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Yang F, Wong RJ, Zakeri K, Singh A, Estilo CL, Lee NY. Osteoradionecrosis Rates After Head and Neck Radiation Therapy: Beyond the Numbers. Pract Radiat Oncol 2024:S1879-8500(24)00084-5. [PMID: 38649030 DOI: 10.1016/j.prro.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 02/14/2024] [Accepted: 02/20/2024] [Indexed: 04/25/2024]
Abstract
PURPOSE Osteoradionecrosis (ORN) is a severe late complication of head and neck radiation therapy shown to have profound negative effect on the quality of life of cancer survivors. Over the past few decades, improvements in radiation delivery techniques have resulted in a decrease in the incidence of ORN. However, even with modern radiation therapy techniques, ORN remains an important clinical concern. In recent literature, there is a wide range of reported ORN rates from 0% to as high as 20%. With such a high level of variability in the reported incidence of ORN, oncologists often encounter difficulties estimating the risk of this serious radiation therapy toxicity. METHODS AND MATERIALS In this review, the authors present a summary of the factors that contribute to the high level of variability in the reported incidence of ORN. RESULTS Variable definition, variable grading, and heterogeneity of both study inclusion criteria and treatment parameters can each significantly influence the reporting of ORN rates. CONCLUSIONS Given numerous factors can affect the reported incidence of ORN, a thorough understanding of the clinical context behind the reported ORN rates is needed to comprehend the true risk of this important radiation therapy toxicity.
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Affiliation(s)
- Fan Yang
- Departments of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Richard J Wong
- Departments of Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kaveh Zakeri
- Departments of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Annu Singh
- Departments of Dentistry, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Cherry L Estilo
- Departments of Dentistry, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nancy Y Lee
- Departments of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York.
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2
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Ravichandran R, Kannan RR. External Beam Radiotherapy in High-risk Head-and-neck Cancers with Reduced Overall Treatment Time in Telecobalt Beam Quality. J Med Phys 2023; 48:409-411. [PMID: 38223795 PMCID: PMC10783190 DOI: 10.4103/jmp.jmp_142_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 10/30/2023] [Accepted: 10/31/2023] [Indexed: 01/16/2024] Open
Affiliation(s)
- Ramamoorthy Ravichandran
- Department of Radiation Oncology, Medical Physics Unit, Cachar Cancer Hospital and Research Centre, Silchar, Assam, India
| | - R Ravi Kannan
- Department of Surgical Oncology, Medical Physics Unit, Cachar Cancer Hospital and Research Centre, Silchar, Assam, India
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3
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Li CX, Sun JL, Gong ZC, Liu H, Ding MC, Zhao HR. An umbrella review exploring the effect of radiotherapy for head and neck cancer patients on the frequency of jaws osteoradionecrosis. Cancer Radiother 2023; 27:434-446. [PMID: 37268457 DOI: 10.1016/j.canrad.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 01/02/2023] [Accepted: 01/31/2023] [Indexed: 06/04/2023]
Abstract
OBJECTIVE Efforts have been made to reduce epidemiological indicators of osteoradionecrosis in patients with head and neck cancer over recent years. This umbrella review aims to synthesize the information of the systematic reviews/meta-analyses investigating the effect of radiotherapy in patients with head and neck cancer on the frequency of osteoradionecrosis and to identify and analyze the gaps in current scientific literature. MATERIAL AND METHODS A systematic review of systematic reviews with and without meta-analysis of intervention studies was conducted. Qualitative analysis of the reviews and their quality evaluation were performed. RESULTS A total of 152 articles were obtained, and ten of them were selected for the final analysis, where six were systematic reviews and four were meta-analysis. According to the guide Assessing the Methodological Quality of Systematic Reviews (Amstar), eight articles included were of high quality and two of medium quality. These descriptive systematic reviews/meta-analyses included a total of 25 randomized clinical trials, showing that radiotherapy has positive effects on the frequency of osteoradionecrosis. Even though a reduction in the incidence of osteoradionecrosis was observed back in the history, in systematic reviews with meta-analysis, overall effect estimators were not significant. CONCLUSIONS Differential findings are not enough to demonstrate that there is a significant reduction in the frequency of osteoradionecrosis in patients with head and neck cancer treated by radiation. Possible explanations are related to factors such as the type of studies analyzed, indicator of irradiated complication considered, and specific variables included in the analysis. Many systematic reviews did not address publication bias and did identify gaps in knowledge that require further clarification.
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Affiliation(s)
- C X Li
- Department of Oral and Maxillofacial Oncology & Surgery, Xinjiang Medical University Affiliated First Hospital, Urumqi 830054, China; School/Hospital of Stomatology, Xinjiang Medical University, Urumqi 830011, China; Stomatological Research Institute of Xinjiang Uygur Autonomous Region, Urumqi 830054, China.
| | - J-L Sun
- Department of Preventive Medicine, School of Medicine, Shihezi University, Shihezi 832003, China
| | - Z-C Gong
- Department of Oral and Maxillofacial Oncology & Surgery, Xinjiang Medical University Affiliated First Hospital, Urumqi 830054, China; School/Hospital of Stomatology, Xinjiang Medical University, Urumqi 830011, China; Stomatological Research Institute of Xinjiang Uygur Autonomous Region, Urumqi 830054, China.
| | - H Liu
- Department of Oral and Maxillofacial Surgery, Shanghai Stomatological Hospital & School of Stomatology, Fudan University, Shanghai 200003, China; Shanghai Key Laboratory of Craniomaxillofacial Development and Diseases, Fudan University, Shanghai 200433, China
| | - M-C Ding
- State Key Laboratory of Military Stomatology, National Clinical Research Center for Oral Diseases, Shaanxi Clinical Research Center for Oral Diseases, Department of Oral and Maxillofacial Surgery, School of Stomatology, The Fourth Military Medical University, Xi'an 710032, China
| | - H-R Zhao
- The First Ward of Oncological Department, Cancer Center, the First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, China.
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4
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de Vasconcellos Ferreira PM, Gomes MDCMF, Almeida ACSM, Cornélio JS, Arruda TJ, Mafra A, Nunes MHS, Salera RB, Nogueira RF, Sclauser JMB, Drummond-Lage AP, Rezende BA. Evaluation of oral mucositis, candidiasis, and quality of life in patients with head and neck cancer treated with a hypofractionated or conventional radiotherapy protocol: a longitudinal, prospective, observational study. Head Face Med 2023; 19:7. [PMID: 36890527 PMCID: PMC9992900 DOI: 10.1186/s13005-023-00356-3] [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: 11/03/2022] [Accepted: 03/05/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, recently, Radiotherapy (RT) protocols requiring fewer sessions (hypofractionated) have been used to shorten RT treatment and minimize patient exposure to medical centers, and decrease the risk of SARS-CoV-2 infection. METHODS This longitudinal, prospective, observational study aimed to compare the quality of life (QoL) and the incidence of oral mucositis and candidiasis in 66 patients with head and neck cancer (HNC) who undergo a hypofractionated RT protocol (GHipo), total of 55 Gy for 4 weeks, or a conventional RT protocol (GConv), total of 66 - 70 Gy for 6 - 7 weeks. PURPOSE To assess the incidence and severity of oral mucositis, the incidence of candidiasis, and QoL were evaluated using the World Health Organization scale, clinical evaluation, and the QLC-30 and H&N-35 questionnaires, respectively, at the beginning and the end of RT. RESULTS The incidence of candidiasis did not show differences between the two groups. However, at the end of RT, mucositis had a higher incidence (p < 0.01) and severity (p < 0.05) in GHipo. QoL was not markedly different between the two groups. Although mucositis worsened in patients treated with hypofractionated RT, QoL did not worsen for patients on this regimen. CONCLUSIONS Our results open perspectives for the potential use of RT protocols for HNC with fewer sessions in conditions that require faster, cheaper, and more practical treatments.
