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Sharma R, Vats S, Seam R, Gupta M, Negi RR, Fotedar V, Singh K. A Comparison of the Toxicities in Patients With Locally Advanced Head and Neck Cancers Treated With Concomitant Boost Radiotherapy Versus Conventional Chemoradiation. Cureus 2023; 15:e38362. [PMID: 37266055 PMCID: PMC10230179 DOI: 10.7759/cureus.38362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 06/03/2023] Open
Abstract
PURPOSE To compare the objective and patient-reported toxicities of concomitant boost radiotherapy (CBRT) and concurrent chemoradiation (CRT) in patients with locally advanced head and neck cancers. METHODS AND MATERIAL In this prospective study, 46 patients with histologically proven stage III-IVA head and neck cancer were randomly assigned to receive either concurrent chemoradiation to a dose of 66 Gy in 33 fractions over 6.5 weeks with concurrent cisplatin (40 mg/m2 IV weekly; control arm) or accelerated radiotherapy with concomitant boost radiotherapy (study arm) to a dose of 67.5 Gy in 40 fractions in five weeks. Acute toxicity was evaluated using RTOG toxicity criteria. The assessment was done weekly after initiation of treatment, at the first follow-up (six weeks), and at three months. The four main patient-reported symptoms of pain, hoarseness of voice, dryness of mouth, and loss of taste were also compared between the two groups to assess patient quality of life during treatment. RESULTS The mean treatment duration was 37 days in the CBRT arm and 49 days in the CRT arm. Treatment-related interruptions were less in the study group,17.3% in the study, and 27.2% in the control with insignificant P-value. Grade III laryngeal toxicity was significantly higher in the study group (P=0.029). Other acute grade I-III toxicities (pharyngeal, skin, mucositis, and salivary) were comparable in both CRT and CBRT arms. Grade IV toxicities were seen only in the CBRT arm but were resolved at the first follow-up. Haematological toxicities and renal toxicities were significantly higher in the CRT arm, with significant P-values of 0.0004 and 0.018, respectively. CONCLUSION In patients with locally advanced head and neck cancer, concomitant boost radiotherapy is well tolerated with acceptable local toxicity and minimal systemic toxicity as compared to conventional chemoradiation. It is a feasible option for patients with locally advanced head and neck cancer not fit for concurrent chemoradiation.
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Affiliation(s)
- Ritu Sharma
- Department of Radiotherapy, Shri Lal Bahadur Shastri Government Medical College and Hospital, Mandi, IND
| | - Siddharth Vats
- Department of Radiotherapy, Indira Gandhi Medical College, Shimla, IND
| | - Rajeev Seam
- Department of Radiotherapy, Maharishi Markandeshwar Institiute of Medical Sciences and Research, Ambala, IND
| | - Manish Gupta
- Department of Radiotherapy, Indira Gandhi Medical College, Shimla, IND
| | - Ratti R Negi
- Department of Radiotherapy, Shri Lal Bahadur Shastri Government Medical College and Hospital, Mandi, IND
| | - Vikas Fotedar
- Department of Radiotherapy, Indira Gandhi Medical College, Shimla, IND
| | - Kaalindi Singh
- Department of Radiotherapy, Shri Lal Bahadur Shastri Government Medical College and Hospital, Mandi, IND
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Escalating a Biological Dose of Radiation in the Target Volume Applying Stereotactic Radiosurgery in Patients with Head and Neck Region Tumours. Biomedicines 2022; 10:biomedicines10071484. [PMID: 35884789 PMCID: PMC9313164 DOI: 10.3390/biomedicines10071484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 06/17/2022] [Accepted: 06/21/2022] [Indexed: 11/30/2022] Open
Abstract
Background: The treatment of head and neck tumours is a complicated process usually involving surgery, radiation therapy, and systemic treatment. Despite the multidisciplinary approach, treatment outcomes are still unsatisfactory, especially considering malignant tumours such as squamous cell carcinoma or sarcoma, where the frequency of recurrence has reached 50% of cases. The implementation of modern and precise methods of radiotherapy, such as a radiosurgery boost, may allow for the escalation of the biologically effective dose in the gross tumour volume and improve the results of treatment. Methods: The administration of a stereotactic radiotherapy boost can be done in two ways: an upfront boost followed by conventional radio(chemo)therapy or a direct boost after conventional radio(chemo)therapy. The boost dose depends on the primary or nodal tumour volume and localization regarding the organs at risk. It falls within the range of 10–18 Gy. Discussion: The collection of detailed data on the response of the disease to the radiosurgery boost combined with conventional radiotherapy as well as an assessment of early and late toxicities will contribute crucial information to the prospective modification of fractionated radiotherapy. In the case of beneficial findings, the stereotactic radiosurgery boost in the course of radio(chemo)therapy in patients with head and neck tumours will be able to replace traditional techniques of radiation, and radical schemes of treatment will be possible for future development.
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Parhar HS, Brody RM, Shimunov D, Rajasekaran K, Rassekh CH, Basu D, O'Malley BW, Chalian AA, Newman JG, Loevner L, Lazor JW, Weinstein GS, Cannady SB. Retropharyngeal Internal Carotid Artery Management in TORS Using Microvascular Reconstruction. Laryngoscope 2020; 131:E821-E827. [PMID: 32621638 DOI: 10.1002/lary.28876] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/16/2020] [Accepted: 05/27/2020] [Indexed: 01/06/2023]
Abstract
OBJECTIVES Guidelines for transoral robotic surgery (TORS) have generally regarded patients with retropharyngeal carotid arteries as contraindicated for surgery due to a theoretical risk of intraoperative vascular injury and/or perioperative cerebrovascular accident. We aimed to demonstrate that careful TORS-assisted resection and free flap coverage could not only avoid intraoperative injury and provide a physical barrier for vessel coverage but also achieve adequate margin control. STUDY DESIGN Retrospective cohort analysis. METHODS Retrospective review of patients with oropharyngeal malignancies and radiologically confirmed retropharyngeal carotid arteries who underwent TORS, concurrent neck dissection, and free flap reconstruction between 2015 and 2019. RESULTS Twenty patients were included, 19 (95.0%) with tonsillar tumors and one (5.0%) with a tongue base tumor with significant tonsillar extension. Eighteen patients (90.0%) received a radial artery forearm flap, one (5.0%) an ulnar artery forearm flap, and one (5.0%) an anteromedial thigh flap. All 20 (100%) flaps were inset through combined transcervical and transoral approaches without mandibulotomy. There were no perioperative mortalities, carotid injuries, oropharyngeal bleeds, cervical hematomas, or cerebrovascular accidents. One patient (5.0%) had a free flap failure requiring explant. All patients underwent decannulation and resumed a full oral diet. The mean length of hospitalization was 6.8 (standard deviation 1.2) days. One (5.0%) patient had a positive margin. CONCLUSION In this analysis, 20 patients with oropharyngeal malignancy and retropharyngeal carotid arteries underwent TORS, neck dissection, and microvascular reconstruction without serious complication (perioperative mortality, vascular injury, or neurologic sequalae) with an acceptable negative margin rate. These results may lead to a reconsideration of a commonly held contraindication to TORS. LEVEL OF EVIDENCE 3 Laryngoscope, 131:E821-E827, 2021.
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Affiliation(s)
- Harman S Parhar
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Robert M Brody
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - David Shimunov
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Christopher H Rassekh
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Devraj Basu
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Bert W O'Malley
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Ara A Chalian
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Jason G Newman
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Laurie Loevner
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Jillian W Lazor
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Gregory S Weinstein
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Steven B Cannady
- Department of Otorhinolaryngology - Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
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Rehman JU, Zahra, Ahmad N, Khalid M, Noor ul Huda Khan Asghar H, Gilani ZA, Ullah I, Nasar G, Akhtar MM, Usmani MN. Intensity modulated radiation therapy: A review of current practice and future outlooks. JOURNAL OF RADIATION RESEARCH AND APPLIED SCIENCES 2019. [DOI: 10.1016/j.jrras.2018.07.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Jalil ur Rehman
- Department of Physics, Baluchistan University of Information Technology, Engineering & Management Sciences, Quetta, 87300, Pakistan
| | - Zahra
- Department of Physics, Baluchistan University of Information Technology, Engineering & Management Sciences, Quetta, 87300, Pakistan
| | - Nisar Ahmad
- Department of Physics, Baluchistan University of Information Technology, Engineering & Management Sciences, Quetta, 87300, Pakistan
| | - Muhammad Khalid
- Department of Physics, Baluchistan University of Information Technology, Engineering & Management Sciences, Quetta, 87300, Pakistan
| | - H.M. Noor ul Huda Khan Asghar
- Department of Physics, Baluchistan University of Information Technology, Engineering & Management Sciences, Quetta, 87300, Pakistan
| | - Zaheer Abbas Gilani
- Department of Physics, Baluchistan University of Information Technology, Engineering & Management Sciences, Quetta, 87300, Pakistan
| | - Irfan Ullah
- Centre for Nuclear Medicine and Radiotherapy (CENAR), Quetta, Pakistan
| | - Gulfam Nasar
- Department of Chemistry, Baluchistan University of Information Technology, Engineering & Management Sciences, Quetta, Pakistan
| | - Malik Muhammad Akhtar
- Department of Environmental Science, Baluchistan University of Information Technology, Engineering & Management Sciences, Quetta, Pakistan
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Fallai C, Olmi P. Altered Fractionation Schedules in Radiotherapy of Head and Neck Cancer. A Review. TUMORI JOURNAL 2018; 78:311-25. [PMID: 1494804 DOI: 10.1177/030089169207800506] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
The authors review the main contributions of international literature to show the current status in clinical trials on unconventional fractionations of the dose in radiotherapy of head and neck cancers. Several clinical (but only a few randomized) trials have been conducted over the last 15 years using hyperfractionated (HF), accelerated (AF) or mixed (HF-AF) schedules. HF schedules have obtained promising results in terms of local control in comparison with conventional fractionation (CF) of the dose. Improvement in survival was also obtained by the random trials of Pinto and Sanchiz, whereas in EORTC trial no. 22791, the improvement in survival rate was only marginal. A significant increase in local control and, less frequently, in survival has been claimed in several studies using HF-AF. Such data still need to be confirmed by a random study, since EORTC trial 22811 showed superimposable results in comparison with CF. Selection of the most suitable cases for altered fractionation schemes is also being studied in ongoing trials of the EORTC (22851) and RTOG (90-03). As regards acute reactions during and after altered fractionation, they are more severe than after CF. Only pure HF with a dose intensity approximately comparable to CF seems to produce similar acute reactions. Several factors have been found to influence the severity of acute mucosal reactions: interfraction interval, overall treatment time, total dose, and field size. As regards late damage, genuine HF schemes seem to cause roughly equivalent late damage in comparison to CF, whereas high-dose intensity schedules have a higher rate of complications. Interfraction interval, overall treatment time, total dose, fraction size and field size can influence the risk of late sequelae. Before altered fractionations can be considered standard therapy, more data are needed, which should be provided by multicentric randomized trials, some of which are already in progress.
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Affiliation(s)
- C Fallai
- Unità di Radioterapia, Usl 10/D, Università degli Studi di Firenze, Italy
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Okazaki E, Matsushita N, Tashiro M, Shimatani Y, Ishii K, Hosono M, Oishi M, Teranishi Y, Iguchi H, Miki Y. Efficacy and toxicity profiles of two chemoradiotherapies for stage II laryngeal cancer - a comparison between late course accelerated hyperfractionation (LCAHF) and conventional fractionation (CF). Acta Otolaryngol 2017; 137:883-887. [PMID: 28301268 DOI: 10.1080/00016489.2017.1293295] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To evaluate the treatment results of late course accelerated hyperfractionation (LCAHF) compared with conventional fractionation (CF) for stage II laryngeal cancer. METHODS Fifty-nine consecutive patients treated for stage II laryngeal cancer were retrospectively reviewed. Thirty-two patients underwent LCAHF, twice-daily fractions during the latter half with a total dose of 69 Gy. Twenty-seven patients received CF of 70 Gy. RESULTS The local control rates (LCRs), overall survival (OS), and disease-specific survival (DSS) at 5 years were 80.6%, 74.0%, and 90.4%, respectively, after LCAHF and 64.7%, 68.2%, and 90.5%, respectively, after CF. There were no significant differences in LCR, OS, and DSS (p = .11, 0.68, and 0.69, respectively). In a small number of patients with supraglottic cancer, LCAHF was associated with a significantly higher LCR at 5 years compared with CF (100% vs. 41.7%; p = .02). CONCLUSIONS This is the first report that compared the results of LCAHF and CF for stage II laryngeal cancer. We could not find significant differences in LCR, DSS, and OS rates between LCAHF and CF groups. Although in a small number of patients with supraglottic cancer, LCAHF may improve the LCR compared with CF.
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Affiliation(s)
- Eiichiro Okazaki
- Department of Diagnostic and Interventional Radiology/Radiation Oncology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Naoki Matsushita
- Department of Otolaryngology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Mari Tashiro
- Department of Internal Medicine, Ishikawa Clinic, Osaka, Japan
| | - Yasuhiko Shimatani
- Department of Radiation Oncology, Osaka City General Hospital, Osaka, Japan
| | - Kentaro Ishii
- Department of Radiation Oncology, Tane General Hospital, Osaka, Japan
| | - Masako Hosono
- Department of Diagnostic and Interventional Radiology/Radiation Oncology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Masahiro Oishi
- Department of Otolaryngology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yuichi Teranishi
- Department of Otolaryngology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hiroyoshi Iguchi
- Department of Otolaryngology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yukio Miki
- Department of Diagnostic and Interventional Radiology/Radiation Oncology, Osaka City University Graduate School of Medicine, Osaka, Japan
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7
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Pushpa Naga CH, Janaki MG, Arul Ponni TR, Rajeev AG, Kirthi Koushik AS, Mohan Kumar S. Accelerated Radiation Therapy Using Weekend Boost with Concurrent Cisplatin in Head and Neck Squamous Cell Cancers: An Indian Institutional Experience. J Med Imaging Radiat Sci 2017; 48:307-315. [PMID: 31047415 DOI: 10.1016/j.jmir.2017.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 04/19/2017] [Accepted: 05/08/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of the study was to evaluate the feasibility and efficacy of an accelerated radiotherapy schedule using weekend boost in terms of tumor response, compliance, and acute toxicities for head and neck squamous cell carcinoma, and to report long-term clinical outcomes. MATERIALS AND METHODS Twenty-six patients with stages III-IV head and neck squamous cell carcinoma receiving radical chemoradiotherapy were accrued prospectively into the study. External beam radiation therapy to a total dose of 66-70 Gy in 33-35 fractions, 1.8-2.0 Gy per fraction along with concurrent weekly cisplatin was planned. Radiation regimen included delivery of six fractions per week, with boost field delivered as the sixth fraction on the weekend. The compliance, tumor response, and toxicities were recorded. Survival curves were estimated using the Kaplan-Meier method. RESULTS Twenty-one of 26 patients (81%) completed treatment as planned and five patients died during the course of treatment. Sixteen patients (62%) completed treatment in less than 44 days and, at the end of 3 months' follow-up, 18 patients (69%) showed complete response and two patients (8%) showed partial response. The 2- and 5-year actuarial disease-free survival were 90% and 65%, respectively, and 2- and 5-year actuarial overall survival were 60% and 38%, respectively. CONCLUSION Accelerated fractionation using weekend boost, along with concurrent weekly concurrent cisplatin, is an effective and promising approach with favorable impact on initial tumor response, comparable results, and acceptable toxicities.
