A targeted supradose cisplatin chemoradiation protocol for advanced head and neck cancer

Dose-Finding and Efficacy Confirmation Trial of the Superselective Intra-arterial Infusion of Cisplatin and Concomitant Radiation Therapy for Locally Advanced Maxillary Sinus Cancer (JCOG1212): Results of the Efficacy Confirmation Phase in Patients with T4aN0M0

PURPOSE

Locally advanced maxillary sinus cancers require radical surgery as a standard treatment, but this often results in significant disfigurement and impairment of function. JCOG1212 seeks to evaluate the safety and efficacy of the superselective intra-arterial infusion of cisplatin and concomitant radiation therapy (RADPLAT) for T4aN0M0 and T4bN0M0 maxillary sinus squamous cell carcinomas. We herein report the results of the efficacy confirmation phase in the T4a cohort.

METHODS AND MATERIALS

Patients received 100 mg/m2 cisplatin intra-arterially weekly for 7 weeks with concomitant radiation therapy (total 70 Gy) as determined by the results of the preceding dose-finding phase. The trial aimed to evaluate the primary endpoint of 3-year overall survival (OS), comparing RADPLAT with the historical control for 3-year OS in surgery (80%).

RESULTS

From April 2014 to August 2018, 65 patients were registered in the T4a cohort from 18 institutions, consisting of 54 men and 11 women with a median age of 64 years (range, 40-78 years) and Eastern Cooperative Oncology Group performance status 0/1 (58/7). After excluding 1 ineligible patient, 64 patients were included in the primary analysis of efficacy and safety. The median follow-up was 4.5 years in all eligible patients, and the primary endpoint for 3-year OS was 82.8% (90% CI, 73.4%-89.2%). With regard to acute adverse events, mucositis (grade ≥3), neutropenia (grade ≥3), increased creatinine (grade ≥2), hearing impairment (grade ≥2), and stroke (grade ≥2) were observed in 20.3%, 14.1%, 3.1%, 3.1%, and 1.6% of patients, respectively. One treatment-related death due to a thromboembolic event was reported.

CONCLUSIONS

We demonstrated that RADPLAT showed favorable results for patients with T4aN0M0 maxillary sinus squamous cell carcinomas compared with the historical control for 3-year OS in surgery, which was from an earlier period, and showed some specific toxicities. Therefore, RADPLAT, as well as surgery, can be regarded as a possible treatment option for these patients.

Summary of Japanese clinical practice guidelines for head and neck cancer - 2022 update edited by the Japan society for head and neck cancer

The aim of the "Japanese Clinical Practice Guidelines for Head and Neck Cancer - 2022 Update" is to review the latest evidence regarding head and neck cancer and to present the current standard approaches for diagnosis and treatment. These evidence-based recommendations were created with the consensus of the Guideline Committee, which is composed of otorhinolaryngologists and head and neck surgeons, together with radiologists, radiation oncologists, medical oncologists, plastic surgeons, dentists, palliative care physicians, and rehabilitation physicians. These guidelines were created by the Clinical Practice Guideline Committee of the Japan Society for Head and Neck Cancer based on the "Head and Neck Cancer Treatment Guidelines 2018 Edition," and the revised draft was compiled after evaluation by the Assessment Committee and public comments. The 'Clinical questions and recommendations' section consists of 13 categories, and 59 clinical questions are described in total. Here we describe 6 clinical questions specific to other sets of guidelines with recommendations and comments.

Complete response of glottic cancer to intra-arterial infusion chemotherapy combined with radiotherapy: A report of 4 cases

Surgical resection is recommended for advanced-stage, resectable glottic cancer. However, total laryngectomy results in the loss of vocal function and reduces patients' quality of life. At our institution, patients with cT3N0M0 stage III resectable glottic cancer who wish to preserve their larynx are treated with super-selective cisplatin infusion with concomitant radiotherapy (RADPLAT) to improve local control over systemic chemotherapy. Herein, we present 4 patients with glottic cancer who underwent biweekly intra-arterial infusion chemotherapy combined with radiation therapy 3 times. For intra-arterial infusion chemotherapy, 100 mg cis-diaminodichloroplatinum was infused into the superior thyroid artery, including the superior laryngeal artery branch. Thereafter, intensity-modulated radiation therapy was administered at doses of 70 Gy in 35 fractions for 3 patients and 66 Gy in 33 fractions for 1 patient. These patients showed complete response after chemoradiotherapy with no recurrence or metastases during the follow-up period to date (mean follow-up period: 56 months, range: 39-76 months).

The superselective intra-arterial infusion of cisplatin and concomitant radiotherapy (RADPLAT) is effective for metastatic lymph nodes in head and neck squamous cell carcinoma

BACKGROUND

Superselective intra-arterial infusion of cisplatin and concomitant radiotherapy (RADPLAT) is a very promising treatment modality for locally advanced head and neck squamous cell carcinoma. However, there are some concerns regarding its potential for the control of neck lymph node metastasis. The objective of this study was to investigate whether RADPLAT provided inferior regional control compared to intravenous chemoradiotherapy (IV-CRT).

METHODS

A total of 172 patients with neck lymph node metastases, 66 of whom underwent RADPLAT and 106 IV-CRT, were enrolled in this study. We retrospectively compared regional control rates between RADPLAT and IV-CRT. Furthermore, to adjust for differences in factors related to patient background between the groups, we conducted inverse probability weighting (IPW) analysis using the propensity score.

RESULTS

A comparison between the two groups revealed that the regional control rates were almost equal under unadjusted conditions; however, after adjustment by IPW analysis, the RADPLAT group had a relatively better regional control rate than did the IV-CRT group (1 year regional control rate: 86.6% vs. 79.4%). In addition, the analysis of relative risk factors for regional control in the RADPLAT group showed that the absence of intra-arterial cisplatin infusion into metastatic lymph nodes was the only independent risk factor (Hazard ratio: 4.23, p = 0.04).