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Affiliation(s)
| | | | | | - Júlia Soares Cornélio
- School of Medical Sciences of Minas Gerais, Alameda Ezequiel Dias, Belo Horizonte, 27530130-110, Brazil
| | - Thiago Jardim Arruda
- Mario Penna Institute, 901, Joaquim Candido Filho, Belo Horizonte, 30320-420, Brazil
| | - Arnoldo Mafra
- Mario Penna Institute, 901, Joaquim Candido Filho, Belo Horizonte, 30320-420, Brazil
| | | | - Rafael Borges Salera
- Mario Penna Institute, 901, Joaquim Candido Filho, Belo Horizonte, 30320-420, Brazil
| | | | | | - Ana Paula Drummond-Lage
- School of Medical Sciences of Minas Gerais, Alameda Ezequiel Dias, Belo Horizonte, 27530130-110, Brazil
| | - Bruno Almeida Rezende
- School of Medical Sciences of Minas Gerais, Alameda Ezequiel Dias, Belo Horizonte, 27530130-110, Brazil.
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Hua G, Levin M, Zhang H, Xie M, McHugh T, Gupta M. Post-operative survival in head and neck cancer patients with elevated troponins. Clin Otolaryngol 2023; 48:200-205. [PMID: 36385741 DOI: 10.1111/coa.14009] [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: 04/19/2022] [Revised: 09/27/2022] [Accepted: 11/05/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The strenuous demands of head and neck cancer surgery (HNS) place patients at increased risk of myocardial injury. Troponin positivity (TP) post-operatively is a predictor of increased complications and mortality. The present study is the first to investigate the effects of TP on potential delays in adjuvant treatment and disease-specific survival. DESIGN, SETTING, PARTICIPANTS AND MAIN OUTCOME MEASURES All patients undergoing HNS from 2014 to 2016 had troponins measured at a single academic centre. Relevant patient data was extracted on retrospective chart review. The main outcome measures were the impact of TP on timing of adjuvant treatment and disease-specific survival. RESULTS Of 166 patients, 26 (15.6%) developed TP post-operatively. There was no significant difference between cohorts for baseline characteristics except for age. Overall and disease-specific survival for TP patients were respectively 45.9% and 57.4% at 3 years. There was no significant difference between cohorts for overall and disease-specific survival, and time to adjuvant therapy. CONCLUSION No significant association was found between TP and overall and disease-specific survival, and time to adjuvant therapy.
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Affiliation(s)
- Gordon Hua
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Marc Levin
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada
| | - Han Zhang
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Michael Xie
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Tobial McHugh
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Michael Gupta
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
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Margalit DN, Sacco AG, Cooper JS, Ridge JA, Bakst RL, Beadle BM, Beitler JJ, Chang SS, Chen AM, Galloway TJ, Koyfman SA, Mita C, Robbins JR, Tsai CJ, Truong MT, Yom SS, Siddiqui F. Systematic review of postoperative therapy for resected squamous cell carcinoma of the head and neck: Executive summary of the American Radium Society appropriate use criteria. Head Neck 2021; 43:367-391. [PMID: 33098180 PMCID: PMC7756212 DOI: 10.1002/hed.26490] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 09/21/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The aims of this systematic review are to (a) evaluate the current literature on the impact of postoperative therapy for resected squamous cell carcinoma of the head and neck (SCCHN) on oncologic and non-oncologic outcomes and (b) identify the optimal evidence-based postoperative therapy recommendations for commonly encountered clinical scenarios. METHODS An analysis of the medical literature from peer-reviewed journals was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline. Prospective studies and methodology-based systematic reviews and meta-analyses of postoperative therapy for SCCHN were identified by searching Medline (OVID) and EMBASE (Elsevier) using controlled vocabulary terms (ie, National Library of Medicine Medical Subject Headings [MeSH], EMTREE). Study screening and selection was performed with Covidence software and full-text review. The RAND/UCLA appropriateness method was used by the expert panel to rate the appropriate use of postoperative therapy, and the modified Delphi method was used to come to consensus. RESULTS A total of 5660 studies were identified and screened using the title and abstract, leading to 201 studies assessed for relevance using full-text review. After limitation to the eligibility criteria, 101 studies from 1977 to 2020 were identified, including 77 with oncologic endpoints and 24 with function and quality of life endpoints. All studies reported staging prior to the implementation of American Joint Committee on Cancer (AJCC-8). CONCLUSIONS Prospective clinical studies and systematic reviews identified through the PRISMA systematic review provided good evidence for consensus statements regarding the appropriate use of postoperative therapy for resected SCCHN. Further research is needed in domains where consensus by the expert panel could not be achieved for the appropriateness of specific postoperative therapeutic interventions.
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Affiliation(s)
- Danielle N. Margalit
- Dana‐Farber/Brigham & Women's Cancer Center, Harvard Medical SchoolBostonMassachusettsUSA
| | | | | | | | | | - Beth M. Beadle
- Stanford University School of MedicineStanfordCaliforniaUSA
| | | | | | | | | | | | - Carol Mita
- Countway Library, Harvard Medical SchoolBostonMassachusettsUSA
| | | | | | - Minh T. Truong
- Boston University School of MedicineBostonMassachusettsUSA
| | - Sue S. Yom
- University of CaliforniaSan FranciscoCaliforniaUSA
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Wozniak G, Misiołek M, Idasiak A, Dębosz-Suwińska I, Jaworska M, Bal W, Maciejewski B, Miszczyk L, Składowski K, Suwinski R. Randomised clinical trial on 7-days-a-week postoperative radiotherapy vs. concurrent postoperative radio-chemotherapy in locally advanced cancer of the oral cavity/oropharynx. Br J Radiol 2020; 93:20200288. [PMID: 32960662 DOI: 10.1259/bjr.20200288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To compare the efficacy and tolerance of 7-days-a-week accelerated postoperative radiotherapy (p-CAIR) vs postoperative radio-chemotherapy (p-RTCT). METHODS Between September 2007 and October 2013, 111 patients were enrolled and randomly assigned to receive 63 Gy in 1.8 Gy fractions 7-days-a-week (n = 57, p-CAIR) or 63 Gy in 1.8 Gy fractions 5-days-a-week with concurrent cisplatin 80-100 mg per square meter of body-surface area on days 1, 22 and 43 of the radiotherapy course (p-RTCT). It represents approximately 40% of the intended trial size, that was closed prematurely due to slowing accrual. Only high-risk patients with squamous cell cancer of the oropharynx/oral cavity, considered fit for concurrent treatment were enrolled. RESULTS The rate of locoregional control (LRC) did not differ significantly between treatment arms (p = 0.18, HR = 0.56), 5 year LRC tended, however, to favour p-RTCT (81%) vs p-CAIR (62%). There was no difference in overall survival between treatment arms (p = 0.90, HR = 1.03).The incidence and severity of acute mucosal reactions and late reactions did not differ significantly between treatment arms. Haematological toxicity of p-RTCT was, however, considerably increased compared to p-CAIR. CONCLUSION Concurrent postoperative RTCT tended to improve locoregional control rate as compared to p-CAIR. This, however, did not transferred into improved overall survival. Postoperative RTCT was associated with a substantial increase in haematological toxicity that negatively affected treatment compliance in this arm. ADVANCES IN KNOWLEDGE To our knowledge, this is the first trial that compares accelerated radiotherapy and radio-chemotherapy in postoperative treatment for oralcavity/oropharyngeal cancer.