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Affiliation(s)
- C H Pushpa Naga
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India.
| | - M G Janaki
- Department of Radiation Oncology, M.S. Ramaiah Medical College and Hospitals, Bengaluru, Karnataka, India
| | - T R Arul Ponni
- Department of Radiation Oncology, M.S. Ramaiah Medical College and Hospitals, Bengaluru, Karnataka, India
| | - A G Rajeev
- Department of Radiation Oncology, Radiant Cancer Hospital, Mysooru, Karnataka, India
| | - A S Kirthi Koushik
- Department of Radiation Oncology, M.S. Ramaiah Medical College and Hospitals, Bengaluru, Karnataka, India
| | - S Mohan Kumar
- Department of Radiation Oncology, M.S. Ramaiah Medical College and Hospitals, Bengaluru, Karnataka, India
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Garden AS, Fuller CD, Rosenthal DI, William WN, Gunn GB, Beadle BM, Johnson FM, Morrison WH, Phan J, Frank SJ, Kies MS, Sturgis EM. Radiation therapy (with or without neck surgery) for phenotypic human papillomavirus-associated oropharyngeal cancer. Cancer 2016; 122:1702-7. [PMID: 27019396 DOI: 10.1002/cncr.29965] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 01/21/2016] [Accepted: 01/21/2016] [Indexed: 11/05/2022]
Abstract
BACKGROUND Favorable outcomes for human papillomavirus-associated oropharyngeal cancer have led to interest in identifying a subgroup of patients with the lowest risk of disease recurrence after therapy. De-intensification of therapy for this group may result in survival outcomes that are similar to those associated with current therapy but with less toxicity. To advance this effort, this study analyzed the outcomes of oropharyngeal cancer patients treated with or without systemic therapy. METHODS This was a retrospective study of patients with oropharyngeal cancer treated between 1985 and 2012. The criteria for inclusion were ≤10 pack-years of cigarette smoking and stage III/IVA cancer limited to T1-3, N1-N2b, and T3N0 disease. A survival analysis was performed with the primary endpoint of progression-free survival (PFS). RESULTS The cohort included 857 patients. Systemic therapy was given to 439 patients (51%). The median survival was 80 months. The 2-year PFS rate was 91%. When the analysis was limited to 324 patients irradiated without systemic therapy, the 2- and 5-year PFS rates were 90% and 85%, respectively. Furthermore, for these 324 patients, the 5-year PFS rates for T1, T2, and T3 disease were 90%, 83%, and 70%, respectively. The 5-year PFS rate for patients treated with systemic therapy for T3 disease was 77% (P = .07). CONCLUSIONS According to the low-risk definition currently established in cooperative trials, the patients had a 2-year PFS rate approximating 90%. When patients who were treated with radiation alone were evaluated, no compromise was observed in this high rate of PFS, which is higher than the 2-year PFS thresholds used in current cooperative trials. Cancer 2016;122:1702-7. © 2016 American Cancer Society.
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Affiliation(s)
- Adam S Garden
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Clifton D Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David I Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - William N William
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Gary B Gunn
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Beth M Beadle
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Faye M Johnson
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - William H Morrison
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jack Phan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Steven J Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Merrill S Kies
- Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Erich M Sturgis
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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9
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Rosenthal DI, Fuller CD, Peters LJ, Thames HD. Final Report of Radiation Therapy Oncology Group Protocol 9003: Provocative, but Limited Conclusions From Exploratory Analyses. Int J Radiat Oncol Biol Phys 2015; 92:715-7. [PMID: 26104925 DOI: 10.1016/j.ijrobp.2015.02.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 02/18/2015] [Accepted: 02/26/2015] [Indexed: 11/29/2022]
Affiliation(s)
- David I Rosenthal
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center.
| | - Clifton D Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center
| | - Lester J Peters
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Howard D Thames
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center
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10
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Nguyen-Tan PF, Zhang Q, Ang KK, Weber RS, Rosenthal DI, Soulieres D, Kim H, Silverman C, Raben A, Galloway TJ, Fortin A, Gore E, Westra WH, Chung CH, Jordan RC, Gillison ML, List M, Le QT. Randomized phase III trial to test accelerated versus standard fractionation in combination with concurrent cisplatin for head and neck carcinomas in the Radiation Therapy Oncology Group 0129 trial: long-term report of efficacy and toxicity. J Clin Oncol 2014; 32:3858-66. [PMID: 25366680 PMCID: PMC4239304 DOI: 10.1200/jco.2014.55.3925] [Citation(s) in RCA: 294] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE We tested the efficacy and toxicity of cisplatin plus accelerated fractionation with a concomitant boost (AFX-C) versus standard fractionation (SFX) in locally advanced head and neck carcinoma (LA-HNC). PATIENTS AND METHODS Patients had stage III to IV carcinoma of the oral cavity, oropharynx, hypopharynx, or larynx. Radiation therapy schedules were 70 Gy in 35 fractions over 7 weeks (SFX) or 72 Gy in 42 fractions over 6 weeks (AFX-C). Cisplatin doses were 100 mg/m(2) once every 3 weeks for two (AFX-C) or three (SFX) cycles. Toxicities were scored by using National Cancer Institute Common Toxicity Criteria 2.0 and the Radiation Therapy Oncology Group/European Organisation for Research and Treatment of Cancer criteria. Overall survival (OS) and progression-free survival (PFS) rates were estimated by using the Kaplan-Meier method and were compared by using the one-sided log-rank test. Locoregional failure (LRF) and distant metastasis (DM) rates were estimated by using the cumulative incidence method and Gray's test. RESULTS In all, 721 of 743 patients were analyzable (361, SFX; 360, AFX-C). At a median follow-up of 7.9 years (range, 0.3 to 10.1 years) for 355 surviving patients, no differences were observed in OS (hazard ratio [HR], 0.96; 95% CI, 0.79 to 1.18; P = .37; 8-year survival, 48% v 48%), PFS (HR, 1.02; 95% CI, 0.84 to 1.24; P = .52; 8-year estimate, 42% v 41%), LRF (HR, 1.08; 95% CI, 0.84 to 1.38; P = .78; 8-year estimate, 37% v 39%), or DM (HR, 0.83; 95% CI, 0.56 to 1.24; P = .16; 8-year estimate, 15% v 13%). For oropharyngeal cancer, p16-positive patients had better OS than p16-negative patients (HR, 0.30; 95% CI, 0.21 to 0.42; P < .001; 8-year survival, 70.9% v 30.2%). There were no statistically significant differences in the grade 3 to 5 acute or late toxicities between the two arms and p-16 status. CONCLUSION When combined with cisplatin, AFX-C neither improved outcome nor increased late toxicity in patients with LA-HNC. Long-term high survival rates in p16-positive patients with oropharyngeal cancer support the ongoing efforts to explore deintensification.
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Affiliation(s)
- Phuc Felix Nguyen-Tan
- Phuc Felix Nguyen-Tan and Denis Soulieres, Centre Hospitalier de l'Université de Montréal Hôpital Notre-Dame, Montreal; André Fortin, Centre Hospitalier Universitaire Hôtel-Dieu de Québec, Quebec City, Quebec, Canada; Qiang Zhang, NRG Oncology Statistics and Data Management Center; Thomas J. Galloway, Fox Chase Cancer Center, Philadelphia, PA; K. Kian Ang, Randal S. Weber, and David I. Rosenthal, University of Texas MD Anderson Cancer Center, Houston, TX; Harold Kim, Wayne State University, Detroit, MI; Craig Silverman, James Graham Brown Cancer Center, Louisville, KY; Adam Raben, Christiana Care Community Clinical Oncology Program, Newark, DE; Elizabeth Gore, Medical College of Wisconsin, Milwaukee, WI; William H. Westra and Christine H. Chung, Johns Hopkins University, Baltimore, MD; Richard C. Jordan, University of California at San Francisco, San Francisco; Quynh-Thu Le, Stanford University, Stanford, CA; Maura L. Gillison, Ohio State University Comprehensive Cancer Center, Columbus, OH; and Marcy List, University of Chicago Medicine Comprehensive Cancer Research Center, Chicago, IL.
| | - Qiang Zhang
- Phuc Felix Nguyen-Tan and Denis Soulieres, Centre Hospitalier de l'Université de Montréal Hôpital Notre-Dame, Montreal; André Fortin, Centre Hospitalier Universitaire Hôtel-Dieu de Québec, Quebec City, Quebec, Canada; Qiang Zhang, NRG Oncology Statistics and Data Management Center; Thomas J. Galloway, Fox Chase Cancer Center, Philadelphia, PA; K. Kian Ang, Randal S. Weber, and David I. Rosenthal, University of Texas MD Anderson Cancer Center, Houston, TX; Harold Kim, Wayne State University, Detroit, MI; Craig Silverman, James Graham Brown Cancer Center, Louisville, KY; Adam Raben, Christiana Care Community Clinical Oncology Program, Newark, DE; Elizabeth Gore, Medical College of Wisconsin, Milwaukee, WI; William H. Westra and Christine H. Chung, Johns Hopkins University, Baltimore, MD; Richard C. Jordan, University of California at San Francisco, San Francisco; Quynh-Thu Le, Stanford University, Stanford, CA; Maura L. Gillison, Ohio State University Comprehensive Cancer Center, Columbus, OH; and Marcy List, University of Chicago Medicine Comprehensive Cancer Research Center, Chicago, IL
| | - K Kian Ang
- Phuc Felix Nguyen-Tan and Denis Soulieres, Centre Hospitalier de l'Université de Montréal Hôpital Notre-Dame, Montreal; André Fortin, Centre Hospitalier Universitaire Hôtel-Dieu de Québec, Quebec City, Quebec, Canada; Qiang Zhang, NRG Oncology Statistics and Data Management Center; Thomas J. Galloway, Fox Chase Cancer Center, Philadelphia, PA; K. Kian Ang, Randal S. Weber, and David I. Rosenthal, University of Texas MD Anderson Cancer Center, Houston, TX; Harold Kim, Wayne State University, Detroit, MI; Craig Silverman, James Graham Brown Cancer Center, Louisville, KY; Adam Raben, Christiana Care Community Clinical Oncology Program, Newark, DE; Elizabeth Gore, Medical College of Wisconsin, Milwaukee, WI; William H. Westra and Christine H. Chung, Johns Hopkins University, Baltimore, MD; Richard C. Jordan, University of California at San Francisco, San Francisco; Quynh-Thu Le, Stanford University, Stanford, CA; Maura L. Gillison, Ohio State University Comprehensive Cancer Center, Columbus, OH; and Marcy List, University of Chicago Medicine Comprehensive Cancer Research Center, Chicago, IL
| | - Randal S Weber
- Phuc Felix Nguyen-Tan and Denis Soulieres, Centre Hospitalier de l'Université de Montréal Hôpital Notre-Dame, Montreal; André Fortin, Centre Hospitalier Universitaire Hôtel-Dieu de Québec, Quebec City, Quebec, Canada; Qiang Zhang, NRG Oncology Statistics and Data Management Center; Thomas J. Galloway, Fox Chase Cancer Center, Philadelphia, PA; K. Kian Ang, Randal S. Weber, and David I. Rosenthal, University of Texas MD Anderson Cancer Center, Houston, TX; Harold Kim, Wayne State University, Detroit, MI; Craig Silverman, James Graham Brown Cancer Center, Louisville, KY; Adam Raben, Christiana Care Community Clinical Oncology Program, Newark, DE; Elizabeth Gore, Medical College of Wisconsin, Milwaukee, WI; William H. Westra and Christine H. Chung, Johns Hopkins University, Baltimore, MD; Richard C. Jordan, University of California at San Francisco, San Francisco; Quynh-Thu Le, Stanford University, Stanford, CA; Maura L. Gillison, Ohio State University Comprehensive Cancer Center, Columbus, OH; and Marcy List, University of Chicago Medicine Comprehensive Cancer Research Center, Chicago, IL
| | - David I Rosenthal
- Phuc Felix Nguyen-Tan and Denis Soulieres, Centre Hospitalier de l'Université de Montréal Hôpital Notre-Dame, Montreal; André Fortin, Centre Hospitalier Universitaire Hôtel-Dieu de Québec, Quebec City, Quebec, Canada; Qiang Zhang, NRG Oncology Statistics and Data Management Center; Thomas J. Galloway, Fox Chase Cancer Center, Philadelphia, PA; K. Kian Ang, Randal S. Weber, and David I. Rosenthal, University of Texas MD Anderson Cancer Center, Houston, TX; Harold Kim, Wayne State University, Detroit, MI; Craig Silverman, James Graham Brown Cancer Center, Louisville, KY; Adam Raben, Christiana Care Community Clinical Oncology Program, Newark, DE; Elizabeth Gore, Medical College of Wisconsin, Milwaukee, WI; William H. Westra and Christine H. Chung, Johns Hopkins University, Baltimore, MD; Richard C. Jordan, University of California at San Francisco, San Francisco; Quynh-Thu Le, Stanford University, Stanford, CA; Maura L. Gillison, Ohio State University Comprehensive Cancer Center, Columbus, OH; and Marcy List, University of Chicago Medicine Comprehensive Cancer Research Center, Chicago, IL
| | - Denis Soulieres
- Phuc Felix Nguyen-Tan and Denis Soulieres, Centre Hospitalier de l'Université de Montréal Hôpital Notre-Dame, Montreal; André Fortin, Centre Hospitalier Universitaire Hôtel-Dieu de Québec, Quebec City, Quebec, Canada; Qiang Zhang, NRG Oncology Statistics and Data Management Center; Thomas J. Galloway, Fox Chase Cancer Center, Philadelphia, PA; K. Kian Ang, Randal S. Weber, and David I. Rosenthal, University of Texas MD Anderson Cancer Center, Houston, TX; Harold Kim, Wayne State University, Detroit, MI; Craig Silverman, James Graham Brown Cancer Center, Louisville, KY; Adam Raben, Christiana Care Community Clinical Oncology Program, Newark, DE; Elizabeth Gore, Medical College of Wisconsin, Milwaukee, WI; William H. Westra and Christine H. Chung, Johns Hopkins University, Baltimore, MD; Richard C. Jordan, University of California at San Francisco, San Francisco; Quynh-Thu Le, Stanford University, Stanford, CA; Maura L. Gillison, Ohio State University Comprehensive Cancer Center, Columbus, OH; and Marcy List, University of Chicago Medicine Comprehensive Cancer Research Center, Chicago, IL
