Computed tomography-based tumour volume as a predictor of outcome in laryngeal cancer: Results of the phase 3 ARCON trial

Role of primary tumor volume and metastatic lymph node volume in response to curative effect of definitive radiotherapy for locally advanced head and neck cancer

BACKGROUND

Studies have shown mixed results concerning the role of primary tumor volume (TV) and metastatic lymph node (NV) volume in response to the curative effect of definitive radiotherapy for locally advanced head and neck squamous cell carcinoma (LAHNSCC).

OBJECTIVE

We aimed to evaluate the impact of TV and NV on the efficacy of radical radiotherapy in LAHNSCC patients, with the goal of guiding individualized therapy.

PATIENTS AND METHODS

Patients with LAHNSCC who received radical radiation therapy and were reexamined within 6 months post-therapy from January 2012 to December 2021 were selected. The volumes of the primary tumors and metastatic lymph nodes were calculated by software and then were divided into a large TV group vs small TV group and a large NV group vs small NV group according to the relationship with the median. Additionally, patients who received concurrent chemoradiotherapy (CCRT) or not were divided into the CCRT group and the radiotherapy (RT) group. Patients with lymph node metastasis were divided into node concurrent chemotherapy (N-CCRT) group and a node metastatic chemotherapy (N-RT) group according to whether they received concurrent chemotherapy or not. The volume shrinkage rate (VSR), objective response rate (ORR), local control rate (LCR) and overall survival (OS) were recorded and analyzed.

RESULTS

96 patients were included in the primary tumor volume group, and 73 patients were included in the metastatic lymph node group. Receiver operating characteristic (ROC) curves were constructed for objective remission (OR) endpoints, and a volume threshold was defined for TV and NV patients. The threshold primary tumor volume was 32.45 cm3, and the threshold metastatic lymph node volume was 6.05 cm3.The primary TV shrinkage rates of the small TV and the large TV groups were basically the same, P = 0.801. Similarly, the ORR and LCR were not significantly different between the small TV group and the large TV group (PORR = 0.118, PLCR = 0.315). Additionally, the TV shrinkage rate did not significantly differ between the CCRT group and the RT group, P = 0.133. Additionally, there was no significant difference in ORR or LCR in CCRT group (PORR = 0.057, PLCR = 0.088). However, the metastatic lymph node volume shrinkage rate in the small NV group was significantly greater than that in the large NV group (P = 0.001). The ORR and LCR of the small NV subgroup were significantly greater than those of the large NV subgroup (PORR = 0.002, PLCR = 0.037). Moreover, compared with that of the N-RT group, the NV shrinkage rate of the N-CCRT group was 84.10 ± s3.11%, and the shrinkage rate was 70.76 ± s5.77% (P = 0.047). For the ORR and LCR, the N-CCRT group and N-RT group were significantly different (PORR = 0.030, PLCR = 0.037). The median OS of the whole group was 26 months. However, neither TV/NV nor concurrent chemotherapy seemed to influence OS.

CONCLUSION

Primary tumor volume is not a prognostic factor for the response to curative effect radiotherapy in LAHNSCC patients. Nevertheless, metastatic lymph nodes are a prognostic factor for the response to curative effect radiotherapy in LAHNSCC patients. Patients with smaller lymph nodes have better local control.

Larynx cancer survival model developed through open-source federated learning

INTRODUCTION

Federated learning has the potential to perfrom analysis on decentralised data; however, there are some obstacles to survival analyses as there is a risk of data leakage. This study demonstrates how to perform a stratified Cox regression survival analysis specifically designed to avoid data leakage using federated learning on larynx cancer patients from centres in three different countries.

METHODS

Data were obtained from 1821 larynx cancer patients treated with radiotherapy in three centres. Tumour volume was available for all 786 of the included patients. Parameter selection among eleven clinical and radiotherapy parameters were performed using best subset selection and cross-validation through the federated learning system, AusCAT. After parameter selection, β regression coefficients were estimated using bootstrap. Calibration plots were generated at 2 and 5-years survival, and inner and outer risk groups' Kaplan-Meier curves were compared to the Cox model prediction.

