 resection was performed after IC (5 year OS 8 vs. 0%, lrk, p=0.74), but a statistically significant improvement in OS was observed when an R0 resection was obtained (5 years OS 50%, lrk, p=0.02).

CONCLUSIONS

R0 resections after IC and before RT could indicate an improvement in OS in patients with T4b-SCHNC that obtain less than a 90% PR at primary after IC. We consider that this approach deserves further research in prospective clinical trials.

Concurrent chemoradiotherapy with weekly paclitaxel and carboplatin for locally advanced head and neck cancer: Long-term follow-up of a Brown University Oncology Group Phase II Study (HN-53)

BACKGROUND

A phase II study was conducted using concurrent paclitaxel, carboplatin, and external beam radiotherapy (RT) in patients with advanced head and neck cancer.

METHODS

Forty-three patients (stage III, n = 12; stage IV, n = 31) were treated with 8 cycles of weekly paclitaxel (60 mg/m(2)), carboplatin (area under the curve [AUC] = 1), and RT (1.8 Gy daily; total dose, 66-72 Gy). Patients with initially palpable lymph nodes underwent neck dissection.

RESULTS

The overall clinical response rate was 91% (65% complete, 26% partial). Severe mucositis occurred in 37 (90%) patients, necessitating hospitalization in 13 (31%) patients. With a median follow-up of 49 months, the locoregional and distant failure rates were 26% and 21%, respectively.

CONCLUSIONS

Concurrent paclitaxel, carboplatin, and RT for advanced head and neck cancer results in high complete response rates. Long-term follow-up has revealed the curative potential of this regimen, though the doses used resulted in unacceptable toxicity.

Factors associated with severe late toxicity after concurrent chemoradiation for locally advanced head and neck cancer: an RTOG analysis

PURPOSE

Concurrent chemoradiotherapy (CCRT) for squamous cell carcinoma of the head and neck (SCCHN) increases both local tumor control and toxicity. This study evaluates clinical factors that are associated with and might predict severe late toxicity after CCRT.

METHODS

Patients were analyzed from a subset of three previously reported Radiation Therapy Oncology Group (RTOG) trials of CCRT for locally advanced SCCHN (RTOG 91-11, 97-03, and 99-14). Severe late toxicity was defined in this secondary analysis as chronic grade 3 to 4 pharyngeal/laryngeal toxicity (RTOG/European Organisation for the Research and Treatment of Cancer late toxicity scoring system) and/or requirement for a feeding tube >or= 2 years after registration and/or potential treatment-related death (eg, pneumonia) within 3 years. Case-control analysis was performed, with a multivariable logistic regression model that included pretreatment and treatment potential factors.

RESULTS

A total of 230 patients were assessable for this analysis: 99 patients with severe late toxicities and 131 controls; thus, 43% of assessable patients had a severe late toxicity. On multivariable analysis, significant variables correlated with the development of severe late toxicity were older age (odds ratio 1.05 per year; P = .001); advanced T stage (odds ratio, 3.07; P = .0036); larynx/hypopharynx primary site (odds ratio, 4.17; P = .0041); and neck dissection after CRT (odds ratio, 2.39; P = .018).

CONCLUSION

Severe late toxicity after CCRT is common. Older age, advanced T-stage, and larynx/hypopharynx primary site were strong independent risk factors. Neck dissection after CCRT was associated with an increased risk of these complications.

Head and neck cancer

Most head and neck cancers are squamous cell carcinomas that develop in the upper aerodigestive epithelium after exposure to carcinogens such as tobacco and alcohol. Human papillomavirus has also been strongly implicated as a causative agent in a subset of these cancers. The complex anatomy and vital physiological role of the tumour-involved structures dictate that the goals of treatment are not only to improve survival outcomes but also to preserve organ function. Major improvements have been accomplished in surgical techniques and radiotherapy delivery. Moreover, systemic therapy including chemotherapy and molecularly targeted agents--namely, the epidermal growth factor receptor inhibitors--has been successfully integrated into potentially curative treatment of locally advanced squamous-cell carcinoma of the head and neck. In deciding which treatment strategy would be suitable for an individual patient, important considerations include expected functional outcomes, ability to tolerate treatment, and comorbid illnesses. The collaboration of many specialties is the key for optimum assessment and decision making. We review the epidemiology, molecular pathogenesis, diagnosis and staging, and the latest multimodal management of squamous cell carcinoma of the head and neck.