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Affiliation(s)
- Grzegorz Wozniak
- Department of Radiation Oncology, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Poland
| | - Maciej Misiołek
- Department of Laryngology, Silesian Medical University, Katowice, Poland
| | - Adam Idasiak
- Radiotherapy Clinic and Teaching Hospital, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Poland
| | - Iwona Dębosz-Suwińska
- Department of Radiation Oncology, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Poland
| | - Magdalena Jaworska
- Department of Pathology, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Poland
| | - Wieslaw Bal
- Department of Chemotherapy, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Poland
| | - Boguslaw Maciejewski
- Department of Radiation Oncology, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Poland
| | - Leszek Miszczyk
- Department of Radiation Oncology, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Poland
| | - Krzysztof Składowski
- Radiotherapy Clinic and Teaching Hospital, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Poland
| | - Rafal Suwinski
- Radiotherapy Clinic and Teaching Hospital, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Poland
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Rath S, Khurana R, Sapru S, Rastogi M, Gandhi AK, Hadi R, Sahni K, Mishra SP, Srivastava AK, Syedkather F. Evaluation of purely accelerated six fractions per week radiotherapy in postoperative oral cavity squamous cell carcinoma. Asia Pac J Clin Oncol 2019; 16:14-22. [DOI: 10.1111/ajco.13244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 08/23/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Satyajeet Rath
- Department of Radiation OncologyDr. Ram Manohar Lohia Institute of Medical Sciences Lucknow Uttar Pradesh India
| | - Rohini Khurana
- Department of Radiation OncologyDr. Ram Manohar Lohia Institute of Medical Sciences Lucknow Uttar Pradesh India
| | - Shantanu Sapru
- Department of Radiation OncologyDr. Ram Manohar Lohia Institute of Medical Sciences Lucknow Uttar Pradesh India
| | - Madhup Rastogi
- Department of Radiation OncologyDr. Ram Manohar Lohia Institute of Medical Sciences Lucknow Uttar Pradesh India
| | - Ajeet K. Gandhi
- Department of Radiation OncologyDr. Ram Manohar Lohia Institute of Medical Sciences Lucknow Uttar Pradesh India
| | - Rahat Hadi
- Department of Radiation OncologyDr. Ram Manohar Lohia Institute of Medical Sciences Lucknow Uttar Pradesh India
| | - Kamal Sahni
- Department of Radiation OncologyDr. Ram Manohar Lohia Institute of Medical Sciences Lucknow Uttar Pradesh India
| | - Surendra P. Mishra
- Department of Radiation OncologyDr. Ram Manohar Lohia Institute of Medical Sciences Lucknow Uttar Pradesh India
| | - Anoop K. Srivastava
- Department of Radiation OncologyDr. Ram Manohar Lohia Institute of Medical Sciences Lucknow Uttar Pradesh India
| | - Farzana Syedkather
- Department of Radiation OncologyDr. Ram Manohar Lohia Institute of Medical Sciences Lucknow Uttar Pradesh India
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Harris JP, Chen MM, Orosco RK, Sirjani D, Divi V, Hara W. Association of Survival With Shorter Time to Radiation Therapy After Surgery for US Patients With Head and Neck Cancer. JAMA Otolaryngol Head Neck Surg 2019. [PMID: 29522072 DOI: 10.1001/jamaoto.2017.3406] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Importance Shortening the time from surgery to the start of radiation (TS-RT) is a consideration for physicians and patients. Although the National Comprehensive Cancer Network recommends radiation to start within 6 weeks, a survival benefit with this metric remains controversial. Objective To determine the association of delayed TS-RT with overall survival (OS) using a large cancer registry. Design, Setting, and Participants In this observational cohort study, 25 216 patients with nonmetastatic stages III to IV head and neck cancer were identified from the National Cancer Database (NCDB). Exposures Patients received definitive surgery followed by adjuvant radiation therapy, with an interval duration defined as TS-RT. Main Outcomes and Measures Overall survival as a function of TS-RT and the effect of clinicopathologic risk factors and accelerated fractionation. Results We identified 25 216 patients with nonmetastatic squamous cell carcinoma of the head and neck. There were 18 968 (75%) men and 6248 (25%) women and the mean (SD) age of the cohort was 59 (10.9) years. Of the 25 216 patients, 9765 (39%) had a 42-days or less TS-RT and 4735 (19%) had a 43- to 49-day TS-RT. Median OS was 10.5 years (95% CI, 10.0-11.1 years) for patients with a 42-days or less TS-RT, 8.2 years (95% CI, 7.4-8.6 years; absolute difference, -2.4 years, 95% CI, -1.5 to -3.2 years) for patients with a 43- to 49-day TS-RT, and 6.5 years (95% CI, 6.1-6.8 years; absolute difference, -4.1 years, 95% CI, -3.4 to -4.7 years) for those with a 50-days or more TS-RT. Multivariable analysis found that compared with a 42-days or less TS-RT, there was not a significant increase in mortality with a 43- to 49-day TS-RT (HR, 0.98; 95% CI, 0.93-1.04), although there was for a TS-RT of 50 days or more (HR, 1.07; 95% CI, 1.02-1.12). A significant interaction was identified between TS-RT and disease site. Subgroup effect modeling found that a delayed TS-RT of 7 days resulted in significantly worse OS for patients with tonsil tumors (HR, 1.22; 95% CI, 1.05-1.43) though not other tumor subtypes. Accelerated fractionation of 5.2 fractions or more per week was associated with improved survival (HR, 0.93; 95% CI, 0.87-0.99) compared with standard fractionation. Conclusions and Relevance Delayed TS-RT of 50 days or more was associated with worse overall survival. The multidisciplinary care team should focus on shortening TS-RT to improve survival. Unavoidable delays may be an indication for accelerated fractionation or other dose intensification strategies.
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Affiliation(s)
- Jeremy P Harris
- Department of Radiation Oncology, Stanford University, Stanford, California.,Palo Alto Veterans Affairs Health Care System, Palo Alto, California
| | - Michelle M Chen
- Palo Alto Veterans Affairs Health Care System, Palo Alto, California.,Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California
| | - Ryan K Orosco
- Department of Head and Neck Surgery, University of California San Diego, San Diego
| | - Davud Sirjani
- Palo Alto Veterans Affairs Health Care System, Palo Alto, California.,Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California
| | - Vasu Divi
- Palo Alto Veterans Affairs Health Care System, Palo Alto, California.,Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California
| | - Wendy Hara
- Department of Radiation Oncology, Stanford University, Stanford, California
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10
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Franzese C, Fogliata A, Franceschini D, Navarria P, Cozzi L, Tomatis S, De Virgilio A, Spriano G, Scorsetti M. Impact of hypofractionated schemes in radiotherapy for locally advanced head and neck cancer patients. Laryngoscope 2019; 130:E163-E170. [PMID: 31063588 DOI: 10.1002/lary.28048] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 03/21/2019] [Accepted: 04/16/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To analyze two cohorts of locally advanced head and neck cancer (LAHNC) patients treated with two schedules of hypofractionated radiotherapy and 5 versus 3 mm clinical target volume-planning target volume (CTV-PTV) margins. METHODS 145 patients were included. The patient cohort was divided into two groups. Group A included 97 patients treated with 69.96/54.45 grays (Gy) to the high-risk and low-risk volumes, respectively, in 33 fractions, with 5 mm margins. Group B included 48 patients treated with 66/54 Gy in 30 fractions using 3 mm margins. Toxicity was recorded according to the Common Toxicity Criteria version 3. Patient outcomes for locoregional control (LRC), disease-free survival (DFS), and overall survival (OS) were determined. RESULTS Median follow-up was 26 months. In terms of toxicity, acute dysphagia worsened significantly (P = 0.003) in group B, whereas acute salivary toxicity tended to significance (P = 0.071). No significant late toxicity differences were recorded. Rates of LRC at 1 and 2 years were 90.1% ± 2.6% and 84.2% ± 3.4%, respectively, with superiority for group A (P = 0.045). The statistical significance remained for the low-dose level (P = 0.007) but not for high dose (P = 0.110). Rates of DFS at 1 and 2 years were 84.9% ± 3.1% and 76.5% ± 3.9%, respectively, whereas rates of OS were 95.9% ± 1.8% and 91.6% ± 2.7%, respectively. No differences were observed between the two groups in terms of DFS (P = 0.270) and OS (P = 0.152). CONCLUSION The use of reduced CTV to PTV margins and dose reduction with hypofractionation schedule can improve the pattern of toxicity in LAHNC patients. This approach resulted in an increased rate of locoregional progression, particularly in low-risk regions. LEVEL OF EVIDENCE 4 Laryngoscope, 130:E163-E170, 2020.