RESULTS

The best performing Cox model included log(GTV), performance status, age, smoking, haemoglobin and N-classification; however, the simplest model with similar statistical prediction power included log(GTV) and performance status only. The Harrell C-indices for the simplest model were for Odense, Christie and Liverpool 0.75[0.71-0.78], 0.65[0.59-0.71], and 0.69[0.59-0.77], respectively. The values are slightly higher for the full model with C-index 0.77[0.74-0.80], 0.67[0.62-0.73] and 0.71[0.61-0.80], respectively. Smoking during treatment has the same hazard as a ten-years older nonsmoking patient.

CONCLUSION

Without any patient-specific data leaving the hospitals, a stratified Cox regression model based on data from centres in three countries was developed without data leakage risks. The overall survival model is primarily driven by tumour volume and performance status.

Prognostic imaging variables for recurrent laryngeal and hypopharyngeal carcinoma treated with primary chemoradiotherapy: A systematic review and meta-analysis

Background

In this systematic review, we aim to identify prognostic imaging variables of recurrent laryngeal or hypopharyngeal carcinoma after chemoradiotherapy.

Methods

A systematic search was performed in PubMed and EMBASE (1990–2020). The crude data and effect estimates were extracted for each imaging variable. The level of evidence of each variable was assessed and pooled risk ratios (RRs) were calculated.

Results

Twenty‐two articles were included in this review, 17 on computed tomography (CT) and 5 on magnetic resonance imaging (MRI) variables. We found strong evidence for the prognostic value of tumor volume at various cut‐off points (pooled RRs ranging from 2.09 to 3.03). Anterior commissure involvement (pooled RR 2.19), posterior commissure involvement (pooled RR 2.44), subglottic extension (pooled RR 2.25), and arytenoid cartilage extension (pooled RR 2.10) were also strong prognostic factors.

Conclusion

Pretreatment tumor volume and involvement of several subsites are prognostic factors for recurrent laryngeal or hypopharyngeal carcinoma after chemoradiotherapy.

18F-FDG-PET/CT in laryngeal cancer: Comparison with conventional imaging and prognostic role

OBJECTIVE

The aim of this study was to investigate the diagnostic accuracy of staging ¹⁸F-FDG-PET/CT in laryngeal cancer, compare these results with conventional imaging (CI) and assess the value of ¹⁸F-FDG-PET/CT features to predict survival.

METHODS

Fifty-four patients with laryngeal squamous cell cancer and baseline ¹⁸F-FDG-PET/CT were retrospectively enrolled. The PET images were analyzed visually and semi-quantitatively by measuring several metabolic parameters. A combination of clinical follow-up/imaging follow-up and/or histopathology was taken as reference standard. Progression free survival (PFS) and disease specific survival (DSS) were computed using Kaplan-Meier curves.

RESULTS

All primary tumors were clearly identified by CI, and 52/54 by ¹⁸F-FDG-PET/CT with a sensitivity of 96.3%. Cervical nodal metastases were detected in 40/54 patients at ¹⁸F-FDG-PET/CT and in 34/49 patients at CI. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy on a patient-based analysis for nodal disease were 100%, 85.7%, 94.6%, 100% and 95.9% at ¹⁸F-FDG-PET/CT, and 91.4%, 85.7%, 94.1%, 80%, 89.8% at CI. Diagnostic performances of PET/CT and CI were not significantly different on a patient-based, side-by-side and level-by-level analysis. ¹⁸F-FDG-PET/CT recognized distant metastases in 7 patients allowing to an upstaging. At a median follow-up of 27 months, relapse/progression of disease occurred in 31 patients and death occurred in 32. Metabolic tumor volume (MTV T), MTV total and total lesion glycolysis (TLG) showed to be independent prognostic factors for PFS.

CONCLUSIONS

Both CI and PET/CT had good diagnostic performances for the staging of laryngeal cancer; baseline metabolic features (MTV and TLG) showed an important prognostic value in assessing the rate of PFS.

Developing and validating an integrated gross tumor volume (GTV)-TNM stratification system for supplementing unresectable locally advanced non-small cell lung cancer treated with concurrent chemoradiotherapy

Purpose

The gross tumor volume (GTV) could be an independent prognostic factor for unresectable locally advanced non-small cell lung cancer (LANSCLC). We aimed to develop and validate a novel integrated GTV-TNM stratification system to supplement LANSCLC sub-staging in patients treated with concurrent chemoradiotherapy (CCRT).

