Intensity-modulated radiotherapy for locally advanced cancers of the larynx and hypopharynx

Tumor volumes in T3 supraglottic cancers treated with radiotherapy in the modern era: A study of the Canadian Head & Neck Collaborative Research Initiative

PURPOSE

To evaluate the association of primary tumor volume (TV) with overall survival (OS) and disease-free survival (DFS) in T3 N0-3M0 supraglottic cancers treated with intensity-modulated radiotherapy (IMRT).

METHODS

This was a retrospective cohort study involving 239 patients diagnosed with T3 N0-3M0 supraglottic cancers between 2002 and 2018 from seven regional cancer centers in Canada. Clinical data were obtained from the patient records. Supraglottic TV was measured by neuroradiologists on diagnostic imaging. Kaplan-Meier method was used for survival probabilities, and a restricted cubic spline Cox proportional hazards regression analysis was used to analyze TV associations with OS and DFS.

RESULTS

Mean (SD) of participants was 65.2 (9.4) years; 176 (73.6%) participants were male. 90 (38%) were N0, and 151 (64%) received concurrent systemic therapy. Mean TV (SD) was 11.37 (12.11) cm3 . With mean follow up (SD) of 3.28 (2.60) years, 2-year OS was 72.7% (95% CI 66.9%-78.9%) and DFS was 53.6% (47.4%-60.6%). Increasing TV was associated (per cm3 increase) with worse OS (HR, 1.01, 95% CI 1.00-1.02, p < 0.01) and DFS (HR, 1.01, 95% CI 1.00-1.02, p = 0.02).

CONCLUSIONS

Increasing primary tumor volume is associated with worse OS and DFS in T3 supraglottic cancers treated with IMRT, with no clear threshold. The findings suggest that patients with larger tumors and poor baseline laryngeal function may benefit from upfront laryngectomy with adjuvant radiotherapy.

Patterns of failure for hypopharynx cancer patients treated with limited high-dose radiotherapy treatment volumes

PURPOSE

Optimal radiotherapy treatment volumes for patients with locally advanced hypopharynx squamous cell carcinoma should ensure maximal tumor coverage with minimal inclusion of normal surrounding structures. Here we evaluated the effectiveness of a direct 3-mm high-dose gross tumor volume to planning target volume expansion on clinical outcomes for hypopharynx cancers.

MATERIALS AND METHODS

We performed a retrospective analysis of patients with hypopharynx carcinoma treated between 2004 and 2018 with primary radiotherapy using a direct high-dose gross tumor volume to planning target volume expansion and with or without concurrent systemic therapy. Diagnostic imaging of recurrences was co-registered with the planning CT. Spatial and volumetric analyses of contoured recurrences were compared with planned isodose lines. Failures were initially defined as in field, marginal, elective nodal, and out of field. Each failure was further classified as central high-dose, peripheral high-dose, central intermediate/low-dose, peripheral intermediate/low-dose, and extraneous. Clinical outcomes were analyzed by Kaplan-Meier estimation.

RESULTS

Thirty-six patients were identified. At a median follow-up at 52.4 months, estimated 5-year overall survival was 59.3% (95% confidence interval [CI], 36.3%-74.1%), 5-year local and nodal control was 71.7% (95% CI, 47.1%-86.3%) and 69.9% (95% CI, 57.0%-82.6%), respectively. The most common failure was in the high-dose primary target volume. The gastrostomy tube retention rate at 1 year among patients without recurrence was 13.0% (95% CI, 3.2%-29.7%).

CONCLUSION

Minimal high-dose target volume expansions for hypopharynx cancers were associated with favorable locoregional control. This approach may enable therapy intensification to improve clinical outcomes.

Post-cricoid and Upper Oesophagus Cancers Treated with Organ Preservation Using Intensity-modulated Image-guided Radiotherapy: a Phase II Prospective Study of Outcomes, Toxicity and Quality of Life

AIMS

To prospectively examine the outcomes, toxicity and quality of life (QoL) of patients with post-cricoid and upper oesophagus (PCUE) cancers treated with an organ-preservation approach of (chemo)-radiotherapy using intensity-modulated image-guided radiotherapy (IM-IGRT).