| | - Harold Kim
- Phuc Felix Nguyen-Tan and Denis Soulieres, Centre Hospitalier de l'Université de Montréal Hôpital Notre-Dame, Montreal; André Fortin, Centre Hospitalier Universitaire Hôtel-Dieu de Québec, Quebec City, Quebec, Canada; Qiang Zhang, NRG Oncology Statistics and Data Management Center; Thomas J. Galloway, Fox Chase Cancer Center, Philadelphia, PA; K. Kian Ang, Randal S. Weber, and David I. Rosenthal, University of Texas MD Anderson Cancer Center, Houston, TX; Harold Kim, Wayne State University, Detroit, MI; Craig Silverman, James Graham Brown Cancer Center, Louisville, KY; Adam Raben, Christiana Care Community Clinical Oncology Program, Newark, DE; Elizabeth Gore, Medical College of Wisconsin, Milwaukee, WI; William H. Westra and Christine H. Chung, Johns Hopkins University, Baltimore, MD; Richard C. Jordan, University of California at San Francisco, San Francisco; Quynh-Thu Le, Stanford University, Stanford, CA; Maura L. Gillison, Ohio State University Comprehensive Cancer Center, Columbus, OH; and Marcy List, University of Chicago Medicine Comprehensive Cancer Research Center, Chicago, IL
| | - Craig Silverman
- Phuc Felix Nguyen-Tan and Denis Soulieres, Centre Hospitalier de l'Université de Montréal Hôpital Notre-Dame, Montreal; André Fortin, Centre Hospitalier Universitaire Hôtel-Dieu de Québec, Quebec City, Quebec, Canada; Qiang Zhang, NRG Oncology Statistics and Data Management Center; Thomas J. Galloway, Fox Chase Cancer Center, Philadelphia, PA; K. Kian Ang, Randal S. Weber, and David I. Rosenthal, University of Texas MD Anderson Cancer Center, Houston, TX; Harold Kim, Wayne State University, Detroit, MI; Craig Silverman, James Graham Brown Cancer Center, Louisville, KY; Adam Raben, Christiana Care Community Clinical Oncology Program, Newark, DE; Elizabeth Gore, Medical College of Wisconsin, Milwaukee, WI; William H. Westra and Christine H. Chung, Johns Hopkins University, Baltimore, MD; Richard C. Jordan, University of California at San Francisco, San Francisco; Quynh-Thu Le, Stanford University, Stanford, CA; Maura L. Gillison, Ohio State University Comprehensive Cancer Center, Columbus, OH; and Marcy List, University of Chicago Medicine Comprehensive Cancer Research Center, Chicago, IL
| | - Adam Raben
- Phuc Felix Nguyen-Tan and Denis Soulieres, Centre Hospitalier de l'Université de Montréal Hôpital Notre-Dame, Montreal; André Fortin, Centre Hospitalier Universitaire Hôtel-Dieu de Québec, Quebec City, Quebec, Canada; Qiang Zhang, NRG Oncology Statistics and Data Management Center; Thomas J. Galloway, Fox Chase Cancer Center, Philadelphia, PA; K. Kian Ang, Randal S. Weber, and David I. Rosenthal, University of Texas MD Anderson Cancer Center, Houston, TX; Harold Kim, Wayne State University, Detroit, MI; Craig Silverman, James Graham Brown Cancer Center, Louisville, KY; Adam Raben, Christiana Care Community Clinical Oncology Program, Newark, DE; Elizabeth Gore, Medical College of Wisconsin, Milwaukee, WI; William H. Westra and Christine H. Chung, Johns Hopkins University, Baltimore, MD; Richard C. Jordan, University of California at San Francisco, San Francisco; Quynh-Thu Le, Stanford University, Stanford, CA; Maura L. Gillison, Ohio State University Comprehensive Cancer Center, Columbus, OH; and Marcy List, University of Chicago Medicine Comprehensive Cancer Research Center, Chicago, IL
| | - Thomas J Galloway
- Phuc Felix Nguyen-Tan and Denis Soulieres, Centre Hospitalier de l'Université de Montréal Hôpital Notre-Dame, Montreal; André Fortin, Centre Hospitalier Universitaire Hôtel-Dieu de Québec, Quebec City, Quebec, Canada; Qiang Zhang, NRG Oncology Statistics and Data Management Center; Thomas J. Galloway, Fox Chase Cancer Center, Philadelphia, PA; K. Kian Ang, Randal S. Weber, and David I. Rosenthal, University of Texas MD Anderson Cancer Center, Houston, TX; Harold Kim, Wayne State University, Detroit, MI; Craig Silverman, James Graham Brown Cancer Center, Louisville, KY; Adam Raben, Christiana Care Community Clinical Oncology Program, Newark, DE; Elizabeth Gore, Medical College of Wisconsin, Milwaukee, WI; William H. Westra and Christine H. Chung, Johns Hopkins University, Baltimore, MD; Richard C. Jordan, University of California at San Francisco, San Francisco; Quynh-Thu Le, Stanford University, Stanford, CA; Maura L. Gillison, Ohio State University Comprehensive Cancer Center, Columbus, OH; and Marcy List, University of Chicago Medicine Comprehensive Cancer Research Center, Chicago, IL
| | - André Fortin
- Phuc Felix Nguyen-Tan and Denis Soulieres, Centre Hospitalier de l'Université de Montréal Hôpital Notre-Dame, Montreal; André Fortin, Centre Hospitalier Universitaire Hôtel-Dieu de Québec, Quebec City, Quebec, Canada; Qiang Zhang, NRG Oncology Statistics and Data Management Center; Thomas J. Galloway, Fox Chase Cancer Center, Philadelphia, PA; K. Kian Ang, Randal S. Weber, and David I. Rosenthal, University of Texas MD Anderson Cancer Center, Houston, TX; Harold Kim, Wayne State University, Detroit, MI; Craig Silverman, James Graham Brown Cancer Center, Louisville, KY; Adam Raben, Christiana Care Community Clinical Oncology Program, Newark, DE; Elizabeth Gore, Medical College of Wisconsin, Milwaukee, WI; William H. Westra and Christine H. Chung, Johns Hopkins University, Baltimore, MD; Richard C. Jordan, University of California at San Francisco, San Francisco; Quynh-Thu Le, Stanford University, Stanford, CA; Maura L. Gillison, Ohio State University Comprehensive Cancer Center, Columbus, OH; and Marcy List, University of Chicago Medicine Comprehensive Cancer Research Center, Chicago, IL
| | - Elizabeth Gore
- Phuc Felix Nguyen-Tan and Denis Soulieres, Centre Hospitalier de l'Université de Montréal Hôpital Notre-Dame, Montreal; André Fortin, Centre Hospitalier Universitaire Hôtel-Dieu de Québec, Quebec City, Quebec, Canada; Qiang Zhang, NRG Oncology Statistics and Data Management Center; Thomas J. Galloway, Fox Chase Cancer Center, Philadelphia, PA; K. Kian Ang, Randal S. Weber, and David I. Rosenthal, University of Texas MD Anderson Cancer Center, Houston, TX; Harold Kim, Wayne State University, Detroit, MI; Craig Silverman, James Graham Brown Cancer Center, Louisville, KY; Adam Raben, Christiana Care Community Clinical Oncology Program, Newark, DE; Elizabeth Gore, Medical College of Wisconsin, Milwaukee, WI; William H. Westra and Christine H. Chung, Johns Hopkins University, Baltimore, MD; Richard C. Jordan, University of California at San Francisco, San Francisco; Quynh-Thu Le, Stanford University, Stanford, CA; Maura L. Gillison, Ohio State University Comprehensive Cancer Center, Columbus, OH; and Marcy List, University of Chicago Medicine Comprehensive Cancer Research Center, Chicago, IL
| | - William H Westra
- Phuc Felix Nguyen-Tan and Denis Soulieres, Centre Hospitalier de l'Université de Montréal Hôpital Notre-Dame, Montreal; André Fortin, Centre Hospitalier Universitaire Hôtel-Dieu de Québec, Quebec City, Quebec, Canada; Qiang Zhang, NRG Oncology Statistics and Data Management Center; Thomas J. Galloway, Fox Chase Cancer Center, Philadelphia, PA; K. Kian Ang, Randal S. Weber, and David I. Rosenthal, University of Texas MD Anderson Cancer Center, Houston, TX; Harold Kim, Wayne State University, Detroit, MI; Craig Silverman, James Graham Brown Cancer Center, Louisville, KY; Adam Raben, Christiana Care Community Clinical Oncology Program, Newark, DE; Elizabeth Gore, Medical College of Wisconsin, Milwaukee, WI; William H. Westra and Christine H. Chung, Johns Hopkins University, Baltimore, MD; Richard C. Jordan, University of California at San Francisco, San Francisco; Quynh-Thu Le, Stanford University, Stanford, CA; Maura L. Gillison, Ohio State University Comprehensive Cancer Center, Columbus, OH; and Marcy List, University of Chicago Medicine Comprehensive Cancer Research Center, Chicago, IL
| | - Christine H Chung
- Phuc Felix Nguyen-Tan and Denis Soulieres, Centre Hospitalier de l'Université de Montréal Hôpital Notre-Dame, Montreal; André Fortin, Centre Hospitalier Universitaire Hôtel-Dieu de Québec, Quebec City, Quebec, Canada; Qiang Zhang, NRG Oncology Statistics and Data Management Center; Thomas J. Galloway, Fox Chase Cancer Center, Philadelphia, PA; K. Kian Ang, Randal S. Weber, and David I. Rosenthal, University of Texas MD Anderson Cancer Center, Houston, TX; Harold Kim, Wayne State University, Detroit, MI; Craig Silverman, James Graham Brown Cancer Center, Louisville, KY; Adam Raben, Christiana Care Community Clinical Oncology Program, Newark, DE; Elizabeth Gore, Medical College of Wisconsin, Milwaukee, WI; William H. Westra and Christine H. Chung, Johns Hopkins University, Baltimore, MD; Richard C. Jordan, University of California at San Francisco, San Francisco; Quynh-Thu Le, Stanford University, Stanford, CA; Maura L. Gillison, Ohio State University Comprehensive Cancer Center, Columbus, OH; and Marcy List, University of Chicago Medicine Comprehensive Cancer Research Center, Chicago, IL
| | - Richard C Jordan
- Phuc Felix Nguyen-Tan and Denis Soulieres, Centre Hospitalier de l'Université de Montréal Hôpital Notre-Dame, Montreal; André Fortin, Centre Hospitalier Universitaire Hôtel-Dieu de Québec, Quebec City, Quebec, Canada; Qiang Zhang, NRG Oncology Statistics and Data Management Center; Thomas J. Galloway, Fox Chase Cancer Center, Philadelphia, PA; K. Kian Ang, Randal S. Weber, and David I. Rosenthal, University of Texas MD Anderson Cancer Center, Houston, TX; Harold Kim, Wayne State University, Detroit, MI; Craig Silverman, James Graham Brown Cancer Center, Louisville, KY; Adam Raben, Christiana Care Community Clinical Oncology Program, Newark, DE; Elizabeth Gore, Medical College of Wisconsin, Milwaukee, WI; William H. Westra and Christine H. Chung, Johns Hopkins University, Baltimore, MD; Richard C. Jordan, University of California at San Francisco, San Francisco; Quynh-Thu Le, Stanford University, Stanford, CA; Maura L. Gillison, Ohio State University Comprehensive Cancer Center, Columbus, OH; and Marcy List, University of Chicago Medicine Comprehensive Cancer Research Center, Chicago, IL
| | - Maura L Gillison
- Phuc Felix Nguyen-Tan and Denis Soulieres, Centre Hospitalier de l'Université de Montréal Hôpital Notre-Dame, Montreal; André Fortin, Centre Hospitalier Universitaire Hôtel-Dieu de Québec, Quebec City, Quebec, Canada; Qiang Zhang, NRG Oncology Statistics and Data Management Center; Thomas J. Galloway, Fox Chase Cancer Center, Philadelphia, PA; K. Kian Ang, Randal S. Weber, and David I. Rosenthal, University of Texas MD Anderson Cancer Center, Houston, TX; Harold Kim, Wayne State University, Detroit, MI; Craig Silverman, James Graham Brown Cancer Center, Louisville, KY; Adam Raben, Christiana Care Community Clinical Oncology Program, Newark, DE; Elizabeth Gore, Medical College of Wisconsin, Milwaukee, WI; William H. Westra and Christine H. Chung, Johns Hopkins University, Baltimore, MD; Richard C. Jordan, University of California at San Francisco, San Francisco; Quynh-Thu Le, Stanford University, Stanford, CA; Maura L. Gillison, Ohio State University Comprehensive Cancer Center, Columbus, OH; and Marcy List, University of Chicago Medicine Comprehensive Cancer Research Center, Chicago, IL
| | - Marcie List
- Phuc Felix Nguyen-Tan and Denis Soulieres, Centre Hospitalier de l'Université de Montréal Hôpital Notre-Dame, Montreal; André Fortin, Centre Hospitalier Universitaire Hôtel-Dieu de Québec, Quebec City, Quebec, Canada; Qiang Zhang, NRG Oncology Statistics and Data Management Center; Thomas J. Galloway, Fox Chase Cancer Center, Philadelphia, PA; K. Kian Ang, Randal S. Weber, and David I. Rosenthal, University of Texas MD Anderson Cancer Center, Houston, TX; Harold Kim, Wayne State University, Detroit, MI; Craig Silverman, James Graham Brown Cancer Center, Louisville, KY; Adam Raben, Christiana Care Community Clinical Oncology Program, Newark, DE; Elizabeth Gore, Medical College of Wisconsin, Milwaukee, WI; William H. Westra and Christine H. Chung, Johns Hopkins University, Baltimore, MD; Richard C. Jordan, University of California at San Francisco, San Francisco; Quynh-Thu Le, Stanford University, Stanford, CA; Maura L. Gillison, Ohio State University Comprehensive Cancer Center, Columbus, OH; and Marcy List, University of Chicago Medicine Comprehensive Cancer Research Center, Chicago, IL
| | - Quynh-Thu Le
- Phuc Felix Nguyen-Tan and Denis Soulieres, Centre Hospitalier de l'Université de Montréal Hôpital Notre-Dame, Montreal; André Fortin, Centre Hospitalier Universitaire Hôtel-Dieu de Québec, Quebec City, Quebec, Canada; Qiang Zhang, NRG Oncology Statistics and Data Management Center; Thomas J. Galloway, Fox Chase Cancer Center, Philadelphia, PA; K. Kian Ang, Randal S. Weber, and David I. Rosenthal, University of Texas MD Anderson Cancer Center, Houston, TX; Harold Kim, Wayne State University, Detroit, MI; Craig Silverman, James Graham Brown Cancer Center, Louisville, KY; Adam Raben, Christiana Care Community Clinical Oncology Program, Newark, DE; Elizabeth Gore, Medical College of Wisconsin, Milwaukee, WI; William H. Westra and Christine H. Chung, Johns Hopkins University, Baltimore, MD; Richard C. Jordan, University of California at San Francisco, San Francisco; Quynh-Thu Le, Stanford University, Stanford, CA; Maura L. Gillison, Ohio State University Comprehensive Cancer Center, Columbus, OH; and Marcy List, University of Chicago Medicine Comprehensive Cancer Research Center, Chicago, IL