Methods

We performed a retrospective review of 340 patients with unresectable LANSCLC receiving definitive CCRT. All included patients were divided into two randomized cohorts. Then the Kaplan–Meier method and Cox regression were calculated to access the prognostic value of the integrated GTV-TNM stratification system, which was further validated by the area under the receiver operating characteristic curve (AUC) score and F1-score.

Results

The optimal outcome-based GTV cut-off values (70 and 180 cm³) of the modeling cohort were used to determine each patient’s integrated GTV-TNM stratum in the whole cohort. Our results indicated that a lower integrated GTV-TNM stratum could had better overall survival and progression-free survival (all P < 0.001), which was recognized as an independent prognostic factor. Also, its prognostic value was robust in both the modeling and validation cohorts. Furthermore, the prognostic validity of the integrated GTV-TNM stratification system was validated by significantly improved AUC score (0.636 vs. 0.570, P = 0.027) and F1-score (0.655 vs. 0.615, P < 0.001), compared with TNM stage.

Conclusions

We proposed a novel integrated GTV-TNM stratification system to supplement unresectable LANSCLC sub-staging due to its prognostic value independent of TNM stage and other clinical characteristics, suggesting that it could be considered in individual treatment decision-making process.

18F-FDG-PET/CT in laryngeal cancer: comparison with conventional imaging and prognostic role

OBJECTIVE

The aim of this study was to investigate the diagnostic accuracy of staging 18 F-FDG-PET/CT in laryngeal cancer, compare these results with conventional imaging (CI) and assess the value of 18 F-FDG-PET/CT features to predict survival.

METHODS

Fifty-four patients with laryngeal squamous cell cancer and baseline 18 F-FDG-PET/CT were retrospectively enrolled. The PET images were analyzed visually and semi-quantitatively by measuring several metabolic parameters. A combination of clinical follow-up/imaging follow-up and/or histopathology was taken as reference standard. Progression free survival (PFS) and disease specific survival (DSS) were computed using Kaplan-Meier curves.

RESULTS

All primary tumors were clearly identified by CI, and 52/54 by 18 F-FDG-PET/CT with a sensitivity of 96.3%. Cervical nodal metastases were detected in 40/54 patients at 18 F-FDG-PET/CT and in 34/49 patients at CI. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy on a patient-based analysis for nodal disease were 100%, 85.7%, 94.6%, 100% and 95.9% at 18 F-FDG-PET/CT, and 91.4%, 85.7%, 94.1%, 80%, 89.8% at CI. Diagnostic performances of PET/CT and CI were not significantly different on a patient-based, side-by-side and level-by-level analysis. 18 F-FDG-PET/CT recognized distant metastases in 7 patients allowing to an upstaging. At a median follow-up of 27 months, relapse/progression of disease occurred in 31 patients and death occurred in 32. Metabolic tumor volume (MTV T), MTV total and total lesion glycolysis (TLG) showed to be independent prognostic factors for PFS.

CONCLUSIONS

Both CI and PET/CT had good diagnostic performances for the staging of laryngeal cancer; baseline metabolic features (MTV and TLG) showed an important prognostic value in assessing the rate of PFS.

Pathologic Tumor Size as a Predictor of the Survival Outcomes of Patients With Glottic Carcinoma

OBJECTIVES

The purpose of this study was to evaluate the potential predictor of tumor size on rates of overall and disease-free survival (OS and DFS) as determined by postoperative pathologic examination in patients with glottic carcinoma.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary care university hospital.

SUBJECTS AND METHODS

In this study, 1337 consecutive patients with glottic carcinoma who underwent surgical treatment from 2005 to 2010 were retrospectively reviewed. The influence of tumor size that was evaluated by tumor area (tumor length × tumor width) on OS and DFS outcomes was assessed by Cox regression analyses.

RESULTS

In all, 1303 (97.5%) patients were male, and 34 (2.5%) were female, with a mean ± SD age of 60.4 ± 10 years. The 10-year OS and DFS rates were 72.9% and 69.9%, respectively. The tumor area cutoff values that best discriminated OS and DFS rates were both 1.80 cm². Patients with glottic carcinoma with a larger tumor area had inferior OS and DFS rates. Based on the results of multivariate analyses, tumor area was an independent prognostic factor for rates of OS (hazard ratio, 1.87; 95% CI, 1.37-2.56; P < .001) and DFS (hazard ratio, 1.79; 95% CI, 1.34-2.38; P < .001) in patients with glottic carcinoma.