MATERIALS AND METHODS

This phase II prospective study was conducted at a tertiary cancer centre from February 2017 to January 2020. Forty patients with squamous cell carcinoma of PCUE of stage T1-3, N0-2, M0 were accrued. Gross exolaryngeal extension/dysfunctional larynx were major exclusion criteria. Patients received 63-66 Gy in once-daily fractions using volumetric modulated arc therapy with daily IGRT. Outcome measures included disease-related outcomes, patterns of failure, Radiation Therapy Oncology Group toxicities, feeding tube dependency and QoL.

RESULTS

The median follow-up was 22 months. Twenty-six (87.5%) patients had locoregionally advanced disease and 34 (85%) patients received (chemo)-radiotherapy. A complete response was observed in 26 (65%) patients. The 2-year locoregional control, event-free survival and cause-specific survival were 59.6%, 40.2% and 44.8%, respectively. The volume of primary tumour (GTVPvol) exceeding 28 cm³ had inferior overall survival (P = 0.005) on univariate analysis. Multivariable analysis showed GTVPvol and positron emission tomography-computed tomography maximum standardised uptake value to be independently predictive for event-free and overall survival. A feeding tube requirement at presentation was seen in 11 (27.5%) patients, whereas long-term feeding tube dependency at 6 months was seen in 10 (37%) patients. For QoL, a statistical improvement in pain, appetite loss and swallowing was observed over time.

CONCLUSION

Although the outcomes of PCUE cancers remain dismal, the use of state of the art diagnostic modalities, careful case selection and modern radiotherapy techniques improved outcomes as compared with before in this exclusive analysis of PCUE cancers.

Biological consequences of cancer radiotherapy in the context of oral squamous cell carcinoma

Approximately 50% of subjects with cancer have been treated with ionizing radiation (IR) either as a curative, adjuvant, neoadjuvant or as a palliative agent, at some point during the clinical course of their disease. IR kills cancer cells directly by injuring their DNA, and indirectly by inducing immunogenic cell killing mediated by cytotoxic T cells; but it can also induce harmful biological responses to non-irradiated neighbouring cells (bystander effect) and to more distant cells (abscopal effect) outside the primary tumour field of irradiation.Although IR can upregulate anti-tumour immune reactions, it can also promote an immunosuppressive tumour microenvironment. Consequently, radiotherapy by itself is seldom sufficient to generate an effective long lasting immune response that is capable to control growth of metastasis, recurrence of primary tumours and development of second primary cancers. Therefore, combining radiotherapy with the use of immunoadjuvants such as immune checkpoint inhibitors, can potentiate IR-mediated anti-tumour immune reactions, bringing about a synergic immunogenic cell killing effect.The purpose of this narrative review is to discuss some aspects of IR-induced biological responses, including factors that contributes to tumour radiosensitivity/radioresistance, immunogenic cell killing, and the abscopal effect.

Stage Migration and Survival Trends in Laryngeal Cancer

BACKGROUND

During the last two decades, significant advancements in the treatment of laryngeal cancer have occurred. Although survival of head and neck cancer patients has improved over time, the temporal trend of laryngeal cancer survival is an area of controversy.

METHODS

From 2004 to 2016, 77,527 patients who had laryngeal cancer treated with curative intent in the United States were identified in the National Cancer Database. Relative and observed survival rates were assessed for temporal trends. Multinomial logistic regression investigated the relationship between American Joint Committee on Cancer (AJCC) stage and increasing calendar year.

RESULTS

No significant improvement in 2- or 5-year observed survival (OS) or relative survival (RS) was observed. The 5-year RS ranged from 61.72 to 63.97%, and the 5-year OS ranged from 54.26 to 56.52%. With each increasing year, the proportion of stage 4 disease increased, with risk for stage 4 disease at the time of diagnosis increasing 2.2% annually (adjusted odds ratio [aOR], 1.022; 95% confidence interval [CI], 1.017-1.028; p < 0.001). This increase was driven by a 4.7% yearly increase in N2 disease (aOR, 1.047; 95% CI, 1.041-1.053; p < 0.001), with an annual 1.2% increase in T3 disease (aOR, 1.012; 95% CI, 1.007-1.018; p < 0.001) and a 1.2% increase in T4 disease (aOR, 1.012; 95% CI, 1.005-1.018; p < 0.001).

