Local control of T3 carcinomas after accelerated fractionation: a look at the "gap"

Hyperfractionated Radiotherapy for T2N0 Glottic Carcinoma: A Retrospective Analysis at 10 Years Follow-up in a Series of 60 Consecutive Patients

Aims and background

To report results of hyperfractionated radiotherapy for T2N0 glottic carcinoma at a single institution after extended follow-up.

Methods

Between 1980 and 1988 at Varese University Hospital, 60 consecutive patients with T2N0 glottic carcinoma received exclusive radiotherapy consisting of 1.5 Gy/fraction twice a day. Treatment gaps during the radiotherapy course were allowed according to individual tolerance. This policy resulted in a wide range of elapsed treatment time: median, 5.7 weeks; range, 3.7-8.9. Median follow-up is 9.8 years.

Results

As a result of dose/time distribution, 16, 20 and 24 patients received an average weekly dose rate of <10 Gy/week, equal to 10 Gy/week or >10 Gy/week, respectively. Mean total dose for each group was 62.8 Gy, 63.7 Gy and 63.8 Gy, respectively. Five-year local-regional control was 69 ± 6% (95% Cl); ultimate local-regional control, including salvage surgery, was 78 ± 5%. All failures were at the primary site, and no patient developed neck recurrence as first site of failure. The actuarial incidence of grade 2-3 late reactions at 5 years was 42 ± 6%. Most late toxicity events were grade 2: only 2 patients developed grade 3 reactions and none grade 4. None of the several clinical and treatment-related variables showed any statistically significant impact on local-regional control or late toxicity at univariate and multivariate analysis. In particular, 3-year local-regional control rates were 73 ± 11%, 84 ± 8% and 69 ± 10% for an average weekly dose rate of <10 Gy/week, equal to 10 Gy/week and >10 Gy/week, respectively (not significantly different).

Conclusions

At a very long follow-up, the hyperfractionated regimen tested in the study was shown to be effective and devoid of major complications, provided individual patient acute tolerance is carefully taken into account. Also, time factor did not affect outcome in this series.

Randomized Trials on Altered Fractionation in Head and Neck Cancer Radiotherapy with Conventional Fractionation as Control Arm: Another Lap to Go

The Authors present a review of randomized trials on non conventional fractionation in head and neck cancer radiotherapy with conventional fractionation as control arm. Hyperfractionation was studied in 5 trials, accelerated hyperfractionation in 4 trials and accelerated fractionation in 3 trials. Furthermore, the reviews of eminent Authors dealing with the above mentioned trials are summarized. In spite of improved local control rate reported with hyperfractionation, non conventional radiotherapy schedules are not yet recommended as routine clinical practice, but all the radiation oncologists are invited to join trials on this subject.

Nonstandard Fractionation Schedules in Radiation Therapy of Head and Neck Cancer: A Review

The authors present an updated review of the clinical trials on hyperfractionated and accelerated fractionation schedules in radiotherapy of head and neck cancer. The available results in terms of survival and local control, and acute and late toxicity data are summarized in order to show the current status of this research field. The new breed of fractionation schedules that are on study, designed on the ground of new rationales, are presented as well. Finally, an introductory overview of combination therapy including non standard fractionation radiotherapy associated with chemotherapy is reported70.

Concurrent hyperfractionated chemoradiotherapy for head and neck squamous cell carcinoma: the prognostic impact of the overall treatment time and completion rates of chemotherapy

