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Kim MS, Malik NH, Chen H, Poon I, Husain Z, Eskander A, Boldt G, Louie AV, Karam I. Stereotactic radiotherapy as planned boost after definitive radiotherapy for head and neck cancers: Systematic review. Head Neck 2021; 44:770-782. [PMID: 34927313 DOI: 10.1002/hed.26948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 11/02/2021] [Accepted: 12/02/2021] [Indexed: 12/08/2022] Open
Abstract
Management of locoregionally advanced head and neck cancers (HNCs) remains a challenge. Some groups have attempted to use stereotactic radiotherapy (SBRT) to deliver "boost" treatment following conventional radiotherapy to improve local control (LC) and overall survival (OS), while aiming for acceptable toxicities. Medline, EMBASE, and Cochrane Library databases were queried for SBRT as curative-intent planned boost in HNC after conventional radiotherapy. Individual studies were reviewed from inception until January 2021, extracting patient, treatment, and outcome data. Nine studies met inclusion criteria, representing 454 unique patients treated with curative intent across multiple head and neck sites with conventional radiotherapy. At 3 years, median LC was 92% (90%-98%), and median OS was 80% (75%-91%). Seven treatment-related grade 5 toxicities (1.5%) were reported. Despite acceptable LC and OS rates, there were severe treatment-related late toxicities. As such, SBRT boost should only be used in investigational settings until more data is available.
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Affiliation(s)
- Michael S Kim
- Department of Radiation Oncology, Nova Scotia Cancer Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Nauman H Malik
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Ian Poon
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Zain Husain
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Antoine Eskander
- Department of Otolaryngology-Head and Neck Surgery, Sunnybrook Health Sciences Centre, Odette Cancer Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Gabriel Boldt
- Department of Radiation Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Alexander V Louie
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Irene Karam
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Addition of chemotherapy to hyperfractionated radiotherapy in advanced head and neck cancer-a meta-analysis. Strahlenther Onkol 2019; 195:1041-1049. [PMID: 31586229 DOI: 10.1007/s00066-019-01511-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 08/08/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Adding concurrent chemotherapy (CTx) to definitive radiation therapy (RT) in patients with locally advanced head and neck squamous cell carcinoma (LA-HNSCC) improves overall survival. A comparable effect has been reported for hyperfractionated radiotherapy (HFX-RT) alone. Adding concurrent CTx to HFX-RT has been investigated in multiple trials, yet an evident effect on oncological outcomes and toxicity profile has not been established to date. Thus, the aim of the current study was to perform a meta-analysis on the clinical outcome and toxicity of the addition of CTx to HFX-RT. PATIENTS AND METHODS We performed a literature search for randomized controlled trials comparing HFX-RT alone to HFX-RT + concurrent CTx in patients with LA-HNSCC undergoing definite RT. A meta-analysis was performed using the event rates and effect-sizes for overall survival (OS), progression-free survival (PFS), cancer-specific survival (CSS), distant metastasis-free survival and distant recurrence-free interval (DMFS/DMFI) and locoregional recurrence (LRR) as investigated endpoints. Furthermore, we compared selected acute and late toxicities in the included studies. Statistical analysis was performed using the Microsoft Excel (Microsoft, Redmont, WA, USA) add-in MetaXL 5.3 (EpiGear International, Sunrise Beach, Australia), utilizing the inverse variance heterogeneity model. RESULTS We identified six studies (n = 1280 patients) randomizing HFX-RT alone and the concurrent addition of CTx. OS was significantly improved in the HFX-RT + CTx group (HR = 0.77, CI95% = 0.66-0.89; p = <0.001). We found similar results in PFS (HR = 0.74, CI95% = 0.63-0.87; p < 0.001) and CSS (HR = 0.72, CI95% = 0.60-0.88; p = 0.001). In contrast, acute toxicities (≥grade 3 mucositis, ≥grade 3 dysphagia) and late adverse events including ≥grade 3 xerostomia, ≥grade 3 subcutaneous, ≥grade 3 bone, ≥grade 3 skin toxicity, and ≥grade 3 dysphagia did not significantly differ between the two groups. CONCLUSION The addition of CTx to HFX-RT in the definitive treatment of advanced LA-HNSCC improves OS, CSS, PFS, and LRR without a significant increase in high-grade acute and late toxicities.
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Comparison of Functional Organ Preservation by Concomitant Boost Radiotherapy Versus Concurrent Chemoradiation in Locally Advanced Carcinoma of Larynx or Hypopharynx: A Prospective Randomized Study. Indian J Otolaryngol Head Neck Surg 2019; 71:360-366. [PMID: 31559204 DOI: 10.1007/s12070-019-01604-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 01/22/2019] [Indexed: 10/27/2022] Open
Abstract
Functional organ preservation is a major challenge in management of advanced laryngeal and hypopharyngeal carcinoma. Although ideal approach is a subject of much debate, radiotherapy with or without chemotherapy is most commonly used modality. This randomized study was conducted to compare functional organ preservation by chemoradiation (CRT) versus concomitant boost radiotherapy (CBRT). A total of 40 patients with advanced (stage III/stage IVa) laryngeal and hypopharyngeal cancer were randomized to receive either CRT (n = 20) to a dose of 66 Gy in 33 fractions over 6.5 weeks with concurrent cisplatin (100 mg/m2 on days 1, 22 and 43) or CBRT (n = 20) to a dose of 67.5 Gy in 40 fractions over 5 weeks. Patients were assessed for organ preservation rate, toxicities, voice and swallowing functions utilizing Voice Related Quality of Life (VRQOL) and MD Anderson Dysphagia Inventory (MDADI) scores, respectively, for minimum follow up of 6 months. Organ preservation rate (intact disease free larynx) at 6 months post treatment was observed in 100% in CRT arm and 95% in CBRT arm. There was no significant difference in mucositis and dermatitis in two arms (p = 0.82 and 0.78, respectively). Dysphagia was observed more in CRT arm (n = 12 vs n = 6). Late toxicities grade 3 xerostomia, grade 2 dysguesia, were seen significantly more in CRT arm. There was no statistical difference between the two arms in terms of VRQOL (p = 0.55) and MDADI scores (p = 0.13). In CRT arm 13 patients complete response and in CBRT arm 12 patients had complete response. Accelerated fractionation with concomitant boost schedule is as effective as CRT in anatomical and functional preservation of larynx. The toxicities, voice and dysphagia related quality of life is comparable.
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Choudhary A, Gupta A. Conventional Fractionation versus Quad Shot in Advanced Head-and-Neck Cancers: A Randomized Controlled Trial. Indian J Palliat Care 2019; 25:527-534. [PMID: 31673207 PMCID: PMC6812420 DOI: 10.4103/ijpc.ijpc_209_18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Context: A significant number of patients with head-and-neck cancers have an incurable disease with limited life expectancy. The objective of the present study was to compare two different short courses of hypofractionated palliative radiotherapy regimens to evaluate symptoms, disease response, and acute toxicity. Materials and Methods: Previously untreated 50 patients of Stage IV B and IV C head and neck cancers were randomized to receive conventional hypofractionated palliative radiotherapy 30 Gy/10 fractions/2 weeks (control group) or Quad Shot regimen (study group) 14 Gy in 4 fractions given twice a day at least 6 h apart for 2 consecutive days. This regimen was repeated at 4 weekly intervals for a further two courses if there was no tumor progression. Results: Symptom relief was similar among the two schedules for pain (60.86 vs. 57.17), dysphagia (60.86 vs. 52.17%), and hoarseness (43.85 vs. 38.09%). Overall response (that is partial response and stable disease) was seen in majority (>70%) of the patients in both the groups. Treatment was very well tolerated with no patient experiencing more than Grade 3 toxicity in the control group and Grade 2 toxicity in the study group. Conclusions: Quad Shot regimen is an effective hypofractionated palliative radiotherapy schedule with minimal toxicity, good symptom relief, and response rate as compared to conventionally used regimen (30 Gy/10 fractions/2 weeks).