CONCLUSION

Despite advances in the field, laryngeal cancer survival in the United States is not improving over time. This may be due to an increase in the proportion of stage 4 disease, driven primarily by increasing nodal disease. To achieve survival improvement commensurate with scientific and technologic advances, efforts should be made to diagnose and treat laryngeal cancer at earlier stages to prevent further stage migration.

Improved Tumor Control Related to Radiotherapy Technological Development for Hypopharyngeal Cancer

OBJECTIVES/HYPOTHESIS

Squamous cell carcinoma of the hypopharynx (SCCHP) is associated with worse survival compared to other head and neck subsites. This report quantifies the impact of technological improvements in radiotherapy (RT) on outcomes over 6 decades.

METHODS

Patients with SCCHP receiving curative-intent treatment between 1962 and 2015 were retrospectively reviewed. Kaplan-Meier analyses of freedom from local recurrence (FFLR), progression-free survival (PFS), and overall survival (OS) were compared across treatment eras and radiation techniques. Multivariable Cox proportional hazards modeling was performed to specify the effect of RT technique.

RESULTS

One hundred thirty-four patients had a median follow-up of 17 months (IQR = 9-38). There were no differences in staging or use of surgery over time, but use of chemotherapy concurrent with RT increased (P < .001) beginning in the 2000s. The 24-month FFLR using two-dimensional RT (2D-RT), three-dimensional conformal RT (3D-CRT), and intensity-modulated RT (IMRT) was 52%, 55%, and 80%, respectively; 24-month PFS was 39%, 46%, and 73%, respectively; and 24-month OS was 27%, 40%, and 68%, respectively. OS (P = .01), PFS (P = .03), and FFLR (P = 0.02) were improved with IMRT over 2D-RT, and FFLR appeared to be improved over 3D-CRT (P = .06). Controlling for chemotherapy use and other major variables, IMRT produced a strong influence over FFLR (adjusted hazard ratio [HR] = 0.2, 95% confidence interval [CI]: 0.0-1.2, P = .08) and a benefit in OS (adjusted HR = 0.1, 95% CI: 0.0-0.4, P = .005).

CONCLUSIONS

Across 6 decades, patient and tumor characteristics remained similar whereas use of chemoradiation increased and IMRT was adopted. The introduction of IMRT was associated with improved FFLR, PFS, and OS, and a reduction in acute toxicity as compared to earlier radiation technologies.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E452-E458, 2021.

Patterns of regional lymph node failure of locally advanced hypopharyngeal squamous cell carcinoma after first-line treatment with surgery and/or intensity-modulated radiotherapy

Background

To identify the spatial patterns of regional lymph node failure of locally advanced hypopharyngeal squamous cell carcinoma (SCC) after first-line treatment with surgery and/or intensity-modulated radiotherapy (IMRT).

Methods

We retrospectively obtained the clinicopathological characters of 123 hypopharyngeal SCC patients, and investigated the patterns of regional lymph node failure. Univariate and multivariate logistic regression were used to determine the risk factors of regional lymph node failure.

Results

Forty patients (32.5% of total patients) were suffered regional lymph node failure. In these patients, the ipsilateral neck level II nodal failure account for 55.0% (22/40) followed by level III 30.0% (12/40), level VIb 15.0% (6/40), level VII 15.0% (6/40), and level IV 5.0% (2/40). In addition, 17.5% (7/40) patients suffered contralateral neck level II nodal failure and 7.5% (3/40) patients suffered level III nodal failure. The common failure levels were the II (7/46, 15.2%), III (4/46, 8.7%), VIb (4/46, 8.7%), and VII (5/46, 10.9%) for treatment by surgery. The lymph node recurrence and persistent disease at levels II (19/77, 24.7%) and III (10/77, 13.0%) remained the major cause of failure following curative intent of IMRT. The postoperative radiation significantly decreased the risk of regional lymph node failure (OR = 0.082, 95% CI: 0.007–1.000, P = 0.049); and the radiologic extranodal extension significantly increased the risk of regional lymph node failure (OR = 11.07, 95% CI: 2.870–42.69, P < 0.001).