CONCLUSIONS

The results of this study indicate that patients with glottic carcinoma with a tumor area >1.8 cm² have inferior survival outcomes, and this factor independently predicts survival outcomes in these patients.

Decision making in advanced larynx cancer: An evidenced based review

Organ preservation versus total laryngectomy for advanced laryngeal cancer continues to be hotly debated. This review presents evidence-based decision making points for these patents.

Three-dimensional imaging assessment of anatomic invasion and volumetric considerations for chemo/radiotherapy-based laryngeal preservation in T3 larynx cancer

OBJECTIVES

To investigate the impact of 3-Diminsional (3D) tumor volume (TV) and extent of involvement of primary tumor on treatment outcomes in a large uniform cohort of T3 laryngeal carcinoma patients treated with nonsurgical laryngeal preservation strategies.

MATERIALS AND METHODS

The pretreatment contrast-enhanced computed tomography images of 90 patients with T3 laryngeal carcinoma were reviewed. Primary gross tumor volume (GTVp) was delineated to calculate the 3D TV and define the extent of invasion. Cartilage and soft tissue involvement was coded. The extent of invasion was dichotomized into non/limited invasion versus multiple invasion extension (MIE), and was subsequently correlated with survival outcomes.

RESULTS

The median TV was 6.6 cm3. Sixty-five patients had non/limited invasion, and 25 had MIE. Median follow-up for surviving patients was 52 months. The 5-year local control and overall survival rates for the whole cohort were 88% and 68%, respectively. There was no correlation between TV and survival outcomes. However, patients with non/limited invasion had better 5-year local control (LC) than those with MIE (95% vs 72%, p = .009) but did not have a significantly higher rate of overall survival (OS) (74% vs 67%, p = .327). In multivariate correlates of LC, MIE maintained statistical significance whereas baseline airway status showed a statistically significance trend with poor LC (p = .0087 and 0.06, respectively). Baseline good performance status was an independent predictor of improved OS (p = .03) in multivariate analysis.

CONCLUSION

The extent of primary tumor invasion is an independent prognostic factor of LC of the disease after definitive radiotherapy in T3 larynx cancer.

Tumor volume as a predictor of survival in T3 glottic carcinoma: A novel approach to patient selection

BACKGROUND

The optimal treatment for T3 glottic cancers continues to be debated. Organ preservation has become the standard of care, but not all tumors respond equally. The purpose of this was to investigate the long-term survival outcomes of organ preservation protocols based on tumor volume.

METHODS

A retrospective review of prospectively collected data from 1966 to 2016 was performed. Patients with T3 vocal cord cancer treated with radiation therapy (RT) at the University of Florida were included. Local control rates as well as survival rates were determined with a Kaplan Meier and Cox regression analysis. Survival was analyzed as a function of tumor volume and an optimal cut point was determined.

RESULTS

107/234 patients were included. 79% received RT and 21% chemo-RT. 5-year local control was 61.5% and 5-year disease specific survival was 79.3%. Tumor volume was a significant predictor of survival (p = 0.007). An optimal cut point for tumor volume was 2.5 cc. Patients with tumor volumes ≥2.5 cc had significantly worse (p < 0.05) tumor control rates (100% vs. 70.4%).

CONCLUSION

Tumor volume is a significant predictor of survival outcomes in T3 vocal cord cancers, but will need external validation. Tumors <2.5 cc have favorable outcomes. Those with higher volume tumors should be counselled appropriately and be considered for primary surgical management.

Curcumin inhibits cell proliferation and promotes apoptosis of laryngeal cancer cells through Bcl-2 and PI3K/Akt, and by upregulating miR-15a