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Affiliation(s)
- Akansha Choudhary
- Department of Radiotherapy, Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi, India
| | - Ajay Gupta
- Department of Radiotherapy, Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi, India
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Smet S, Pötter R, Haie-Meder C, Lindegaard JC, Schulz-Juergenliemk I, Mahantshetty U, Segedin B, Bruheim K, Hoskin P, Rai B, Huang F, Cooper R, van Limbergen E, Tanderup K, Kirchheiner K. Fatigue, insomnia and hot flashes after definitive radiochemotherapy and image-guided adaptive brachytherapy for locally advanced cervical cancer: An analysis from the EMBRACE study. Radiother Oncol 2018; 127:440-448. [DOI: 10.1016/j.radonc.2018.03.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Revised: 03/11/2018] [Accepted: 03/13/2018] [Indexed: 11/25/2022]
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Olmi P, Fallai C. Nonstandard Fractionation Schedules in Radiation Therapy of Head and Neck Cancer: A Review. TUMORI JOURNAL 2018; 83:633-42. [PMID: 9267479 DOI: 10.1177/030089169708300302] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The authors present an updated review of the clinical trials on hyperfractionated and accelerated fractionation schedules in radiotherapy of head and neck cancer. The available results in terms of survival and local control, and acute and late toxicity data are summarized in order to show the current status of this research field. The new breed of fractionation schedules that are on study, designed on the ground of new rationales, are presented as well. Finally, an introductory overview of combination therapy including non standard fractionation radiotherapy associated with chemotherapy is reported70.
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Affiliation(s)
- P Olmi
- Dipartimento di Fisiopatologia Clinica, Università degli Studi di Firenze, Florence, Italy
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Dirix P, Lambrecht M, Nuyts S. Radiotherapy for laryngeal squamous cell carcinoma: current standards. Expert Rev Anticancer Ther 2014; 10:1461-9. [DOI: 10.1586/era.10.110] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Jensen DH, Oliveri RS, Trojahn Kølle SF, Fischer-Nielsen A, Specht L, Bardow A, Buchwald C. Mesenchymal stem cell therapy for salivary gland dysfunction and xerostomia: a systematic review of preclinical studies. Oral Surg Oral Med Oral Pathol Oral Radiol 2013; 117:335-342.e1. [PMID: 24528792 DOI: 10.1016/j.oooo.2013.11.496] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Revised: 10/27/2013] [Accepted: 11/14/2013] [Indexed: 12/14/2022]
Abstract
The most severe forms of xerostomia and salivary gland dysfunction, as well as a severely reduced quality of life, are seen in Sjögren syndrome (SS) and after radiotherapy for head and neck cancer. For both conditions, no effective regenerative therapies yet exist. Thus, the aim of this article was to assess, through systematic review, the potential benefit of mesenchymal stem cell (MSC) therapy in radiation-induced and SS-related salivary gland dysfunction and xerostomia. We searched PubMed/MEDLINE, Embase, Web of Science, the Cochrane Database of Systematic Reviews, the World Health Organization Clinical Trials Registry Platform, and Google Scholar. We identified 6 separate study comparisons eligible for inclusion. Owing to the limited number of studies, we conclude that more randomized, adequately powered clinical trials are needed to validate the potential beneficial effect of MSCs on salivary gland dysfunction and xerostomia. Nonetheless, the preliminary studies identified in the present review were encouraging for further research.
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Affiliation(s)
- David Hebbelstrup Jensen
- Department of Otorhinolaryngology, Head & Neck Surgery and Audiology, Copenhagen University Hospital Rigshospitalet, and Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Roberto Stefan Oliveri
- Cell Therapy Facility, Blood Bank, Department of Clinical Immunology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Stig-Frederik Trojahn Kølle
- Department of Plastic Surgery, Breast Surgery & Burns, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Anne Fischer-Nielsen
- Cell Therapy Facility, Blood Bank, Department of Clinical Immunology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Lena Specht
- Department of Oncology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Allan Bardow
- Department of Oral Medicine, School of Dentistry, University of Copenhagen, Copenhagen, Denmark
| | - Christian Buchwald
- Department of Otorhinolaryngology, Head & Neck Surgery and Audiology, Copenhagen University Hospital Rigshospitalet, and Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Abstract
Treatment for patients with head and neck cancer requires a multidisciplinary approach. Radiotherapy is employed as a primary treatment or as an adjuvant to surgery. Each specific subsite dictates the appropriate radiotherapy techniques, fields, dose, and fractionation scheme. Quality of life is also an important issue in the management of head and neck cancer. The radiation-related complications have a tremendous impact on the quality of life. Modern radiotherapy techniques, such as intensity-modulated radiotherapy and image-guided radiotherapy, can offer precise radiation delivery and reduce the dose to the surrounding normal tissues without compromise of target coverage. In the future, efforts should be made in the exploration of novel strategies to improve treatment outcome in patients with head and neck cancer.
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Affiliation(s)
- Shyh-An Yeh
- Department of Radiation Oncology, E-Da Hospital, Kaohsiung, Taiwan
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Nabil S, Samman N. Risk factors for osteoradionecrosis after head and neck radiation: a systematic review. Oral Surg Oral Med Oral Pathol Oral Radiol 2012; 113:54-69. [DOI: 10.1016/j.tripleo.2011.07.042] [Citation(s) in RCA: 173] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Revised: 07/14/2011] [Accepted: 07/23/2011] [Indexed: 11/28/2022]
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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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Glenny A, Furness S, Worthington HV, Conway DI, Oliver R, Clarkson JE, Macluskey M, Pavitt S, Chan KKW, Brocklehurst P, The CSROC Expert Panel. Interventions for the treatment of oral cavity and oropharyngeal cancer: radiotherapy. Cochrane Database Syst Rev 2010; 2010:CD006387. [PMID: 21154367 PMCID: PMC10749265 DOI: 10.1002/14651858.cd006387.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The management of advanced oral cavity and oropharyngeal cancers is problematic and has traditionally relied on surgery and radiotherapy, both of which are associated with substantial adverse effects. Radiotherapy has been in use since the 1950s and has traditionally been given as single daily doses. This method of dividing up the total dose, or fractionation, has been modified over the years and a variety of approaches have been developed with the aim of improving survival whilst maintaining acceptable toxicity. OBJECTIVES To determine which radiotherapy regimens for oral cavity and oropharyngeal cancers result in increased overall survival, disease free survival, progression free survival and locoregional control. SEARCH STRATEGY The following electronic databases were searched: the Cochrane Oral Health Group's Trials Register (to 28 July 2010), CENTRAL (The Cochrane Library 2010, Issue 3), MEDLINE via OVID (1950 to 28 July 2010) and EMBASE via OVID (1980 to 28 July 2010). There were no restrictions regarding language or date of publication. SELECTION CRITERIA Randomised controlled trials where more than 50% of participants had primary tumours of the oral cavity or oropharynx, and which compared two or more radiotherapy regimens, radiotherapy versus other treatment modality, or the addition of radiotherapy to other treatment modalities. DATA COLLECTION AND ANALYSIS Data extraction and assessment of risk of bias was undertaken independently by two or more authors. Study authors were contacted for additional information as required. Adverse events data were collected from published trials. MAIN RESULTS 30 trials involving 6535 participants were included. Seventeen trials compared some form of altered fractionation (hyperfractionation/accelerated) radiotherapy with conventional radiotherapy; three trials compared different altered fractionation regimens; one trial compared timing of radiotherapy, five trials evaluated neutron therapy and four trials evaluated the addition of pre-operative radiotherapy. Pooling trials of any altered fractionation radiotherapy compared to a conventional schedule showed a statistically significant reduction in total mortality (hazard ratio (HR) 0.86, 95% confidence interval (CI) 0.76 to 0.98). In addition, a statistically significant difference in favour of the altered fractionation was shown for the outcome of locoregional control (HR 0.79, 95% CI 0.70 to 0.89). No statistically significant difference was shown for disease free survival.No statistically significant difference was shown for any other comparison. AUTHORS' CONCLUSIONS Altered fractionation radiotherapy is associated with an improvement in overall survival and locoregional control in patients with oral cavity and oropharyngeal cancers. More accurate methods of reporting adverse events are needed in order to truly assess the clinical performance of different radiotherapy regimens.