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Affiliation(s)
- Ciro Franzese
- Radiation Oncology Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - Antonella Fogliata
- Radiation Oncology Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - Davide Franceschini
- Radiation Oncology Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - Pierina Navarria
- Radiation Oncology Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - Luca Cozzi
- Radiation Oncology Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy.,Biomedical Science Department, Humanitas University, Milan-Rozzano, Italy
| | - Stefano Tomatis
- Radiation Oncology Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - Armando De Virgilio
- Otolaryngology Head and Neck Surgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - Giuseppe Spriano
- Otolaryngology Head and Neck Surgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy.,Biomedical Science Department, Humanitas University, Milan-Rozzano, Italy
| | - Marta Scorsetti
- Radiation Oncology Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy.,Biomedical Science Department, Humanitas University, Milan-Rozzano, Italy
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11
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Geiger JL, Ku JA. Postoperative Treatment of Oropharyngeal Cancer in the Era of Human Papillomavirus. Curr Treat Options Oncol 2019; 20:20. [DOI: 10.1007/s11864-019-0620-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Avkshtol V, Handorf EA, Ridge JA, Leachman BK, Liu JC, Bauman J, Galloway TJ. Examining adjuvant radiation dose in head and neck squamous cell carcinoma. Head Neck 2019; 41:2133-2142. [PMID: 30737968 DOI: 10.1002/hed.25680] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 11/16/2018] [Accepted: 01/09/2019] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Compare adjuvant radiation dose trends and outcomes in head and neck squamous cell carcinoma (HNSCC). METHODS Nonmetastatic HNSCCs treated between 2004 and 2014 with primary site surgery, lymph node dissection, and adjuvant radiation were identified in the National Cancer Database. Standard dose radiation (SD-RT) was defined as an equivalent dose in 2 Gy (EQD2) ≥56.64 and ≤60 Gy and high-dose radiation (HD-RT) as an EQD2 >60 and <70 Gy. RESULTS HD-RT was given to 46% of the 15 836 HNSCC patients managed with adjuvant radiation. When adjusted for poor prognostic factors, HD-RT was associated with increased mortality (HR1.09; 95%CI 1.02-1.16). In nonoropharynx or human papillomavirus-negative oropharynx primary that had positive margins, ≥5 positive lymph nodes, and/or extranodal extension, HD-RT was still not associated with improved survival (HR 1.01, 95% CI 0.91-1.12). CONCLUSIONS There was no survival benefit from postoperative dose escalation above EQD2 60 Gy even in a high-risk cohort.
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Affiliation(s)
- Vladimir Avkshtol
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Elizabeth A Handorf
- Department of Biostatistics, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - John A Ridge
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Brooke K Leachman
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Jeffrey C Liu
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Jessica Bauman
- Department Medical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Thomas J Galloway
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
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Matuschek C, Haussmann J, Bölke E, Gripp S, Schuler PJ, Tamaskovics B, Gerber PA, Djiepmo-Njanang FJ, Kammers K, Plettenberg C, Anooshahr B, Orth K, Budach W. Accelerated vs. conventionally fractionated adjuvant radiotherapy in high-risk head and neck cancer: a meta-analysis. Radiat Oncol 2018; 13:195. [PMID: 30286777 PMCID: PMC6172789 DOI: 10.1186/s13014-018-1133-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 09/14/2018] [Indexed: 12/16/2022] Open
Abstract
Background Adjuvant radiotherapy in advanced head and neck squamous cell cancer (HNSCC) reduces the risk of local-regional failure and most likely increases the survival rate. Patients at high risk for tumor recurrence may benefit from more aggressive altered fractionation schedules in order to reduce the overall time from surgery to completion of radiotherapy. Here, we reviewed the results of six randomized trials addressing the above hypothesis. Methods In the six trials of interest, a total of 988 patients with locally advanced HNSCC were randomly assigned to receive either accelerated or conventionally fractionated adjuvant radiotherapy. Hazard ratios (HR) were extracted from available publications for local-regional control, distant metastasis as well as overall-, cancer specific- and disease-free survival. Meta-analysis of the effect sizes was performed using fixed and random effect models. Acute and late side effects were categorized and summarized for comparison. Results Accelerated radiotherapy did not improve the loco-regional control (n = 988, HR = 0.740, CI = 0.48–1.13, p = 0.162), progression-free survival (HR = 0.89, CI = 0.76–1.04, p = 0.132) or overall survival (HR = 0.88, CI = 0.75–1.04, p = 0.148) significantly. Acute confluent mucositis occurred with significant higher frequency with accelerated radiotherapy. Late side effects did not differ significantly in either group. Conclusion Accelerated radiotherapy does not result in a significant improvement of loco-regional control or overall survival in high-risk patients. Acute but not late radiation toxicity were more frequent with the accelerated RT technique. In clinical practice accelerated postoperative radiation therapy might be a suitable option only for a subset of patients.
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Affiliation(s)
- Christiane Matuschek
- Department of Radiotherapy and Radiooncology, Medical Faculty, Heinrich Heine University, Moorenstr. 5, 40225, Dusseldorf, Germany
| | - Jan Haussmann
- Department of Radiotherapy and Radiooncology, Medical Faculty, Heinrich Heine University, Moorenstr. 5, 40225, Dusseldorf, Germany
| | - Edwin Bölke
- Department of Radiotherapy and Radiooncology, Medical Faculty, Heinrich Heine University, Moorenstr. 5, 40225, Dusseldorf, Germany.
| | - Stephan Gripp
- Department of Radiotherapy and Radiooncology, Medical Faculty, Heinrich Heine University, Moorenstr. 5, 40225, Dusseldorf, Germany
| | - Patrick J Schuler
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
| | - Bálint Tamaskovics
- Department of Radiotherapy and Radiooncology, Medical Faculty, Heinrich Heine University, Moorenstr. 5, 40225, Dusseldorf, Germany
| | - Peter Arne Gerber
- Department of Dermatology, Medical Faculty Heinrich Heine University Dusseldorf, Dusseldorf, Germany
| | - Freddy-Joel Djiepmo-Njanang
- Department of Radiotherapy and Radiooncology, Medical Faculty, Heinrich Heine University, Moorenstr. 5, 40225, Dusseldorf, Germany
| | - Kai Kammers
- Division of Biostatistics and Bioinformatics, Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christian Plettenberg
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Heinrich Heine University Dusseldorf, Dusseldorf, Germany
| | | | - Klaus Orth
- Department of Radiotherapy and Radiooncology, Medical Faculty, Heinrich Heine University, Moorenstr. 5, 40225, Dusseldorf, Germany
| | - Wilfried Budach
- Department of Radiotherapy and Radiooncology, Medical Faculty, Heinrich Heine University, Moorenstr. 5, 40225, Dusseldorf, Germany
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Lacas B, Bourhis J, Overgaard J, Zhang Q, Grégoire V, Nankivell M, Zackrisson B, Szutkowski Z, Suwiński R, Poulsen M, O'Sullivan B, Corvò R, Laskar SG, Fallai C, Yamazaki H, Dobrowsky W, Cho KH, Beadle B, Langendijk JA, Viegas CMP, Hay J, Lotayef M, Parmar MKB, Aupérin A, van Herpen C, Maingon P, Trotti AM, Grau C, Pignon JP, Blanchard P. Role of radiotherapy fractionation in head and neck cancers (MARCH): an updated meta-analysis. Lancet Oncol 2017; 18:1221-1237. [PMID: 28757375 PMCID: PMC5737765 DOI: 10.1016/s1470-2045(17)30458-8] [Citation(s) in RCA: 173] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 05/29/2017] [Accepted: 05/31/2017] [Indexed: 01/30/2023]
Abstract
BACKGROUND The Meta-Analysis of Radiotherapy in squamous cell Carcinomas of Head and neck (MARCH) showed that altered fractionation radiotherapy is associated with improved overall and progression-free survival compared with conventional radiotherapy, with hyperfractionated radiotherapy showing the greatest benefit. This update aims to confirm and explain the superiority of hyperfractionated radiotherapy over other altered fractionation radiotherapy regimens and to assess the benefit of altered fractionation within the context of concomitant chemotherapy with the inclusion of new trials. METHODS For this updated meta-analysis, we searched bibliography databases, trials registries, and meeting proceedings for published or unpublished randomised trials done between Jan 1, 2009, and July 15, 2015, comparing primary or postoperative conventional fractionation radiotherapy versus altered fractionation radiotherapy (comparison 1) or conventional fractionation radiotherapy plus concomitant chemotherapy versus altered fractionation radiotherapy alone (comparison 2). Eligible trials had to start randomisation on or after Jan 1, 1970, and completed accrual before Dec 31, 2010; had to have been randomised in a way that precluded prior knowledge of treatment assignment; and had to include patients with non-metastatic squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx, or larynx undergoing first-line curative treatment. Trials including a non-conventional radiotherapy control group, investigating hypofractionated radiotherapy, or including mostly nasopharyngeal carcinomas were excluded. Trials were grouped in three types of altered fractionation: hyperfractionated, moderately accelerated, and very accelerated. Individual patient data were collected and combined with a fixed-effects model based on the intention-to-treat principle. The primary endpoint was overall survival. FINDINGS Comparison 1 (conventional fractionation radiotherapy vs altered fractionation radiotherapy) included 33 trials and 11 423 patients. Altered fractionation radiotherapy was associated with a significant benefit on overall survival (hazard ratio [HR] 0·94, 95% CI 0·90-0·98; p=0·0033), with an absolute difference at 5 years of 3·1% (95% CI 1·3-4·9) and at 10 years of 1·2% (-0·8 to 3·2). We found a significant interaction (p=0·051) between type of fractionation and treatment effect, the overall survival benefit being restricted to the hyperfractionated group (HR 0·83, 0·74-0·92), with absolute differences at 5 years of 8·1% (3·4 to 12·8) and at 10 years of 3·9% (-0·6 to 8·4). Comparison 2 (conventional fractionation radiotherapy plus concomitant chemotherapy versus altered fractionation radiotherapy alone) included five trials and 986 patients. Overall survival was significantly worse with altered fractionation radiotherapy compared with concomitant chemoradiotherapy (HR 1·22, 1·05-1·42; p=0·0098), with absolute differences at 5 years of -5·8% (-11·9 to 0·3) and at 10 years of -5·1% (-13·0 to 2·8). INTERPRETATION This update confirms, with more patients and a longer follow-up than the first version of MARCH, that hyperfractionated radiotherapy is, along with concomitant chemoradiotherapy, a standard of care for the treatment of locally advanced head and neck squamous cell cancers. The comparison between hyperfractionated radiotherapy and concomitant chemoradiotherapy remains to be specifically tested. FUNDING Institut National du Cancer; and Ligue Nationale Contre le Cancer.