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11
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Burbach JPM, den Harder AM, Intven M, van Vulpen M, Verkooijen HM, Reerink O. Impact of radiotherapy boost on pathological complete response in patients with locally advanced rectal cancer: a systematic review and meta-analysis. Radiother Oncol 2014; 113:1-9. [PMID: 25281582 DOI: 10.1016/j.radonc.2014.08.035] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 08/25/2014] [Accepted: 08/31/2014] [Indexed: 02/07/2023]
Abstract
PURPOSE We conducted a systematic review and meta-analysis to quantify the pathological complete response (pCR) rate after preoperative (chemo)radiation with doses of ⩾60Gy in patients with locally advanced rectal cancer. Complete response is relevant since this could select a proportion of patients for which organ-preserving strategies might be possible. Furthermore, we investigated correlations between EQD2 dose and pCR-rate, toxicity or resectability, and additionally between pCR-rate and chemotherapy, boost-approach or surgical-interval. METHODS AND MATERIALS PubMed, EMBASE and Cochrane libraries were searched with the terms 'radiotherapy', 'boost' and 'rectal cancer' and synonym terms. Studies delivering a preoperative dose of ⩾60 Gy were eligible for inclusion. Original English full texts that allowed intention-to-treat pCR-rate calculation were included. Study variables, including pCR, acute grade ⩾3 toxicity and resectability-rate, were extracted by two authors independently. Eligibility for meta-analysis was assessed by critical appraisal. Heterogeneity and pooled estimates were calculated for all three outcomes. Pearson correlation coefficients were calculated between the variables mentioned earlier. RESULTS The search identified 3377 original articles, of which 18 met our inclusion criteria (1106 patients). Fourteen studies were included for meta-analysis (487 patients treated with ⩾60 Gy). pCR-rate ranged between 0.0% and 44.4%. Toxicity ranged between 1.3% and 43.8% and resectability-rate between 34.0% and 100%. Pooled pCR-rate was 20.4% (95% CI 16.8-24.5%), with low heterogeneity (I2 0.0%, 95% CI 0.00-84.0%). Pooled acute grade ⩾3 toxicity was 10.3% (95% CI 5.4-18.6%) and pooled resectability-rate was 89.5% (95% CI 78.2-95.3%). CONCLUSION Dose escalation above 60 Gy for locally advanced rectal cancer results in high pCR-rates and acceptable early toxicity. This observation needs to be further investigated within larger randomized controlled phase 3 trials in the future.
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Affiliation(s)
| | | | - Martijn Intven
- Department of Radiation Oncology, University Medical Center, Utrecht, The Netherlands
| | - Marco van Vulpen
- Department of Radiation Oncology, University Medical Center, Utrecht, The Netherlands
| | | | - Onne Reerink
- Department of Radiation Oncology, University Medical Center, Utrecht, The Netherlands
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12
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Lapierre A, Martin F, Lapeyre M. [Intensity-modulated radiation therapy and stereotactic body radiation therapy for head and neck tumors: evidence-based medicine]. Cancer Radiother 2014; 18:468-72. [PMID: 25155467 DOI: 10.1016/j.canrad.2014.06.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 06/21/2014] [Accepted: 06/24/2014] [Indexed: 11/20/2022]
Abstract
Over the last decade, there have been many technical advances in radiation therapy, such as the spread of intensity-modulated conformal radiotherapy, and the rise of stereotactic body radiation therapy. By allowing better dose-to-target conformation and thus better organs at risk-sparing, these techniques seem very promising, particularly in the field of head and neck tumors. The present work aims at analyzing the level of evidence and recommendation supporting the use of high-technology radiotherapy in head and neck neoplasms, by reviewing the available literature.
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Affiliation(s)
- A Lapierre
- Service d'oncologie-radiothérapie, centre hospitalier Lyon Sud, 165, chemin du Grand-Revoyet, 69310 Pierre-Bénite, France.
| | - F Martin
- Département de radiothérapie, centre Jean-Perrin, 58, rue Montalembert, BP 392, 63011 Clermont-Ferrand cedex 1, France
| | - M Lapeyre
- Département de radiothérapie, centre Jean-Perrin, 58, rue Montalembert, BP 392, 63011 Clermont-Ferrand cedex 1, France
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13
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Beitler JJ, Zhang Q, Fu KK, Trotti A, Spencer SA, Jones CU, Garden AS, Shenouda G, Harris J, Ang KK. Final results of local-regional control and late toxicity of RTOG 9003: a randomized trial of altered fractionation radiation for locally advanced head and neck cancer. Int J Radiat Oncol Biol Phys 2014; 89:13-20. [PMID: 24613816 PMCID: PMC4664465 DOI: 10.1016/j.ijrobp.2013.12.027] [Citation(s) in RCA: 143] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Revised: 12/12/2013] [Accepted: 12/14/2013] [Indexed: 11/12/2022]
Abstract
PURPOSE To test whether altered radiation fractionation schemes (hyperfractionation [HFX], accelerated fractionation, continuous [AFX-C], and accelerated fractionation with split [AFX-S]) improved local-regional control (LRC) rates for patients with squamous cell cancers (SCC) of the head and neck when compared with standard fractionation (SFX) of 70 Gy. METHODS AND MATERIALS Patients with stage III or IV (or stage II base of tongue) SCC (n=1076) were randomized to 4 treatment arms: (1) SFX, 70 Gy/35 daily fractions/7 weeks; (2) HFX, 81.6 Gy/68 twice-daily fractions/7 weeks; (3) AFX-S, 67.2 Gy/42 fractions/6 weeks with a 2-week rest after 38.4 Gy; and (4) AFX-C, 72 Gy/42 fractions/6 weeks. The 3 experimental arms were to be compared with SFX. RESULTS With patients censored for LRC at 5 years, only the comparison of HFX with SFX was significantly different: HFX, hazard ratio (HR) 0.79 (95% confidence interval 0.62-1.00), P=.05; AFX-C, 0.82 (95% confidence interval 0.65-1.05), P=.11. With patients censored at 5 years, HFX improved overall survival (HR 0.81, P=.05). Prevalence of any grade 3, 4, or 5 toxicity at 5 years; any feeding tube use after 180 days; or feeding tube use at 1 year did not differ significantly when the experimental arms were compared with SFX. When 7-week treatments were compared with 6-week treatments, accelerated fractionation appeared to increase grade 3, 4 or 5 toxicity at 5 years (P=.06). When the worst toxicity per patient was considered by treatment only, the AFX-C arm seemed to trend worse than the SFX arm when grade 0-2 was compared with grade 3-5 toxicity (P=.09). CONCLUSIONS At 5 years, only HFX improved LRC and overall survival for patients with locally advanced SCC without increasing late toxicity.
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Affiliation(s)
- Jonathan J Beitler
- Winship Cancer Institute of Emory University School of Medicine, Atlanta, Georgia.
| | - Qiang Zhang
- Radiation Therapy Oncology Group Statistical Center, Philadelphia, Pennsylvania
| | - Karen K Fu
- University of California San Francisco, San Francisco, California
| | - Andy Trotti
- H. Lee Moffitt Cancer Center at the University of South Florida, Tampa, Florida
| | - Sharon A Spencer
- University of Alabama at Birmingham Medical Center, Birmingham, Alabama
| | | | - Adam S Garden
- MD Anderson Cancer Center, University of Texas, Houston, Texas
| | | | - Jonathan Harris
- Radiation Therapy Oncology Group Statistical Center, Philadelphia, Pennsylvania
| | - Kian K Ang
- MD Anderson Cancer Center, University of Texas, Houston, Texas
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14
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Final results of a phase II single-institutional trial with hyperfractionated radiation therapy (HFX) and four-weekly continuous cisplatin in locally advanced head and neck carcinoma. Clin Transl Oncol 2013; 16:555-60. [PMID: 24203760 DOI: 10.1007/s12094-013-1118-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2013] [Accepted: 09/23/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND To evaluate the efficacy and toxicity of hyperfractionated radiation therapy and continuous infusion of cisplatin on weeks 1 and 5 in locally advanced head and neck carcinoma. METHODS There were 53 patients: 3 (5.7 %) T2 patients, 31 T3 patients (58.4 %), and 19 T4 patients (35.8 %). Forty-one patients (77.4 %) were N-positive. According to the AJCC, 40 (75.4 %) patients had stage IV and the rest stage III. Treatment consisted of hyperfractionated radiation therapy, 120 cGy bid to a dose of 76.8-81.6 Gy, and cisplatin 20 mg/m(2)/day administered by continuous infusion over 120 h during days 1-5 and 21-25 of radiation therapy. RESULTS Tumor response and toxicity There were 40 (75.5 %) complete responses, 6 partial responses (11.3 %), and 5 (9.4 %) non-responses or progression. Two patients were non-evaluable for response due to toxic death. All patients had some acute toxicity grade, the most frequent being mucositis (grade 3-4 in 33 patients) and epithelitis (grade 3-4 in 30 patients). Regarding late toxicity, only 2/24 long-term survivors had tracheostomy, and none of them needed enteral nutrition. Survival and local control With a median follow-up of 66 months, the 5-year overall survival rate for all the series was 49.1 % (95 % CI 58.9-39.3 %) with a median survival duration of 32.83 months. Five-year local control was 68.4 % (95 % CI 81.3-55.5 %). CONCLUSIONS Hyperfractionated radiation therapy and continuous infusion of cisplatin during weeks 1 and 5 are an active treatment in patients with LAHNC. Nevertheless, new strategies are necessary to increase the local control rates and reduce the incidence of distant metastasis and second tumors.
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15
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Giraud P, Servagi-Vernat S. [IMRT and head and neck tumors: does differential fractionation have a role?]. Cancer Radiother 2013; 17:502-7. [PMID: 23969241 DOI: 10.1016/j.canrad.2013.05.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 05/25/2013] [Indexed: 11/19/2022]
Abstract
For head and neck cancer, intensity-modulated radiation therapy (IMRT) provides benefits in terms of coverage of the target tumour volume and reduction of the dose to organs at risk. Altered fractionation called SMART (simultaneous modulated accelerated radiation therapy) or SIB (simultaneous integrated boost), equivalent to the "concomitant boost" of conventional techniques, provides additional theoretical gain in the therapeutic index and simplifies the practical implementation of the treatment. The impact on tumour control and acute and late toxicities is encouraging but needs to be confirmed by prospective clinical studies with sufficient follow-up. A lot of different protocols have been tested without really bringing out a "gold standard". However, the current results tend to suggest a SIB/SMART-IMRT moderately accelerated without combined chemotherapy for limited stages (I and II), and SIB-IMRT slightly accelerated with induction and/or concomitant chemotherapy for more advanced stages (III and IV).
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Affiliation(s)
- P Giraud
- Service d'oncologie-radiothérapie, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France; Université Paris Descartes, Sorbonne Paris-Cité , 75015 Paris, France.
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16
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Comparison of concomitant boost radiotherapy against concurrent chemoradiation in locally advanced oropharyngeal cancers: a phase III randomised trial. Radiother Oncol 2013; 107:317-24. [PMID: 23746674 DOI: 10.1016/j.radonc.2013.05.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 05/14/2013] [Accepted: 05/14/2013] [Indexed: 11/21/2022]
Abstract
PURPOSE To test the toxicity and efficacy of concomitant boost radiotherapy alone against concurrent chemoradiation (conventional fractionation) in locally advanced oropharyngeal cancer in our patient population. METHODS AND MATERIALS In this open-label, randomised trial, 216 patients with histologically proven Stage III-IVA oropharyngeal cancer were randomly assigned between June 2006 and December 2010 to receive either chemoradiation (CRT) to a dose of 66 Gy in 33 fractions over 6.5 weeks with concurrent cisplatin (100 mg/m(2) on days 1, 22 and 43) or accelerated radiotherapy with concomitant boost (CBRT) to a dose of 67.5 Gy in 40 fractions over 5 weeks. The compliance, toxicity and quality of life were investigated. Disease-free survival (DFS) and overall survival (OS) curves were estimated with the Kaplan-Meier method and compared using log rank test. RESULTS The compliance to radiotherapy was superior in concomitant boost with lesser treatment interruptions (p=0.004). Expected acute toxicities were significantly higher in CRT, except for grade 3/4 mucositis which was seen more in CBRT arm (39% and 55% in CRT and CBRT, respectively; p=0.02). Late toxicities like Grade 3 xerostomia were significantly high in CRT arm than CBRT arm (33% versus 18%; p<0.0001). The quality of life was significantly poor in CRT arm at all follow up visits (p<0.0001). The rates of 2 year disease-free survival were similar with 56% in the chemoradiotherapy group and 61% in CBRT group (p=0.2; HR-0.81, 95%CI-0.53-1.2). Subgroup analysis revealed that patients with nodal size >2 cm had significantly better DFS with CRT (p=0.05; HR-1.59, 95%CI-0.93-2.7). CONCLUSION In selected patients of locally advanced oropharyngeal cancer, concomitant boost offers a better compliance, toxicity profile and quality of life with similar disease control, than chemoradiation.