CONCLUSION

This study showed that the regional control rate in patients treated with RADPLAT was noninferior to that for IV-CRT. Locally advanced head and neck cancers is a good indication for RADPLAT, even if the patients have neck lymph node metastases.

Ligation of the ethmoid arteries in superselective intra-arterial infusion of cisplatin for advanced maxillary sinus cancer fed by the ophthalmic artery

BACKGROUND

Superselective cisplatin (CDDP) infusion via the external carotid artery system and concomitant radiotherapy (RADPLAT) provides favorable oncological and functional outcomes in patients with maxillary sinus cancer. However, targeted lesions are occasionally fed by the branch of the internal carotid artery.

METHODS

In RADPLAT for maxillary sinus cancer partly fed by the ophthalmic artery, the ethmoid arteries were ligated in two patients without medial orbital wall involvement. In four patients with that, CDDP was administered via the ophthalmic artery.

RESULTS

A complete response was obtained in all six patients. Locoregional recurrence was not observed in any cases. However, visual acuity was lost in four patients who received the ophthalmic artery infusion.

CONCLUSIONS

Ligation of the ethmoid arteries is recommended in RADPLAT for maxillary sinus cancer with lesions fed by the ophthalmic artery. CDDP administered via the ophthalmic artery may be considered if a patient accepts the possibility of visual loss.

Intra-arterial chemotherapy targeting metastatic cervical lymph nodes in head and neck cancer

BACKGROUND

Large cervical lymph nodes and the extranodal extension of metastatic lymph nodes are considered poor prognostic factors in head and neck squamous cell carcinoma (HNC).

AIMS/OBJECTIVES

The efficacy of intra-arterial chemotherapy (iaCT) targeting lymph node (LN) in HNC was examined.

MATERIALS AND METHODS

We performed a retrospective review of 41 patients with laryngeal and hypopharyngeal cancer showing metastatic cervical LN larger than 20 mm treated with iaCT with concurrent radiotherapy. The administration of cisplatin into LN was divided into three groups: no administration (NO), via the same artery as that supplying the primary tumor (SAME), and via a different artery from that supplying the primary tumor (DIFFERENT).

RESULTS

A trend toward a more favorable three-year regional control in DIFFERENT compared to NO was observed, although the mean size of LN in DIFFERENT was larger than in the other groups. A better regional control was obtained in both DIFFERENT (p < .05) and DIFFERENT + SAME (p < .05) when overall rather than partial enhancement of lymph node by CT angiography was observed. Extranodal extension could be a factor predicting unfavorable regional control.

CONCLUSIONS/SIGNIFICANCE

Targeting lymph node may be helpful to avoid neck dissection when iaCT was planned in HNC with relatively large LNs.

Superselective intra-arterial chemoradiotherapy using altered blood flow compared to conventional systemic chemoradiotherapy for locally advanced oral squamous cell carcinoma: a single-center retrospective study

PURPOSE

To evaluate the efficacy and safety of superselective intra-arterial (IA) chemoradiotherapy with cisplatin and transcatheter arterial embolization (TAE) on advanced oral cancer, and to compare it with that of systemic chemoradiotherapy.

MATERIALS AND METHODS

This single-center retrospective study included 23 consecutive patients with locally advanced oral squamous cell carcinoma from November 2011 to November 2019. Of these, 15 received superselective IA cisplatin chemoradiotherapy with altered blood flow in the branches of the external carotid artery, and eight received systemic chemoradiotherapy. Medical charts were reviewed for the evaluation of patient data, drug toxicity, and antitumor efficacy.

RESULTS

Local control rate for the superselective IA infusion group, who underwent 6-7 cycles was significantly higher than that of the systemic chemotherapy group (11/13, 85% vs 3/8, 38%; p = 0.04). Regional control, locoregional control, disease-free survival, and overall survival rates were not significantly different between the groups (p = 0.15-0.907). Acute toxicity rates of grade 3 or higher were not significantly different between the IA and IV chemotherapy groups (p = 0.221).

CONCLUSION

Superselective IA chemoradiotherapy with cisplatin using altered blood flow in the branches of the external carotid artery with TAE may be useful for inoperable oral cancer.

Interventional Management of Head and Neck Tumors

Advancements in medical imaging and device technology allow minimal invasive procedures for the diagnosis and treatment of various disorders. For the management of tumors in head and neck region, these image-guided interventions play essential role in the often used multidisciplinary approach. Tissue sampling under ultrasound or computed tomography guidance is generally the first step to reach a pathological diagnosis. For head and neck tumors with high vascularity, embolization using particulate matter, liquid embolic agents, or coils is used to achieve successful tumor resection with minimal blood loss. Hemorrhage related to head and neck tumors can be evaluated and managed with endovascular techniques with minimal morbidity and mortality. Intra-arterial chemotherapy, radiofrequency ablation, and cryotherapy are new techniques for the management of advanced head and neck cancer which may serve as an alternative to achieve locoregional control and survival when curative resection may not be feasible.

Prognostic factors and treatment outcomes of advanced maxillary gingival squamous cell carcinoma treated by intra-arterial infusion chemotherapy concurrent with radiotherapy

BACKGROUND

The aim of this study was to evaluate the prognostic factors and treatment outcomes of advanced maxillary gingival squamous cell carcinoma (SCC) treated with intra-arterial infusion chemotherapy concurrent with radiotherapy.

METHODS

A total of 46 patients were reviewed retrospectively in this study. The treatment schedule comprised intra-arterial chemotherapy (total, 60 mg/m² docetaxel and 150 mg/m² cisplatin) and three-dimensional computed tomography based, daily conventional radiotherapy (total, 60 Gy/30 fr) for 6 weeks.

RESULTS

The median follow-up period was 40 months (range, 3-110 months). The 3-year overall survival and locoregional control rates for all patients were 64.3% and 84.3%, respectively. The OS rate of the patients with N0-1 was significantly higher than that of the patients with N ≥ 2 (P < .05). No grade 5 toxicities were observed.

