Accelerated fractionation radiotherapy and concomitant chemotherapy in patients with stage IV inoperable head and neck cancer

Utility of the Midface Degloving Approach for Extended Exposure in Maxillary Pathologies

Introduction

A generous exposure of the midface region is essential for a comprehensive and thorough execution of midface surgical procedures, especially bilateral procedures. Traditional approaches to the midface the midface like the lateral rhinotomy and Weber-Fergusson/Dieffenbach incision with their modifications leave a visible scar, and they are limited in their unilateral exposure. The midface degloving approach with its exclusive intranasal and intraoral incisions leaves no external scars and lends excellent bilateral exposure of the maxilla, zygoma, paranasal areas and infraorbital margins from one side to the other. The midface degloving approach is mainly used to expose pathologies of the maxilla, nasal cavities, paranasal sinuses, nasopharynx, and the central compartment of the anterior and middle cranial base. This approach can also be used to treat midface trauma and perform high-level osteotomies.

Materials and Methods

We describe the midface degloving procedure for nine cases operated in the Department of Oral and Maxillofacial Surgery over a period of 7 years (2012-2018): seven maxillary tumors and two maxillary cysts.

Results

We obtained excellent exposure for all the cases using this approach. Complications included mild distortion of the lower lateral nasal cartilages and oro-nasal communication.

Conclusion

The midface degloving approach lends excellent surgical access to the midfacial skeleton including the maxilla, the paranasal areas, the maxillary sinus, the zygoma, and infraorbital rims. The advantages of this approach besides its generous exposure, is the excellent cosmesis it provides leaving no external scars.

Esophageal Stricture Following Radiation, Concurrent Immunochemotherapy, Treated With Hyperbaric Oxygen and Dilation

Low-dose palliative radiation may offer symptomatic relief in patients with spinal metastases from primary renal cell cancer and is unlikely to result in radiation injury. Patients with advanced malignancy requiring palliative radiation are often also receiving chemotherapy. Synergistic adverse effects resulting from combined palliative radiation and novel antiprogrammed cell death-1 (anti-PD 1) and/or multityrosine kinase inhibitors are rare.

We report about a 60-year-old woman with metastatic clear-cell renal cancer, status post-left nephrectomy, with debilitating mid-back pain from metastatic tumor burden and foraminal nerve compression. Her chemotherapeutic regimen was repeatedly altered because of progression of disease until she was maintained on the anti-PD 1 checkpoint inhibitor, nivolumab. She received palliative radiation to her thoracic spine over a 2-week period, and nivolumab was then switched to cabozantinib midway through a course of palliative radiation. The patient rapidly developed severe esophagitis, progressing to esophageal stricture, and required placement of a percutaneous endoscopic gastrostomy tube. She was successfully treated with serial esophageal dilation and hyperbaric oxygen treatments to diminish inflammation and improve tissue vascularity. Concurrent use of anti-PD 1 and/or multityrosine kinase drugs may accelerate development of radiation injury regardless of radiation dosage. Radiation-induced esophageal stricture was managed successfully in this patient with serial esophageal dilation and adjuvant hyperbaric oxygen.

Accelerated Bifractionated Radiation with Concurrent Cisplatin Administration in Locally Advanced Head and Neck Cancer: A Feasibility Study

Aims and Background

To test the feasibility of accelerated interrupted twice-daily radiation and concurrent cisplatin administration in patients with locally advanced head and neck cancer.

Patients and Methods

Nineteen patients with locally advanced head and neck cancer were treated with accelerated bifractionated radiation with concurrent administration of cisplatin. There were 18 men and 1 female with a median age of 60 years (range, 17–71) and median performance status of 90 (-range, 80–100). Sixteen patients (85%) presented with stage IV disease. Primary site included the nasopharynx (n = 7), oropharynx (n = 5), hypopharynx (n = 1) and larynx (n = 6). Radiation consisted of two fractions of 1.6 Gy each daily, five times weekly to a total dose of 64 Gy. Cisplatin was administered at a dose of 100 mg/m2 on days 2 and 28 of the treatment period.