Conclusions

Whatever the treatment modality, the lymph node failure at level II and III was the most popular pattern for hypopharyngeal SCC. Moreover, for patients who underwent surgery, the nodal failure at level VIb and VII was frequent. Thus, postoperative radiation of level VIb and VII may give rise to benefit to locally advanced hypopharyngeal SCC patients.

Surgery vs. radiotherapy for locally advanced hypopharyngeal cancer in the contemporary era: A population-based study

Objectives

To compare overall survival (OS) in locally advanced hypopharyngeal cancer treated with surgery or definitive chemoradiotherapy in the contemporary era.

Methods

From 2010 to 2015, data for patients diagnosed with hypopharyngeal cancer (T2‐T4aM0) and treated with total pharyngectomy with lymph node dissection (surgery group) or definitive radiotherapy and chemotherapy (chemoradiotherapy group) was retrieved from the SEER database. Multivariate analyses were performed in each subgroup divided according to T category (T2‐3 or T4a).

Results

The number of patients in the surgery and chemoradiotherapy groups was 209 and 648, respectively. Among them, the number of T4a patients was 111 and 126 in each group. Three‐year OS rate in the surgery and chemoradiotherapy groups was 37.9% and 44.1%, respectively (P = 0.178). The 3‐year OS rate for the T2‐3 patients was 46.5% and 48.7% (P = 0.598), and the 3‐year OS rate for the T4a patients was 29.9% and 26.1% in the surgery and chemoradiotherapy groups, respectively (P = 0.439). On multivariate analysis, the chemoradiotherapy group was not inferior to the surgery group in T2‐T4a patients (Hazard ratio [HR] for the chemoradiotherapy group 0.889, 95% confidence interval [CI] 0.699‐1.129, P = 0.334), in T2‐3 patients (HR 0.932, 95% CI 0.699‐1.297, P = 0.675), and in T4a patients (HR 0.880, 95% CI 0.617‐1.256, P = 0.481).

Conclusions

Chemoradiotherapy for locally advanced hypophagyngeal cancer showed a comparable OS rate to surgery. For patients with T4a category cancer with high possibility of preserving the laryngopharyngeal function, chemoradiotherapy may be a promising alternative treatment.

Oncological and Functional Evaluation of Open Conservation Surgery for Hypopharyngeal Cancer with/without Reconstruction

Objectives

Oncological and functional results of open conservation surgery for hypopharyngeal cancer have been desired.

Methods

We performed a chart review of 33 patients with hypopharyngeal cancer who underwent open conservation surgery. Oncological and functional results were evaluated in surgery with primary closure (Group A) and surgery with reconstruction (Group B). Postoperative functions were evaluated by interval to resumption of oral intake, Functional Outcome Swallowing Scale (FOSS) and Communication Scale (CS).

Results

Five-year disease-specific and overall cumulative survival rates by Kaplan-Meier method for all cases were 95.7% and 82.3%, respectively. Duration from surgery to full oral intake was 12 days in Group A and 14 days in Group B. FOSS rates were 83.3 in Group A and 95.5 in Group B. CS was 0 in both groups.

Conclusion

Oncological and functional results of open conservation surgery were comparable to those with transoral surgery and chemo/radiotherapy. Our technique represents a reliable treatment for hypopharyngeal cancer.

A Phase I/II Study of Nab-Paclitaxel, Cisplatin, and Cetuximab With Concurrent Radiation Therapy for Locally Advanced Squamous Cell Cancer of the Head and Neck

Nab-paclitaxel might impact efficacy of radiation for head and neck (H&N) cancer. Nab-paclitaxel, cisplatin, cetuximab, and radiation were evaluated in patients with locally advanced head and neck cancer in this phase I/II trial. Median follow-up was 24 months for 34 patients. The maximum tolerated dose of nab-paclitaxel was 20 mg/m² with 20 mg/m² cisplatin and 250 mg/m² cetuximab. The 2-year progression-free survival (PFS) was 60% (95% confidence interval (CI) 0.42, 0.78), local control 71% (95% CI 0.55, 0.87), and overall survival 68% (95% CI 0.50, 0.86). This is the first study evaluating these agents with radiation in humans, with similar 2-year PFS as historic control.