Concurrent platinum-based chemotherapy and simultaneous modulated accelerated radiation therapy for locally advanced squamous cell carcinoma of the tongue base

BACKGROUND

Randomized data support use of chemotherapy concurrently with radiation in treatment of advanced squamous cell carcinoma (SCC) of the oropharynx. Intensity modulated radiation therapy (IMRT) is increasingly being used to deliver such radiotherapy; no published reports specifically describe results of chemotherapy with IMRT for SCC of the base of tongue (BOT). We present outcomes data using simultaneous modulated accelerated radiation therapy (SMART) combined with platinum-based chemotherapy in treatment of locally advanced SCC of the BOT METHODS: The records of the Otolaryngology/Head and Neck Surgery Department of Emory University were screened for patients undergoing definitive chemoradiotherapy for SCC of the BOT. Radiation Oncology records were reviewed for dosimetry and prescription data. Hospital and clinic records were reviewed for control and toxicity data. All patients were treated definitively with platinum-based chemotherapy and once-daily RT. Median dose and dose per fraction to sites of gross primary or nodal disease, clinically involved neck, and clinically uninvolved neck were 70.29 Gy (2.13 Gy/fx), 63.03 Gy (1.91 Gy/fx), and 57.75 Gy (1.75 Gy/fx), respectively.

RESULTS

Between January 2003 and August 2005, 34 patients underwent definitive therapy for SCC of the BOT using SMART and chemotherapy. Follow-up was documented in all cases (median, 20.1 months). There have been 3 distant failures and 3 locoregional failures.

CONCLUSION

With moderate follow-up, chemotherapy and SMART contributes to excellent results, with 24-month actuarial overall survival and local control of 90% and 92%, respectively. Toxicity may be increased, however, with 15% of patients developing esophageal stricture or stenosis. .

SMART (Simultaneous Modulated Accelerated RadioTherapy) for locally advanced nasopharyngeal carcinomas

BACKGROUND

Concurrent chemoradiotherapy is commonly used for locally advanced nasopharyngeal carcinoma (NPC). We retrospectively analyzed the clinical outcomes of simultaneous modulated accelerated radiotherapy (SMART) with concurrent chemotherapy.

METHODS

Between January 2003 and May 2005, 24 patients with stage IIB to IVB NPC underwent SMART encompassing 3 targets: gross tumor volume (GTV), high-risk subclinical disease (CTV1), and low-risk subclinical disease (CTV2). Daily fractions of 2.4, 2.15, and 1.9 Gy were delivered to GTV, CTV1, and CTV2 to a total dose of 64.8, 58.05, and 51.3 Gy in 27 fractions over 5.5 weeks, respectively. Fifteen patients received concurrent cisplatin (DDP group), and 9 received 5-fluorouracil plus cisplatin (FP group).

RESULTS

With a median follow-up of 26 months (range, 17-45 months), 3-year overall and local-, regional-, and distant-progression-free survivals were 96% and 93%, 87%, and 88%, respectively. Grade 3 acute mucositis and pharyngitis were observed in 16 (67%) and 14 (59%) patients, respectively. Severe acute mucositis (100% vs 47%) and pharyngitis (100% vs 34%) were more frequently observed in the FP group than the DDP group (p < .01).

CONCLUSIONS

Despite short follow-up with a small number of patients, our preliminary results demonstrated encouraging local-regional control and survival at the cost of modest increase in treatment related toxicities. The total dose and fractionation scheme of SMART used in our study is feasible with no life-threatening or fatal complications. However, the administration of fluorouracil in addition to cisplatin during SMART was associated with increased acute and late toxicities, and it should be administered with caution.

Consensus guidelines for the management of radiation dermatitis and coexisting acne-like rash in patients receiving radiotherapy plus EGFR inhibitors for the treatment of squamous cell carcinoma of the head and neck

BACKGROUND

Radiation dermatitis occurs to some degree in most patients receiving radiotherapy, with or without chemotherapy. Patients with squamous cell carcinoma of the head and neck (SCCHN) who receive radiotherapy in combination with epidermal growth factor receptor (EGFR) inhibitors, such as cetuximab, may develop a characteristic acne-like rash in addition to dermatitis.

DESIGN

An advisory board of 11 experienced radiation oncologists, medical oncologists and dermatologists discussed the management options for skin reactions in patients receiving EGFR inhibitors and radiotherapy for SCCHN. Skin toxicity was categorised according to the National Cancer Institute-Common Terminology Criteria for Adverse Events (version 3) grading.

RESULTS

Both general and grade-specific approaches for the management of dermatitis in this patient group are presented. It was concluded that where EGFR inhibitor-related acne-like rash and dermatitis coexist within irradiated fields, management should be based on the grade of dermatitis: for grade 1 (or no dermatitis), treatment recommendations for EGFR-related acne-like rash outside irradiated fields should be followed; for grades 2 and above, treatment recommendations for dermatitis were proposed.

CONCLUSIONS

This paper presents comprehensive consensus guidelines for the treatment of dermatitis in patients with SCCHN receiving EGFR inhibitors in combination with radiotherapy.

Frequency of esophageal stenosis after simultaneous modulated accelerated radiation therapy and chemotherapy for head and neck cancer

BACKGROUND

Chronic esophageal toxicity after radiotherapy alone for cancer of the head and neck (HNCa) is rare: 2.6% for strictures and 0.8% for stenosis after a 60-Gy dose. With combined modality therapy, stricture rates of 22% to 37% have been reported. We report the frequency of esophageal toxicity after simultaneous modulated accelerated radiation therapy (SMART) with chemotherapy for HNCa.