Results

Nine patients achieved a complete response (47%; 95% CI, 25%–70%) and 5 a partial response (26%; 95% CI, 7%–46%). Grade III–IV toxicity included leukopenia (16%), mucositis (26%), dry mouth (5%), weight loss (16%) and infection (5%). After a median follow-up of 27.11 months (range, 1–33+), 9 patients have died. Median time to progression was 11 months (range, 1–32+) and median survival 25 months (range, 1–32+).

Conclusions

Accelerated twice-daily radiation with concurrent cisplatin is effective in locally advanced head and neck cancer and can be safely given with manageable toxicity.

Influence of dosimetric and clinical criteria on the requirement of artificial nutrition during radiotherapy of head and neck cancer patients

PURPOSE/OBJECTIVE(S)

Intensification of radiotherapy and chemotherapy for head-and-neck cancer (HNC) may lead to increased rates of long term dysphagia as a severe side effect. Mucositis and consequent swallowing problems require artificial nutrition in many HNC patients undergoing radiotherapy or chemoradiation. It is unknown, which predict factors for prophylactic PEG tube insertion appear useful.

MATERIALS/METHODS

From an institutional database, 101 patients (72 male, 29 female, mean age 59.5years) were identified who underwent radiotherapy or chemoradiation for HNC. Primary end point of the investigation was the need for artificial nutrition for more than 4days during radiotherapy. Dose volume parameters of defined normal tissue structures potentially of relevance for swallowing ability as well as clinical factors were used to develop a predictive model using a binary multiple logistic regression model.

RESULTS

Whereas several dosimetric and clinical factors were significant predictors for the need of artificial nutrition on univariate analysis, on multivariate analysis only three factors remained independently significant: mean dose to the oropharynx+1cm circumferential margin, ECOG performance state (0-1 vs. 2-4), and the use of chemotherapy (yes vs. no).

CONCLUSIONS

Using a 3 parameter model we could distinguish HNC-patients with different risks for the need of artificial nutrition during radiotherapy. After independent validation, the model could be helpful to decision on prophylactic PEG tube insertion.

Concurrent therapy with taxane versus non-taxane containing regimens in locally advanced squamous cell carcinomas of the head and neck (SCCHN): a systematic review

BACKGROUND

Platinum compounds remain the most widely utilized systemic agents in combination with radiation for treating SCCHN in the concurrent setting. Despite recent interest in using taxanes in this setting, there is a lack of randomized clinical trials to support this approach. We conducted a systematic review of published clinical trials of taxane-containing versus standard non-taxane-based regimens used in definitive treatment of SCCHN.

METHODS

Trials published between 1994 and 2012 were identified by an electronic search of public databases (MEDLINE, EMBASE, Cochrane library). All prospective studies were independently identified by two authors for inclusion. Studies were excluded if induction therapy was part of the regimen or if targeted agents were used. Trials using cisplatin- or carboplatin-based regimens and paclitaxel or docetaxel were included. Demographic data, treatment response, locoregional failure free rate (LFFR), progression-free and overall survival (PFS, OS) and toxicities were extracted and analyzed using Comprehensive Meta Analysis software (Version 2.0). Outcome data were pooled and reported as weighted response rate (RR), PFS and OS.

RESULTS

A total of 790 studies were retrieved and 42 studies with 3120 patients were included: 804 patients were treated with taxanes (80% males, median age 57years) and 2316 with non-taxanes (86% males, median age 56years). Progression free survival was not different between the two groups. Weighted median survival was compared from those studies that reported these data; taxanes=36.7months (N=197) versus non-taxanes=25months (N=503), P<0.001. Toxicity (grade 3 and above) was higher in non-taxane containing trials.