Curcumin is a natural compound extracted from the dried rhizomes of Curcuma (curcuma root or zedoary) that exhibits extensive pharmacological effects and low toxicity. The aim of the present study was to investigate whether curcumin inhibits cell proliferation and promotes apoptosis of laryngeal cancer through Bcl-2 and phosphoinositide 3-kinase (PI3K)/protein kinase B (Akt), and by upregulating microRNA-15a (miR-15a). It was demonstrated that curcumin inhibits cell proliferation, and promotes apoptosis and increased caspase-3 activity of human laryngeal cancer cells. Furthermore, curcumin decreased Bcl-2 and PI3K protein expression, and decreased the phospho (p)-Akt protein expression of human laryngeal cancer cells. Furthermore, curcumin activated miR-15a expression by human laryngeal cancer cells. Suppression of miR-15a expression reversed the anticancer effect of curcumin on cell proliferation of human laryngeal cancer cells and increased Bcl-2 and PI3K/Akt protein expression in AMC-HN-8 cells treated with 40 µM of curcumin. The results of the present study suggest that curcumin inhibits cell proliferation and promotes apoptosis of laryngeal cancer cells through Bcl-2 and PI3K/Akt, and by upregulating miR-15a.

Quantitative pretreatment CT volumetry: Association with oncologic outcomes in patients with T4a squamous carcinoma of the larynx

BACKGROUND

The purpose of this study was to determine the impact of CT-determined pretreatment primary tumor volume on survival and disease control in T4a laryngeal squamous cell carcinoma (SCC).

METHODS

We retrospectively reviewed 124 patients with T4a laryngeal cancer from 2000-2011. Tumor volume measurements were collected and correlated with outcomes.

RESULTS

Five-year overall survival (OS) for patients with tumor volume ≥21 cm³ treated with larynx preservation (n = 26 of 41) was significantly inferior compared to <21 cm³ (42% vs 64%, respectively; P = .003). Five-year OS for patients with tumor volumes ≥21 cm³ in the cohort treated with total laryngectomy followed by radiotherapy (RT; n = 42 of 83) was not statistically significant when compared to <21 cm³ (50% vs 63%, respectively; P = .058). On multivariate analysis, tumor volume ≥21 cm³ was a significant independent correlate of worse disease-specific survival (DSS; P = .004), event-free survival (P = .005), recurrence-free survival (RFS; P = .04), noncancer cause-specific survival (P = .02), and OS (P = .0002).

CONCLUSION

Pretreatment CT-based tumor volume is an independent prognostic factor of outcomes in T4a laryngeal cancer.

Tumor Volumes and Prognosis in Laryngeal Cancer

Tumor staging systems for laryngeal cancer (LC) have been developed to assist in estimating prognosis after treatment and comparing treatment results across institutions. While the laryngeal TNM system has been shown to have prognostic information, varying cure rates in the literature have suggested concern about the accuracy and effectiveness of the T-classification in particular. To test the hypothesis that tumor volumes are more useful than T classification, we conducted a retrospective review of 78 patients with laryngeal cancer treated with radiation therapy at our institution. Using multivariable analysis, we demonstrate the significant prognostic value of anatomic volumes in patients with previously untreated laryngeal cancer. In this cohort, primary tumor volume (GTV_P), composite nodal volumes (GTV_N) and composite total volume (GTV_P + GTV_N = GTV_C) had prognostic value in both univariate and multivariate cox model analysis. Interestingly, when anatomic volumes were measured from CT scans after a single cycle of induction chemotherapy, all significant prognosticating value for measured anatomic volumes was lost. Given the literature findings and the results of this study, the authors advocate the use of tumor anatomic volumes calculated from pretreatment scans to supplement the TNM staging system in subjects with untreated laryngeal cancer. The study found that tumor volume assessment after induction chemotherapy is not of prognostic significance.

Temporal changes in tumor oxygenation and perfusion upon normo- and hyperbaric inspiratory hyperoxia

BACKGROUND

Inspiratory hyperoxia under hyperbaric conditions has been shown to effectively reduce tumor hypoxia and to improve radiosensitivity. However, applying irradiation (RT) under hyperbaric conditions is technically difficult in the clinical setting since RT after decompression may be effective only if tumor pO2 remains elevated for a certain period of time. The aim of the present study was to analyze the time course of tumor oxygenation and perfusion during and after hyperbaric hyperoxia.

MATERIALS AND METHODS

Tumor oxygenation, red blood cell (RBC) flux for perfusion monitoring, and vascular resistance were assessed continuously in experimental rat DS-sarcomas by polarographic catheter electrodes and laser Doppler flowmetry at 1 and 2 atm (bar) of environmental pressure during breathing of pure O2 or carbogen (95 % O2 + 5 % CO2).