CONCLUSIONS

Intra-arterial infusion chemotherapy concurrent with radiotherapy was effective for advanced maxillary gingival SCC.

A Comparative Study of Two Chemo-Radiation Regimens for the Cancer of Larynx

The region of head and neck is critical for respiration, nutrition, and speech. The management of laryngeal tumours can stimulate mutilations and cosmetic deformities and worsen the life. A “non-operative approach” is preferred for patients to whom radiation following surgery, possibly, will direct severe functional destruction predominantly in advanced stage patients having a bulk of carcinoma larynx. The case material for the study was selected from the cross-section of patients registered at the J. K. Cancer Institute, Kanpur. Histologically squamous cell carcinoma 64 patients were registered and equally and randomly placed into Arm I and Arm II. “Arm I” patients and “Arm II” was comprised of randomly selected 64 patients, having histopathologically proven squamous cell carcinoma of the larynx. All patients (32 patients) belonging to “Arm I” received concurrent chemoradiotherapy of Inj. Cisplatin 100 mg/m² for three-weekly underwent EBRT with 60 Co/LINAC and photon radiation of 70 Gy in 35 fractions for 7 weeks (2 parallel opposed fields). All the patients (32 patients) belongs to “Arm II” received chemo boost as Inj. Cisplatin 6 mg/m2 on last 15 fractions of treatment underwent EBRT with 60 Co/ LINAC photon radiation of 70 Gy in 35 fractions for 7 weeks. Radiotherapy was delivered in supine position by parallel opposing fields including the primary tumour, disease extension, and neck nodes. The study concluded that the loco-regional responses are analogous in Arm I and Arm 2, however Arm II had additional treatment allied toxicities and resulting from numerous of treatment breaks.

Dose-finding and efficacy confirmation trial of the superselective intra-arterial infusion of cisplatin and concomitant radiotherapy for locally advanced maxillary sinus cancer (Japan Clinical Oncology Group 1212): Dose-finding phase

BACKGROUND

We are currently undertaking a multi-institutional prospective trial of the superselective intra-arterial infusion of high-dose cisplatin with concomitant radiotherapy for patients with T4aN0M0 or T4bN0M0 locally advanced maxillary sinus squamous cell carcinomas (SCC). We herein report the results of the dose-finding phase.

METHODS

The dose-finding phase sought to evaluate the incidence of dose-limiting toxicities and determine the recommended number of cycles of the intra-arterial infusion of cisplatin. In this phase, 100 mg/m² of cisplatin was administered intra-arterially weekly for 7 weeks with concomitant radiotherapy (70 Gy).

RESULTS

All 18 patients received a full dose of radiotherapy. The number of cycles of cisplatin was 7 in 13 patients and 6 in 5 patients. The dose-limiting toxicities were observed in 5 patients.

CONCLUSION

These results indicated that this therapy is safe and well-tolerated at 7 cycles of cisplatin, which was determined to be the recommended number of cycles for locally advanced maxillary sinus SCC.

Cerebral infarction after intraarterial and intravenous chemoradiotherapy for head and neck cancer: A retrospective analysis using a Japanese inpatient database

BACKGROUND

The occurrence of cerebral infarction after intraarterial chemoradiotherapy (CRT) remains uncertain.

METHODS

We conducted a retrospective cohort study using the Diagnosis Procedure Combination (DPC) database from 2010 to 2013. We performed a 1:4 propensity score-matched analysis between patients undergoing intraarterial or intravenous CRT, and determined the association between cerebral infarction and intraarterial CRT.

RESULTS

Among patients with head and neck cancer receiving platinum-based chemotherapy and concurrent radiotherapy, we identified 776 patients with intraarterial CRT and 7157 with intravenous CRT. The occurrence of cerebral infarction was significantly higher in the intraarterial CRT group than in the intravenous CRT group: 1.4% (11 of 775) versus 0.4% (12 of 3100; p = .002). There was no significant difference in mucosal toxicity or febrile neutropenia.

CONCLUSION

About 10% of patients received intraarterial CRT. Intraarterial CRT was associated with a higher incidence of cerebral infarction than was intravenous CRT. This result is useful when considering the procedure-related risks and the potential benefits of intraarterial CRT. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1354-1358, 2016.

Comparison of swallowing function after intensity-modulated radiation therapy and conventional radiotherapy for head and neck cancer

BACKGROUND

Intensity-modulated radiotherapy (IMRT) is hoped to protect structures important for swallow function. We compared posttreatment swallow function in 7 pairs of patients with head and neck cancer treated with either IMRT or conventional radiotherapy (RT).

METHODS

Patients were matched on tumor characteristics. Swallowing function was evaluated with the modified barium swallow procedure pretreatment and at 3 and 6 months postcancer treatment completion. Swallows were analyzed for bolus transit times, bolus residues, laryngeal closure (LAC) duration, cricopharyngeal opening (CPO) duration, and oropharyngeal swallow efficiency (OPSE). Data were analyzed using multifactor repeated measures analysis of variance and adjusted for baseline function.

RESULTS

Main effect of radiation type was significant for all measures on at least 1 bolus type. Patients treated with IMRT demonstrated shorter bolus transit times, less oral and pharyngeal residue, longer LAC, and larger OPSE.

CONCLUSION

Patients treated with IMRT demonstrated faster, more efficient swallows, and greater airway protection.

Intra-arterial chemoradiotherapy for head and neck cancer

Intra-arterial chemotherapy has been used to treat localized malignant neoplasms in patients with head and neck cancer for over 50 years as the head and neck region is particularly well suited to regional chemotherapy. Early intra-arterial chemotherapy did not prove its efficacy. In addition, the additional complications associated with establishing and maintaining arterial access have further dampened enthusiasm for this approach. Subsequent significant advances in vascular radiology techniques and the development of new devices, such as fluoroscopy units and angiographic catheters, have made possible safe, accurate and repeated superselective intra-arterial chemotherapy. Intra-arterial infusion of high-dose cisplatin with systemic neutralization by intravenous sodium thiosulfate (RADPLAT) is a theoretically attractive approach to the treatment of advanced head and neck cancer. However, a Dutch trial comparing intra-arterial and intravenous chemoradiotherapy for advanced head and neck cancer showed that RADPLAT was not superior to intravenous chemoradiotherapy. Therefore, further investigation of RADPLAT, including the refinement of the indications for its application, is needed.