Hypopharyngeal squamous cell carcinoma: Three-dimensional or Intensity-modulated radiotherapy? A single institution's experience

OBJECTIVES/HYPOTHESIS

Compare outcomes of hypopharyngeal carcinoma that received conventional radiotherapy versus intensity-modulated radiotherapy (IMRT).

STUDY DESIGN

Retrospective single-institution trial.

METHODS

Between April 1990 and May 2011, 100 patients with hypopharyngeal cancer underwent curative radiotherapy (RT) at our institution: 50 with IMRT and 50 with conventional RT. The median age was 63 years. There were 12 T1, 22 T2, 37 T3, and 28 T4 patients. The majority of patients (82%) had nodal disease: 54% N2 and 8% N3. The majority of patients (83%) received chemotherapy. Of the patients who received chemotherapy, 84% received a platinum-based regimen. The median RT dose was 7,000 cGy. The majority of patients (62%) had prophylactic percutaneous endoscopic gastrostomy tube placement. Toxicities were reviewed. Local control (LC), locoregional control (LRC), freedom from distant metastasis (FFM) rates, functional larynx preservation (LP), laryngectomy-free survival (LFS), and overall-survival (OS) curves were generated using the Kaplan-Meier method. The log-rank test was used to test prognostic variables.

RESULTS

With a median follow up of 48.4 months, the 3/5-year LC, LRC, FFM, LP, LFS and OS rates were 74%/69%, 77%/74%, 70%/66%, 51%/29%, 49.6%/31.8%, and 49%/34%, respectively. The median OS was 2.9 years. The 3-year LC rate for IMRT was 77% versus 81% for conventional RT (P = .91); 3-year LRC for IMRT was 85% versus 76% for conventional RT (P = .32). There was no increased local failure with IMRT. There was no difference in the rate of stricture with IMRT (32%) versus conventional RT (25.3%) (P = .86).

CONCLUSIONS

IMRT achieved comparable LC and LRC rates to conventional RT.

LEVEL OF EVIDENCE

4 Laryngoscope, 126:620-626, 2016.

Improving target dose coverage and organ-at-risk sparing in intensity-modulated radiotherapy of advanced laryngeal cancer by a simple optimization technique

OBJECTIVE

To evaluate a simple optimization technique intended to improve planning target volume (PTV) dose coverage and organ-at-risk (OAR) sparing in intensity-modulated radiotherapy (IMRT) of advanced laryngeal cancer.

METHODS

Generally acceptable initial IMRT plans were generated for 12 patients and were improved individually by the following two techniques: (1) base dose function-based (BDF) technique, in which the treatment plans were reoptimized based on the initial IMRT plans; (2) dose-controlling structure-based (DCS) technique, in which the initial IMRT plans were reoptimized by adding constraints for hot and cold spots. The initial, BDF and DCS IMRT plans and additionally generated volumetric modulated arc therapy (VMAT) plans were compared concerning homogeneity index (HI) and conformity index (CI) of PTVs prescribed at 70 Gy/60 Gy (PTV70/PTV60), OAR sparing, monitor units (MUs) per fraction and total planning time.

RESULTS

Compared with the initial IMRT and DCS IMRT plans, the BDF technique provided superior HI/CI, by approximately 19-37%/4-11%, and lower doses to most OARs, by approximately 1-7%, except for the comparable HI of PTV60 to DCS IMRT plans. Compared with VMAT plans, the BDF technique provided comparable HI, CI and most-OAR sparing, except for the superior HI of PTV70, by approximately 13%. The BDF technique produced more MUs and reduced the planning time.

CONCLUSION

The BDF optimization technique for IMRT of advanced laryngeal cancer can improve target dose homogeneity and conformity, spare most OARs and is efficient.

ADVANCES IN KNOWLEDGE

A novel optimization technique for improving IMRT was assessed and found to be effective and efficient.