The purpose of this study was to investigate whether the overall treatment time and completion rates of chemotherapy were predictive factors for the survival rates in patients with squamous cell carcinoma of the head and neck (SCCHN) who were treated with concurrent chemoradiotherapy (CCRT) using hyperfractionated radiotherapy (RT) and daily carboplatin. The number of intermission days of RT were as follows; 0 (n = 37), 1–5 (n = 8), 6–10 (n = 12) and ≥11 (n = 12), and the days of RT without carboplatin; 0 (n = 27), 1–5 (n = 13), 6–10 (n = 13) and ≥7 (n = 16). The overall treatment time (≤48 vs ≥49 days) was a significant prognostic factor for the local control, disease-free survival and overall survival rates. The completion rate of chemotherapy, as the number of days of RT without carboplatin, was not a significant factor affecting any of the survival rates. In discussion, the strengths of the present study contain that all the patients were treated with 72 Gy delivered as 1.2 Gy twice daily, and received concurrent chemotherapy comprising daily carboplatin as a radio-sensitizer. Based on the results, the completion rate of chemotherapy may have a lower impact on the local control rate in comparison with the overall treatment time. We believe that when a treatment interruption is needed because of the acute toxicities, hyperfractionated RT should be resumed as soon as possible independently while continuing the break of daily carboplatin. The overall treatment time influenced the clinical outcomes in SCCHN patients treated with hyperfractionated CCRT using carboplatin, while the impact of the completion rates of daily carboplatin was limited. Sixty-nine consecutive patients with SCCHN were initially treated with definitive CCRT and were retrospectively analyzed. All 69 patients were treated with CCRT using hyperfractionated RT of 72 Gy in 60 fractions and daily carboplatin (25 mg/m²). The patients treated with other chemotherapeutic regimens or induction chemotherapy were excluded. On the intermission days of the RT, carboplatin was not prescribed. After the intermission, CCRT using RT plus daily carboplatin or RT alone was resumed.

Clinical and biological factors affecting response to radiotherapy in patients with head and neck cancer: a review

OBJECTIVE

The main aim of this article was to review the clinical and biological factors that have been shown to influence the response of the head and neck squamous cell carcinoma (HNSCC) to primary radiotherapy and briefly discuss how some of these factors could be exploited to improve outcome.

DESIGN

Medline based search covering 1982-2006 to identify the HNSCC literature where the effect of clinical and biological factors on locoregional control and overall survival were investigated.

RESULTS

Clinical factors are routinely used in management decisions. Nevertheless, identically staged tumours receiving the same treatment may have different outcomes. Biological factors such as hypoxia, proliferation and radio-sensitivity play an important role in radiation response. However, these are not currently used in practise because tests that are clinically reliable and feasible are not available.

CONCLUSION

High-quality translational research will allow us to develop biological tests that can be used in routine clinical practise to tailor individual treatment, with the ability to improve patient outcome further by modifying the underlying tumour biology.

Patients with moderate chemotherapy-induced mucositis: pain therapy using low intensity lasers

BACKGROUND

Intensive cancer therapy normally affects malignant and normal cells with high replication rates. Cells in the gastrointestinal tract are therefore commonly affected by cytotoxins. This often results in the development of chemotherapy-induced oral mucositis (COM). COM is the inflammatory response of the oral mucous membrane to the chemotherapy drugs. Low level laser therapy (LLLT) has proved to be effective in treating and repairing biologically damaged tissue and to reduce pain. LLLT has also proven to be an efficient method for the prevention of oral mucositis.

OBJECTIVE

To investigate the effect of LLLT on pain relief among patients who have developed COM.

METHOD

The study was performed as a clinical test with a sample consisting of 13 adult patients receiving oncology treatment. The patients were treated during a 5-day period, and the pain was measured before and after each laser application. The laser used was an AsGaAl, with a wavelength of 830 nm and a potency of 250 mW. The energy given was 35 J cm(-2).

ANALYSIS

The results were analysed using the Wilcoxon test.

RESULTS

There was a significant (P = 0.007) 67% decrease in the daily average experience of pain felt before and after each treatment, confirming that LLLT can relieve pain among patients who have developed COM.

STUDY LIMITATIONS

The low number of COM patients at the hospital did not allow a control group to be included in the study, and therefore the results contain a potential placebo effect. IMPLICATIONS FOR NURSING CARE: The most important benefit the authors consider to be the value for the patients of better and quicker treatment with a drastic reduction in painful mucositis.