Protective effects of sodium thiosulfate for cisplatin-mediated ototoxicity in patients with head and neck cancer

CONCLUSIONS

Intra-arterial high-dose cisplatin chemoradiation (CRT-IA) with sodium thiosulfate (STS) causes relatively less severe cisplatin ototoxicity than intravenous cisplatin chemoradiation without STS (CRT-IV). The results of this study also suggest that early detection of ototoxicity is possible by testing the hearing loss at ultra-high frequencies.

OBJECTIVES

To investigate protective effects of STS against cisplatin ototoxicity.

METHODS

Between 2011 and 2013, 18 patients with head and neck carcinomas were treated with intra-arterial infusions of high-dose cisplatin (range 100-180 mg/body, mean 111 mg/body; range 2-5 courses, mean 3.6 courses) and systemic administration of cisplatin (range 66-185 mg/body, mean 130 mg/body; range 1-3 courses, mean 2.6 courses) and concurrent radiation therapy (range 60-70 Gy, mean 69 Gy). Cisplatin was neutralized by STS in CRT-IA but not in CRT-IV.

RESULTS

Intra-arterial infusion in the high-dose cisplatin group caused significant hearing loss at ultra-high frequencies of 10 and 12 kHz (p = 0.028, 0.039, respectively), whereas the group receiving systemic administration of cisplatin had significant hearing loss at high frequencies of 8 and 10 kHz (p = 0.016, 0.027, respectively).

Tongue cancer with mental retardation due to microcephaly: a clinical report

Oral cancer in patients with mental retardation has not been reported in detail, although the literature on clinical management of oral malignancies in the general population is extensive. No clear consensus has been established regarding the management of oral cancer in patients with mental retardation. We present herein the case of a 32-year-old Japanese man with mental retardation due to microcephaly who presented with advanced tongue cancer. He was treated with three courses of chemotherapy using superselective intra-arterial infusion of cisplatin at 100 mg/m2 via the femoral artery (Seldinger method). No major complications were encountered, and complete response was achieved. The patient has shown no clinical or radiological evidence of local recurrence or distant metastases as of 22 months after the end of treatment. This case provides a basis for the future appropriate management of oral cancer in patients with mental retardation.

Thyroid dysfunction after intra-arterial chemotherapy for hypopharyngeal and laryngeal cancer

OBJECTIVE

Hypothyroidism is a late side effect after curative radiotherapy in the head and neck region. Superselective intra-arterial chemotherapy (SSIAC), when combined with radiation (SSIAC-R), shows higher control potential for locally advanced head and neck cancers, which is attributable to a delivery of higher concentrations of chemotherapeutic agents. However, it could enhance damages in the normal tissues. Hypothyroidism is a late adverse effect after curative radiotherapy in the head and neck region. This study focuses on the toxic effect of treatment modality for thyroid function.

METHODS

A retrospective analysis was performed to examine patients' thyroid function after SSIAC-R for laryngeal and hypopharyngeal cancer.

RESULTS

Hypothyroidism was observed in 21 (77.8%) of 27 patients receiving SSIAC-R, 4 (33.3%) of 12 patients treated with radiation alone, and 7 (41.1%) of 17 who underwent systemic chemoradiotherapy. The number of administered vessels significantly correlated with the incidence of developing hypothyroidism among SSIAC-R treated patients (P=0.03).

CONCLUSION

Concurrent setting of SSIAC with radiation significantly raises the possibility of hypothyroidism. Therefore, monitoring late complications of therapeutic procedures is essential during follow-up visits.

[The efficacy of superselective intra-arterial chemo-radiotherapy for cervical neck lymph node metastases]

We report herein on 32 cases of head and neck carcinoma with cervical lymph node metastases treated by radiotherapy and concomitant intraarterial cisplatin (RADPLAT) from April 2009 to May 2013. N3 cases revealed residual disease of the cervical lymph nodes in 7/9 cases. Among the 22 patients excluding N1 and N3 cases, the pathological CR rate was 63.6%. Among the 13 patients in whom the anticancer drug was directly infused into the cervical lymph nodes, the pathological CR rate was 76.9%, whereas in the 9 patients without direct infusion of the cervical lymph nodes, the pathological CR rate was 44.4%. Therefore, we recommend the direct infusion into cervical lymph node metastases for not only N3 cases but also N2 cases if a feeding artery is identified easily. When clinical examination after RADPLAT leads to suspected residual disease, neck dissection should be adapted. If the clinical examination leads to a diagnosis of CR, we recommend a biopsy of the original cervical lymph nodes because the cases which we diagnosed as CR revealed residual disease of the cervical lymph nodes in 4/16.

Reporting standards for endovascular chemotherapy of head, neck and CNS tumors

BACKGROUND

The goal of this article is to provide expert consensus recommendations for reporting standards, terminology and definitions when reporting on neurointerventional chemotherapy administration for head and neck tumors. These criteria may be used to design clinical trials, to provide definitions for patient stratification and to permit robust analysis of published data.

METHODS

This publication represents a consensus document by the Society for Neurointerventional Surgery. A PubMed search was conducted and included articles published in 2002-2011, with the search strategy designed to identify all studies of intra-arterial chemotherapy for tumors of neck and head. Articles were evaluated for evidence class, and recommendations were made using guidelines for evidence-based medicine proposed by a joint committee of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons. Specifically, technical methods, outcome variables and reported complications were highlighted.