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Affiliation(s)
- Benjamin Lacas
- Ligue Nationale Contre le Cancer Meta-Analysis Platform, Service de Biostatistique et d'Epidémiologie, Gustave Roussy Cancer Campus, INSERM U1018, CESP, Université Paris-Sud, Université Paris-Saclay, Villejuif, France
| | - Jean Bourhis
- Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Jens Overgaard
- Department of Experimental Clinical Oncology, Aarhus, Denmark
| | - Qiang Zhang
- NRG Oncology Statistics and Data Management Center (formerly RTOG), Philadelphia, PA, USA
| | - Vincent Grégoire
- Radiation Oncology Department, UCL-Cliniques Universitaires St-Luc, Brussels, Belgium
| | - Matthew Nankivell
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Björn Zackrisson
- Department of Radiation Sciences, Oncology, Umeå University, Umeå, Sweden
| | - Zbigniew Szutkowski
- Department of Radiotherapy, Cancer Center, Marie Curie-Sklodowska Memorial Institute, Warsaw, Poland
| | - Rafał Suwiński
- Radiotherapy and Chemotherapy Clinic and Teaching Hospital, Marie Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice, Poland
| | - Michael Poulsen
- Radiation Oncology Services, Mater Centre, Brisbane, QLD, Australia
| | - Brian O'Sullivan
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | | | | | - Carlo Fallai
- Department of Radiotherapy, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Hideya Yamazaki
- Department of Radiation Oncology, Osaka Medical Center for Cancer and Cardiovascular Disease, Osaka, Japan
| | - Werner Dobrowsky
- Department of Clinical Oncology, Freeman Hospital, Newcastle, UK
| | - Kwan Ho Cho
- Proton Therapy Center, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Beth Beadle
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Johannes A Langendijk
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Celia Maria Pais Viegas
- Radiation Oncology Department, Instituto Nacional de Cancer, Brasil National Cancer Institute, Rio de Janeiro, Brazil
| | - John Hay
- Division of Radiation Oncology, British Columbia Cancer Agency, Vancouver, BC, Canada
| | - Mohamed Lotayef
- Radiation Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Mahesh K B Parmar
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Anne Aupérin
- Ligue Nationale Contre le Cancer Meta-Analysis Platform, Service de Biostatistique et d'Epidémiologie, Gustave Roussy Cancer Campus, INSERM U1018, CESP, Université Paris-Sud, Université Paris-Saclay, Villejuif, France
| | - Carla van Herpen
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Philippe Maingon
- European Organisation for Research and Treatment of Cancer, Radiation Oncology Group, Brussels, Belgium; Service d'Oncologie, Radiothérapie, Hôpitaux Universitaires Pitié Salpêtrière, Charles Foix, Paris, France
| | - Andy M Trotti
- Moffitt Cancer Center, Department of Radiation Oncology, Tampa, FL, USA
| | - Cai Grau
- Department of Experimental Clinical Oncology, Aarhus, Denmark
| | - Jean-Pierre Pignon
- Ligue Nationale Contre le Cancer Meta-Analysis Platform, Service de Biostatistique et d'Epidémiologie, Gustave Roussy Cancer Campus, INSERM U1018, CESP, Université Paris-Sud, Université Paris-Saclay, Villejuif, France.
| | - Pierre Blanchard
- Department of Radiation Therapy, Gustave Roussy Cancer Campus, INSERM U1018, CESP, Université Paris-Sud, Université Paris-Saclay, Villejuif, France
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Trials in head and neck oncology: Evolution of perioperative adjuvant therapy. Oral Oncol 2017; 72:80-89. [PMID: 28797466 DOI: 10.1016/j.oraloncology.2017.07.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 07/02/2017] [Accepted: 07/08/2017] [Indexed: 11/22/2022]
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Sher DJ, Adelstein DJ, Bajaj GK, Brizel DM, Cohen EE, Halthore A, Harrison LB, Lu C, Moeller BJ, Quon H, Rocco JW, Sturgis EM, Tishler RB, Trotti A, Waldron J, Eisbruch A. Radiation therapy for oropharyngeal squamous cell carcinoma: Executive summary of an ASTRO Evidence-Based Clinical Practice Guideline. Pract Radiat Oncol 2017; 7:246-253. [DOI: 10.1016/j.prro.2017.02.002] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 02/02/2017] [Accepted: 02/06/2017] [Indexed: 11/28/2022]
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Mallick S, Benson R, Julka PK, Rath GK. Altered fractionation radiotherapy in head and neck squamous cell carcinoma. J Egypt Natl Canc Inst 2016; 28:73-80. [PMID: 26994645 DOI: 10.1016/j.jnci.2016.02.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 02/04/2016] [Accepted: 02/20/2016] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Fractionation plays a pivotal role in determining the effectiveness of radiation and follows the principle of 4 "R" of radiobiology. The various altered fractionation schedules used are hyper-fractionation, accelerated fractionation, and hypo fractionation. METHODS We reviewed the landmark articles published in the peer reviewed journals to summarize the beneficial role of altered fractionation in the treatment of head and neck carcinoma. RESULTS Hyper-fractionation definitely gives very good overall survival benefit for locally advanced head and neck patient's equivalent to survival benefit to that of concurrent chemoradiotherapy. Adding concomitant chemotherapy to altered fractionation is a logical approach to improve survival in locally advanced head and neck cancer patients, but it may be at a cost of higher toxicity. Mild hypo fractionation may be beneficial in early laryngeal cancers and may help in achieving better local control. CONCLUSION Altered fractionation is a very important treatment schema and requires the reinforcement of its use.