CONCLUSIONS

The improved overall survival observed supports the choice of taxane-based regimens in the concurrent setting but may also reflect the predominance of single arm multi-agent phase II trials in the taxane arm. Our findings urge the need for better standardization of taxane-based regimens.

Pharmacokinetic analysis based on dynamic contrast-enhanced MRI for evaluating tumor response to preoperative therapy for oral cancer

PURPOSE

To evaluate whether a pharmacokinetic analysis is useful for monitoring the response of oral cancer to chemoradiotherapy (CRT).

MATERIALS AND METHODS

Twenty-nine patients were included. They underwent dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) before and after CRT. The DCE-MRI data were analyzed using a Tofts and Kermode (TK) model. The histological evaluation of the effects of CRT was performed according to Ohboshi and Shimosato's classification.

RESULTS

None of the pre-CRT parameters were significantly different between the responders and nonresponders. The post-CRT volume of the extravascular extracellular space (EES) per unit volume of tissue (v(e) ) of responders (0.397 ± 0.080) was higher than that of nonresponders (0.281 ± 0.076) (P = 0.01). The change of the v(e) between the pre- and post-CRT of the responders (0.154 ± 0.093) was larger than that of the nonresponders (0.033 ± 0.073) (P = 0.001). Therefore, the increase in the v(e) strongly suggested a good tumor response to CRT, which reflected an increase of the EES secondary to the destruction of the cancer nest. The changes in the volume transfer constant (K(trans) ) were significantly different between the responders and nonresponders (P = 0.018).

CONCLUSION

Both the increase of the v(e) and the elevation of permeability (K(trans) ) were indicative of a good tumor response to CRT. The pharmacokinetic analysis had potential for monitoring the histopathological response to CRT.

A Prospective Phase II Study of Induction Carboplatin and Vinorelbine followed by Concomitant Topotecan and Accelerated Radiotherapy (ART) in Locally Advanced Non-small Cell Lung Cancer (NSCLC)

BACKGROUND

Survival of locally advanced/unresectable non-small cell lung cancer (NSCLC) has improved with the use of concurrent radiation and chemotherapy over the past decades, but local and distant failure remain high. In addition, a key limiting factor in combining chemotherapy with accelerated radiotherapy (ART) is severe esophagitis. We investigated the toxicity, response rate, and overall survival (OS) with induction carboplatin and vinorelbine followed by concomitant topotecan and ART in patients with locally advanced/unresectable NSCLC.

METHODS

In this phase II trial, stage IIIA or IIIB NSCLC patients with a Karnofsky performance score >60 were eligible. Patients received induction carboplatin (area under the curve = 5.5) on days 1 and 22, and vinorelbine (25 mg/m2) on days 1, 8, 22, and 29. During the concurrent chemoradiation, patients received intravenous topotecan (0.5 mg/m2) on days 43 to 47, days 57 to 61, and days 71 to 75 before the morning radiotherapy (RT) fraction. RT was administered in an accelerated fashion at 2 Gy per fraction, twice daily for five consecutive days, every other week, to a cumulative dose of 60 Gy during a 5-week period.

RESULTS

Thirty-seven patients were accrued; of these, 35 were evaluable. Overall response rate was 71% (14% complete response, 57% partial response). Six of 35 (17%) patients had stable disease. Four (11%) patients progressed during treatment. At a median follow-up of 45 months for surviving patients, the median survival based on Kaplan-Meier estimates is 17.9 months. OS at 1, 2, and 3 years is 62%, 41%, and 33%, respectively. Actuarial 5-year OS is 21%. The median time to first relapse is 12.2 months (9.1-24.7 months). There were no cases of grade 3 or 4 esophagitis.

CONCLUSIONS

This combined-modality regimen yielded encouraging OS rates, with no severe esophagitis. Using four-dimensional RT treatment planning, we plan to further evaluate altered fractionation RT and chemotherapy for this group of patients.