RESULTS

Thirty-five publications were included in the review. While most studies represent class III evidence, there was sufficient concordance to justify level 2 recommendations regarding technical methods for administration of intra-arterial chemotherapy. The data also support level 2 recommendations regarding reporting of particular outcome variables subsumed within broad categories entitled 'Procedure-related', 'Disease control' and 'Survival'. The data support recommendations for the reporting of access site-related, neurologic, head and neck, ocular, hematologic and systemic complications, and also complications related to the percutaneous access site.

CONCLUSIONS

Intra-arterial chemotherapy is a growing field in interventional neuroradiology. It is important to adopt uniform technical and reporting standards that will allow cross-publication comparisons and facilitate homogeneous practice standards. Published data support such standards, which are vital for the consistent evaluation of future published research.

Selective intraarterial chemoradiation therapy for oropharyngeal carcinoma with high-dose cisplatin

PURPOSE

Cisplatin has shown a high tumor response rate among head and neck carcinomas, and the tumor response is related to the cisplatin dosage. The purpose of this study was to evaluate the efficacy and toxicity of selective intraarterial chemoradiation therapy for oropharyngeal carcinomas with high-dose cisplatin.

MATERIALS AND METHODS

This retrospective study consisted of 21 patients with oropharyngeal carcinoma, stages II-IVB, in whom intraarterial chemoradiation therapy was performed between 2000 and 2008. All patients were given two courses of selective intraarterial infusions of cisplatin (300 mg/m(2)), systemic chemotherapy with 5-fluorouracil, and simultaneous radiation therapy (58-61 Gy/30 fractions), with a 1-week rest period.

RESULTS

The 2-year overall survival rate of the 15 patients who completed the therapeutic regimen was 71.3%. The 2-year locoregional control rate and disease-free survival rate were 95.0% and 67.7%, respectively.

CONCLUSION

Selective intraarterial high-dose cisplatin chemotherapy with concomitant radiation therapy shows results similar to those of original methods in terms of survival and locoregional control with a reduction in the number of procedure times.

Targeted infusions of supradose Cisplatin with systemic neutralization for carcinomas invading the temporal bone

In an attempt to improve the dismal prognosis for patients with advanced cancer involving the temporal bone, a regional chemotherapy technique was piloted as part of the multimodality therapy for such patients. Rapid supradose cisplatin infusions selectively delivered to the lesion were given to 14 patients with carcinoma involving the temporal bone. Concurrent systemic cisplatin neutralization was achieved with sodium thiosulfate which permitted the use of cisplatin dose intensity regimens equivalent to fivefold the conventional amount. Four patients received chemotherapy alone, four had concomitant irradiation, and six had subsequent irradiation and/or temporal bone surgery. All patients tolerated the chemotherapy without significant complications or toxicity.All three of the patients with previously untreated disease responded to chemotherapy (2 Crs, 1 PR); three of the seven patients with recurrent disease responded to chemotherapy; and all four patients treated with chemoradiation had a complete response (including one patient with recurrent disease). The median follow-up time was 19 months (range, 5 to 63 months). Nine of the 14 patients are alive, including the 4 who were treated with targeted chemoradiation.The use of targeted high-dose chemotherapy for patients with malignant skull base lesions offers hope for improved outcome, particularly when this regimen is given simultaneously with radiation.

Concurrent Superselective Intra-Arterial Chemotherapy and Radiotherapy for Late-Stage Squamous Cell Carcinoma of the Temporal Bone

Objectives:

This study evaluated the efficacy of concurrent superselective intra-arterial chemotherapy and radiotherapy without surgery for late-stage squamous cell carcinoma of the temporal bone, which typically has a poor prognosis.

Methods:

The subjects were 5 patients treated at our hospital between 2007 and 2010 for primary cancer of the temporal bone. One patient had a stage T3 tumor, and 4 patients had T4 tumors, according to the Pittsburgh staging system. All patients received irradiation with a conventional once-daily fraction of 2 Gy, and the total dose ranged from 60 to 66 Gy. Intra-arterial cisplatin via transfemoral catheterization and intravenous sodium thiosulfate were administered. The contribution of each vessel in supplying blood to the primary tumor was determined by real-time computed tomographic angiography.

Results:

Three patients obtained a complete response. The same 3 patients remain alive without local recurrence (mean survival, 28 months), 1 patient died of distant metastasis without local recurrence after 19 months, and 1 patient remains alive with local recurrence.

Conclusions:

Although the small number of patients prevents comparisons with other treatments, the present study obtained good results. This may become an effective treatment for patients with late-stage squamous cell carcinoma of the temporal bone.

Salvage surgery for local recurrence after chemoradiotherapy or radiotherapy in hypopharyngeal cancer patients

This retrospective study aimed to assess the role of salvage surgery for local recurrence in hypopharyngeal cancer (HPC) patients who had received radiotherapy (RT) or concomitant chemoradiotherapy (CRT) as an initial treatment. The local recurrence rate, salvage rate after local recurrence and overall survival rate were investigated in 104 HPC patients who received treatment between 1991 and 2005. Local recurrence in the primary site was observed in 41 patients (rate, 39.4%) of whom only 12 could undergo further salvage surgery. Disease control was achieved in seven of these patients (successful salvage rate, 17.1%). The 5-year overall survival rate was 40.6% in the RT/CRT patient group and successful salvage rates for T1, T2, T3 and T4 primary disease were 33.3% (1/3), 20.0% (4/20), 16.7% (2/12) and 0% (0/6), respectively. Severe postoperative complications such as pharyngo-cutaneous fistula were seen in six patients (50.0%). Prognosis of patients with locally recurring HPC after RT/CRT is poor at any primary T-stage and the incidence of postoperative complication is relatively high. This should be taken into consideration when the initial treatment plan is decided and the choice of salvage surgery for such recurrent cases should be carefully determined.