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Affiliation(s)
- Anne‐Marie Glenny
- School of Dentistry, The University of ManchesterCochrane Oral Health GroupCoupland III Building, Oxford RoadManchesterUKM13 9PL
| | - Susan Furness
- The University of ManchesterCochrane Oral Health Group, School of DentistryCoupland III Bldg, Oxford RdManchesterUKM13 9PL
| | - Helen V Worthington
- School of Dentistry, The University of ManchesterCochrane Oral Health GroupCoupland III Building, Oxford RoadManchesterUKM13 9PL
| | - David I Conway
- University of GlasgowGlasgow Dental School378 Sauchiehall StreetGlasgowUKG2 3JZ
| | - Richard Oliver
- RED (Research and Education in Dentistry)10 Longbow Close, Harlescott LaneShrewsburyUKSY1 3GZ
| | - Jan E Clarkson
- Cochrane Oral Health Group, The University of ManchesterDental Health Services & Research Unit, University of Dundee, DundeeManchesterUK
| | - Michaelina Macluskey
- University of DundeeUnit of Oral Surgery and MedicineUniversity of Dundee Dental Hospital and SchoolPark PlaceDundeeScotlandUKDD1 4NR
| | - Sue Pavitt
- University of LeedsClinical Trials Research UnitClinical Trials Research House71‐75 Clarendon RoadLeedsUKLS2 9NP
| | - Kelvin KW Chan
- Princess Margaret Hospital610 University AvenueTorontoOntarioCanadaM5G 2M9
| | - Paul Brocklehurst
- School of Dentistry, The University of ManchesterCoupland III BuildingOxford RoadManchesterUKM13 9PL
| | - The CSROC Expert Panel
- School of Dentistry, The University of ManchesterCochrane Oral Health GroupCoupland III Building, Oxford RoadManchesterUKM13 9PL
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Wygoda A, Maciejewski B, Skladowski K, Hutnik M, Pilecki B, Golen M, Rutkowski T. Pattern Analysis of Acute Mucosal Reactions in Patients With Head and Neck Cancer Treated With Conventional and Accelerated Irradiation. Int J Radiat Oncol Biol Phys 2009; 73:384-90. [DOI: 10.1016/j.ijrobp.2007.12.057] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2007] [Revised: 12/18/2007] [Accepted: 12/18/2007] [Indexed: 10/22/2022]
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Agarwal JP, Nemade B, Murthy V, Ghosh-Laskar S, Budrukkar A, Gupta T, D’Cruz A, Pai P, Chaturvedi P, Dinshaw K. Hypofractionated, palliative radiotherapy for advanced head and neck cancer. Radiother Oncol 2008; 89:51-6. [DOI: 10.1016/j.radonc.2008.06.007] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2008] [Revised: 06/03/2008] [Accepted: 06/18/2008] [Indexed: 11/25/2022]
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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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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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Nuyts S, Dirix P, Hermans R, Poorten VV, Delaere P, Weltens C, Van den Bogaert W. Early experience with a hybrid accelerated radiotherapy schedule for locally advanced head and neck cancer. Head Neck 2007; 29:720-30. [PMID: 17315171 DOI: 10.1002/hed.20565] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Our aim was to determine feasibility and efficacy of a hybrid radiotherapy schedule in locally advanced head and neck cancer. METHODS Seventy-three patients with locally advanced head and neck cancer were irradiated according to a hybrid accelerated schedule consisting of 20 fractions of 2 Gy (once daily), followed by 20 fractions of 1.6 Gy (twice daily), to a total dose of 72 Gy. RESULTS Locoregional control was 55% after 2 years. Overall survival was 59%, disease-specific survival was 63%, and disease-free survival was 46%. Acute toxicity was prospectively scored in all 73 patients: the most frequent toxicities were mucositis (50.7%, grade 3), dysphagia (47.9%, grade 3), and dermatitis (34.5%, grade 3). All patients were treated to full dose, without treatment interruption. CONCLUSION With this regimen, acceptable locoregional control and survival rates are achieved. Toxicity was well manageable, suggesting that a combination of this schedule with concomitant chemotherapy is possible and could lead to further improvement in the treatment of locally advanced head and neck cancer.
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Affiliation(s)
- Sandra Nuyts
- Department of Radiation Oncology, Leuvens Kanker Instituut (LKI), University Hospital Gasthuisberg, Leuven, Belgium
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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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Wilson GD, Saunders MI, Dische S, Daley FM, Buffa FM, Richman PI, Bentzen SM. Pre-treatment proliferation and the outcome of conventional and accelerated radiotherapy. Eur J Cancer 2006; 42:363-71. [PMID: 16386890 DOI: 10.1016/j.ejca.2005.10.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2005] [Revised: 10/07/2005] [Accepted: 10/09/2005] [Indexed: 11/28/2022]
Abstract
This study investigated the influence of pre-treatment proliferation characteristics, assessed by Ki-67 staining, in patients treated in the CHART trial of accelerated radiotherapy in head and neck cancer. Histological material from 402 patients was collected and stained for the presence and pattern of Ki-67 staining. Locoregional control and overall survival were the main clinical endpoints. Increasing Ki-67 positivity was associated with decreasing differentiation (P < 0.001) and increasing N-stage (P < 0.004). Increasing N-stage was also associated with the progression of proliferation pattern from marginal to random (P < 0.001). Using a multivariate model, a trend was seen towards a greater benefit from CHART in the lower Ki-67 tumours (P = 0.08); this became significant by pooling the low and intermediate Ki-67 groups in comparison with the high Ki-67 group (P = 0.032). Tumours with marginal proliferation pattern showed a lower hazard ratio with CHART versus conventional for locoregional control (P = 0.005). The data presented in this study do not support that a high pre-treatment Ki-67 is associated with a therapeutic benefit from accelerated radiotherapy.
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Affiliation(s)
- George D Wilson
- Gray Cancer Institute, Mount Vernon Hospital, Northwood, Middlesex HA6 2JR, UK.