Definitive intensity modulated radiotherapy in locally advanced hypopharygeal and laryngeal squamous cell carcinoma: mature treatment results and patterns of locoregional failure

PURPOSE

To assess clinical outcomes and patterns of loco-regional failure (LRF) in relation to clinical target volumes (CTV) in patients with locally advanced hypopharyngeal and laryngeal squamous cell carcinoma (HL-SCC) treated with definitive intensity modulated radiotherapy (IMRT) and concurrent systemic therapy.

METHODS

Data from HL-SCC patients treated from 2007 to 2010 were retrospectively evaluated. Primary endpoint was loco-regional control (LRC). Secondary endpoints included local (LC) and regional (RC) controls, distant metastasis free survival (DMFS), laryngectomy free survival (LFS), overall survival (OS), and acute and late toxicities. Time-to-event endpoints were estimated using Kaplan-Meier method, and univariate and multivariate analyses were performed using Cox proportional hazards models. Recurrent gross tumor volume (RTV) on post-treatment diagnostic imaging was analyzed in relation to corresponding CTV (in-volume, > 95% of RTV inside CTV; marginal, 20-95% inside CTV; out-volume, < 20% inside CTV).

RESULTS

Fifty patients (stage III: 14, IVa: 33, IVb: 3) completed treatment and were included in the analysis (median follow-up of 4.2 years). Three-year LRC, DMFS and overall survival (OS) were 77%, 96% and 63%, respectively. Grade 2 and 3 acute toxicity were 38% and 62%, respectively; grade 2 and 3 late toxicity were 23% and 15%, respectively. We identified 10 patients with LRF (8 local, 1 regional, 1 local + regional). Six out of 10 RTVs were fully included in both elective and high-dose CTVs, and 4 RTVs were marginal to the high-dose CTVs.

CONCLUSION

The treatment of locally advanced HL-SCC with definitive IMRT and concurrent systemic therapy provides good LRC rates with acceptable toxicity profile. Nevertheless, the analysis of LRFs in relation to CTVs showed in-volume relapses to be the major mode of recurrence indicating that novel strategies to overcome radioresistance are required.

Intensity-modulated radiotherapy in definitive oncological treatment of hypopharyngeal squamous cell carcinoma

Hypopharyngeal squamous cell carcinoma (HSCC) is treated by definitive concomitant chemoradiotherapy at most centres. Intensity-modulated radiotherapy (IMRT) is an advanced computer-controlled high-precision radiotherapy technique that has been used at our institution in the treatment of HSCC since 2002. Our aim was to review the treatment results of IMRT-based chemoradiotherapy (CRT) in patients diagnosed with HSCC. The cohort comprised all patients with previously untreated, biopsy-proven squamous cell carcinoma of the hypopharynx treated by definitive CRT using IMRT between March 2002 and November 2010. All patients were diagnosed M0. Forty-five eligible patients were identified. Six patients were treated by radiotherapy alone and 39 patients received concomitant chemotherapy. All patients had a minimum follow-up of 3 years or until death. Complete response was achieved in 29/45 (64 %) patients. Salvage surgery was performed on 10/16 patients with incomplete response. The 5-year estimates for overall survival, disease-specific survival, and local control in the whole cohort were 31, 45, and 64 %, respectively. Classifications T4 and N2c-N3 were prognostic for worse survival. None of the surviving patients needed permanent tracheotomy or PEG tube. We conclude that survival after IMRT-based CRT remained unsatisfactory with frequent relapses at distant sites. The outcome figures were comparable with those that have been achieved by surgery and postoperative radiotherapy. However, all the surviving patients in the current study cohort could retain their functioning larynx. These results using IMRT-based definitive CRT as the primary option for the treatment of HSCC support its continued usage for the delivery of radiotherapy.

Toward magnetic resonance-only simulation: segmentation of bone in MR for radiation therapy verification of the head

PURPOSE

To develop a practical method to localize bones in magnetic resonance (MR) images, to create "computed tomography-like" MR images (ctMRI) that could be used for radiation therapy verification, and to generate MR-based digitally reconstructed radiographs (DRR).