Impact of superselective transarterial infusion therapy of high-dose cisplatin on maxillary cancer with orbital invasion

BACKGROUND AND PURPOSE

We have been performing the superselective transarterial infusion of high-dose cisplatin for advanced maxillary cancer since 1998 and the local control rate, disease free survival rate, and organ preservation have improved markedly compared with our former therapy. This study evaluates the effectiveness of superselective transarterial infusion therapy by using high-dose cisplatin on maxillary cancer with orbital invasion.

MATERIALS AND METHODS

We treated 23 patients with maxillary cancer by using superselective transarterial infusion therapy with high-dose cisplatin and concomitant radiation therapy for 10 years. Of all patients, 15 showed orbital invasion, with 11 of these tumors fed by both internal maxillary and ophthalmic arteries. In all patients, we performed superselective transarterial infusion therapy via the internal maxillary artery and/or the other feeding branches from the external carotid artery. After the operation, we determined whether a pCR had occurred by checking for the presence of viable cells. In addition, we calculated the overall survival rate, preservation rate of the eyeball, and disease-free survival rate.

RESULTS

For all 23 patients, pCR and overall survival rates were 95.7% and 78.4%, respectively. To date, 2 of these patients died of lung metastasis without local recurrence. For the 15 patients with orbital invasion, the respective pCR and disease-free survival rates were 93.3% and 87.5%. Eyeballs were preserved in all patients, and local recurrence occurred in only 1 patient, at the inferior wall of the maxillary sinus (not in the orbit).

CONCLUSIONS

Superselective transarterial infusion therapy with high-dose cisplatin remarkably improved the local control rate and disease-free survival rate of maxillary cancer. Even in patients with orbital invasion, a high local control rate was achieved, with preservation of the eyeball, through infusion only into branches of the external carotid artery.

Superselective, intra-arterial, rapid infusion chemotherapy for external auditory canal carcinoma

Previously, the treatment of carcinoma of the external auditory canal has mainly involved surgical resection. In order to enable organ preservation and to obtain cancer-free surgical margins, we introduced the use of superselective, intra-arterial, rapid infusion chemotherapy combined with radiotherapy to treat this condition.

We reviewed our patients' tumour stages, feeding arteries and clinical outcomes. Tumours were staged according to the Pittsburgh staging system. Chemotherapy was administered intra-arterially in the angiography suite via transfemoral catheterisation of the feeding arteries. Four patients underwent superselective, intra-arterial, rapid infusion chemo-radiotherapy. A complete response was obtained in all four patients. The overall toxic side effects were modest.

Superselective, intra-arterial, rapid infusion chemotherapy can be an effective, organ-preserving treatment for external auditory canal carcinoma, with a high cure rate.

Selective (intra-arterial), rapid infusion chemo-radiotherapy to preserve the larynx in advanced laryngeal carcinoma: preliminary results

Objectives:

We had previously treated patients with advanced stage laryngeal cancer by laryngectomy with or without post-operative radiotherapy. In order to improve such patients' quality of life, we sought to preserve the larynx by selective (intra-arterial), rapid infusion chemotherapy combined with radiotherapy.

Methods:

Chemotherapy was administered intra-arterially in the angiography suite via transfemoral catheterisation of the superior thyroid artery. Patients received up to four once-weekly infusions of cisplatin (75 mg/patient) with simultaneous intravenous administration of sodium thiosulphate, a neutralising agent. Patients also received external radiation simultaneously at a dose of 1.8 or 2.0 Gy per fraction, once daily for five days a week for 7 weeks.

Results:

Intra-arterial infusion chemo-radiotherapy was performed in eight patients with advanced laryngeal carcinoma (four glottic, three supraglottic and one subglottic type carcinoma). A complete response was achieved at the primary site and at lymph node metastases in all eight patients. Overall toxic side effects were modest. No catheter-related thrombo-embolic complications were observed during any of the chemotherapy sessions.

Conclusions:

Selective (intra-arterial), rapid infusion chemo-radiotherapy may enable laryngeal preservation in patients with advanced laryngeal carcinoma.

Concurrent Intra-Arterial Chemotherapy and Radiotherapy for Advanced Laryngeal Cancer

Objectives:

An intra-arterial chemoradiotherapy regimen (RADPLAT) provides remarkable local control for head and neck cancer. This study evaluates the efficacy of a reduced RADPLAT protocol in patients who are candidates for total laryngectomy.

Methods:

Forty-three patients with advanced laryngeal cancer were treated with 2 courses of intra-arterial cisplatin infusion (100 mg per body) during 40-Gy irradiation. The patients who showed a greatly diminished tumor received sequential irradiation. The patients with obvious residual disease received chemotherapy during the sequential irradiation. Poor responders, with less than 50% tumor reduction, underwent total laryngectomy.

Results:

Forty-two patients completed the protocol. All surviving patients were followed for at least 3 years. Thirty-four patients were alive (80% of the supraglottic cases and 87.5% of the glottic cases). Local control was achieved in 27 patients (67.5% of the 11 glottic cases and 64.0% of the supraglottic cases). The glottic cohort showed better progression-free survival rates than did the supraglottic cohort (68.8% and 45.0%, respectively; p = 0.019). There were 2 cases of grade 3 neutropenia and 3 cases of grade 3 mucositis. No patients required tube feeding. One patient required tracheostomy 3 months after the completion of the treatment protocol.

Conclusions:

Concurrent chemoradiotherapy with a reduced dose of intra-arterial cisplatin is feasible for patients with advanced glottic cancer.

Intra-arterial chemotherapy for head and neck cancer: experiences from three continents

Intra-arterial infusion of chemotherapy agents for cancer of the head and neck has been used for several decades. This article provides the rationale, historical background, and current state of investigations for patients treated in this manner. The experience with this route of drug delivery comes from three geographic regions: Europe, Japan, and North America. While the results of the trials have yet to establish the approach as being superior to intravenous infusions, continued research is warranted.