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Johnson FM, Garden AS, Palmer JL, Shin DM, Morrison W, Papadimitrakopoulou V, Khuri F, Clayman G, Goepfert H, Ang KK, Hong WK, Glisson BS. A phase I/II study of neoadjuvant chemotherapy followed by radiation with boost chemotherapy for advanced T-stage nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys 2005; 63:717-24. [PMID: 16199307 DOI: 10.1016/j.ijrobp.2005.03.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2004] [Revised: 03/03/2005] [Accepted: 03/07/2005] [Indexed: 11/29/2022]
Abstract
PURPOSE Local recurrence is the most common site of failure for locally advanced nasopharyngeal carcinoma (NPC) treated with neoadjuvant cisplatin/5-fluorouracil (PF) and definitive radiation at our center. Based on this, we studied the addition of chemotherapy during the boost phase of radiation after neoadjuvant PF for advanced T-stage (T3-T4) NPC. This strategy was based on theoretical radiosensitization with chemotherapy during accelerated repopulation of the tumor with relatively radioresistant clonogens. METHODS AND MATERIALS Three cycles of neoadjuvant PF was followed by conventionally fractionated radiation with additional PF during the boost portion of the radiation course. An initial Phase I study was done to establish the maximum tolerated dose of concurrent PF. RESULTS Forty-four patients were enrolled. Six patients in Phase I defined the MTD for concurrent PF as: cisplatin 10 mg/m2/day and PF 320 mg/m2/day, on Days 1-5 during Weeks 6 and 7 of radiation therapy based on dose-limiting toxicities of mucositis, neutropenia, and thrombocytopenia. Forty-one patients were treated with concurrent therapy per protocol: complete, partial, and minor responses were seen in 23, 16, and 2 patients, respectively. Progression-free and overall survival rates at 5 years were 55% (95% CI, 41-75%) and 66% (95% CI, 52-85%), respectively. Seven of 11 tumor-related deaths were due to local recurrence. Nine of 10 patients with local recurrence had T4-stage disease at presentation. Local control of T4 disease was achieved in 74% of patients overall, and in 25% (1/4) with World Health Organization (WHO) type 1, 76% (16/21) with WHO type 2, and 90% (9/10) with WHO type 3 histology. Common toxicities included mucositis, dermatitis, fatigue, vomiting, and weight loss. CONCLUSIONS This regimen was feasible and associated with promising overall survival. Local recurrence remains the major reason for treatment failure in advanced T-stage NPC, especially WHO types 1 and 2. Other strategies to improve local control in these patients should be investigated.
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Affiliation(s)
- Faye M Johnson
- Department of Thoracic/Head & Neck Medical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA
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Ishii K, Tashiro M, Hosono M, Fukuda H, Takada Y, Kondo S, Inoue Y, Iguchi H, Kusuki M, Yamane H. Accelerated hyperfractionated irradiation with concomitant boost for stage II laryngeal cancer and locally advanced head and neck cancer. Acta Otolaryngol 2004:62-6. [PMID: 15513514 DOI: 10.1080/03655230410018345] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE This study was conducted to evaluate the efficacy and feasibility of our accelerated hyperfractionation with concomitant boost for stage II laryngeal cancer and stages III-IVb locally advanced head and neck cancer. PATIENTS AND METHODS From January 2000 to October 2001, eight patients with AJCC 1998 stage II laryngeal cancer and 11 patients with AJCC 1998 stages III-IVb locally advanced head and neck cancer underwent accelerated hyperfractionated radiation therapy. For the stage II laryngeal cancer, radiation was delivered at a 2.0 Gy fraction a day, 5 fractions per week for the first 3 weeks, then 2 fractions (1.8 and 1.2 Gy) a day, 5 times a week for 2.5 weeks, with total dose of 69 Gy. For stages III-IVb head and neck cancer, radiation was given at a 1.8 Gy fraction a day, 5 fractions per week for 6 weeks and a boost was added up to 70.5 Gy with 1.5 Gy as a second daily fraction during the last 2.2 weeks. Among the patients, 16 (84%) received concomitant chemotherapy, mainly with low-dose carboplatin. Acute toxicity based on RTOG criteria and tumor response at 1 month post-treatment were estimated as initial effects. RESULTS The overall response rate was 100% in patients with stage II laryngeal cancer and 91% in patients with stages III and IVb head and neck cancer. The incidence of grade 3 or worse acute effects was 47%. Eighteen patients (95%) completed radiation therapy without interruption related to acute side effects, while one had prolongation of the treatment for more than 1 week because of neutropenia. CONCLUSIONS Our results demonstrated that accelerated hyperfractionation, mostly combined with concomitant chemotherapy, had a good overall response rate with acceptable toxicity in stage II laryngeal cancers and stages III-IVb head and neck tumors.
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Affiliation(s)
- Kenntaro Ishii
- Department of Radiology, Osaka City University Graduate School of Medicine, Osaka, Japan.
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Mohanti BK, Umapathy H, Bahadur S, Thakar A, Pathy S. Short course palliative radiotherapy of 20 Gy in 5 fractions for advanced and incurable head and neck cancer: AIIMS study. Radiother Oncol 2004; 71:275-80. [PMID: 15172142 DOI: 10.1016/j.radonc.2004.03.009] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2003] [Revised: 02/26/2004] [Accepted: 03/12/2004] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE A proportion of advanced stage head and neck cancer patients are incurable and have a limited life expectancy of 100 days or less. The study aimed to offer a short course of palliative radiotherapy (PRT) and evaluate the symptom relief, disease response and duration of survival. PATIENTS AND METHODS Between 1995 and 2001, 505 patients of stage IV squamous cell carcinoma received uniform dose of 20 Gy in 5 fractions over 1 week along with symptom relief drugs. Incurable status and decision for palliation was made conjointly. Distressing symptoms were assessed before PRT. Patients showing more than 50% objective regression (PR) at tumor and nodal sites received further RT (FRT) up to 70 Gy. RESULTS The overall PR rate was 37% (189 patients), but 153 (30%) completed FRT, and rest 352 were followed up after PRT only. None of the patients died due to radiation toxicity, and the radiation morbidities were confined to dry desquamation and patchy mucositis, which healed over 1 month. Symptom relief for pain, dysphagia, hoarseness, cough and otalgia was obtained in 47%-59% of the patients following PRT. The overall survival ranged from 34 days to 2065 days and median survival to PRT and FRT were 200 days and 400 days, respectively. Only 10% were disease-free after FRT. CONCLUSIONS Unfavourable advanced stage head and neck cancer can be identified for a suitable short course of palliative radiotherapy which will achieve growth restraint and symptom relief in sizeable proportions for an approximate period of 7 months.
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Affiliation(s)
- Bidhu K Mohanti
- Department of Radiation Oncology, Institute Rotary Cancer Hospital (IRCH), All India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi 110029, India
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Abstract
Intensity-modulated radiotherapy (IMRT) is a novel conformal radiotherapy technique which is gaining increasing clinical use worldwide. This article aims to summarize the published data pertaining to clinical indications of this therapy for head and neck, central nervous system, and lung tumours. The main indications in head and neck cancer are parotid gland sparing and dose escalation to tumours close to organs at risk. For central nervous system tumours, IMRT has been used to reduce normal tissue radiation by more conformal dose distributions. To date, the majority of reports concern patients treated in the context of clinical trials, and for most tumour types longer term follow up of treated patients will be required to confirm the clinical benefits of IMRT.