[Accelerated hyperfractionated radiotherapy with concurrent chemotherapy in locally advanced nasopharyngeal carcinomas]

BACKGROUND

The excellent results yielded by hyperfractionated and accelerated radiotherapy associated with concurrent chemotherapy in locally advanced oropharyngeal and hypopharyngeal carcinomas led to investigation of this therapeutic regimen in nasopharyngeal carcinomas also.

METHODS

Thirty-five patients with stage III and IV nasopharyngeal carcinomas received accelerated hyperfractionated radiotherapy with concurrent chemotherapy (5-FU, mitomycin C + leucovorin). In the first 3 weeks of treatment five 2-Gy doses per week were delivered to the primary tumour and regional lymph nodes. The fractionation was then accelerated, with 1.4 Gy given twice daily until a total dose of 72 Gy had been administered.

RESULTS

The overall objective response rate was 100%. The median follow-up period was 71 months. Salvage surgery of the lymph nodes was performed in 10 patients, revealing vital tumour tissue in 6 of these. The actuarial 5-year local control rate was 64% (95%CI: 47-81%), while overall actuarial survival at 5 years was 70% (95%CI: 53-86%).

CONCLUSION

Hyperfractionated accelerated radiotherapy with concurrent chemotherapy is effective and feasible in locally advanced nasopharyngeal carcinoma.

Predictive factors for the histologic response to preoperative radiotherapy in advanced oral cancer

PURPOSE

Preoperative radiotherapy and chemotherapy are important in treating advanced oral cancer. We attempted to elucidate predictive factors for the histologic response to preoperative radiotherapy or chemoradiotherapy.

PATIENTS AND METHODS

Forty-three patients with locally advanced cancer of the oral cavity and oropharynx were treated preoperatively with radiotherapy (50 Gy); surgery included modification of the resected area to preserve organ function.

RESULTS

Hemoglobin level and histologic differentiation were independent factors significantly associated with the histologic response by multivariate analysis. Locoregional failure occurred only in patients with poor histologic response, and there was a significant difference in the 5-year survival rate between patients with good and poor responses (84% vs 32%). Multivariate analysis indicated that the histologic response at the primary site and the number of metastatic lymph nodes were prognostic factors.

CONCLUSION

We identified predictive factors for a good response to preoperative therapy and found a high survival rate in patients with a good response.

Concomitant boost radiotherapy with concurrent weekly cisplatin in advanced head and neck cancers: a phase II trial

BACKGROUND AND PURPOSE

To determine the safety and efficacy of concomitant boost radiotherapy (CBRT) with concurrent cisplatin chemotherapy (CT) in advanced head and neck cancers.

PATIENTS AND METHODS

Between February 2000 and June 2001, 95 previously untreated patients of advanced head and neck cancers were treated with CBRT and concurrent cisplatin CT. CBRT consisted of: phase I--44 Gy/22fx/4.5 weeks, phase IIa--16 Gy/8fx/1.5 weeks and phase IIb--10 Gy/8fx (delivered as a second daily fraction after a gap of 6h along with phase IIa). CT (cisplatin 35 mg/m(2)) was administered weekly usually preceding CBRT by an hour.

RESULTS

The median follow-up was 39 months (range 8-50 months). CBRT compliance (70 Gy in 40-44 days) was seen in 66% (63/95). Six cycles of CT was delivered in 73% (69/95). Acute grade III/IV mucosal toxicity was seen in 79% and resulted, on average, in a total weight loss of 7.9 kg from a mean pretreatment weight of 51 kg. Nasogastric tube placements were required in 26% (25/95) for an average duration of 19.3 days. Grade III leucopenia was seen in 2%. Mortality during and within 30 days of treatment was seen in 14% (13/95). Crude incidence of late subcutaneous fibrosis (grade III) was 21% (12/57) and a case of mandibular necrosis and thyroid cartilage necrosis each were seen. Initial loco regional disease clearance was seen in 59% (56/95) and the Kaplan-Meier estimates of 3-year loco-regional control rate and overall survival were 25% (median 7 months, 95% C.I. 3-11) and 27% (median 12 months, 95% C.I. 8-16), respectively.