METHODS

The records of the otolaryngology/head and neck surgery department of Emory University, Atlanta, GA, were screened for patients undergoing combined modality therapy using SMART for HNCa. Radiation Oncology records were reviewed for target and critical normal structure dosimetry, with detailed analysis of esophageal and supraglottic laryngeal dosimetry. Hospital and clinic records were reviewed for evidence of esophageal toxicity.

RESULTS

From January 2003 to August 2005, 99 patients underwent definitive therapy for squamous cell HNCa using SMART and chemotherapy. Follow-up was documented in all cases. Median dose to sites of gross primary or nodal disease was 70.29 Gy, at 2.13 Gy per fraction. Median dose to the ipsilateral neck was 63.03 Gy at 1.91 Gy per fraction. Median dose to the contralateral neck in 97 patients treated was 57.75 Gy at 1.75 Gy per fraction. Thirteen (13%) patients developed esophageal strictures. Five (5%) patients had complete esophageal stenosis. Four (14%) of the 29 patients with either a hypopharyngeal primary or a N2c nodal disease developed complete stenosis. A statistically larger esophageal volume of esophagus reactivity > or = 60 Gy (V(60)) was found in patients who developed stenosis/stricture when compared with a randomly selected population of N2a/b patients who did not develop those toxicities. Esophageal stenosis/stricture was also numerically more common in patients receiving taxane-based chemotherapy, developing in 23%, as opposed to 9% in patients treated with platinum-based chemotherapy.

CONCLUSION

The risk of esophageal stenosis may increase with SMART and chemotherapy for HNCa. Potential mechanisms to reduce this include (a) contouring the esophagus as a dose-limiting structure; (b) early flexible examination posttreatment, with early intervention with dilation; (c) improved therapy for mucositis.

Toxicity of two cisplatin-based radiochemotherapy regimens for the treatment of patients with stage III/IV head and neck cancer

BACKGROUND

This nonrandomized study compared 2 radiochemotherapy regimens for toxicity in 128 patients with stage III/IV head and neck cancer.

METHODS

Patients received conventionally fractionated radiotherapy. The total dose to primary tumor and involved lymph nodes did depend on preceding surgery. Patients received 66 to 70 Gy if surgery was not performed, 60 to 66 Gy after R0 resection, 66 Gy after R1 resection, and 70 to 72 Gy after R2 resection. Concurrent chemotherapy consisted of 3 courses cisplatin (100 mg/m(2)/d1,22,43) (group A, N = 61) or 2 courses cisplatin (20 mg/m(2)/d1-5 + 29-33)/5-fluorouracil (5-FU) (600 mg/m(2)/d1-5 + 29-33) (group B, N = 67).

RESULTS

Acute toxicity was more severe in group A, especially nausea/vomiting (p = .002), nephrotoxicity (p = .001), ototoxicity (p = .034), and hematotoxicity (p = .049). Forty-eight percent of group A and 10% of group B patients could not complete chemotherapy due to toxicity (p = .018). Late toxicity was similar (p = .99).

CONCLUSION

Two courses of fractionated cisplatin (20 mg/m(2)/d) and 5-FU were associated with significantly less acute toxicity than were 3 courses cisplatin (100 mg/m(2)/d).

Patterns and levels of hypoxia in head and neck squamous cell carcinomas and their relationship to patient outcome

PURPOSE

EF5, a 2-nitroimidazole hypoxia marker, was used to study the presence, levels, and prognostic significance of hypoxia in primary head and neck squamous cell tumors.

METHODS AND MATERIALS

Twenty-two patients with newly diagnosed squamous cell carcinoma of the oral cavity, oropharynx, or larynx with at least 2 years of clinical follow-up were included in this study. Quantitative analyses of EF5 immunofluorescence was carried out, and these data were compared with patient outcome.

RESULTS

EF5 immunostaining showed substantial intra- and intertumoral hypoxic heterogeneity. The majority of cells in all tumors were well oxygenated. Three patterns of EF5 binding in cells were identified using criteria based on the cellular region that was stained (peripheral or central) and the relationship of binding to necrosis. We tested the association between EF5-binding levels with event-free and overall survival irrespective of the pattern of cellular binding or treatment regimen. Patients with tumors containing EF5-binding regions corresponding to severe hypoxia (< or =0.1% oxygen) had a shorter event-free survival time than patients with pO(2) values greater than 0.1% (p = 0.032). Nodal status was also predictive for outcome.

CONCLUSIONS

These data illustrate the potential utility of EF5 binding based on quantitative immunohistochemistry of tissue pO(2) and provide support for the development of noninvasive hypoxia positron emission tomographic studies with fluorine 18-labeled EF5.