RESULTS

During room air breathing, the tumor pO2 followed very rapidly within a few minutes the change of the ambient pressure during compression or decompression. With O2 breathing under hyperbaric conditions, the tumor pO2 increased more than expected based on the rise of the environmental pressure, although the time course was comparably rapid. Breathing carbogen, the tumor pO2 followed with a slight delay of the pressure change, and within 10 min after decompression the baseline values were reached again. RBC flux increased during carbogen breathing but remained almost constant with pure O2, indicating a vasodilation (decrease in vascular resistance) with carbogen but a vasoconstriction (increase in vascular resistance) with O2 during hyperbaric conditions.

CONCLUSION

Since the tumor pO2 directly followed the environmental pressure, teletherapy after hyperbaric conditions does not seem to be promising as the pO2 reaches baseline values again within 5-10 min after decompression.

Spatial oxygenation profiles in tumors during normo- and hyperbaric hyperoxia

BACKGROUND

Inspiratory hyperoxia reduces tumor hypoxia, which is responsible for limited radiosensitivity of tumors. However, very little is known about the heterogeneity of intratumoral oxygenation during this supportive treatment. The study analyzes whether local hypoxia is still present during normobaric and hyperbaric inspiratory hyperoxia and whether the addition of CO2 to the inspiratory gas affects the spatial pO2 distribution.

MATERIAL AND METHODS

Tumor oxygenation of experimental DS-sarcomas in rats was assessed by polarographic needle electrodes at 1 and 2 atm (bar) environmental pressure during pure O2 or carbogen (95 % O2 + 5 % CO2) breathing. Up to 320 individual pO2 measurements were performed in a strictly oriented grid resulting in an oxygenation profile in a horizontal tumor layer.

RESULTS

In the experimental tumors used the oxygenation showed pronounced heterogeneities with closely adjacent hypoxic and oxygenated regions. This heterogeneity was still visible under normobaric hyperoxia where large confluent hypoxic regions were detectable. At 1 atm, the addition of CO2 improved tumor oxygenation significantly (at least in large tumors). At 2 atm, only very small local regions of hypoxia were detected. However, under this condition hypercapnia had no impact on tumor oxygenation.

CONCLUSIONS

The data show that even under hyperbaric hyperoxia, hypoxic regions are detectable despite the average pO2 increased by a factor of 100. The results also clearly indicate that the oxygenation pattern improves disproportionally with increasing environmental pressure.

Treatment of T3 laryngeal cancer in the Netherlands: a national survey

Background

Treatment strategies for T3 laryngeal carcinoma include radiotherapy (RT) with or without chemotherapy (CT) and sometimes surgery. We conducted a national survey to determine how T3 laryngeal carcinoma is currently being managed in the Netherlands.

Methods

A questionnaire on general treatment policy, also inquiring details on RT and CT, was sent to all 13 radiotherapy departments accredited for treatment of head and neck cancer (HNC) in the Netherlands.

Results

Twelve centers completed the questionnaire. All centers reported using RT with or without CT. Upfront laryngectomy is rarely performed.

At 9/12 centers, CT is added to RT in cases with large tumors in T3N0 disease. Three centers use a volume criterion (3–6 cc); 6 centers don’t specify “large” with such criteria. CT consists of cisplatin 3-weekly (7 centers) or weekly (2 centers), unless contra-indicated or age; 6 centers use an age limit of 70 years. RT is given concomitantly with CT 5×/week except at the 2 centers where cisplatin weekly is combined with 6 fractions/week. In case of RT only, treatment is accelerated. Lymph node levels II-IV are treated electively.

In T3N+ disease, 11/12 centers treat non-bulky T3N1 with RT only. Volume criteria for combined CT-RT are the same as above. Two centers perform an upfront neck dissection in case of (resectable) N3 disease; 10 centers treat T3N2-3 cancer with primary CT-RT, 2 centers don’t use the N-stage criterion.

Total RT dose is 68–70 Gy, the elective dose varies between 46 and 57.75 Gy. Eight centers use a simultaneous integrated boost technique.

Conclusions

Treatment of T3 laryngeal cancer in the Netherlands is generally comparable, with CT-RT for voluminous T3N0 and most T3N+ tumors, but there are some differences between the centers in the use of chemotherapy and the dose-fractionation schemes. Therefore, the aim of the National Platform RT HNC is further standardization of RT dose, fractionation and delivery techniques.