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Affiliation(s)
- M T Guerrero Urbano
- Radiotherapy Department and Head and Neck Unit, Institute of Cancer Research and Royal Marsden NHS Trust, Fulham Road, London SW3 6JJ, UK
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Affiliation(s)
- Natia Esiashvili
- Department of Radiation Oncology, Emory University, Atlanta, Georgia, USA
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O'Sullivan JM, Hollywood DP, Cody N, Dillon J, Buckney S, Moriarty MJ, Armstrong JG. Accelerated radiation therapy, seven fractions per week, for advanced head and neck cancer--a feasibility study. Clin Oncol (R Coll Radiol) 2002; 14:236-40. [PMID: 12109829 DOI: 10.1053/clon.2001.0039] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM The feasibility and improved efficacy of six conventional fractions per week has previously been proven in a Danish randomized trial. We tested the tolerance and efficacy of seven conventional fractions per week using a concomitant boost technique. METHODS From September 1996 to May 1998, 20 patients with squamous cancer of the head and neck were treated with radiation alone. The site of disease was oropharynx in 35%, larynx in 30%, oral cavity 20%, and hypopharynx in 15%. All patients had stage III (10%)/IV (90%) disease. The planned total dose to gross disease was 66 Gy delivered in 33 fractions of 2 Gy each in 31 days. Large volumes were treated to 46 Gy, 2 Gy per fraction, once each morning, Monday-Friday. Boosts to gross disease consisted of 20 Gy in 10 fractions > or = 6 h after the morning dose on Tuesday and Thursday. RESULTS Acute toxicity > or = grade 3 was mucous membrane 75%, pharynx 60%, skin 65%, and larynx 35%. One acute toxicity was fatal. Chronic toxicity > or = grade 3 (three patients) was mucous membrane 5%, pharynx 10%, skin 5%, salivary 15%, and larynx 5%. All patients with grade III or greater late toxicity had grade III acute toxicity in each toxicity category. At 30 months Kaplan-Meier survival is 55%, and local control is 39%. CONCLUSIONS Without increasing resource utilization this scheme accelerates treatment by 30%. As expected acute toxicity is high but manageable. Chronic toxicity appears comparable to other altered fractionation strategies however the median follow up is only 30 months more toxicity may emerge as the data matures. We plan further trials using 1.8 Gy fractions to reduce toxicity.
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Affiliation(s)
- Joe M O'Sullivan
- Department of Radiotherapy, St Luke's Hospital, Rathgar, Dublin, Ireland
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Laszlo A, Rosset A, Hermann F, Ozsahin M, Zouhair A, Mirimanoff RO. Radiothérapie trifractionnée accélérée seule ou alternée avec la chimiothérapie chez des patients souffrant d’un cancer localement évolué de la sphère ORL : analyse de la toxicité tardive. Cancer Radiother 2001; 5:130-7. [PMID: 11355577 DOI: 10.1016/s1278-3218(01)00085-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE To assess late effects and quality of life in patients treated by three times daily (t.i.d.) radiotherapy with or without alternating chemotherapy for locally advanced squamous cell carcinoma of the head and neck. PATIENTS AND METHOD Between 1986 and 1991, 153 patients with locally advanced tumors have been included in a phase I/II study consisting of t.i.d. radiotherapy (4 h. between fractions) of 2 Gy/fraction to a total dose of 60 Gy, alternated or not with combination chemotherapy. The first group of patients received radiotherapy alone, the other group received combined modality. Ninety-two patients were eligible for late effect assessment: 61 in the combined modality group and 31 in the radiation therapy only group. The median follow-up was 45 months. All patients have been assessed according to the follow-up clinical records using the RTOG/EORTC classification. Twenty-nine patients, who were alive at the time of our study, received a questionnaire on their quality of life, and were invited for a clinical evaluation using the SOMA-LENT scale. RESULTS Ninety percent of the patients treated by radiation therapy alone developed one or more late complications. Overall, 47% of the patients have developed severe complications (grade III and IV): 42% in the group treated by radiation therapy alone and 49% in the group treated with combined modality. In the group treated by radiation therapy alone, the most commonly damaged organs were the mucosa (83%), skin (51%) and salivary glands (42%). We observed one case of osteonecrosis and one case of radiation myelitis. In the combined modality group, 95% of patients developed one or more late sequelae, of which 79% had skin, 51% mucosa and 42% salivary gland late effects, respectively. We observed four cases of osteonecrosis. Quality of life and overall physical condition of the patients have been judged to be average by self-questionnaire. Assessment according to the SOMA-LENT scale showed serious late effects mainly at the level of the salivary glands, mandibles and teeth. Correspondence between the RTOG/EORTC and the SOMA-LENT scale was mediocre. CONCLUSION This unconventional 4-h three times daily radiotherapy protocol resulted in very severe late effects on normal tissue. However, combination with chemotherapy resulted in minimal additional toxicity. We emphasise that the SOMA-LENT scale is neither simple to use nor easy to interpret. Quality of life is a very subjective notion and is not necessarily correlated with the objective seriousness of complications.
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Affiliation(s)
- A Laszlo
- Département de radio-oncologie, centre hospitalier universitaire Vaudois (CHUV), 46, rue du Bugnon, 1011 Lausanne, Suisse
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Brizel DM, Wasserman TH, Henke M, Strnad V, Rudat V, Monnier A, Eschwege F, Zhang J, Russell L, Oster W, Sauer R. Phase III randomized trial of amifostine as a radioprotector in head and neck cancer. J Clin Oncol 2000; 18:3339-45. [PMID: 11013273 DOI: 10.1200/jco.2000.18.19.3339] [Citation(s) in RCA: 534] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Radiotherapy for head and neck cancer causes acute and chronic xerostomia and acute mucositis. Amifositine and its active metabolite, WR-1065, accumulate with high concentrations in the salivary glands. This randomized trial evaluated whether amifostine could ameliorate these side effects without compromising the effectiveness of radiotherapy in these patients. PATIENTS AND METHODS Patients with previously untreated head and neck squamous cell carcinoma were eligible. Primary end points included the incidence of grade > or =2 acute xerostomia, grade > or =3 acute mucositis, and grade > or =2 late xerostomia and were based on the worst toxicity reported. Amifostine was administered (200 mg/m(2) intravenous) daily 15 to 30 minutes before irradiation. Radiotherapy was given once daily (1.8 to 2.0 Gy) to doses of 50 to 70 Gy. Whole saliva production was quantitated preradiotherapy and regularly during follow-up. Patients evaluated their symptoms through a questionnaire during and after treatment. Local-regional control was the primary antitumor efficacy end point. RESULTS Nausea, vomiting, hypotension, and allergic reactions were the most common side effects. Fifty-three percent of the patients receiving amifostine had at least one episode of nausea and/or vomiting, but it only occurred with 233 (5%) of 4,314 doses. Amifostine reduced grade > or =2 acute xerostomia from 78% to 51% (P<.0001) and chronic xerostomia grade > or = 2 from 57% to 34% (P=.002). Median saliva production was greater with amifostine (0.26 g v 0.10 g, P=.04). Amifostine did not reduce mucositis. With and without amifostine, 2-year local-regional control, disease-free survival, and overall survival were 58% versus 63%, 53% versus 57%, and 71% versus 66%, respectively. CONCLUSION Amifostine reduced acute and chronic xerostomia. Antitumor treatment efficacy was preserved.
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Affiliation(s)
- D M Brizel
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA.