CONCLUSIONS

On present evidence, in the settings of a developing country, CBRT with concurrent cisplatin cannot be recommended as primary therapy in advanced head and neck cancers without formal comparison with other treatment modalities.

Perspectives on cancer therapy-induced mucosal injury: pathogenesis, measurement, epidemiology, and consequences for patients

BACKGROUND

A frequent complication of anticancer treatment, oral and gastrointestinal (GI) mucositis, threatens the effectiveness of therapy because it leads to dose reductions, increases healthcare costs, and impairs patients' quality of life. The Multinational Association of Supportive Care in Cancer and the International Society for Oral Oncology assembled an international multidisciplinary panel of experts to create clinical practice guidelines for the prevention, evaluation, and treatment of mucositis.

METHODS

The panelists examined medical literature published from January 1966 through May 2002, presented their findings at two separate conferences, and then created a writing committee that produced two articles: the current study and another that codifies the clinical implications of the panel's findings in practice guidelines.

RESULTS

New evidence supports the view that oral mucositis is a complex process involving all the tissues and cellular elements of the mucosa. Other findings suggest that some aspects of mucositis risk may be determined genetically. GI proapoptotic and antiapoptotic gene levels change along the GI tract, perhaps explaining differences in the frequency with which mucositis occurs at different sites. Studies of mucositis incidence in clinical trials by quality and using meta-analysis techniques produced estimates of incidence that are presented herein for what to our knowledge may be a broader range of cancers than ever presented before.

CONCLUSIONS

Understanding the pathobiology of mucositis, its incidence, and scoring are essential for progress in research and care directed at this common side-effect of anticancer therapies.

The role of midfacial degloving approach for maxillary cysts and tumors

PURPOSE

The midfacial degloving approach has been used as a surgical approach to gain access to regions of the midface that would otherwise require external incisions. This article describes the role of this technique for various maxillary lesions.

PATIENTS AND METHODS

Thirteen patients underwent the midfacial degloving technique for 8 maxillary benign lesions and 5 malignant lesions. This procedure uses 4 basic incisions: 1) sublabial incision, 2) bilateral intercartilaginous incisions, 3) septocolumellar-complete transfixion incisions, and 4) bilateral piriform aperture incisions extending to the vestibule.

RESULTS

All patients successfully underwent the planned procedures after the midfacial degloving technique for the treatment of benign or malignant lesions without significant complications. Postoperative sequelae were nasal crusting and infraorbital hypesthesia, both of which resolved.

CONCLUSIONS

The midfacial degloving approach offers good exposure of the mid third of the face with excellent cosmetic results. This approach may be combined with downfracture of the maxilla for access to expose and resect sinonasal malignancies. The midfacial degloving technique is a viable procedure with low morbidity and excellent cosmetic outcomes.

Results of phase I-II trial of concomitant hyperfractionated radiation and oral etoposide (VP-16) in patients with unresectable squamous cell carcinoma of the head and neck

PURPOSE

The purpose of the current study was to investigate the efficacy of concomitant oral etoposide and hyperfractionated radiation for patients with unresectable head and neck squamous cell carcinoma.

METHODS

A prospective nonrandomized phase I-II study was conducted using concomitant oral etoposide (50 mg/d for 13-27 days) and hyperfractionated radiotherapy (1.2 Gy twice daily to a total of 7440 rads) for patients with unresectable squamous cell carcinoma of the head and neck. Toxicity was graded according to the NCI common toxicity criteria. Patients were followed for a minimal period of 2 years. Endpoints for follow-up were recurrence or death.