Rehabilitation of dysphagia following head and neck cancer

Patients who have cancers of the oral cavity, pharynx, or larynx may be treated with surgery, radiotherapy, chemotherapy, or a combination of these modalities. Each treatment type may have a negative impact on posttreatment swallowing function; these effects are presented in this article. A number of rehabilitative procedures are available to the clinician to reduce or eliminate swallowing disorders in patients treated for cancer of the head and neck. The various procedures-including postures, maneuvers, modifications to bolus volume and viscosity, range-of-motion exercises, and strengthening exercises-and their efficacy in patients treated for head and neck cancer are discussed.

Superselective intra-arterial chemotherapy for advanced maxillary sinus cancer: an evaluation of arterial perfusion with computed tomographic arteriography and of tumor response

OBJECTIVE

The purpose of our study was to elucidate the relationship between arterial perfusion in advanced maxillary sinus cancer which was opacified by superselective intra-arterial computed tomographic arteriography (IA-CTA) and the tumor response to intra-arterial chemotherapy.

METHODS

Superselective IA-CTA was performed to identify the feeding arteries and their perfusion in advanced maxillary sinus cancer in 10 patients. Cisplatin was selectively infused into these feeding arteries, except for the internal carotid artery.

RESULTS

The results were assessed in 9 of the 10 patients, and a complete response was achieved in 5 patients in whom either the entire tumor, or most of the tumor, was perfused by the branches of the external carotid artery. In 4 patients with a partial response, the residual tumors were seen in the territory of the perfusion defect or in the perfusion territory of the internal carotid artery.

CONCLUSION

Superselective IA-CTA is a useful technique to correctly identify the intratumoral perfusion and to predict tumor response to the intra-arterial chemotherapy of advanced maxillary sinus cancer.

Intra-arterial chemotherapy less intensive than RADPLAT with concurrent radiotherapy for resectable advanced head and neck squamous cell carcinoma: a prospective study

OBJECTIVES

This study was designed to evaluate the efficacy and feasibility of our intra-arterial chemotherapy protocol with a lower amount and frequency of cisplatin delivery than in RADPLAT for the treatment of resectable advanced head and neck cancer.

METHODS

Fifty-one patients with advanced squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx, or larynx were included in this prospective study. The patients were treated with 3 courses of cisplatin (100 mg at 1 treatment, intra-arterial) and sodium thiosulfate (28 g at 1 treatment, intravenous) once every 2 weeks during concurrent radiotherapy (66 to 70 Gy, 2 Gy per fraction, daily for 5 days over 7 weeks). Nodal metastases larger than 3 cm in diameter were treated with an additional 50 mg of cisplatin. The patients with less than 50% tumor reduction after 40 Gy and 2 courses of chemotherapy were treated with surgery.

RESULTS

The protocol was completed for 49 patients. All living patients had a minimum follow-up period of 2 years. Including the 3 patients with salvage surgery, local disease-free control was achieved in 39 patients (80%). For 36 patients (73.5%), disease-free primary organs were preserved at 2 years after treatment. Locoregional disease-free control for 2 years was obtained for 38 patients (77.6%), in 30 of them without salvage surgery. The patients treated with surgery had an overall survival rate similar to that of the patients with a complete response (80% and 84.6%, respectively). The patients with a partial response had a worse prognosis (40%; p = .0069).

CONCLUSIONS

This treatment regimen is feasible and effective for advanced resectable head and neck cancer.

Ototoxicity in a Randomized Phase III Trial of Intra-Arterial Compared With Intravenous Cisplatin Chemoradiation in Patients With Locally Advanced Head and Neck Cancer

Purpose

Cisplatin concomitantly administered with radiotherapy is increasingly used in locally advanced head and neck squamous cell carcinoma. We aimed to compare the incidence of hearing loss between patients treated with intra-arterial high-dose cisplatin chemoradiation with sodium thiosulfate (CRT-IA) and intravenous high-dose cisplatin chemoradiation without sodium thiosulfate (CRT-IV).

Patients and Methods

We conducted a prospective analysis of hearing thresholds at low and (ultra-) high frequencies obtained before, during, and after treatment in 158 patients. Patients were randomly assigned for either CRT-IA (150 mg/m2, four courses) with sodium thiosulfate cisplatin neutralization or CRT-IV (100 mg/m2, three courses) without rescue. All patients received concomitant radiation therapy (RT; 70 Gy).

Results

CRT-IA resulted in approximately 10% less hearing loss at frequencies vital for speech perception, compared with CRT-IV (P < .001). In CRT-IA, fewer ears qualified for hearing aids (36% v 49%; P = .03). However, in both treatment arms, the incidence expressed in National Cancer Institute Common Terminology Criteria of Adverse Events (version 3) did not deviate (P > .14). Age, cumulative cisplatin dose, cumulative RT dose, and the considered frequency area determine the degree of hearing loss (P < .001). Cisplatin induced increasing hearing loss of 24% to 60% with increasing frequencies. RT induced hearing loss at speech frequencies of 9% to 12%.

Conclusion

Depending on the criteria used to assess hearing loss due to treatment, differences in ototoxicity between CRT-IA and CRT-IV were found in favor of CRT-IA. It is desirable to specify hearing loss criteria toward frequencies vital for speech perception, and to refine grading scales to reveal subtle and clinically relevant dissimilarities in ototoxicity between different treatment protocols.

Risk Factors of Ototoxicity After Cisplatin-Based Chemo-Irradiation in Patients With Locally Advanced Head-and-Neck Cancer: A Multivariate Analysis

PURPOSE

Cisplatin chemo-irradiation is increasingly used in locally advanced squamous cell carcinoma of the head and neck. The objective of this study is to determine risk factors of ototoxicity due to intra-arterial high-dose cisplatin chemoradiation.

METHODS AND MATERIALS

A prospective analysis of hearing thresholds at low and (ultra) high frequencies obtained before, during, and after treatment in 146 patients. Treatment consisted of intra-arterial infusion of high-dose cisplatin (150 mg/m(2), four courses) with sodium thiosulfate rescue and concurrent radiation therapy (70 Gy). Patient and chemoradiation variables were studied in a multivariate analysis.