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Affiliation(s)
- Supriya Mallick
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India.
| | - Rony Benson
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Pramod K Julka
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Goura K Rath
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India
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Suwinski R, Wozniak G, Misiolek M, Jaworska M, Kozaczka M, Bal W, Nowara E, Miszczyk L. Randomized clinical trial on 7-days-a-week post-operative radiotherapy vs concurrent post-operative radiochemotherapy in locally advanced cancer of the oral cavity/oropharynx: a report on acute normal tissue reactions. Br J Radiol 2016; 89:20150805. [PMID: 26934504 DOI: 10.1259/bjr.20150805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE The purpose of the study was to evaluate acute normal tissue reactions and treatment compliance in a randomized clinical trial on 7-days-a-week post-operative radiotherapy (p-CAIR) vs post-operative concurrent radiochemotherapy (p-RTCT) in locally advanced cancer of the oral cavity/oropharynx. The sample analyzed at present represents approximately 30% of the intended future trial size. METHODS The patients were randomly assigned to receive 63 Gy in 1.8-Gy fractions 7 days a week (n = 44) or 63 Gy in 1.8-Gy fractions 5 days a week with concurrent cisplatin 80-100 mg per square metre of body surface area on Days 1, 22 and 43 of the course of radiotherapy (n = 40). Acute mucosal reactions were scored using the modified Dische system. RESULTS 15 (17.9%) patients, including 5 patients in p-CAIR and 10 patients in p-RTCT, did not comply with the assigned radiation treatment, mostly because of rapid tumour progression or deteriorating general performance. In p-RTCT, 22 (55%) patients received less than the intended three courses of chemotherapy mostly owing to haematological toxicity. The average maximum mucosal severity score was 14.2 in p-CAIR compared with 13.4 in p-RTCT; the difference was not statistically significant (p = 0.31). CONCLUSION The schedules compared (p-CAIR and p-RTCT) did not differ considerably with respect to acute mucosal reactions. Haematological toxicity in p-RTCT was elevated compared with p-CAIR. Both schedules were considered tolerable with respect to acute toxicity, which justifies further recruitment to the trial. ADVANCES IN KNOWLEDGE The results show that early mucosal reactions are comparable in both trial arms but haematological toxicity is more pronounced during radiochemotherapy.
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Affiliation(s)
- Rafal Suwinski
- 1 Radiotherapy and Chemotherapy Clinic and Teaching Hospital, Center of Oncology, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Poland
| | - Grzegorz Wozniak
- 2 Department of Radiation Oncology, Center of Oncology, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Poland
| | - Maciej Misiolek
- 3 Department of Laryngology, Silesian Medical University, Katowice, Poland
| | - Magdalena Jaworska
- 4 Department of Pathology, Center of Oncology, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Poland
| | - Maciej Kozaczka
- 5 Department of Medical Oncology, Center of Oncology, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Poland
| | - Wieslaw Bal
- 5 Department of Medical Oncology, Center of Oncology, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Poland
| | - Elzbieta Nowara
- 5 Department of Medical Oncology, Center of Oncology, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Poland
| | - Leszek Miszczyk
- 2 Department of Radiation Oncology, Center of Oncology, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Poland
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Yamoah K, Showalter TN, Ohri N. Radiation Therapy Intensification for Solid Tumors: A Systematic Review of Randomized Trials. Int J Radiat Oncol Biol Phys 2015; 93:737-45. [PMID: 26530740 PMCID: PMC4635974 DOI: 10.1016/j.ijrobp.2015.07.2284] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 07/24/2015] [Indexed: 12/18/2022]
Abstract
PURPOSE To systematically review the outcomes of randomized trials testing radiation therapy (RT) intensification, including both dose escalation and/or the use of altered fractionation, as a strategy to improve disease control for a number of malignancies. METHODS AND MATERIALS We performed a literature search to identify randomized trials testing RT intensification for cancers of the central nervous system, head and neck, breast, lung, esophagus, rectum, and prostate. Findings were described qualitatively. Where adequate data were available, pooled estimates for the effect of RT intensification on local control (LC) or overall survival (OS) were obtained using the inverse variance method. RESULTS In primary central nervous system tumors, esophageal cancer, and rectal cancer, randomized trials have not demonstrated that RT intensification improves clinical outcomes. In breast cancer and prostate cancer, dose escalation has been shown to improve LC or biochemical disease control but not OS. Radiation therapy intensification may improve LC and OS in head and neck and lung cancers, but these benefits have generally been limited to studies that did not incorporate concurrent chemotherapy. CONCLUSIONS In randomized trials, the benefits of RT intensification have largely been restricted to trials in which concurrent chemotherapy was not used. Novel strategies to optimize the incorporation of RT in the multimodality treatment of solid tumors should be explored.
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Affiliation(s)
- Kosj Yamoah
- Department of Radiation Oncology, Kimmel Cancer Center, Jefferson Medical College of Thomas Jefferson University, 111 South 11th Street, Room G-301, Bodine Center, Philadelphia, PA 19107, (215) 955-6700, (215) 955-0412 (fax),
| | - Timothy N. Showalter
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA 22908, (434) 982-6278, (434) 243-9789 (fax),
| | - Nitin Ohri
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, New York 10467, (718) 920-4140, (718) 231-5064 (fax),
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Tukiendorf A, Miszczyk L, Bojarski J. Damped sinusoidal function to model acute irradiation in radiotherapy patients. Phys Med 2013; 29:513-9. [PMID: 23333064 DOI: 10.1016/j.ejmp.2012.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Revised: 12/04/2012] [Accepted: 12/13/2012] [Indexed: 11/25/2022] Open
Abstract
In the paper, we suggest a damped sinusoidal function be used to model a regenerative response of mucosa in time after the radiotherapy treatment. The medical history of 389 RT patients irradiated within the years 1994-2000 at the Radiotherapy Department, Cancer Center, Maria Skłodowska-Curie Memorial Institute of Oncology, Gliwice, Poland, was taken into account. In the analyzed group of patients, the number of observations of a single patient ranged from 2 to 25 (mean = 8.3, median = 8) with severity determined by use of Dische's scores from 0 to 24 (mean = 7.4, median = 7). Statistical modeling of radiation-induced mucositis was performed for five groups of patients irradiated within the following radiotherapy schedules: CAIR, CB, Manchester, CHA-CHA, and Conventional. All of the regression parameters of the assumed model, i.e. amplitude, damping coefficient, angular frequency, phase of component, and offset, estimated in the analysis were statistically significant (p-value < 0.05) for the radiotherapy schedules. The model was validated using a non-oscillatory function. Following goodness-of-fit statistics, the damped sinusoidal function fits the data better than the non-oscillatory damped function. Model curves for harmonic characteristics with confidence intervals were plotted separately for each of the RT schedules and together in a combined design. The suggested model might be helpful in the numeric evaluation of the RT toxicity in the groups of patients under analysis as it allows for practical comparisons and treatment optimization. A statistical approach is also briefly described in the paper.
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Affiliation(s)
- Andrzej Tukiendorf
- Department of Epidemiology, Cancer Center, Maria Skłodowska-Curie Memorial Institute of Oncology, ul. Wybrzeże AK 15, 44-101 Gliwice, Poland.
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Snietura M, Jaworska M, Mlynarczyk-Liszka J, Goraj-Zajac A, Piglowski W, Lange D, Wozniak G, Nowara E, Suwinski R. PTEN as a prognostic and predictive marker in postoperative radiotherapy for squamous cell cancer of the head and neck. PLoS One 2012; 7:e33396. [PMID: 22413021 PMCID: PMC3296680 DOI: 10.1371/journal.pone.0033396] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2011] [Accepted: 02/14/2012] [Indexed: 12/03/2022] Open
Abstract
Background Tumor suppressor PTEN is known to control a variety of processes related to cell survival, proliferation, and growth. PTEN expression is considered as a prognostic factor in some human neoplasms like breast, prostate, and thyroid cancer. Methodology/Principal Findings In this study we analyzed the influence of PTEN expression on the outcome of a randomized clinical trial of conventional versus 7-days-a-week postoperative radiotherapy for squamous cell cancer of the head and neck. The patients with cancer of the oral cavity, oropharynx, and larynx were randomized to receive 63 Gy in fractions of 1.8 Gy given 5 days a week (CF) or 7 days a week (p-CAIR). Out of 279 patients enrolled in the study, 147 paraffin blocks were available for an immunohistochemical assessment of PTEN. To evaluate the prognostic value of PTEN expression and the effect of fractionation relative to PTEN, the data on the outcome of a randomized clinical trial were analyzed. Tumors with a high intensity of PTEN staining had significant gain in the loco-regional control (LRC) from p-CAIR (5-year LRC 92.7% vs. 70.8%, for p-CAIR vs. CF, p = 0.016, RR = 0.26). By contrast, tumors with low intensity of PTEN did not gain from p-CAIR (5-year LRC 56.2% vs. 47.2%, p = 0.49, RR = 0.94). The intensity of PTEN highly affected the LRC in a whole group of 147 patients (5-year LRC 80.9% vs. 52.3% for high vs. low PTEN, p = 0.0007, RR = 0.32). In multivariate Cox analysis, including neck node involvement, EGFR, nm23, Ki-67, p53, cyclin D1, tumor site and margins, PTEN remained an independent predictor of LRC (RR = 2.8 p = 0.004). Conclusions/Significance These results suggest that PTEN may serve as a potent prognostic and predictive marker in postoperative radiotherapy for high-risk squamous cell cancer of the head and neck.