RESULTS

Seventeen patients were enrolled in the study. Grade III hematological toxicity occurred in 1 patient and moderate to severe mucositis occurred in all but 2 patients requiring a gastrostomy tube (n = 13) or intravenous fluids hydration (n = 2). One patient died of cardiac arrest unrelated to the treatment regimen. The overall response rates in patients that finished the protocol were 80% for the primary site and 100% for the neck. A complete response was observed in 47% at the primary site and 33% in the neck. Local control and disease-free survival (DFS) at an average follow-up of 3.7 years were 47% and 29%, respectively.

CONCLUSIONS

Concomitant etoposide and hyperfractionated radiation is well tolerated and seems to be effective in the treatment of unresectable HNSCC with acceptable mucosal toxicity.

Combined chemotherapy and radiation therapy for head and neck malignancies: quality of life issues

BACKGROUND

The standard of care for locally advanced head and neck carcinoma usually has been surgery followed by radiation therapy. Patient survival using this approach has been reported to be poor. The disfiguration resulting from surgery and the long-term morbidity of postoperative radiation often results in considerable distress. Concurrent chemotherapy and radiation was introduced to improve outcome. Excellent local control and survival results often have been reported in Phase II and Phase III studies. The acute toxicity of combined chemotherapy and radiation is significant. However, organ preservation may improve quality of life. This review article summarizes the findings from published series of surgery, postoperative radiation, radiation therapy alone, and chemoradiation with regard to quality of life issues for patients with locally advanced head and neck carcinoma.

METHODS

A literature search was used to identify quality-of-life studies of postoperative radiation, radiation therapy alone, and chemoradiation in patients with locally advanced head and neck carcinoma. Factors affecting long-term quality-of-life issues in each treatment modality were identified, compared, and evaluated.

RESULTS

Speech disorder, dysphagia, pain, and depression were found to be the common side effects affecting quality of life regardless of the treatment modality. Xerostomia is the major complication affecting patients undergoing radiation or chemoradiation.

CONCLUSIONS

Acute side effects of combined chemotherapy and radiation therapy usually were found to resolve after treatment. Long-term morbidity is substantial because of xerostomia and severe dysphagia. However, preliminary studies suggest that because of organ preservation, patients may achieve a better quality of life after chemoradiation compared with the conventional use of surgery and postoperative radiation.

Hyperfractionated chemoradiation with carbogen breathing, with or without erythropoietin: a stepwise developed treatment schedule for advanced head-and-neck cancer

PURPOSE

To investigate the influence of carbogen breathing on chemoradiation and the effects of erythropoietin on transfusions.

METHODS AND MATERIALS

From March 1996 to April 2000, 42 (4 Stage III and 38 Stage IV) patients with head and neck cancer were treated with a twice-a-day hyperfractionated schedule. Each fraction consisted of 5 mg/m(2) of carboplatin plus 115 cGy with carbogen breathing. Treatment was given 5 days per week up to total doses of 350 mg/m(2) of carboplatin plus 8050 cGy in 7 weeks. Anemia was treated either by transfusion or by erythropoietin.

RESULTS

Forty-one patients tolerated the treatment as scheduled. All patients tolerated the planned radiation dose. Five transfusions were given in the first group, but no transfusion was needed in the erythropoietin group. Local toxicities remained at the level expected with irradiation alone. Chemotherapy toxicity was moderate. Forty-two complete responses were achieved. At two years actuarial local control, cause-specific survival and overall survival are respectively 85%, 69%, and 68%. At four years estimated probabilities of local control, cause-specific survival and overall survival are also 85%, 69%, and 68%.

CONCLUSIONS

These results compare favorably with those of most reported studies. The addition of carbogen breathing appears to improve the results of chemoradiation alone. Erythropoietin therapy avoided transfusions.