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Fu KK, Pajak TF, Trotti A, Jones CU, Spencer SA, Phillips TL, Garden AS, Ridge JA, Cooper JS, Ang KK. A Radiation Therapy Oncology Group (RTOG) phase III randomized study to compare hyperfractionation and two variants of accelerated fractionation to standard fractionation radiotherapy for head and neck squamous cell carcinomas: first report of RTOG 9003. Int J Radiat Oncol Biol Phys 2000; 48:7-16. [PMID: 10924966 DOI: 10.1016/s0360-3016(00)00663-5] [Citation(s) in RCA: 905] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE The optimal fractionation schedule for radiotherapy of head and neck cancer has been controversial. The objective of this randomized trial was to test the efficacy of hyperfractionation and two types of accelerated fractionation individually against standard fractionation. METHODS AND MATERIALS Patients with locally advanced head and neck cancer were randomly assigned to receive radiotherapy delivered with: 1) standard fractionation at 2 Gy/fraction/day, 5 days/week, to 70 Gy/35 fractions/7 weeks; 2) hyperfractionation at 1. 2 Gy/fraction, twice daily, 5 days/week to 81.6 Gy/68 fractions/7 weeks; 3) accelerated fractionation with split at 1.6 Gy/fraction, twice daily, 5 days/week, to 67.2 Gy/42 fractions/6 weeks including a 2-week rest after 38.4 Gy; or 4) accelerated fractionation with concomitant boost at 1.8 Gy/fraction/day, 5 days/week and 1.5 Gy/fraction/day to a boost field as a second daily treatment for the last 12 treatment days to 72 Gy/42 fractions/6 weeks. Of the 1113 patients entered, 1073 patients were analyzable for outcome. The median follow-up was 23 months for all analyzable patients and 41.2 months for patients alive. RESULTS Patients treated with hyperfractionation and accelerated fractionation with concomitant boost had significantly better local-regional control (p = 0.045 and p = 0.050 respectively) than those treated with standard fractionation. There was also a trend toward improved disease-free survival (p = 0.067 and p = 0.054 respectively) although the difference in overall survival was not significant. Patients treated with accelerated fractionation with split had similar outcome to those treated with standard fractionation. All three altered fractionation groups had significantly greater acute side effects compared to standard fractionation. However, there was no significant increase of late effects. CONCLUSIONS Hyperfractionation and accelerated fractionation with concomitant boost are more efficacious than standard fractionation for locally advanced head and neck cancer. Acute but not late effects are also increased.
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Affiliation(s)
- K K Fu
- Department of Radiation Oncology, University of California San Francisco, 94143-0226, USA.
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Morris MM, Schmidt-Ullrich R, Johnson CR. Advances in Radiotherapy for Carcinoma of the Head and Neck. Surg Oncol Clin N Am 2000. [DOI: 10.1016/s1055-3207(18)30140-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Garden AS, Glisson BS, Ang KK, Morrison WH, Lippman SM, Byers RM, Geara F, Clayman GL, Shin DM, Callender DL, Khuri FR, Goepfert H, Hong WK, Peters LJ. Phase I/II trial of radiation with chemotherapy "boost" for advanced squamous cell carcinomas of the head and neck: toxicities and responses. J Clin Oncol 1999; 17:2390-5. [PMID: 10561301 DOI: 10.1200/jco.1999.17.8.2390] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Extrapolating from our experience delivering a "boost" field of radiation concurrently with fields treating both gross and subclinical disease at the end of a course of radiation therapy, we developed a regimen to deliver concurrent chemotherapy during the last 2 weeks of a conventionally fractionated course of radiation. PATIENTS AND METHODS Patients had stage III or IV biopsy-proven squamous cell carcinoma originating from a head and neck mucosal site. The regimen was 70 Gy delivered over 7 weeks with concurrent fluorouracil (5-FU) and cisplatin given daily with each radiation dose during the last 2 weeks. A phase I study was performed to determine the maximum-tolerated dose (MTD) before a phase II study was conducted. RESULTS The MTD was 400 mg/m(2) per day for 5-FU and 10 mg/m(2) per day for cisplatin. Mucositis persisting more than 6 weeks after therapy was the dose-limiting toxicity. A total of 60 patients were treated on the two phases of the study. Eighteen patients (35%) treated at the MTD developed prolonged mucositis. There were two cases of neutropenic sepsis, including one fatality. The actuarial 2-year rates for overall survival, freedom from relapse, and local control were 62%, 59%, and 80%, respectively. CONCLUSION Preliminary locoregional control rates seem to be higher than those reported for treatment with radiation alone. Toxicity was also greater than that seen with radiation alone, but the regimen was designed to deliver an intense treatment schedule, which could be completed without significant interruptions, and to obtain high control rates above the clavicles. These end points were achieved.
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Affiliation(s)
- A S Garden
- Departments of Radiation Oncology, Thoracic Head and Neck Medical Oncology, and Head and Neck Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA.
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Abstract
Radiation therapy plays a crucial role in the management of children with parameningeal rhabdomyosarcomas. Because of the close proximity to the skull base, most lesions are not amenable to complete surgical resection without mutilation, and treatment has primarily been chemoradiation. Adequate radiotherapy dose, coverage of the tumor, and knowledge of potential areas of invasion are of paramount importance as demonstrated by early data from the Intergroup Rhabdomyosarcoma Study Group. The timing, dose, and treatment volume for parameningeal rhabdomyosarcomas have evolved in the last 25 years in a continuous effort to find ways of maximizing local control while reducing possible late sequelae. Hyperfractionated radiation therapy is currently being tested against conventional dose radiation therapy for group III tumors. At present, approximately 70% of children treated for parameningeal rhabdomyosarcoma on the Intergroup Rhabdomyosarcoma Study are alive at 5 years compared with a 25% survival before the formation of multi-institutional cooperative group studies.
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Affiliation(s)
- A C Paulino
- Department of Radiotherapy, Loyola University of Chicago, Stritch School of Medicine, Maywood, Illinois, USA
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Abstract
The effectiveness of accelerated fractionation and hyperfractionation in cancer of the head and neck has been confirmed by randomized studies. These new fractionation strategies are almost invariably accompanied by an increase of early normal tissue reactions, in particular mucosal reactions. This paper presents a survey of the available experimental and clinical mucositis data and aims to assess to what extent the upper aerodigestive tract mucosa is limiting to treatment intensification by altered fractionation. The rate of dose delivery is the most important determinant for early radiation reactions. With accelerated radiotherapy, relative to a conventional treatment of 7 weeks, the achievable gain in treatment time is 2 weeks at most with the mucosa being the limiting tissue. Any further acceleration requires a reduction of dose. Manipulations with the temporal distribution of dose, fraction dose, and optimization of interfraction intervals can improve tolerance but probably do not allow significant further intensification of the existing accelerated schedules. Dose escalation by hyperfractionation does not seem to be directly limited by early mucosal reactions. Late reacting tissues are more likely to limit intensification of these schedules. Suggestions for further improvement of treatment outcome include: the generation of a potent agent which can ameliorate radiation mucositis and so permit further intensification of radiotherapy schedules; combination of altered fractionation schedules with hypoxic modifiers; and tailoring of the treatment strategy based on patient and tumour characteristics.
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Affiliation(s)
- J H Kaanders
- The Institute of Radiotherapy, University of Nijmegen, The Netherlands
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Akimoto T, Mitsuhashi N, Hayakawa K, Sakurai H, Murata O, Ishizeki K, Ishikawa H, Nasu S, Yamakawa M, Niibe H. Split-course accelerated hyperfractionation radiotherapy for advanced head and neck cancer: influence of split time and overall treatment time on local control. Jpn J Clin Oncol 1997; 27:240-3. [PMID: 9379511 DOI: 10.1093/jjco/27.4.240] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
We analyzed 52 patients with stage III and IV head and neck cancer who were given split-course accelerated hyperfractionated radiotherapy with curative intent, focusing particularly on the influence of split-time on local control. An initial complete response was achieved in 16 patients (31%), and the rate of persistent local control at 3 years was 23%. The cause specific survival rate at 3 years was 29%. Univariate analysis of local control according to the split-time duration and overall treatment time showed that shorter duration (< or = 14 days or < or = 45 days, respectively) had a significantly positive impact on local control (P < 0.05). Multivariate analysis using local control as an endpoint also demonstrated that gender (women showing a better outcome than men) and split-time (< or = 14 days was better than > 14 days) were statistically significant factors for local control. These results suggest that shortening the split-time during radiotherapy might improve local control in accelerated hyperfractionation.