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de Almeida JR, Genden EM. Robotic assisted reconstruction of the oropharynx. Curr Opin Otolaryngol Head Neck Surg 2012; 20:237-45. [DOI: 10.1097/moo.0b013e328354c24e] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
PURPOSE OF REVIEW To revisit the biologic rationale, the clinical methodology, the outcome and perspectives of altered fractionation in head and neck oncology. RECENT FINDINGS Various prospective trials and meta-analyses clearly underline the major benefit patients with locally advanced disease draw from hyperfractionation and the need for an adequate selection of time-dose factors to optimize therapeutic index for accelerated regimens. In addition, the advent of high-precision techniques such as intensity-modulated radiation therapy is bound to favor the development of more intensive regimens of irradiation in the management of locally advanced head and neck squamous cell carcinomas. SUMMARY Altered fractionation, both as stand-alone strategy or as part of approaches combining radiation to systemic treatments, is offering a lot of opportunities to the radiation oncologist. Its role is likely to gain ground in all high-risk patients not amenable to systemic treatments, or for whom the high toxicity of chemotherapy is not justified, in case, for instance, of intermediate-risk disease.
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Effect of radiotherapy and chemotherapy on the risk of mucositis during intensity-modulated radiation therapy for oropharyngeal cancer. Int J Radiat Oncol Biol Phys 2011; 83:235-42. [PMID: 22104358 DOI: 10.1016/j.ijrobp.2011.06.2000] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2010] [Revised: 05/18/2011] [Accepted: 06/29/2011] [Indexed: 11/23/2022]
Abstract
PURPOSE To define the roles of radiotherapy and chemotherapy on the risk of Grade 3+ mucositis during intensity-modulated radiation therapy (IMRT) for oropharyngeal cancer. METHODS AND MATERIALS 164 consecutive patients treated with IMRT at two institutions in nonoverlapping treatment eras were selected. All patients were treated with a dose painting approach, three dose levels, and comprehensive bilateral neck treatment under the supervision of the same radiation oncologist. Ninety-three patients received concomitant chemotherapy (cCHT) and 14 received induction chemotherapy (iCHT). Individual information of the dose received by the oral mucosa (OM) was extracted as absolute cumulative dose-volume histogram (DVH), corrected for the elapsed treatment days and reported as weekly (w) DVH. Patients were seen weekly during treatment, and peak acute toxicity equal to or greater than confluent mucositis at any point during the course of IMRT was considered the endpoint. RESULTS Overall, 129 patients (78.7%) reached the endpoint. The regions that best discriminated between patients with/without Grade 3+ mucositis were found at 10.1 Gy/w (V10.1) and 21 cc (D21), along the x-axis and y-axis of the OM-wDVH, respectively. On multivariate analysis, D21 (odds ratio [OR] = 1.016, 95% confidence interval [CI], 1.009-1.023, p < 0.001) and cCHT (OR = 4.118, 95% CI, 1.659-10.217, p = 0.002) were the only independent predictors. However, V10.1 and D21 were highly correlated (rho = 0.954, p < 0.001) and mutually interchangeable. cCHT would correspond to 88.4 cGy/w to at least 21 cc of OM. CONCLUSIONS Radiotherapy and chemotherapy act independently in determining acute mucosal toxicity; cCHT increases the risk of mucosal Grade 3 toxicity ≈4 times over radiation therapy alone, and it is equivalent to an extra ≈6.2 Gy to 21 cc of OM over a 7-week course.
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Cartmill B, Cornwell P, Ward E, Davidson W, Porceddu S. Swallowing, nutrition and patient-rated functional outcomes at 6 months following two non-surgical treatments for T1-T3 oropharyngeal cancer. Support Care Cancer 2011; 20:2073-81. [PMID: 22081206 DOI: 10.1007/s00520-011-1316-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Accepted: 11/01/2011] [Indexed: 01/09/2023]
Abstract
PURPOSE Altered fractionation radiotherapy with concomitant boost (AFRT-CB) may be considered an alternative treatment for patients not appropriate for chemoradiation (CRT). As functional outcomes following AFRT-CB have been minimally reported, this exploratory paper describes the outcomes of patients managed with AFRT-CB or CRT at 6 months post-treatment. METHODS Using a cross-sectional analysis design, functional outcomes of 14 AFRT-CB and 17 CRT patients with T1-T3 oropharyngeal cancers were explored at 6 months post-treatment. Clinical and instrumental swallow assessments, weight and nutritional status, and the functional impact of treatment were examined. RESULTS Inferior outcomes were observed for the CRT patients on the RBHOMS (p = 0.03) which was reflected in diet and fluid restrictions with 18% of the CRT group requiring modified fluids and diets. Although a trend (p = 0.07) was noted for increased lingual deficits and aspiration risk for fluids in the CRT group, no other significant differences were observed. Both groups experienced an average of 10 kg weight loss and reported reduced general and swallowing-related function. CONCLUSIONS These preliminary data suggest functional outcomes following AFRT-CB and CRT were largely comparable at 6 months post-treatment. Treatment intensification in any form may contribute to impaired function which requires multidimensional intervention. Larger cohort investigations with systematic methodology are needed to further examine these initial findings.
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Affiliation(s)
- Bena Cartmill
- Division of Speech Pathology, The University of Queensland and Speech Pathology Department, Princess Alexandra Hospital, Woolloongabba, QLD, Australia.
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Corry J, Rischin D, Cotton S, D'Costa I, Chua M, Vallance N, Lyons B, Kleid S, Sizeland A, Peters LJ. Larynx preservation with primary non-surgical treatment for loco-regionally advanced larynx cancer. J Med Imaging Radiat Oncol 2011; 55:229-35. [PMID: 21501415 DOI: 10.1111/j.1754-9485.2011.02256.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The objective of this paper was to review the results of primary non-surgical treatment with the aim of larynx preservation for loco-regionally advanced larynx cancer (LALC). METHODS All patients with LALC presenting between January 2002 and December 2006 who were selected for primary non-surgical treatment were included in this study. RESULTS There were 60 patients, 48% with stage III and 52% with stage IV disease. The median follow-up of living patients was 41 months. Larynx preservation with local disease control was achieved in 83% and 77% of patients at 3 and 5 years, respectively. Failure-free survival at 3 and 5 years was 66% and 59%, respectively, and overall survival was 67% and 45%, respectively. All patients with larynx preservation had a functional voice. Two patients became feeding tube dependant. Thirty-nine percent of all deaths were unrelated to LALC. CONCLUSIONS Primary non-surgical treatment achieves high rates of larynx preservation with a low rate of severe complications but overall survival remains disappointing.
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Affiliation(s)
- June Corry
- Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia. June
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Bruzzaniti V, Abate A, Pedrini M, Benassi M, Strigari L. IsoBED: a tool for automatic calculation of biologically equivalent fractionation schedules in radiotherapy using IMRT with a simultaneous integrated boost (SIB) technique. JOURNAL OF EXPERIMENTAL & CLINICAL CANCER RESEARCH : CR 2011; 30:52. [PMID: 21554675 PMCID: PMC3117739 DOI: 10.1186/1756-9966-30-52] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Accepted: 05/09/2011] [Indexed: 12/22/2022]
Abstract
Background An advantage of the Intensity Modulated Radiotherapy (IMRT) technique is the feasibility to deliver different therapeutic dose levels to PTVs in a single treatment session using the Simultaneous Integrated Boost (SIB) technique. The paper aims to describe an automated tool to calculate the dose to be delivered with the SIB-IMRT technique in different anatomical regions that have the same Biological Equivalent Dose (BED), i.e. IsoBED, compared to the standard fractionation. Methods Based on the Linear Quadratic Model (LQM), we developed software that allows treatment schedules, biologically equivalent to standard fractionations, to be calculated. The main radiobiological parameters from literature are included in a database inside the software, which can be updated according to the clinical experience of each Institute. In particular, the BED to each target volume will be computed based on the alpha/beta ratio, total dose and the dose per fraction (generally 2 Gy for a standard fractionation). Then, after selecting the reference target, i.e. the PTV that controls the fractionation, a new total dose and dose per fraction providing the same isoBED will be calculated for each target volume. Results The IsoBED Software developed allows: 1) the calculation of new IsoBED treatment schedules derived from standard prescriptions and based on LQM, 2) the conversion of the dose-volume histograms (DVHs) for each Target and OAR to a nominal standard dose at 2Gy per fraction in order to be shown together with the DV-constraints from literature, based on the LQM and radiobiological parameters, and 3) the calculation of Tumor Control Probability (TCP) and Normal Tissue Complication Probability (NTCP) curve versus the prescribed dose to the reference target.
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Affiliation(s)
- Vicente Bruzzaniti
- Laboratory of Medical Physics and Expert System, Regina Elena Cancer Institute, Rome, Italy.
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Cartmill B, Cornwell P, Ward E, Davidson W, Porceddu S. A prospective investigation of swallowing, nutrition, and patient-rated functional impact following altered fractionation radiotherapy with concomitant boost for oropharyngeal cancer. Dysphagia 2011; 27:32-45. [PMID: 21344190 DOI: 10.1007/s00455-011-9333-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2010] [Accepted: 01/22/2011] [Indexed: 11/30/2022]
Abstract
Altered fractionation radiotherapy for head and neck cancer has been associated with improved locoregional control, overall survival, and heightened toxicity compared with conventional treatment. Swallowing, nutrition, and patient-perceived function for altered fractionation radiotherapy with concomitant boost (AFRT-CB) for T1-T3 oropharyngeal squamous cell carcinoma (SCC) have not been previously reported. Fourteen consecutive patients treated with AFRT-CB for oropharyngeal SCC were recruited from November 2006 to August 2009 in a tertiary hospital in Brisbane, Australia. Swallowing, nutrition, and patient-perceived functional impact assessments were conducted pretreatment, at 4-6 weeks post-treatment, and at 6 months post-treatment. Deterioration from pretreatment to 4-6 weeks post-treatment in swallowing, nutrition, and functional impact was evident, likely due to the heightened toxicity associated with AFRT-CB. There was significant improvement at 6 months post-treatment in functional swallowing, nutritional status, patient-perceived swallowing, and overall function, consistent with recovery from acute toxicity. However, weight and patient perception of physical function and side effects remained significantly worse than pretreatment scores. The ongoing deficits related to weight and patient-perceived outcomes at 6 months revealed that this treatment has a long-term impact on function possibly related to the chronic effects of AFRT-CB.
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Affiliation(s)
- Bena Cartmill
- Speech Pathology Department, Princess Alexandra Hospital, Australia.
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Hittelman WN, Liao Y, Wang L, Milas L. Are cancer stem cells radioresistant? Future Oncol 2011; 6:1563-76. [PMID: 21062156 DOI: 10.2217/fon.10.121] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Based on findings that cancer cell clonogens exhibit stem cell features, it has been suggested that cancer stem-like cells are relatively radioresistant owing to different intrinsic and extrinsic factors, including quiescence, activated radiation response mechanisms (e.g., enhanced DNA repair, upregulated cell cycle control mechanisms and increased free-radical scavengers) and a surrounding microenvironment that enhances cell survival mechanisms (e.g., hypoxia and interaction with stromal elements). However, these radiosensitivity features are probably dynamic in nature and come into play at different times during the course of chemo/radiotherapy. Therefore, different molecularly targeted radiosensitization strategies may be needed at different stages of therapy. This article describes potential sensitization approaches based on the dynamics and changing properties of cancer stem-like cells during therapy.
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Affiliation(s)
- Walter N Hittelman
- Department of Experimental Therapeutics - 019, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA.
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Pretreatment prognostic factors of survival in patients with locally advanced nonmetastatic squamous cell carcinoma of the head and neck treated with radiation therapy with or without concurrent chemotherapy. Am J Clin Oncol 2009; 32:163-8. [PMID: 19307954 DOI: 10.1097/coc.0b013e31818254cc] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Identification of pretreatment prognostic factors influencing overall survival (OS) in locally advanced squamous cell carcinoma of the head and neck is an important issue in head and neck oncology. METHODS A total of 289 patients were treated with standard fraction or hyperfractionated radiation therapy with or without concurrent low-dose daily chemotherapy. RESULTS Gender (P = 0.43) and age (P = 0.26) did not influence OS whereas Karnofsky Performance Status (KPS) (P < 0.0001), T stage (P < 0.0001), and N stage (P < 0.0001) did. Stage grouping was another factor that influenced OS (P < 0.001). Patients with larynx and nasopharynx fared better than those with other primaries (P = 0.0153). Finally, treatment significantly influenced OS. Multivariate analysis showed that KPS, T and N stage, and treatment were independent prognosticators of OS. CONCLUSIONS KPS, T and N stage, and treatment are independent prognosticators of OS in patients with locally advanced squamous cell carcinoma of the head and neck treated with radiation therapy with or without concurrent low-dose daily chemotherapy.