METHODS AND MATERIALS

Using T1-weighted MR images, an air mask was derived from the manual contouring of all airways within the head and neck region using axial images at 6 anatomic levels. Compact bone, spongy bone, and soft tissue masks were then automatically generated using the statistical data derived from MR intensities and the air mask. ctMRI were then generated by mapping the MR intensities of the voxels within these masks into the CT number ranges of corresponding tissues. MR-based DRRs created from ctMRI were quantitatively evaluated using the co-registered MR and CT head images of 20 stereotactic radiosurgery patients. Ten anatomical points, positioned on the skull segmented using a threshold of 300 HU, in CT and ctMRI, were used to determine the differences in distance between MR-based DRRs and CT-based DRRs, and to evaluate the geometric accuracy of ctMRI and MR-based DRRs.

RESULTS

The bony structures were identified on ctMRI and were visible in the MR-based DRRs. From the 20 patient cases, the mean geometric difference and standard deviation between the 10 anatomical points on MR-based and CT-based DRRs was -0.05 ± 0.85 mm, respectively. This included uncertainty in image fusion. The maximum distance difference was 1.88 mm.

CONCLUSIONS

A practical method was developed to segment bone from MR images. The ctMRI created can be used for radiation treatment verification when MR-only simulation is performed. MR-based DRRs can be used in place of CT-based DRRs.

Outcomes of intensity-modulated radiotherapy versus conventional radiotherapy for hypopharyngeal cancer

BACKGROUND

The purpose of this study was to discuss if the adoption of intensity-modulated radiotherapy (IMRT) for hypopharyngeal squamous cell carcinoma (SCC) has improved the outcome.

METHODS

We compared 3-dimensional (3D) radiotherapy (RT) and IMRT in all patients with hypopharyngeal SCC treated with curative intent RT or chemoradiation therapy (CRT) from January 1, 2000, to February 28, 2010. Locoregional control, overall survival (OS), distant relapse rate, larynx preservation rate, and enteral feeding tube duration were analyzed.

RESULTS

Of 181 consecutive patients, 90 received 3D-RT and 91 received IMRT. At 3 years, the IMRT group had higher locoregional control compared with the 3D-RT group (75% vs 58%; p = .003), but similar OS (50% vs 52%; p = .99), distant relapse rate (23% vs 20%; p = .79), and larynx-preservation rate (90% vs 86%; p = .16). The 2-year enteral feeding tube dependency rate was similar in both groups (19% vs 18%; p = .12).

CONCLUSION

Patients with hypopharyngeal SCC treated with IMRT showed a higher locoregional control compared with 3D-RT. However, distant-relapse rate and OS remain comparable between treatment techniques.

Management of locally advanced laryngeal cancer

Background

Management of advanced laryngeal cancer is complex and ideal strategy is yet to be defined. This study evaluates the experience of a single head and neck oncologic centre in the management of T4 laryngeal cancer.

Methods

Retrospective assessment of cases primarily treated for T4a squamous cell carcinoma of the larynx, between 1980 and 2007, at a tertiary referral center.

Results

A total of 384 cases were studied. Five-year disease specific survival was 56.2% and local control 87.4%. Regional and distal control estimates were 90.3% and 88.3% respectively. Prognosis was significantly superior for cases treated with primary surgery compared to cases solely managed with non-surgical modalities. Positive surgical margins and regional disease worsened prognosis.

Conclusion

This study suggests that primary surgery remains a key element in the treatment of advanced laryngeal cancer. The need for well-designed, prospective, randomised studies in order to further evaluate the remaining role of primary surgery in the modern management of locally advanced laryngeal lesions is emphasized.

Laryngeal preservation with induction chemotherapy for hypopharyngeal squamous cell carcinoma: 10-year results of EORTC trial 24891

BACKGROUND

We report the 10-year results of the EORTC trial 24891 comparing a larynx-preservation approach to immediate surgery in hypopharynx and lateral epilarynx squamous cell carcinoma.