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Affiliation(s)
- T Akimoto
- Department of Radiology and Radiation Oncology, Gunma University School of Medicine, Japan
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Allal AS, Bieri S, Miralbell R, Marchal F, Lehmann W, Kurtz JM. Feasibility and outcome of a progressively accelerated concomitant boost radiotherapy schedule for head and neck carcinomas. Int J Radiat Oncol Biol Phys 1997; 38:685-9. [PMID: 9240633 DOI: 10.1016/s0360-3016(97)00061-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE To evaluate toxicity and treatment outcome in patients with head and neck carcinomas treated with a modified bifractionated concomitant boost radiotherapy schedule. METHODS AND MATERIALS Eighty-five patients were treated from February 1991 to October 1995. According to clinical TN stage 23 tumors were T1, 33 T2, 20 T3, 9 T4, 44 N0, and 41 N1-N3. The primary tumor was located in the oral cavity in 6 patients, oropharynx in 36, larynx in 19, hypopharynx in 17, and nasopharynx in 7. The basic treatment delivered 50.4 Gy in 28 fractions, once a day, to the primary site and both sides of the neck. During the last 3.5 weeks, a boost to the initial gross disease was delivered in 13 fractions of 1.5 Gy each as a second daily fraction in a progressively accelerated schedule (total dose 69.9 Gy). Eighteen patients had a uni- or bilateral neck dissection, and 2 an adenectomy before radiotherapy. The median follow-up for the surviving patients was 28 months (range: 3-61 months). RESULTS All the patients completed the planned radiotherapy schedule. According to the RTOG scoring system, 57 patients (67%) presented with Grade 3-4 acute toxicity. Grade 3 dysphagia was observed in 20 patients (23.5%). Three patients died during the 3 months following the treatment. Among 73 patients evaluable for late effects, five developed Grade 3-4 complications. At 3 years actuarial loco-regional control was 67% and overall survival was 62%. CONCLUSIONS Although longer follow-up is needed to evaluate the definitive results, we conclude that this particular concomitant boost schedule is feasible and appears to be effective. While acute toxicity was greater than in monofractionated schedules, it was manageable, provided that supportive care measures were implemented in a timely fashion.
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Affiliation(s)
- A S Allal
- Division of Radiation Oncology, University Hospital, Geneva, Switzerland
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Merchant TE. Delayed-accelerated hyperfractionated radiation therapy for advanced-stage or high-risk rhabdomyosarcoma. MEDICAL AND PEDIATRIC ONCOLOGY 1997; 29:45-50. [PMID: 9142206 DOI: 10.1002/(sici)1096-911x(199707)29:1<45::aid-mpo9>3.0.co;2-s] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The treatment of six patients with advanced-stage or high-risk rhabdomyosarcoma (RMS) is described. These patients were treated with a delayed-accelerated hyperfractionated radiation therapy (DAHFRT) regimen which delivers 5200 cGy over 20 treatment days. Acceptable early toxicity was noted when radiation therapy was given after a full course of chemotherapy and major attempts at resection of the primary tumor. The DAHFRT regimen has inherent biological and time-intensity advantages compared to other fractionation schemes which may be exploited to improve local control. The DAHFRT regimen should be considered as an alternate fractionation scheme for RMS patients and a possible foundation from which dose-escalation of radiation therapy may be attempted using advanced treatment planning technology. Late effects of high-dose radiation therapy, although a major concern, should assume less priority given the high local failure rates of advanced-stage patients and the advent of conformed radiation therapy treatment planning and delivery which can be used to reduce treatment-related toxicity.
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Affiliation(s)
- T E Merchant
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
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Kavanagh BD, Gieschen HL, Schmidt-Ullrich RK, Arthur D, Zwicker R, Kaufman N, Goplerud DR, Segreti EM, West RJ. A pilot study of concomitant boost accelerated superfractionated radiotherapy for stage III cancer of the uterine cervix. Int J Radiat Oncol Biol Phys 1997; 38:561-8. [PMID: 9231680 DOI: 10.1016/s0360-3016(97)89484-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE Retrospective studies suggest that prolonged treatment time adversely affects control rates of squamous carcinomas managed by radiotherapy. From 1989 to 1994 a prospective clinical trial was conducted to assess the feasibility and efficacy of concomitant boost accelerated superfractionated (CBASF) radiotherapy for advanced uterine cervical carcinoma. METHODS AND MATERIALS Twenty newly diagnosed patients with FIGO stage III squamous cell carcinoma of the cervix were irradiated using a CBASF regimen. Patients received 45 Gy administered to the whole pelvis in 25 fractions in 5 weeks. On Monday, Wednesday, and Friday of the last 3 weeks, an additional 1.6 Gy boost was given 6 hours after the whole pelvis treatment. The 9 boost treatments, totaling 14.4 Gy, were given via lateral fields encompassing the parametria and primary tumor for a cumulative tumor dose of 59.4 Gy. A single low-dose rate brachytherapy procedure was performed within 1 week after the external beam radiotherapy to raise the point A dose to 85-90 Gy in 42 days. Primary endpoints of analysis were local control, complications, and patterns of failure. Results are compared with the outcomes of 21 patients treated with conventionally fractionated (CF) radiotherapy during the same years. RESULTS Median total treatment time was 46 days in the CBASF group (range 37-62). Median follow-up interval among surviving CBASF patients is 3.8 years. The four-year actuarial local control rates are 78% and 70% in the CBASF and CF groups, respectively (p = ns). Only 2 CBASF patients required a treatment break because of acute toxicity, but severe late complications occurred in 8/20 CBASF patients for a crude rate of 40%. Distant failure was more common than local failure in the CBASF group, and para-aortic node failure occurred in six of the eight CBASF patients with distant failure. CONCLUSIONS In the management of stage III cervix cancer, the CBASF regimen produced a trend toward improved local control when compared with the CF regimen, shifting the patterns of failure toward a higher rate of isolated distant failures. The high frequency of para-aortic node failure warrants consideration of elective treatment to this region in stage III patients treated with curative intent. Although the high local control rate of the CBASF regimen supports further investigation of accelerated treatment regimens for locally advanced cervix cancer, the unacceptable risk of late complications necessitates refinement in technique and scheduling to improve the therapeutic ratio.
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Affiliation(s)
- B D Kavanagh
- Department of Radiation Oncology, Medical College of Virginia, Virginia Commonwealth University, Richmond 23298-0058, USA
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Kim JJ, Hao Y, Jang D, Wong CS. Lack of influence of sequence of top-up doses on repair kinetics in rat spinal cord. Radiother Oncol 1997; 43:211-7. [PMID: 9192969 DOI: 10.1016/s0167-8140(97)01928-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND PURPOSE The rat spinal cord model was used to determine whether repair kinetics changed during a course of fractionated radiotherapy if twice daily doses were given either at the initial or final period of a concomitant boost irradiation schedule. MATERIALS AND METHODS The rat cervical spinal cord was irradiated from C2-T2 in 870 animals with top-up doses of three daily fractions of 9 Gy representing 75% of the biologic dose at the ED50 level for white matter necrosis. To simulate concomitant boost protocols, these top-up doses were given either preceding (initial top-up) or following (final top-up) a b.i.d. schedule of 1 Gy/F delivered at 0, 1, 2, 4, 8 or 24 h interfraction intervals. The end point was forelimb paralysis secondary to white matter necrosis. RESULTS For interfraction intervals of 0, 1, 2, 4, 8 and 24 h, the initial top-up schedules yielded ED50 values of 18.2, 19.2, 23.7, 21.3, 27.2 and 29.7 Gy, respectively; the corresponding ED50s from the final top-up schedules were 17.5, 19.0, 20.7, 21.2, 26.9 and 30.3 Gy, respectively. A 10% reduction in the ED50 value from pooled data was observed when the interfraction interval was reduced from 24 (ED50 = 30.3 Gy) to 8 h (ED50 = 27.1 Gy). Fitting the incomplete repair (IR) version of the LQ model with mono-exponential repair kinetics gave alpha/beta values of 1.4 and 1.5 Gy, and similar repair half-times of 4.3 and 5.0 h for the initial and final top-up experiments, respectively. The IR model with bi-exponential repair kinetics did not provide a better fit to the data. CONCLUSIONS We conclude that the sequence of top-up doses has no apparent influence on radiation sensitivity or repair kinetics in the rat spinal cord. The clinical implication is that the interfraction interval but not the timing of the boost is a critical determinant of spinal cord tolerance in concomitant boost protocols.