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Kies MS, Holsinger FC, Lee JJ, William WN, Glisson BS, Lin HY, Lewin JS, Ginsberg LE, Gillaspy KA, Massarelli E, Byers L, Lippman SM, Hong WK, El-Naggar AK, Garden AS, Papadimitrakopoulou V. Induction chemotherapy and cetuximab for locally advanced squamous cell carcinoma of the head and neck: results from a phase II prospective trial. J Clin Oncol 2009; 28:8-14. [PMID: 19917840 DOI: 10.1200/jco.2009.23.0425] [Citation(s) in RCA: 177] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To determine the potential efficacy of combining cetuximab with chemotherapy in patients with advanced nodal disease, we conducted a phase II trial with induction chemotherapy (ICT) consisting of six weekly cycles of paclitaxel 135 mg/m(2) and carboplatin (area under the curve = 2) with cetuximab 400 mg/m(2) in week 1 and then 250 mg/m(2) (PCC). PATIENTS AND METHODS Forty-seven previously untreated patients (41 with oropharynx primaries; 33 men, 14 women; median age, 53 years; performance status of 0 or 1) with squamous cell carcinoma of the head and neck (SCCHN; T1-4, N2b/c/3) were treated and evaluated for clinical and radiographic response. After ICT, patients underwent risk-based local therapy, which consisted of either radiation, concomitant chemoradiotherapy, or surgery, based on tumor stage and site at diagnosis. Results After induction PCC, nine patients (19%) achieved a complete response, and 36 patients (77%) achieved a partial response. The most common grade 3 or 4 toxicity was skin rash (45%), followed by neutropenia (21%) without fever. At a median follow-up time of 33 months, locoregional or systemic disease progression was observed in six patients. The 3-year progression-free survival (PFS) and overall survival (OS) rates were 87% (95% CI, 78% to 97%) and 91% (95% CI, 84% to 99%), respectively. Human papillomavirus (HPV) 16, found in 12 (46%) of 26 biopsies, was associated with improved PFS (P = .012) and OS (P = .046). CONCLUSION ICT with weekly PCC followed by risk-based local therapy seems to be feasible, effective, and well tolerated. PFS is promising, and this sequential treatment strategy should be further investigated. Patients with HPV-positive tumors have an excellent prognosis.
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Affiliation(s)
- Merrill S Kies
- Departments of Thoracic/Head and Neck Medical Oncology, Head and Neck Surgery, Radiation Oncology, Biostatistics, Radiology, and Pathology, The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA.
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Pretreatment Prognostic Factors Influencing Distant Metastasis-Free Survival in Locally Advanced Squamous Cell Carcinoma of the Head and Neck Treated With Radiation Therapy With or Without Concurrent Chemotherapy. Am J Clin Oncol 2009; 32:483-7. [DOI: 10.1097/coc.0b013e3181942a3b] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Cancer stem cells and tumor response to therapy: current problems and future prospects. Semin Radiat Oncol 2009; 19:96-105. [PMID: 19249647 DOI: 10.1016/j.semradonc.2008.11.004] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The presence of a subpopulation of cells within tumors, so-called cancer stemlike cells, that is uniquely capable of reestablishing the tumor during and after definitive radio(chemo)therapy and must be effectively controlled for a long-term cure is being increasingly appreciated. The existence and physiology of a rare cancer cell population, termed cancer cell clonogens, with similar properties has been extensively described in the radiobiology literature for several decades based on studies using tumor cells transplanted into syngeneic or immunodeficient animals. The earlier studies have identified important features that govern tumor establishment; tumor growth and homeostasis; and therapeutic resistance, including clonogen number, tumor type, vascular status, hypoxia, repopulation dynamics during treatment, and immunologic and microenvironmental status. These discoveries led to therapeutic strategies, some of which have shown efficacy and have become current standard clinical practice (eg, concomitant boost and concurrent radio chemotherapy). Although the identity of cancer stemlike cells and cancer cell clonogens has not been definitively shown, recent characterization of molecular signaling pathways controlling stem cells and their microenvironmental niche combined with the earlier findings on clonogen physiology may now lead to the development of molecularly targeted strategies to overcome therapeutic resistance of this rare subpopulation of tumor cells. Along these lines, we describe 3 unique treatment settings (ie, before, during, and after definitive radio[chemo]therapy) in which molecularly targeted approaches might specifically counteract cancer stemlike cell resistance mechanisms and enhance the curative efficiency of radio(chemo)therapy.
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Orlandi E, Palazzi M, Pignoli E, Fallai C, Giostra A, Olmi P. Radiobiological basis and clinical results of the simultaneous integrated boost (SIB) in intensity modulated radiotherapy (IMRT) for head and neck cancer: A review. Crit Rev Oncol Hematol 2009; 73:111-25. [PMID: 19409808 DOI: 10.1016/j.critrevonc.2009.03.003] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2008] [Revised: 12/30/2008] [Accepted: 03/05/2009] [Indexed: 11/24/2022] Open
Abstract
The simultaneous integrated boost (SIB)-IMRT technique allows the simultaneous delivery of different dose levels to different target volumes within a single treatment fraction. The most significant aspect associated with SIB-IMRT is related to the fractionation strategy, concerning two time-dose parameters: (1) the shortening of the overall treatment time (OTT); (2) the increase of fraction size (FS) to the boost volume. The SIB-IMRT technique represents, therefore, a new way to investigate the accelerated fractionation in definitive treatment of head and neck (H&N) cancers. The aims of this paper are the following: (1) to briefly review the influence of OTT and FS on H&N tumors and on acutely and late responding normal tissues; (2) to review the results of clinical studies of accelerated radiotherapy not employing IMRT in H&N cancer; (3) to review the clinical experiences of the SIB-IMRT technique and to compare the different SIB regimes in terms of radiobiological efficacy.
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Affiliation(s)
- Ester Orlandi
- Fondazione IRCCS, Istituto Nazionale dei Tumori, Milan, Italy.
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Ghoshal S, Goda JS, Mallick I, Kehwar TS, Sharma SC. Concomitant boost radiotherapy compared with conventional radiotherapy in squamous cell carcinoma of the head and neck--a phase III trial from a single institution in India. Clin Oncol (R Coll Radiol) 2008; 20:212-20. [PMID: 18343310 DOI: 10.1016/j.clon.2008.01.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2007] [Revised: 01/22/2008] [Accepted: 01/30/2008] [Indexed: 11/29/2022]
Abstract
AIMS To test the efficacy of an accelerated fractionation schedule (concomitant boost) against standard conventional fractionation in squamous cell carcinomas of the head and neck region in our patient population. MATERIALS AND METHODS Patients were randomised to receive either conventional radiotherapy with 2 Gy/fraction/day, to a dose of 66 Gy in 33 fractions over 6.5 weeks or accelerated radiotherapy in the form of concomitant boost to a dose of 67.5 Gy/40 fractions over 5 weeks (phase 1: 45 Gy/25 fractions/5 weeks and phase 2: 22.5 Gy/15 fractions/3 weeks as a second daily fraction after a 6h gap). The primary and secondary end points were disease-free survival and locoregional control respectively. RESULTS The compliance was 97.2% and 96.5% in the concomitant boost and conventional arms, respectively. Patients treated with concomitant boost had a better 2-year disease-free survival (71.7% vs 52.17%, P=0.0007) and locoregional control rates (73.6% vs 54.5%, P=0.0006) than with conventional fractionation. On exploratory subgroup analysis, the oropharynx (P<0.001), T4 lesions (P=0.017), N+ disease (P<0.001) and stage IV disease (P<0.001) were statistically significant prognostic variables in favour of the concomitant boost arm. Grade 3 mucositis was seen in 35% of patients in the concomitant boost arm, whereas in the conventional arm only 19% of patients had grade 3 mucositis (P=0.01). The median radiotherapy duration in the concomitant boost arm was 36 days (range 36-53 days), whereas in the conventional arm it was 46 days (range 46-64 days). The mean gap in radiation treatment in the concomitant boost arm was 1.68 days (range 0-14 days), whereas the mean gap in the conventional arm was 1.58 days (range 0-14 days). CONCLUSIONS Concomitant boost is a therapeutically superior and logistically feasible accelerated radiotherapy regimen in advanced head and neck cancers, especially in the setting of a developing country.
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Affiliation(s)
- S Ghoshal
- Post Graduate Institute of Medical Education and Research, Chandigarh, India.
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Strigari L, D'Andrea M, Abate A, Benassi M. A heterogeneous dose distribution in simultaneous integrated boost: the role of the clonogenic cell density on the tumor control probability. Phys Med Biol 2008; 53:5257-73. [PMID: 18758004 DOI: 10.1088/0031-9155/53/19/001] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
IMRT with inverse planning allows simultaneous integrated boost strategies that exploit the heterogeneous dose distribution within the planning target volumes (PTVs). In this scenario, the location of cold spots within the target becomes a crucial issue and has to be related to the distribution of the clonogenic cell density (CCD). The main aim of this work is to provide the means to calculate the optimal prescription dose in a relative inhomogeneous dose distribution. To achieve this, the prescription dose has to be assigned to obtain the same tumor control probability (TCP) as the ideal homogeneous distribution, taking into account different CCDs in different PTVs (i.e. visible and subclinical regions). An adapted formulation of the linear-quadratic model, within the F-factor formalism, has been derived to preserve a chosen TCP value for the whole target volume. The F-factor has been investigated to show its potential applications in clinical practice.
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Affiliation(s)
- L Strigari
- Laboratory of Medical Physics and Expert Systems, Regina Elena National Cancer Institute, Rome, Italy.
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Pretreatment Prognostic Factors of Local Recurrence-Free Survival in Locally Advanced Squamous Cell Carcinoma of the Head and Neck Treated With Radiation Therapy With or Without Concurrent Chemotherapy. Am J Clin Oncol 2008; 31:213-8. [DOI: 10.1097/coc.0b013e318161dbef] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Strojan P, Karner K, Smid L, Soba E, Fajdiga I, Jancar B, Anicin A, Budihna M, Zakotnik B. concomitant chemoradiotherapy with mitomycin C and cisplatin in advanced unresectable carcinoma of the head and neck: phase I-II clinical study. Int J Radiat Oncol Biol Phys 2008; 72:365-72. [PMID: 18394816 DOI: 10.1016/j.ijrobp.2007.12.060] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2007] [Revised: 12/20/2007] [Accepted: 12/20/2007] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate the toxicity and efficacy of concomitant chemoradiotherapy with mitomycin C and cisplatin in the treatment of advanced unresectable squamous cell carcinoma of the head and neck. PATIENTS AND METHODS Treatment consisted of conventional radiotherapy (70 Gy in 35 fractions), mitomycin C 15 mg/m(2) IV, applied after the delivery of 10 Gy, and cisplatin at an initial dose of 10 mg/m(2)/d IV, applied during the last 10 fractions of irradiation ("chemoboost"). The cisplatin dose was escalated with respect to the toxic side effects by 2 mg/m(2)/d up to the maximum tolerated dose (MTD) or at the most 14 mg/m(2)/d (Phase I study), which was tested in the subsequent Phase II study. RESULTS All 36 patients had Stage T4 and/or N3 disease, and the majority had oropharyngeal (50%) or hypopharyngeal (39%) primary tumors. Six patients were treated at each of the three cisplatin dose levels tested (Phase I study). Dose-limiting toxicity was not reached even at 14 mg/m(2)/d of cisplatin, which was determined as the MTD and tested in an additional 18 patients (Phase II study). After a median follow-up time of 48 months, 4-year locoregional control, failure-free, and overall survival rates were 30%, 14%, and 20%, respectively. In 24 patients treated at the cisplatin dose level of 14 mg/m(2)/d, the corresponding rates were 40%, 20%, and 22%, respectively. CONCLUSION Concomitant chemoradiotherapy with mitomycin C and cisplatin "chemoboost" at 14 mg/m(2)/d is feasible, with encouraging survival results if the extremely poor disease profile of the treated patients is considered.
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Affiliation(s)
- Primoz Strojan
- Department of Radiation Oncology, Institute of Oncology, Ljubljana, Slovenia.
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de Andrade RS, Heron DE. Radiation Treatment Planning for Head and Neck Malignancies. PET Clin 2007; 2:511-9. [DOI: 10.1016/j.cpet.2008.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Elting LS, Cooksley CD, Chambers MS, Garden AS. Risk, outcomes, and costs of radiation-induced oral mucositis among patients with head-and-neck malignancies. Int J Radiat Oncol Biol Phys 2007; 68:1110-20. [PMID: 17398022 DOI: 10.1016/j.ijrobp.2007.01.053] [Citation(s) in RCA: 319] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2006] [Revised: 01/19/2007] [Accepted: 01/21/2007] [Indexed: 01/02/2023]
Abstract
PURPOSE To study the risk, outcomes, and costs of radiation-induced oral mucositis (OM) among patients receiving radiotherapy (RT) to head and neck primary cancers. METHODS AND MATERIALS A retrospective cohort consisting of 204 consecutive head-and-neck cancer patients who received RT with or without chemotherapy during 2002 was formed; their records were reviewed for clinical and resource use information. Patients who had received prior therapy, had second primary cancers, or received palliative radiation therapy were excluded. The risk of OM was analyzed by multiple variable logistic regression. The cost of care was computed from the provider's perspective in 2006 U.S. dollars and compared among patients with and without OM. RESULTS Oral mucositis occurred in 91% of patients; in 66% it was severe (Grade 3-4). Oral mucositis was more common among patients with oral cavity or oropharynx primaries (odds ratio [OR], 44.5; 95% confidence interval [CI], 5.2 to >100; p < 0.001), those who received chemotherapy (OR = 7.8; 95% CI, 1.5-41.6; p = 0.02), and those who were treated with altered fractionation schedules (OR = 6.3; 95% CI, 1.1-35.1; p = 0.03). Patients with OM were significantly more likely to have severe pain (54% vs. 6%; p < 0.001) and a weight loss of > or =5% (60% vs. 17%; p < 0.001). Oral mucositis was associated with an incremental cost of $1700-$6000, depending on the grade. CONCLUSIONS Head-and-neck RT causes OM in virtually all patients. Oral mucositis is associated with severe pain, significant weight loss, increased resource use, and excess cost. Preventive strategies are needed.