RESULTS

After treatment, 23% of the ears were under consideration for hearing aids because of therapy. Twenty-two percent of the patients developed an increase in air-bone gap >10 dB during or after therapy. In the multivariate explanatory analysis, cumulative dose of cisplatin and radiation therapy, and young age displayed a causal relationship with increased sensorineural hearing loss during and after therapy (p < 0.001). In the multivariate prediction analysis, pretreatment hearing level of the concerning ear was identified as an independent predictive factor for hearing capability after therapy (p < 0.0001).

CONCLUSIONS

Both cisplatin and radiation therapy were proven to induce sensorineural hearing loss, in this study with short-term follow-up. Of all patient and treatment variables studied, the patients pretreatment hearing level appeared to be the main predictive factor for hearing capability after high-dose intra-arterial cisplatin chemoradiation.

Combined therapy after superselective arterial cisplatin infusion to treat maxillary squamous cell carcinoma

OBJECTIVE

We sought to assess the efficacy of combined therapy after superselective arterial cisplatin infusion (SACI) therapy to treat the maxillary squamous cell carcinoma.

STUDY DESIGN

We conducted a retrospective chart review of 50 patients. After completion of two courses of SACI, 25 of the patients were successively treated by concurrent SACI and radiotherapy (AR), while the other 25 patients were treated by surgery with postoperative radiotherapy (ASR).

RESULTS

Patients with surgery (ASR) had an 88% local control rate with 75% disease-free survival rate at 60 months by Kaplan-Meier analysis, compared with 62% disease-free survival rate for patients with AR treatment. A particularly good outcome was obtained in T4 cases of the ASR group (n=8) whose 5-year survival rate was 87% and local control rate was 100%.

CONCLUSION/SIGNIFICANCE

Combined SACI therapy is very effective for the treatment of maxillary squamous cell carcinomas and contributes to the improving prognoses of patients and organ preservation rates.

Relationship between swallow motility disorders on videofluorography and oral intake in patients treated for head and neck cancer with radiotherapy with or without chemotherapy

BACKGROUND

Current research demonstrates that swallow function is impaired after treatment with organ-sparing chemoradiotherapy. Few studies, however, have related observed swallowing disorders with the patient's oral intake and diet in a large cohort of patients.

METHODS

Swallowing function was examined using the modified barium swallow (MBS) procedure in 170 patients treated with radiotherapy with or without chemotherapy for cancer of the head and neck at 5 evaluation points: pretreatment and at 1, 3, 6, and 12 months posttreatment. Fisher's exact test was used to examine the relationship between swallow motility disorders and oral intake or diet consistencies.

RESULTS

Limitations in oral intake and diet during the first year after cancer treatment were significantly related to reduced laryngeal elevation, reduced cricopharyngeal opening, and rating of nonfunctional swallow on at least 1 swallow of any bolus type.

CONCLUSIONS

Swallow motility disorders had a significant impact on the eating ability of patients after treatment for head and neck cancer with radiotherapy with or without chemotherapy.

RADPLAT: an alternative to surgery?

Head and neck cancer frequently presents at a late stage, leading to a poor prognosis despite optimal treatment with surgery and/or radiotherapy. Chemotherapy for advanced disease has shown little benefit as a single-modality treatment, and the use of concurrent chemoradiation is limited by problems with severe toxicity at higher doses. RADPLAT is the acronym used to describe a new technique, combining intra-arterial delivery of cisplatin with systemic neutralization by i.v. sodium thiosulphate, and concurrent radiotherapy. This allows very high cisplatin dose intensities to be used while potentially minimizing adverse systemic effects. Initial results suggest that excellent locoregional control rates are achievable in patients with unresectable disease, with a favorable side-effect profile when compared with conventional chemoradiation protocols. In addition, RADPLAT may potentially be of benefit in selected patients with resectable disease, allowing for preservation of organ function and quality of life without compromising locoregional control or survival. While current phase II data are encouraging, phase III randomized controlled trials are required in order to directly compare RADPLAT with i.v. chemoradiation therapy, the current standard of care. This article reviews the evolution of the RADPLAT concept, from initial clinical trials to its current application in the treatment of patients with advanced head and neck cancer.

Preclinical efficacy and pharmacokinetics of AP5346, a novel diaminocyclohexane-platinum tumor-targeting drug delivery system

PURPOSE

AP5346 is designed to target a diaminocyclohexane platinum (Pt) moiety to tumors through pH-sensitive linkage to a 25 kDa hydroxypropylmethacrylamide polymer. The goal of these studies was to determine the rate of release of Pt as a function of pH, the antitumor activity, and plasma and tumor pharmacokinetics of AP5346 in preclinical models.

EXPERIMENTAL DESIGN

Antitumor activity was assessed in mice bearing B16F10 melanoma and M5076 and 2008 ovarian carcinomas. Pt levels in plasma, tumors, and tumor DNA were measured by atomic absorption and inductively coupled plasma mass spectrometry.

RESULTS

AP5346 did not release Pt when suspended in 5% dextrose and released only 3.5% of its Pt in 24 hours in buffer at pH 7.4; the rate of release was 7-fold higher at pH 5.4. When given at their respective maximum tolerated doses, the antitumor activity of AP5346 was superior to that of oxaliplatin against both the B16 melanoma and 2008 human ovarian carcinoma. It was more effective than cisplatin in both cisplatin-sensitive and cisplatin-resistant variants of the M5076 tumor. When given at equitoxic doses, the peak plasma concentration was 25-fold higher, and AUC((0-infinity)) was 93 times higher, for AP5346 than for oxaliplatin. AP5346 delivered 16.3-fold more Pt to the tumor and 14.2-fold more Pt to tumor DNA than oxaliplatin based on AUC((1-168)).

CONCLUSIONS

AP5346 has a substantially better therapeutic index than oxaliplatin. AP5346 produced a marked increase in the delivery of diaminocyclohexane Pt to the tumor and tumor DNA over and above that attainable with oxaliplatin.