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Affiliation(s)
- J J Kim
- Department of Radiation Oncology, University of Toronto, Ontario, Canada
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Jackson SM, Weir LM, Hay JH, Tsang VH, Durham JS. A randomised trial of accelerated versus conventional radiotherapy in head and neck cancer. Radiother Oncol 1997; 43:39-46. [PMID: 9165135 DOI: 10.1016/s0167-8140(97)01944-0] [Citation(s) in RCA: 128] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND PURPOSE To study the effect of accelerated radiation treatment in locally advanced head and neck cancer, a prospective randomised trial was conducted comparing two fractionation schemes which differed only in the overall treatment time; fraction size and total dose were the same in both arms. MATERIALS AND METHODS Eighty-two patients with stage 3 or 4 squamous cell cancer of the oral cavity, oropharynx, hypopharynx or larynx considered suitable for radical radiotherapy as primary treatment were stratified by site and stage and randomised to receive 66 Gy in 33 2 Gy daily fractions in 45-48 days (o.d.) or 66 Gy in 33 2 Gy twice daily fractions in 22-25 days (b.i.d.). RESULTS An initial improved clinical response in tumour control in the b.i.d. arm was not sustained and the 3 year recurrence free survival and overall survival rates were similar and not significantly different. The actuarial recurrence free survival was 49.1% in the b.i.d. arm and 44.3% in the o.d. arm. The disease free 3 year survival was 59.4% and 56.8%, respectively. The acute and late normal tissue effects were scored using the RTOG scale. As expected the acute effects were much greater in the b.i.d. arm. The combined grade 3 and 4 late effects were similar but the proportion of grade 4 reactions was significantly higher in the b.i.d. arm. The increase in grade 4 toxicity caused the trial to be discontinued after 82 of the planned 226 patients had been randomised. CONCLUSIONS The severity of the normal tissue effects and a failure to demonstrate sustained local control does not support this fractionation scheme in patients with such extensive head and neck cancer.
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Affiliation(s)
- S M Jackson
- British Columbia Cancer Agency, Vancouver Cancer Centre, Canada
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Allal AS, Miralbell R, Pipard G, Guillemin C, Lehmann W, Kurtz JM. Early and long-term results of an original accelerated radiation therapy schedule in head and neck carcinoma. Acta Oncol 1997; 36:267-71. [PMID: 9208895 DOI: 10.3109/02841869709001261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
From November 1985 until October 1988, 39 patients with head and neck carcinoma (6 patients stage I-II and 33 stage III-IV) were treated with an accelerated radiotherapy schedule designed to deliver 69.6 Gy over a period of 5 weeks. Treatment was started with 20 Gy in 10 daily fractions to sites of initial macroscopic involvement, followed by bi-fractionated radiotherapy (2 x 1.6 Gy/day) to a larger head and neck volume. Twenty patients received neo-adjuvant chemotherapy. A homolateral radical neck dissection was performed in 2 patients. Twenty-six patients (66.6%) presented with acute grade 3 complications and 5 patients (13%) with grade 4 complications. Thirteen patients (33.3%) were hospitalized for supportive care. None of the patients who were evaluated on a long-term basis developed grade 3 or 4 late complications. The 5-year loco-regional control and overall survival rates were 62.4% and 33.6% respectively. Although acute toxicity is higher than in monofractionated schedules, it is manageable, and can be considered acceptable in the light of the apparently good loco-regional control thus obtained. This schedule is one of several accelerated radiotherapy programs which might merit study in prospective trials.
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Affiliation(s)
- A S Allal
- Division of Radiation Oncology, University Hospital, Geneva, Switzerland
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Fu KK, Cooper JS, Marcial VA, Laramore GE, Pajak TF, Jacobs J, Al-Sarraf M, Forastiere AA, Cox JD. Evolution of the Radiation Therapy Oncology Group clinical trials for head and neck cancer. Int J Radiat Oncol Biol Phys 1996; 35:425-38. [PMID: 8655364 DOI: 10.1016/s0360-3016(96)80003-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
During the past 25 years, the Radiation Therapy Oncology Group (RTOG) has played a major role in head and neck cancer clinical research. The major research themes for recent and currently active trials have been: (a) combined modality therapy, (b) altered fractionation radiotherapy, (c) hypoxic cell sensitizers, (d) organ preservation, (e) chemoprevention, and (f) clinical/laboratory correlations. For advanced operable disease, the RTOG showed improved local-regional control with postoperative radiotherapy as compared to preoperative radiotherapy for carcinoma of the supraglottic larynx and hypopharynx. This established the use of surgery followed by postoperative radiotherapy as the standard treatment in subsequent RTOG and Intergroup trials for operable disease. For advanced inoperable disease, the RTOG demonstrated the feasibility of testing altered fractionation radiotherapy in a multiinstitutional clinical trials setting. A Phase III trial comparing hyperfractionation and accelerated fractionation to conventional fractionation is now in progress. Phase I/II combined modality studies established the efficacy of concurrent high-dose cisplatin and radiotherapy in the treatment of advanced disease and provided the basis for further testing in Phase III trials for nasopharyngeal carcinoma, larynx preservation, and high-risk advanced operable disease. Analysis of the extensive RTOG Head and Neck Cancer database established the incidence of second malignancies and their adverse impact on patients whose initial tumors were cured by radiotherapy, and provided the basis for chemoprevention trials. Recursive partitioning analysis identified 6 distinct prognostically homogeneous patient groups based on pretreatment tumor or patient characteristics and/or treatment variables. Retrospective analysis identified tumor p105 antigen density as an independent prognostic indicator in patients irradiated for head and neck cancer. Future trials will continue to focus on the reduction of morbidity and mortality, and improvement of the quality of life of head and neck cancer patients through innovative radiotherapy delivery, multimodality approaches, use of chemical and biological modifiers, and other novel therapies, identification of clinical and biological prognostic indicators, and prevention or diminution of acute morbidity and late complications of the disease and its treatment.
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Affiliation(s)
- K K Fu
- University of California, San Francisco, CA, USA
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Brenner DJ, Hall EJ. Alternative fractionation schemes -- is the "gap" the way ? Int J Radiat Oncol Biol Phys 1996; 35:629-30. [PMID: 8655390 DOI: 10.1016/s0360-3016(96)80029-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Wang CC. Accelerated fractionation: the do's and don'ts--regarding Fu et al., Bourhis et al. and Delaney et al., IJROBP 32:589-597; 1995. Int J Radiat Oncol Biol Phys 1995; 32:889-90. [PMID: 7790278 DOI: 10.1016/0360-3016(95)00188-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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