Compliance to the prescribed dose and overall treatment time in five randomized clinical trials of altered fractionation in radiotherapy for head-and-neck carcinomas

PURPOSE

To investigate compliance to the prescribed dose-fractionation schedule in five randomized controlled trials of altered fractionation in radiotherapy for head-and-neck carcinoma.

METHODS AND MATERIALS

Individual patient data from 2566 patients participating in the European Organization for Research and Treatment of Cancer (EORTC) 22791, EORTC 22811, EORTC 22851, Princess Margaret Hospital (PMH), and continuous hyperfractionated accelerated radiotherapy (CHART) head-and-neck trials were merged in the fractionation IMPACT (Intergroup Merger of Patient data from Altered or Conventional Treatment schedules) study database. The ideal treatment time was defined as the minimum time required to deliver a prescribed schedule. Compliance to the prescribed overall treatment time was quantified as the difference between the actual and the ideal overall time. An overall measure of compliance in an individual patient, the total dose lost (TDL), was calculated as the dose lost due to prolongation of therapy (assuming a D(prolif) of 0.64 Gy/day) plus the difference between the prescribed and the actual dose given.

RESULTS

The time in excess of the ideal ranged up to 97 days (average 3.9 days), and 25% of the patients had delays of 6 days or more. World Health Organization (WHO) performance status and nodal stage had a significant effect on TDL. TDL was significantly higher in the conventional than in the altered arm of the EORTC 22851 and CHART trials. In the PMH trial, TDL was significantly higher in the hyperfractionation than in the conventional arm. Centers participating in the three EORTC trials varied significantly in their compliance. There was a significant improvement in compliance in patients treated more recently.

CONCLUSIONS

Even in randomized controlled trials, compliance to the prescribed radiation therapy schedule may be relatively poor, especially after conventional fractionation. This affects the interpretation of the outcome of these trials.

Accelerated hyperfractionated irradiation for advanced head and neck cancer: effect of shortening the median treatment duration by 13 days

BACKGROUND AND PURPOSE

Optimal treatment duration of altered fractionation schedules in head and neck cancer is still undefined. A retrospective study on local tumor control, survival, and complications of accelerated hyperfractionated irradiation in head and neck cancer was undertaken to investigate whether there was an advantage in further shortening overall time from 6.5 weeks.

METHODS

Four hundred nineteen consecutive male patients treated with radiation alone for cure 1987-1998 were analyzed. Patients with stage I, or treated also with brachytherapy implants or chemotherapy, were excluded. Treatment with accelerated hyperfractionation was performed twice daily, at a median of 1.6 Gy/fraction, to a total median dose of 68 Gy in 39 days. The patient population was divided into two groups: those with < or =39 days overall treatment time (group A, n = 227; median, 33 days) and those with >39 days (group B, n = 192; median, 46 days). Group A received a significant median tumor dose reduction of 7% compared with group B.

RESULTS

The 7-year actuarial local control (LC) rates were 59% and 48% for groups A and B, respectively (p =.02). The actuarial LC rates for T1-2 patients were 79% and 74% at 7 years for groups A and B, respectively (p = NS). Similarly, for T3-4 patients, they were 47% and 35% (p =.02), respectively. The 7-year actuarial disease-free survival (DFS) rates for groups A and B were 39% and 26% (p =.01), respectively. For stage II patients, DFS was 62% and 60% at 7 years (p = NS) for groups A and B, respectively. And similarly, for stage III-IV patients, DFS was 33% and 20% (p =.04), respectively, at 7 years. LC and DFS rates at 7 years for T4 and stage IV patients, respectively, were significantly improved in group A. Cox regression analyses for LC showed that both T stage and overall time were significant prognostic factors. Similarly, UICC clinical stage and overall time were significant prognostic factors for DFS. There was no difference in acute morbidity between the two groups: 3% of patients in both groups required tube or parenteral feeding. The 7-year actuarial probability of RTOG/EORTC grades 3-5 late effects was 15% and 13%, respectively, for each group (p = NS).