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Affiliation(s)
- Linda S Elting
- Section of Health Services Research, Department of Biostatistics, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
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Garden AS, Morrison WH, Wong PF, Tung SS, Rosenthal DI, Dong L, Mason B, Perkins GH, Ang KK. Disease-control rates following intensity-modulated radiation therapy for small primary oropharyngeal carcinoma. Int J Radiat Oncol Biol Phys 2006; 67:438-44. [PMID: 17141972 PMCID: PMC4125020 DOI: 10.1016/j.ijrobp.2006.08.078] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2006] [Revised: 08/30/2006] [Accepted: 08/31/2006] [Indexed: 11/16/2022]
Abstract
BACKGROUND The purpose of this study was to assess the ability of intensity-modulated radiation therapy (IMRT) to achieve favorable disease-control rates while minimizing parotid gland doses in patients treated for small primary tumors of the oropharynx. METHODS AND MATERIALS We retrospectively identified all patients who received IMRT as treatment for a small (<4 cm) primary tumor of the oropharynx between October 2000 and June 2002. Tumor characteristics, IMRT parameters, and patient outcomes were assessed. RESULTS Fifty-one patients met the criteria for our study. All patients had treatment to gross disease with margin (CTV1), and all but 1 had treatment to the bilateral necks. The most common treatment schedule (39 patients) was a once-daily fractionation of prescribed doses of 63-66 Gy to the CTV1 and 54 Gy to subclinical sites, delivered in 30 fractions. Twenty-one patients (40%) had gastrostomy tubes placed during therapy; in 4 patients, the tube remained in place for more than 6 months after completion of IMRT. The median follow-up was 45 months. The 2-year actuarial locoregional control, recurrence-free, and overall survival rates were 94%, 88%, and 94%, respectively. CONCLUSIONS These preliminary data suggest that treatment with IMRT results in favorable locoregional control of small primary oropharynx tumors. IMRT did not appear to have a more favorable acute toxicity profile in this group with respect to the use of a feeding tube; however, the mean dose of radiation delivered to the parotid gland by IMRT was decreased, because 95% of patients had a mean dose of <30 Gy to at least one gland.
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Affiliation(s)
- Adam S Garden
- Division of Radiation Oncology, The University of Texas M D Anderson Cancer Center, Houston, TX 77030, USA.
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Bangalore M, Matthews S, Suntharalingam M. Recent Advances in Radiation Therapy for Head and Neck Cancer. ORL J Otorhinolaryngol Relat Spec 2006; 69:1-12. [PMID: 17085946 DOI: 10.1159/000096710] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2005] [Accepted: 05/26/2005] [Indexed: 11/19/2022]
Abstract
The treatment of locally advanced or recurrent head and neck cancers has improved from single modality interventions of surgery and radiation therapy alone to include combined modality therapy with surgery, chemotherapy and radiation. Combined therapy has led to improved local control and disease-free survival. New developments in radiation oncology such as altered fractionation, three-dimensional conformal radiotherapy, intensity-modulated radiotherapy, stereotactic radiosurgery, fractionated stereotactic radiotherapy, charged-particle radiotherapy, neutron-beam radiotherapy, and brachytherapy have helped to improve this outlook even further. These recent advances allow for a higher dose to be delivered to the tumor while minimizing the dose delivered to the surrounding normal tissue. This article provides an update of the new developments in radiotherapy in the management of head and neck cancers.
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Sanguineti G, Endres EJ, Gunn BG, Parker B. Is there a “mucosa-sparing” benefit of IMRT for head-and-neck cancer? Int J Radiat Oncol Biol Phys 2006; 66:931-8. [PMID: 17011465 DOI: 10.1016/j.ijrobp.2006.05.060] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2006] [Revised: 05/25/2006] [Accepted: 05/30/2006] [Indexed: 11/24/2022]
Abstract
PURPOSE To investigate whether intensity-modulated radiation therapy (IMRT) allows more mucosal sparing than standard three-field technique (3FT) radiotherapy for early oropharyngeal cancer. METHODS AND MATERIALS Whole-field IMRT plans were generated for 5 patients with early-stage oropharyngeal cancer according to Radiation Therapy Oncology Group 0022 (66 Gy/30 fractions/6 weeks) guidelines with and without a dose objective on the portion of mucosa not overlapping any PTV. 3FT plans were also generated for the same 5 patients with two fractionation schedules: conventional fractionation (CF) to 70 Gy/35 fractions/7 weeks and concomitant boost (CB) to 72 Gy/40 fractions/6 weeks. Cumulative dose volume histograms (DVHs) of the overall mucosal volume (as per in-house definition) from all trials were compared after transformation into the linear quadratic equivalent dose at 2 Gy per fraction with a time factor correction. RESULTS Compared with IMRT without dose objective on the mucosa, a 30-Gy maximum dose objective on the mucosa allows approximately 20% and approximately 12% mean absolute reduction in the percentage of mucosa volume exposed to a dose equivalent to 30 Gy (p < 0.01) and 70 Gy (p < 0.01) at 2 Gy in 3 and 7 weeks, respectively, without detrimental effect on the coverage of other regions of interest. Without mucosal dose objective, IMRT is associated with a larger amount of mucosa exposed to clinically relevant doses compared with both concomitant boost and conventional fractionation; however, if a dose objective is placed, the reverse is true, with up to approximately 30% reduction in the volume of the mucosa in the high-dose region compared with both concomitant boost and conventional fractionation (p < 0.01). CONCLUSIONS Intensity-modulated radiation therapy can be potentially provide more mucosal sparing than traditional approaches.
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Affiliation(s)
- Giuseppe Sanguineti
- Department of Radiation Oncology, University of Texas Medical Branch, Galveston, TX 77555-0711, USA.
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Graham PH, Clark C, Abell F, Browne L, Capp A, Clingan P, De Sousa P, Fox C, Links M. Concurrent end-phase boost high-dose radiation therapy for non-small-cell lung cancer with or without cisplatin chemotherapy. ACTA ACUST UNITED AC 2006; 50:342-8. [PMID: 16884421 DOI: 10.1111/j.1440-1673.2006.01597.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The aim of this study was to audit the results of a high-dose, combined-modality prospective protocol for non-small-cell lung cancer in terms of survival, disease-specific survival and toxicity. One hundred and twenty-one patients with non-small-cell lung cancer were treated with a concurrent, end-phase, boost, high-dose radiotherapy protocol with 65 Gy in 35 fractions for more than 5 weeks. Sixty-six patients received radiotherapy alone (group 1), 29 received concurrent chemoradiation (group 2) and 26 received neoadjuvant and concurrent chemotherapy (group 3). Thirty-four patients had stage I disease, six had stage II and 81 had stage III. Overall median survival was 23 months: 75% at 1 year and 23% at 5 years. Median survivals for patients with stage I and stages II and III disease were 43 and 19 months, respectively. For stages II and III patients by groups 1-3, median survivals were 18, 25 and 18 months, respectively, and 2-year survivals were 36, 52 and 38%, respectively. Toxicity was acceptable. Overall, 9% had symptomatic pneumonitis and 7% had grades 3 and 4 oesophagitis. For those who had the mediastinum included in the volume, grade > or = 3 oesophagitis occurred in 0, 11 and 22% (n = 110, P = 0.001), respectively, for treatment groups 1-3. Overall treatment-related mortality was 3%, consisting of two septic deaths, one pneumonitis and possibly one late cardiac event, all occurring in patients who had chemotherapy (7% of 55 patients). Treatment-related mortality declined over the study period. Accelerated radiotherapy was well tolerated, with only moderate increased acute toxicity when combined with concurrent platinum chemotherapy. Toxicity was enhanced by induction chemotherapy. Overall survival outcomes were excellent for this condition. Continued use of this radiotherapy schedule is recommended as the platform for assessment of other chemotherapy schedules.
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Affiliation(s)
- P H Graham
- Cancer Care Centre, St George Hospital, Sydney, New South Wales, Australia.
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Tishler RB, Posner MR, Norris CM, Mahadevan A, Sullivan C, Goguen L, Wirth LJ, Costello R, Case M, Stowell S, Sammartino D, Busse PM, Haddad RI. Concurrent weekly docetaxel and concomitant boost radiation therapy in the treatment of locally advanced squamous cell cancer of the head and neck. Int J Radiat Oncol Biol Phys 2006; 65:1036-44. [PMID: 16682134 DOI: 10.1016/j.ijrobp.2006.02.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2005] [Revised: 02/05/2006] [Accepted: 02/06/2006] [Indexed: 11/30/2022]
Abstract
PURPOSE In a Phase I/II trial, we investigated concurrent weekly docetaxel and concomitant boost radiation in patients with locally advanced squamous cell cancer of the head and neck (SCCHN) after induction chemotherapy. PATIENTS AND METHODS Patients presented with American Joint Committee on Cancer Stage III/IV and were treated initially with induction chemotherapy using cisplatinum/5-fluorouracil (PF), carboplatinum-5-FU, or docetaxel-PF. Patients then received docetaxel four times weekly with concomitant boost (CB) radiation (1.8 Gy once-daily X20, 1.8/1.5 Gy twice a day). Fifteen patients each received 20 mg/M2 and 25 mg/M2. RESULTS Thirty-one patients were enrolled and 30 were evaluable for response and toxicity. Median follow-up was 42 months (range, 27-63 months). Primary sites were: oropharynx 19, oral cavity 2, larynx/hypopharynx 5, and unknown primary 4. Eighty-seven percent of patients had N2/N3 disease; 60% had T3/T4 disease. Twenty percent of patients had a complete response (CR) to induction chemotherapy. After chemoradiotherapy, 21 of 30 patients had a CR, 2 had progressive disease, and 7 had partial response (PR). Nineteen of 26 patients presenting with neck disease had neck dissections, and 7 of 19 were positive. Ninety-three percent of all patients were rendered disease-free after all planned therapy. Treatment failed in 8 patients, and 7 have died of disease. An additional patient died with no evidence of disease. Twenty-one patients (70%) are currently alive with no evidence of disease. No acute dose-limiting toxicity was observed at either dose level. CONCLUSIONS This intensive treatment regimen of concurrent docetaxel/concomitant boost radiation and surgery after induction chemotherapy in poor prognosis patients yields good local regional control and survival. Docetaxel/CB chemoradiotherapy represents an aggressive alternative regimen to platinum-based chemoradiotherapy or surgery in patients who have a poor response to induction chemotherapy.
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Affiliation(s)
- Roy B Tishler
- Department of Radiation Oncology, Dana Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA 02115, USA.
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Bernier J, Bentzen SM. Radiotherapy for head and neck cancer: latest developments and future perspectives. Curr Opin Oncol 2006; 18:240-6. [PMID: 16552235 DOI: 10.1097/01.cco.0000219252.45467.88] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Despite recent advances in multimodality management the prognosis of patients with stage III-IV squamous cell head and neck cancer remains disappointing. The objective of this review is to identify how, within the main axes of the current translational and clinical research and in an attempt to improve treatment outcome, a number of institutions and cooperative groups have embarked on systematic investigations of novel strategies for radiotherapy delivery and for combining radiation with systemic treatments. RECENT FINDINGS Four domains of translational and clinical researches can be identified in head and neck radio-oncology: altered fractionation, concurrent delivery of chemotherapy and radiotherapy, combination of targeted therapies with radiation, and high-conformality radiotherapy. SUMMARY Here we provide a critical appraisal of recent strategies allowing an increase in dose intensity for treatments based on radiotherapy and drug-radiation interactions, and revisit the potential opportunities they offer as well as the possible caveats they may present in patients with locally advanced head and neck cancers.
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Affiliation(s)
- Jacques Bernier
- Department of Radio-Oncology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland.
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Chufal KS, Rastogi M, Srivastava M, Pant MC, Bhatt MLB. Late chemo-intensification with cisplatin and 5-fluorouracil as an adjunct to radiotherapy: A pragmatic approach for locally advanced head and neck squamous cell carcinoma. Oral Oncol 2006; 42:517-25. [PMID: 16480913 DOI: 10.1016/j.oraloncology.2005.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2005] [Accepted: 10/10/2005] [Indexed: 11/18/2022]
Abstract
The aim of this study was to define the feasibility of a late chemo-intensification treatment regimen with conventionally fractionated radiotherapy (70 Gy/7 weeks). Seventy four patients with Stage III and IV biopsy proven squamous cell carcinoma of oropharynx, hypopharynx and larynx were treated with this regimen. Chemotherapy consisted of continuous infusion of 5-FU at 350 mg/m(2)/day and cisplatin as 1h infusion at 10 mg/m(2)/day on days 1-5 of week 6 and 7 of radiotherapy. Grade III mucositis was present in 48 (64.9%) patients. After surgical salvage 59 (79.7%) patients had overall complete response. Locoregional control rate at 3 year was 80.8%. Three year locoregional relapse free survival (LRFS), overall survival (OS) and disease free survival (DFS) was 63.1%, 66.7% and 44.4%, respectively. The late chemo-intensification regimen was feasible in terms of response rate, toxicity and survival functions.
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Affiliation(s)
- Kundan S Chufal
- Department of Oncology, Batra Hospital and Medical Research Centre, 1, Tughlakabad Institutional Area, New Delhi, India.
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Pfister DG, Su YB, Kraus DH, Wolden SL, Lis E, Aliff TB, Zahalsky AJ, Lake S, Needle MN, Shaha AR, Shah JP, Zelefsky MJ. Concurrent cetuximab, cisplatin, and concomitant boost radiotherapy for locoregionally advanced, squamous cell head and neck cancer: a pilot phase II study of a new combined-modality paradigm. J Clin Oncol 2006; 24:1072-8. [PMID: 16505426 DOI: 10.1200/jco.2004.00.1792] [Citation(s) in RCA: 249] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Cetuximab is a chimeric monoclonal antibody that targets the epidermal growth factor receptor. Cetuximab has activity in squamous cell carcinoma and enhances both chemotherapy and radiotherapy. We conducted a pilot phase II study of a new combined-modality paradigm of targeted therapy (cetuximab) with chemoradiotherapy. PATIENTS AND METHODS Eligible patients had stage III or IV, M0, squamous cell head and neck cancer. Treatment included concomitant boost radiotherapy (1.8 Gy/d weeks 1 to 6; boost: 1.6 Gy 4 to 6 hours later weeks 5 to 6; 70 Gy total to gross disease), cisplatin (100 mg/m2 intravenously weeks 1 and 4), and cetuximab (400 mg/m2 intravenously week 1, followed by 250 mg/m2 weeks 2 to 10). RESULTS Twenty-two patients were enrolled (median age, 57 years; range, 41 to 72 years; median Karnofsky status, 90%; range, 70% to 90%; oropharynx primary tumor, 59% of patients; T4, 36%; N2/3, 77%; stage IV disease, 86%). One patient did not receive study treatment because of an ineligible diagnosis. The severity of expected, acute toxicities was typical of concurrent cisplatin and radiotherapy alone. Grade 3 or 4 cetuximab-related toxicities included acne-like rash (10%) and hypersensitivity (5%). However, the study was closed for significant adverse events, including two deaths (one pneumonia and one unknown cause), one myocardial infarction, one bacteremia, and one atrial fibrillation. With a median follow-up of 52 months, the 3-year overall survival rate is 76%, the 3-year progression-free survival rate is 56%, and the 3-year locoregional control rate is 71%. CONCLUSION This regimen is not currently recommended outside of the clinical trial setting. Further investigation of its safety profile is needed. However, preliminary efficacy is encouraging, and further development of this targeted combined-modality paradigm is warranted.