MATERIAL AND METHODS

Two hundred and two patients were randomized to either the surgical approach (total laryngectomy with partial pharyngectomy and neck dissection, followed by irradiation) or to the chemotherapy arm up to three cycles of induction chemotherapy (cisplatin 100 mg/m(2) day 1 + 5-FU 1000 mg/m(2) day 1-5) followed for complete responders by irradiation and otherwise by conventional treatment. The end points were overall survival [OS, noninferiority: hazard ratio (preservation/surgery) ≤ 1.428, one-sided α = 0.05], progression-free survival (PFS) and survival with a functional larynx (SFL).

RESULTS

At a median follow-up of 10.5 years on 194 eligible patients, disease evolution was seen in 54 and 49 patients in the surgery and chemotherapy arm, respectively, and 81 and 83 patients had died. The 10-year OS rate was 13.8% in the surgery arm and 13.1% in the chemotherapy arm. The 10-year PFS rates were 8.5% and 10.8%, respectively. In the chemotherapy arm, the 10-year SFL rate was 8.7%.

CONCLUSION

This strategy did not compromise disease control or survival (that remained poor) and allowed more than half of the survivors to retain their larynx.

Validation that metabolic tumor volume predicts outcome in head-and-neck cancer

PURPOSE

We have previously reported that metabolic tumor volume (MTV) obtained from pretreatment (18)F-fluorodeoxydeglucose positron emission tomography (FDG PET)/ computed tomography (CT) predicted outcome in patients with head-and-neck cancer (HNC). The purpose of this study was to validate these results on an independent dataset, determine whether the primary tumor or nodal MTV drives this correlation, and explore the interaction with p16(INK4a) status as a surrogate marker for human papillomavirus (HPV).

METHODS AND MATERIALS

The validation dataset in this study included 83 patients with squamous cell HNC who had a FDG PET/CT scan before receiving definitive radiotherapy. MTV and maximum standardized uptake value (SUV(max)) were calculated for the primary tumor, the involved nodes, and the combination of both. The primary endpoint was to validate that MTV predicted progression-free survival and overall survival. Secondary analyses included determining the prognostic utility of primary tumor vs. nodal MTV.

RESULTS

Similarly to our prior findings, an increase in total MTV of 17 cm(3) (difference between the 75th and 25th percentiles) was associated with a 2.1-fold increase in the risk of disease progression (p = 0.0002) and a 2.0-fold increase in the risk of death (p = 0.0048). SUV(max) was not associated with either outcome. Primary tumor MTV predicted progression-free (hazard ratio [HR] = 1.94; p < 0.0001) and overall (HR = 1.57; p < 0.0001) survival, whereas nodal MTV did not. In addition, MTV predicted progression-free (HR = 4.23; p < 0.0001) and overall (HR = 3.21; p = 0.0029) survival in patients with p16(INK4a)-positive oropharyngeal cancer.

CONCLUSIONS

This study validates our previous findings that MTV independently predicts outcomes in HNC. MTV should be considered as a potential risk-stratifying biomarker in future studies of HNC.

Functional organ preservation for laryngeal cancer: past, present and future

OBJECTIVE

Management of laryngeal cancer has focused on improving survival while preserving function. Over the past 20 years, the trends have shifted from surgery to chemoradiotherapy and presently we are facing various challenges. It is imperative to re-examine what has happened and what can be done.

METHODS

Review of the literature along with our experience in the management of functional organ preservation for laryngeal cancer.

RESULTS

There was an increasing use of chemoradiotherapy with a decreasing use of surgery. Inappropriate patient selection along with inability to properly apply salvage surgeries have been presumed to be responsible for survival deterioration in laryngeal cancer. Reports concerning late adverse events after chemoradiotherapy are also increasing. Reconfirmation of the multidisciplinary team approach is imperative. Transoral laser microsurgery can be used for early laryngeal cancer and, in some experienced institutes, for advanced-stage cancers. Supracricoid laryngectomy demonstrated satisfactory oncologic and functional outcomes, based on our experience.

CONCLUSIONS

Treatment selection for larynx preservation should not merely be decided by guidelines but considering each patient's individual condition. Head and neck surgeons are encouraged to take reasonable risks in performing salvage larynx preservation surgery when it is the only option to save a functioning larynx.