Preoperative concurrent chemoradiotherapy plus radical surgery for advanced squamous cell carcinoma of the oral cavity: an analysis of long-term results

Locoregionally advanced squamous cell carcinomas of the head and neck continue to be a major clinical problem. We demonstrated in 1996 that preoperative concurrent cisplatin- or carboplatin-based chemotherapy and radiotherapy plus radical surgery in advanced oral cancer had minimal toxicity, had high clinical tumor response rates, was well tolerated and produced impressive complete response rates and a high 5-year survival rate. The purpose of the present study was the long-term follow-up of this treatment regimen for advanced oral carcinoma. Forty-eight patients with squamous cell carcinoma of the oral cavity (including soft palate) were treated preoperatively with cisplatin- or carboplatin-based chemotherapy in combination with simultaneous irradiation to a target volume of 40 Gy, and 2-6 weeks later underwent curative surgery. All patients with advanced Stage II (n=7), Stage III (n=22) and Stage IV (n=19) were treated and followed for an average of 7.2 years (range: 61-144 months). The overall actuarial survival of all patients was 81.3% at 5 years and also at 10 years. Progression-free survival at both 5 and 10 years was 84.8% for all patients, and 85.7% for Stage II, 90.0% for Stage III, and 78.9% for Stage IV patients. Progression-free survival rates according to the histopathologic regression grade of primary tumor following preoperative chemoradiotherapy at 10 years were 40. 0% for Grade IIa, 88.9% for Grade IIb, 100% for Grade III, and 87.5% for Grade IV. Patients who achieved good responses histopathologically (Grades IIb, III, IV) had superior survival rates in comparison to patients with extensive residual tumor (Grade IIa) in surgically resected specimens (p=0.0012). A better histologic regression grade was also associated with a higher survival rate even in the long-term analysis. This treatment regimen for advanced oral cancer produced high clinical and pathologic complete response and survival rates with an acceptable acute toxicity profile and lack of late therapeutic complications. The long-term follow-up showed gratifying results even for advanced oral cancers without a substantial increase in distant metastasis and second primary malignancy.

Chemotherapy as a part of each treatment fraction in a twice-a-day hyperfractionated schedule: a new chemoradiotherapy approach for advanced head and neck cancer

BACKGROUND

Using chemotherapy as a part of each treatment fraction remains unexplored. This study integrates the concomitant administration of carboplatin with hyperfractionated irradiation by optimizing chemopotentiation through carboplatin administration with each irradiation fraction.

METHODS

From February 1993 to August 1996, 52 patients with advanced head and neck cancer were treated on a twice-a-day chemoradiotherapy schedule. Each fraction consisted of 115 cGy preceded by 5 mg/m2 of carboplatin. Treatment was given 5 days a week up to total doses of 350 mg/m2 of carboplatin + 8050 cGy in 7 weeks.

RESULTS

All (100%) of patients tolerated the treatment (83% as scheduled). Acute and late toxicities were moderate. Rates of 96% complete response (CR) and 4% partial response (PR) were achieved. At 52 months, local control and cause-specific survival rates are 72% and 59%, respectively. Nodal control rate is 95%.

CONCLUSION

These results show potential for improvement upon hyperfractionated radiotherapy alone and compare favorably with those of most reported trials.

Split-course accelerated hyperfractionation radiotherapy for advanced head and neck cancer: influence of split time and overall treatment time on local control

We analyzed 52 patients with stage III and IV head and neck cancer who were given split-course accelerated hyperfractionated radiotherapy with curative intent, focusing particularly on the influence of split-time on local control. An initial complete response was achieved in 16 patients (31%), and the rate of persistent local control at 3 years was 23%. The cause specific survival rate at 3 years was 29%. Univariate analysis of local control according to the split-time duration and overall treatment time showed that shorter duration (< or = 14 days or < or = 45 days, respectively) had a significantly positive impact on local control (P < 0.05). Multivariate analysis using local control as an endpoint also demonstrated that gender (women showing a better outcome than men) and split-time (< or = 14 days was better than > 14 days) were statistically significant factors for local control. These results suggest that shortening the split-time during radiotherapy might improve local control in accelerated hyperfractionation.