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MESH Headings
- Adult
- Aged
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal/adverse effects
- Antibodies, Monoclonal/pharmacokinetics
- Antibodies, Monoclonal, Humanized
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Carcinoma, Squamous Cell/drug therapy
- Carcinoma, Squamous Cell/pathology
- Carcinoma, Squamous Cell/radiotherapy
- Cetuximab
- Chemotherapy, Adjuvant
- Cisplatin/administration & dosage
- Cisplatin/adverse effects
- Disease-Free Survival
- Female
- Head and Neck Neoplasms/drug therapy
- Head and Neck Neoplasms/pathology
- Head and Neck Neoplasms/radiotherapy
- Humans
- Lymphatic Metastasis
- Male
- Middle Aged
- Neoplasm Staging
- Pilot Projects
- Radiotherapy, Adjuvant
- Survival Analysis
- Treatment Outcome
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Affiliation(s)
- David G Pfister
- Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021, USA.
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Wolden SL, Chen WC, Pfister DG, Kraus DH, Berry SL, Zelefsky MJ. Intensity-modulated radiation therapy (IMRT) for nasopharynx cancer: Update of the Memorial Sloan-Kettering experience. Int J Radiat Oncol Biol Phys 2006; 64:57-62. [PMID: 15936155 DOI: 10.1016/j.ijrobp.2005.03.057] [Citation(s) in RCA: 354] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2005] [Revised: 03/24/2005] [Accepted: 03/24/2005] [Indexed: 11/27/2022]
Abstract
PURPOSE We previously demonstrated that intensity-modulated radiation therapy (IMRT) significantly improves radiation dose distribution over three-dimensional planning for nasopharynx cancer and reported positive early clinical results. We now evaluate whether IMRT has resulted in improved outcomes for a larger cohort of patients with longer follow-up. METHODS AND MATERIALS Since 1998, all 74 patients with newly diagnosed, nonmetastatic nasopharynx cancer were treated with IMRT using accelerated fractionation to 70 Gy; 59 received a hyperfractionated concomitant boost, and more recently 15 received once-daily treatment with dose painting. With the exception of Stage I disease (n = 5) and patient preference (n = 1), 69 patients received concurrent and adjuvant platinum-based chemotherapy similar to that in the Intergroup 0099 trial. RESULTS PATIENT CHARACTERISTICS median age 45; 32% Asian; 72% male; 65% World Health Organization III; 6% Stage I, 16% Stage II, 30% Stage III, 47% Stage IV. Median follow-up is 35 months. The 3-year actuarial rate of local control is 91%, and regional control is 93%; freedom from distant metastases, progression-free survival, and overall survival at 3 years are 78%, 67%, and 83%, respectively. There was 100% local control for Stage T1/T2 disease, compared to 83% for T3/T4 disease (p = 0.01). Six patients failed at the primary site, with median time to local tumor progression 16 months; 5 were exclusively within the 70 Gy volume, and 1 was both within and outside the target volume. There is a trend for improved local control with IMRT when compared to local control of 79% for 35 patients treated before 1998 with three-dimensional planning and chemotherapy (p = 0.11). Six months posttherapy, 21%, 13%, 15%, and 0% of patients with follow-up audiograms (n = 24 patients) had Grade 1, 2, 3, and 4 sensorineural hearing loss, respectively. For patients with >1 year follow-up (n = 59), rates of long-term xerostomia were as follows: 26% none, 42% Grade 1, 32% Grade 2, and zero Grade 3. CONCLUSIONS The pattern of primary site failure within the target volume suggests locally advanced T stage disease may require a higher biologic dose to gross tumor. Rates of severe (Grade 3-4) ototoxicity and xerostomia are low with IMRT as a result of normal-tissue protection. Distant metastases are now the dominant form of failure, emphasizing the need for improved systemic therapy.
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Affiliation(s)
- Suzanne L Wolden
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
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Kwong DLW, Sham JST, Leung LHT, Cheng ACK, Ng WM, Kwong PWK, Lui WM, Yau CC, Wu PM, Wei W, Au G. Preliminary results of radiation dose escalation for locally advanced nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys 2005; 64:374-81. [PMID: 16213105 DOI: 10.1016/j.ijrobp.2005.07.968] [Citation(s) in RCA: 120] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2005] [Revised: 07/14/2005] [Accepted: 07/17/2005] [Indexed: 10/25/2022]
Abstract
PURPOSE To study the safety and efficacy of dose escalation in tumor for locally advanced nasopharyngeal carcinoma (NPC). METHODS AND MATERIALS From September 2000 to June 2004, 50 patients with T3-T4 NPC were treated with intensity-modulated radiotherapy (IMRT). Fourteen patients had Stage III and 36 patients had Stage IVA-IVB disease. The prescribed dose was 76 Gy to gross tumor volume (GTV), 70 Gy to planning target volume (PTV), and 72 Gy to enlarged neck nodes (GTVn). All doses were given in 35 fractions over 7 weeks. Thirty-four patients also had concurrent cisplatin and induction or adjuvant PF (cisplatin and 5-fluorouracil). RESULTS The average mean dose achieved in GTV, GTVn, and PTV were 79.5 Gy, 75.3 Gy, and 74.6 Gy, respectively. The median follow-up was 25 months, with 4 recurrences: 2 locoregional and 2 distant failures. All patients with recurrence had IMRT alone without chemotherapy. The 2-year locoregional control rate, distant metastases-free and disease-free survivals were 95.7%, 94.2%, and 93.1%, respectively. One treatment-related death caused by adjuvant chemotherapy occurred. The 2-year overall survival was 92.1%. CONCLUSIONS Dose escalation to 76 Gy in tumor is feasible with T3-T4 NPC and can be combined with chemotherapy. Initial results showed good local control and survival.
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Affiliation(s)
- Dora L W Kwong
- Department of Clinical Oncology, the University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong.
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Kumar S, Pandey M, Lal P, Rastogi N, Maria Das KJ, Dimri K. Concomitant boost radiotherapy with concurrent weekly cisplatin in advanced head and neck cancers: a phase II trial. Radiother Oncol 2005; 75:186-92. [PMID: 16086908 DOI: 10.1016/j.radonc.2004.12.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2004] [Revised: 11/24/2004] [Accepted: 12/10/2004] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Shaleen Kumar
- Department of Radiotherapy, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
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Ding M, Newman F, Raben D. New Radiation Therapy Techniques for the Treatment of Head and Neck Cancer. Otolaryngol Clin North Am 2005; 38:371-95, vii-viii. [PMID: 15823599 DOI: 10.1016/j.otc.2004.10.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This article reviews the most recent technology used in the treatment of head and neck cancer. It discusses brachytherapy, new ways to mix radionuclides for enhanced radiobiologic effects, and different fractionation schemes that have grown in clinical importance. Intensity-modulated radiotherapy has become a mainstay in head and neck cancer treatment, and the authors discuss several popular and emerging approaches. Patient immobilization and imaging are also discussed.
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Affiliation(s)
- Meisong Ding
- Department of Radiation Oncology, University of Colorado Health Science Center, Suite 1032, 1665 North Ursula Street, Aurora, CO 80010, USA.
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Sanguineti G, Richetti A, Bignardi M, Corvo' R, Gabriele P, Sormani MP, Antognoni P. Accelerated versus conventional fractionated postoperative radiotherapy for advanced head and neck cancer: results of a multicenter Phase III study. Int J Radiat Oncol Biol Phys 2005; 61:762-71. [PMID: 15708255 DOI: 10.1016/j.ijrobp.2004.07.682] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2004] [Revised: 07/05/2004] [Accepted: 07/12/2004] [Indexed: 10/25/2022]
Abstract
PURPOSE To determine whether, in the postoperative setting, accelerated fractionation (AF) radiotherapy (RT) yields a superior locoregional control rate compared with conventional fractionation (CF) RT in locally advanced squamous cell carcinomas of the oral cavity, oropharynx, larynx, or hypopharynx. METHODS AND MATERIALS Patients from four institutions with one or more high-risk features (pT4, positive resection margins, pN >1, perineural/lymphovascular invasion, extracapsular extension, subglottic extension) after surgery were randomly assigned to either RT with one daily session of 2 Gy up to 60 Gy in 6 weeks or AF. Accelerated fractionation consisted of a "biphasic concomitant boost" schedule, with the boost delivered during the first and last weeks of treatment, to deliver 64 Gy in 5 weeks. Informed consent was obtained. The primary endpoint of the study was locoregional control. Analysis was on an intention-to-treat basis. RESULTS From March 1994 to August 2000, 226 patients were randomized. At a median follow-up of 30.6 months (range, 0-110 months), 2-year locoregional control estimates were 80% +/- 4% for CF and 78% +/- 5% for AF (p = 0.52), and 2-year overall survival estimates were 67% +/- 5% for CF and 64% +/- 5% for AF (p = 0.84). The lack of difference in outcome between the two treatment arms was confirmed by multivariate analysis. However, interaction analysis with median values as cut-offs showed a trend for improved locoregional control for those patients who had a delay in starting RT and who were treated with AF compared with those with a similar delay but who were treated with CF (hazard ratio = 0.5, 95% confidence interval 0.2-1.1). Fifty percent of patients treated with AF developed confluent mucositis, compared with only 27% of those treated with CF (p = 0.006). However, mucositis duration was not different between arms. Although preliminary, actuarial Grade 3+ late toxicity estimates at 2 years were 18% +/- 4% and 27% +/- 6% for CF and AF, respectively (p = 0.10). CONCLUSION Accelerated fractionation does not seem to be worthwhile for squamous cell carcinoma of the head and neck after resection; however, AF might be an option for patients who delay starting RT.
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Affiliation(s)
- Giuseppe Sanguineti
- Department of Radiation Oncology, Istituto Nazionale per la Ricerca sul Cancro, Genoa, Italy.
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Arias de la Vega F, Domínguez Domínguez MA, Manterola Burgaleta A, Vera García R, Echeverría Zabalza ME, Oria Mundin E, Martínez López E, Romero Rojano P, Villafranca Iture E. Concomitant boost radiation and concurrent cisplatin for advanced head and neck carcinomas. Preliminary results of a phase II, single-institutional trial. Clin Transl Oncol 2005; 7:60-5. [PMID: 15899210 DOI: 10.1007/bf02710011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
INTRODUCTION This study aims to asses the effectiveness and toxicity of boost radiotherapy concomitant and concurrent cisplatin for patients with locally advanced head and neck cancer (LAHNC). MATERIAL AND METHODS There were 30 patients included in a prospective, phase II single-institution trial and of whom, 29 were at AJCC stage IV and 1 at stage III. Treatment consisted of radiotherapy acceleration fractionation with concomitant boost, 72 Gy, and 2 cycles of concomitant cisplatin (20 mg/m2/day continuous infusion; days 1-5 and 29-33). Amifostine, (i.v. 200 mg/m2) was administered to 26 prior to the first fraction of radiotherapy. Endpoints of the study were quality-of-life (QL), overall survival, and local control of disease. RESULTS Complete response (CR) was achieved in 23 patients (77%), 2 patients had partial response (PR) (7%), 4 had no response (13%), and 1 was not evaluated for response. The 2-year overall survival and loco-regional control were 60% and 56%, respectively. Main toxicity was grade 3 or 4 mucositis in 93% of the patients. QL scores (questionnaire QLQC30; version 3.0) and the HN cancer module QLQ-HN35) showed a worsening in areas related to the treatment e.g. dry mouth, problems stretching the mouth, and sticky saliva. CONCLUSIONS this combination modality is active, but toxic, in the treatment for LAHNC. Concomitant boost radiotherapy is probably, not the best radiotherapy schema for combining with chemotherapy in LAHNC.
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Rischin D, Peters L, Fisher R, Macann A, Denham J, Poulsen M, Jackson M, Kenny L, Penniment M, Corry J, Lamb D, McClure B. Tirapazamine, Cisplatin, and Radiation versus Fluorouracil, Cisplatin, and Radiation in patients with locally advanced head and neck cancer: a randomized phase II trial of the Trans-Tasman Radiation Oncology Group (TROG 98.02). J Clin Oncol 2005; 23:79-87. [PMID: 15625362 DOI: 10.1200/jco.2005.01.072] [Citation(s) in RCA: 213] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To select one of two chemoradiotherapy regimens for locally advanced squamous cell carcinoma (SCC) of the head and neck as the experimental arm for the next Trans-Tasman Radiation Oncology Group phase III trial. PATIENTS AND METHODS One hundred twenty-two previously untreated patients with stage III/IV SCC of the head and neck were randomized to receive definitive radiotherapy (70 Gy in 7 weeks) concurrently with either cisplatin (75 mg/m(2)) plus tirapazamine (290 mg/m(2)/d) on day 2 of weeks 1, 4, and 7, and tirapazamine alone (160 mg/m(2)/d) on days 1, 3, and 5 of weeks 2 and 3 (TPZ/CIS), or cisplatin (50 mg/m(2)) on day 1 and infusional fluorouracil (360 mg/m(2)/d) on days 1 through 5 of weeks 6 and 7 (chemoboost). RESULTS Three-year failure-free survival rates were 55% with TPZ/CIS (95% CI, 39% to 70%) and 44% with chemoboost (95% CI, 30% to 60%; log-rank P = .16). Three-year locoregional failure-free rates were 84% in the TPZ/CIS arm (95% CI, 71% to 92%) and 66% in the chemoboost arm (95% CI, 51% to 79%; P = .069). More febrile neutropenia and grade 3 or 4 late mucous membrane toxicity were observed with TPZ/CIS, while acute skin radiation reaction was more severe and prolonged with chemoboost. Compliance with protocol treatment was satisfactory on both arms. CONCLUSION Both regimens are feasible and are associated with significant but acceptable toxicity profiles in the cooperative group setting. Based on the promising efficacy seen in this trial, TPZ/CIS is being evaluated in a large phase III trial.
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Affiliation(s)
- Danny Rischin
- Division of Haematology and Medical Oncology, University of Melbourne, Peter MacCallum Cancer Centre, Locked Bag No. 1, A'Beckett St, Melbourne 8006, Australia.
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