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Affiliation(s)
- Miroslaw Snietura
- Tumor Pathology Department, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Poland.
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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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Denaro N, Russi EG, Adamo V, Colantonio I, Merlano MC. Postoperative therapy in head and neck cancer: state of the art, risk subset, prognosis and unsolved questions. Oncology 2011; 81:21-9. [PMID: 21912194 DOI: 10.1159/000330818] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Accepted: 07/04/2011] [Indexed: 02/03/2023]
Abstract
Head and neck cancer may be easily controlled at early stages, but resectable locally advanced disease often relapses at T and N sites. Therefore, adequate adjuvant treatment is of crucial importance for improving local control and/or survival. Unfortunately, little data are available on the adjuvant setting. Adjuvant radiotherapy is regarded as a standard approach for patients with locally advanced radically resected head and neck cancer, while postoperative chemotherapy alone cannot be considered outside of clinical trials. However, chemoradiotherapy is widely considered superior to radiotherapy in patients at a high risk of relapse and may be considered the standard treatment in this population. In this respect, in the last few decades, there has been a growing interest due to the emerging data on both tumor biology and clinical trials. Several pathological and molecular factors, affecting behavior and head and neck cancer prognosis, could allow for a better selection of postoperative treatment. More recently, new prognostic and predictive factors were identified, including biomolecular aspects, human papillomavirus infection and lifestyle. The integration of these new factors deserves dedicated clinical studies, but the available knowledge already allows some deductive hypotheses. We performed a review of the literature to analyze the role of therapy in the postoperative setting and to discuss both the possibility of a different approach to each class of risk and the unsolved question for which randomized trials are warranted.
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Affiliation(s)
- Nerina Denaro
- Department of Oncology, AOU G. Martino Messina University, Messina, Italy.
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Baujat B, Bourhis J, Blanchard P, Overgaard J, Ang KK, Saunders M, Le Maître A, Bernier J, Horiot JC, Maillard E, Pajak TF, Poulsen MG, Bourredjem A, O'Sullivan B, Dobrowsky W, Andrzej H, Skladowski K, Hay JH, Pinto LHJ, Fu KK, Fallai C, Sylvester R, Pignon JP. Hyperfractionated or accelerated radiotherapy for head and neck cancer. Cochrane Database Syst Rev 2010; 2010:CD002026. [PMID: 21154350 PMCID: PMC8407183 DOI: 10.1002/14651858.cd002026.pub2] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Several trials have studied the role of altered fractionation radiotherapy in head and neck squamous cell carcinoma, but the effect of such treatment on survival is not clear. OBJECTIVES The aim of this individual patient data (IPD) meta-analysis was to assess whether this type of radiotherapy could improve survival. SEARCH STRATEGY We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; CENTRAL (2010, Issue 3); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The date of the most recent search was 8 August 2010. SELECTION CRITERIA We identified randomised trials comparing conventional radiotherapy with hyperfractionated or accelerated radiotherapy, or both, in patients with non-metastatic head and neck squamous cell carcinomas and grouped trials into three pre-specified treatment categories: hyperfractionated, accelerated and accelerated with total dose reduction. Trials were eligible if they began recruitment after 1969 and ended before 1998. DATA COLLECTION AND ANALYSIS We obtained updated individual patient data. Overall survival was the main outcome measure. The secondary outcome measures were local or regional control rates (or both), distant control rates and cause-specific mortality. MAIN RESULTS We included 15 trials with 6515 patients. The median follow up was six years. Tumour sites were mostly oropharynx and larynx; 5221 (74%) patients had stage III-IV disease (UICC 2002). There was a significant survival benefit with altered fractionation radiotherapy, corresponding to an absolute benefit of 3.4% at five years (hazard ratio (HR) 0.92, 95% CI 0.86 to 0.97; P = 0.003). The benefit was significantly higher with hyperfractionated radiotherapy (8% at five years) than with accelerated radiotherapy (2% with accelerated fractionation without total dose reduction and 1.7% with total dose reduction at five years, P = 0.02). There was a benefit in locoregional control in favour of altered fractionation versus conventional radiotherapy (6.4% at five years; P < 0.0001), which was particularly efficient in reducing local failure, whereas the benefit on nodal control was less pronounced. The benefit was significantly higher in the youngest patients (under 50 year old) (HR 0.78, 95% CI 0.65 to 0.94), 0.95 (95% CI 0.83 to 1.09) for 51 to 60 year olds, 0.92 (95% CI 0.81 to 1.06) for 61 to 70 year olds, and 1.08 (95% CI 0.89 to 1.30) for those over 70 years old; test for trends P = 0.007). AUTHORS' CONCLUSIONS Altered fractionation radiotherapy improves survival in patients with head and neck squamous cell carcinoma. Comparison of the different types of altered radiotherapy suggests that hyperfractionation provides the greatest benefit. An update of this IPD meta-analysis (MARCH 2), which will increase the power of this analysis and allow for other comparisons, is currently in progress.
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Affiliation(s)
- Bertrand Baujat
- Hôpital TenonService ORL‐CCF4 rue de la ChineParisFrance75020
| | - Jean Bourhis
- Institut Gustave RoussyDépartement de Radiothérapie39 rue Camille DesmoulinsVillejuif CedexFrance94805
| | - Pierre Blanchard
- Institut Gustave RoussyBiostatistics and Epidemiology Department39, rue Camille DesmoulinsVillejuif CedexFrance94805
| | - Jens Overgaard
- Aarhus University HospitalDepartment of Experimental Clinical OncologyNorrebrogade 44 Bldg 5AarhusDenmarkC DK‐8000
| | - Kian K Ang
- MD Anderson Cancer CenterRadiation Oncology Department1515 Holcombe Blvd Box 97HoustonTexasUSA77030
| | - Michelle Saunders
- Marie Curie Research Wing for OncologyRadiation Oncology DepartmentMount Vernon Centre for Cancer TreatmentRickmansworth RoadNorthwoodMiddlesexUKHA6 2RN
| | - Aurélie Le Maître
- Institut Gustave RoussyBiostatistics and Epidemiology Department39, rue Camille DesmoulinsVillejuif CedexFrance94805
| | - Jacques Bernier
- Clinique de GenoliaService de Radio‐OncologieGenolierSwitzerlandCH‐1272
| | | | - Emilie Maillard
- Institut Gustave RoussyBiostatistics and Epidemiology Department39, rue Camille DesmoulinsVillejuif CedexFrance94805
| | - Thomas F Pajak
- RTOGStatistical Headquarters1818 Market Street, Suite 1600PhiladelphiaPAUSA19103
| | - Michael G Poulsen
- Mater Queensland Radium InstituteRaymond Terrace, South BrisbaneBrisbaneAustralia4101
| | - Abderrahmane Bourredjem
- Institut Gustave RoussyBiostatistics and Epidemiology Department39, rue Camille DesmoulinsVillejuif CedexFrance94805
| | - Brian O'Sullivan
- Princess Margaret HospitalRadiation Oncology Department610 University AvenueTorontoONCanadaM5G 2M9
| | - Werner Dobrowsky
- Northern Centre for Cancer TreatmentNewcastle General HospitalWestgate roadNewcastle upon TyneUKNE4 6BE
| | | | - Krzystof Skladowski
- Centrum Onkologii‐Inst. M. CurieRadiotherapy ClinicWybrzeze Armii Krajowej 15GliwicePoland44‐101
| | - John H Hay
- Vancouver Cancer CenterDepartment of Radiation Oncology600 W, 10th AvenueVancouverBCCanadaV5Z 4E6
| | - Luiz HJ Pinto
- Instituto Nacional de CancerDepartamento de RadioterapiaRio de JaneiroBrazil20230
| | - Karen K Fu
- University of California San Francisco555 Laurel Ave Apt 508San MateoCAUSA94401‐4153
| | - Carlo Fallai
- Instituto Nazionale dei TumoriDipartimento di RadiotherapiaVia Venezian 1MilanoItaly20133
| | - Richard Sylvester
- European Organisation for Research and Treatment of CancerData CenterAvenue E Mounier 83 ‐ Bte 11BrusselsBelgium1200
| | - Jean Pierre Pignon
- Gustave Roussy Cancer CampusPlateforme LNCC de Méta‐analyse en Oncologie et Service de Biostatistique et d’EpidémiologieVillejuifFrance
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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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Snietura M, Piglowski W, Jaworska M, Mucha-Malecka A, Wozniak G, Lange D, Suwinski R. Impact of HPV infection on the clinical outcome of p-CAIR trial in head and neck cancer. Eur Arch Otorhinolaryngol 2010; 268:721-6. [PMID: 20938670 PMCID: PMC3071948 DOI: 10.1007/s00405-010-1396-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2010] [Accepted: 09/24/2010] [Indexed: 12/31/2022]
Abstract
The purpose of the study was to analyse the influence of HPV infection on the outcome of a randomized clinical trial of conventional (CF) versus 7-days-a-week postoperative radiotherapy (p-CAIR) for squamous cell cancer of the head and neck (SCCHN). Between 2001 and 2004, 279 patients with high-risk SCC of the larynx or cancer of the oral cavity/oropharynx were randomized to receive 63 Gy in fractions of 1.8 Gy given 5 days a week or 7 days a week (Radiother Oncol 87:155-163, 2008). The presence of HPV DNA in 131 archival paraffin blocks was assessed with multiplex quantitative real-time PCR using five consensus primers for the conservative L1 region and molecular beacon probes targeting 14 high-risk HPV subtypes. Following the RT-PCR procedure, we could determine the presence and type of HPV16, HPV18 and the other 12 less frequent oncogenic subtypes. Out of 131 samples, 9 were positive for HPV infection (6.9%), all of them with HPV16 subtype. None of the 65 laryngeal tumours was HPV positive. The 5-year LRC in HPV-positive patients was 100%, compared to 58% in the HPV-negative group (p = 0.02, log-rank test). Amongst 122 patients with HPV-negative tumours, 5-year LRC was 50.3% in p-CF versus 65.2 in p-CAIR (p = 0.37). HPV infection was associated with low expression of EGFR and cyclin D. This study demonstrates a favourable outcome for HPV-positive patients with SCCHN treated with postoperative radiotherapy. While considering the small number of HPV+ tumours, the data set can be considered as hypothesis generating only, the outcome raises new questions on the necessity of aggressive postoperative treatment in HPV+ patients.
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Affiliation(s)
- Miroslaw Snietura
- Department of Tumour Pathology, Center of Oncology, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Gliwice, Poland
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27
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Rutkowski T, Wygoda A, Hutnik M, Składowski K, Wydmański J, Maciejewski A, Szymczyk C, Wierzgoń J, Orlef A, Maciejewski B. Intraoperative radiotherapy (IORT) with low-energy photons as a boost in patients with early-stage oral cancer with the indications for postoperative radiotherapy : treatment feasibility and preliminary results. Strahlenther Onkol 2010; 186:496-501. [PMID: 20803185 DOI: 10.1007/s00066-010-2117-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Accepted: 05/20/2010] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate the feasibility and preliminary results of intraoperative radiotherapy (IORT) with low-energy photons as a boost in patients with early-stage oral cancer with the indications for postoperative radiotherapy. PATIENTS AND METHODS Between 2003 and 2006, 16 patients with early-stage cancer of mobile tongue (n = 10 [63%]) or floor of the mouth (n = 6 [37%]) treated at Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Poland, were evaluated for IORT boost with the INTRABEAM®System (Carl Zeiss Surgical GmbH; IORT-PRS) because of the high risk of local recurrence due to positive margins on frozen pathologic section. After tumor resection, the applicator was positioned in the tumor bed. The applicator's diameter (range: 1.5-5 cm) was selected to encompass high-risk area of tumor recurrence. The dose (5 Gy, 7 Gy, or 7.5 Gy) was applied according to tumor volume and bone proximity. External-beam radiotherapy (EBRT) was provided to the tumor bed in all patients (50 Gy) and to the nodal area, when needed. Toxicity and local tumor control were assessed. RESULTS Median follow-up was 36 months. IORT did not increase acute mucosal reaction. Local tumor control was found in all cases. Early mucosal reaction did not exceed 3 according to the RTOG scale and healed in median time of 35 days after completion of EBRT. No late adverse effects were observed. CONCLUSION This preliminary report has demonstrated the feasibility of IORT-PRS for patients with early oral cancer with the indications for postoperative radiotherapy. This method may be considered an alternative boost technique, although additional studies are needed to establish long-term results in a larger group of patients.
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Affiliation(s)
- Tomasz Rutkowski
- Department of Radiation Oncology, Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Poland.
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28
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Langendijk JA, Ferlito A, Takes RP, Rodrigo JP, Suárez C, Strojan P, Haigentz M, Rinaldo A. Postoperative strategies after primary surgery for squamous cell carcinoma of the head and neck. Oral Oncol 2010; 46:577-85. [PMID: 20400361 DOI: 10.1016/j.oraloncology.2010.03.023] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2010] [Revised: 03/29/2010] [Accepted: 03/29/2010] [Indexed: 11/20/2022]
Abstract
This review discusses the role of adjuvant treatment after curative surgery for patients with head and neck squamous cell carcinoma (HNSCC). In general, patients with unfavourable prognostic factors have a high-risk of loco-regional recurrence and subsequent worse survival after surgery alone and are therefore considered proper candidates for adjuvant treatment by either postoperative radiotherapy alone or postoperative chemoradiation. Selection of the most optimal adjuvant treatment strategy should be based on the most important prognostic factors. In this review, the different treatment strategies will be discussed in general. More specifically, we will discuss the role of the interval between surgery and radiotherapy, the overall treatment time of radiation, the selection of target volumes for radiation and the value of adding concomitant chemotherapy to postoperative radiation.
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Affiliation(s)
- Johannes A Langendijk
- Department of Radiation Oncology, University Medical Center Groningen/University of Groningen, Groningen, The Netherlands.
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Suwinski R, Jaworska M, Nikiel B, Grzegorz W, Bankowska-Wozniak M, Wojciech M, Krzysztof S, Dariusz L. Predicting the effect of accelerated fractionation in postoperative radiotherapy for head and neck cancer based on molecular marker profiles: data from a randomized clinical trial. Int J Radiat Oncol Biol Phys 2009; 77:438-46. [PMID: 19733016 DOI: 10.1016/j.ijrobp.2009.05.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2008] [Revised: 04/18/2009] [Accepted: 05/09/2009] [Indexed: 11/28/2022]
Abstract
PURPOSE To determine the prognostic and predictive values of molecular marker expression profiles based on data from a randomized clinical trial of postoperative conventional fractionation (p-CF) therapy versus 7-day-per-week postoperative continuous accelerated irradiation (p-CAIR) therapy for squamous cell cancer of the head and neck. METHODS AND MATERIALS Tumor samples from 148 patients (72 p-CF and 76 p-CAIR patients) were available for molecular studies. Immunohistochemistry was used to assess levels of EGFR, nm23, Ki-67, p-53, and cyclin D1 expression. To evaluate the effect of fractionation relative to the expression profiles, data for locoregional tumor control (LRC) were analyzed using the Cox proportional hazard regression model. Survival curves were compared using the Cox f test. RESULTS Patients who had tumors with low Ki-67, low p-53, and high EGFR expression levels and oral cavity/oropharyngeal primary cancer sites tended to benefit from p-CAIR. A joint score for the gain in LRC from p-CAIR based of these features was used to separate the patients into two groups: those who benefited significantly from p-CAIR with respect to LRC (n = 49 patients; 5-year LRC of 28% vs. 68%; p = 0.01) and those who did not benefit from p-CAIR (n = 99 patients; 5-year LRC of 72% vs. 66%; p = 0.38). The nm23 expression level appeared useful as a prognostic factor but not as a predictor of fractionation effect. CONCLUSIONS These results support the studies that demonstrate the potential of molecular profiles to predict the benefit from accelerated radiotherapy. The molecular profile that favored accelerated treatment (low Ki-67, low p-53, and high EGFR expression) was in a good accordance with results provided by other investigators. Combining individual predictors in a joint score may improve their predictive potential.
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Affiliation(s)
- Rafal Suwinski
- Department of Radiation Oncology, Center of Oncology, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Poland.
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