CONCLUSIONS

This study, with the limitations of a retrospective study, has shown a significant improvement in local tumor control and disease-free survival, in patients treated with shorter overall treatment times (median, 33 days) with an accelerated hyperfractionated irradiation schedule compared with those treated with a median duration of 46 days. No significant enhancement of acute reactions and late morbidity were observed with the shorter schedule.

Altered fractionation in the treatment of head and neck cancer

Several altered fractionation schemes have evolved to exploit different aspects of head and neck cancer growth kinetics and normal tissue repair. Hyperfractionation schedules exploit the differential repair abilities of tumor and normal tissue, whereas accelerated fractionation regimens minimize the time of tumor repopulation. Significant clinical data have accumulated that indicate an improvement between 15% and 20% in locoregional control from altered fractionation. Preliminary analysis of a randomized Radiation Therapy Oncology Group trial testing four fractionation schemes confirms the benefit of one altered fractionation approach. Several promising concurrent chemoradiation treatments involving altered fractionation have been reported. Future trials will determine whether the addition of chemotherapy to altered fractionation schemes is warranted in light of the factor of added toxicity.

Treatment of upper aerodigestive tract cancers in England and its effect on survival

The evidence base for head and neck cancers is low with relatively few randomized controlled trials of the two main treatments, surgery and radiotherapy. The aim of the study was to investigate the patterns of surgery and radiotherapy treatment for head and neck cancers in three large areas of England and to investigate their effects on survival. This was a retrospective study of 13510 cases of head and neck cancers (ICD10: C00-C14, C30-C32) diagnosed and treated from 1984 to 1992 in England. We undertook multivariate analyses of survival using a step-wise Cox proportional hazard model and Kaplan-Meier analysis. There were regional variations in the treatments given to patients. Four in ten patients did not receive currently recommended treatments. In multivariate analyses treatment content and timing had an independent effect on survival. Better survival was associated with surgery for mouth cancers, radiotherapy for laryngeal cancers and combined treatment for pharyngeal cancers independent of tumour and demographic factors. Further research is needed to investigate the findings of this study through large randomized controlled trials and multi-centre audits.

Phase I/II trial of radiation with chemotherapy "boost" for advanced squamous cell carcinomas of the head and neck: toxicities and responses

PURPOSE

Extrapolating from our experience delivering a "boost" field of radiation concurrently with fields treating both gross and subclinical disease at the end of a course of radiation therapy, we developed a regimen to deliver concurrent chemotherapy during the last 2 weeks of a conventionally fractionated course of radiation.

PATIENTS AND METHODS

Patients had stage III or IV biopsy-proven squamous cell carcinoma originating from a head and neck mucosal site. The regimen was 70 Gy delivered over 7 weeks with concurrent fluorouracil (5-FU) and cisplatin given daily with each radiation dose during the last 2 weeks. A phase I study was performed to determine the maximum-tolerated dose (MTD) before a phase II study was conducted.

RESULTS

The MTD was 400 mg/m(2) per day for 5-FU and 10 mg/m(2) per day for cisplatin. Mucositis persisting more than 6 weeks after therapy was the dose-limiting toxicity. A total of 60 patients were treated on the two phases of the study. Eighteen patients (35%) treated at the MTD developed prolonged mucositis. There were two cases of neutropenic sepsis, including one fatality. The actuarial 2-year rates for overall survival, freedom from relapse, and local control were 62%, 59%, and 80%, respectively.

CONCLUSION

Preliminary locoregional control rates seem to be higher than those reported for treatment with radiation alone. Toxicity was also greater than that seen with radiation alone, but the regimen was designed to deliver an intense treatment schedule, which could be completed without significant interruptions, and to obtain high control rates above the clavicles. These end points were achieved.

Accounting for treatment delays when treating highly proliferative tumours

This study was undertaken to investigate the possibility of increasing the dose per fraction or increasing the number of fractions to account for treatment delays occurring during radiotherapy treatments for highly proliferative tumours. The linear quadratic model with time was used to determine the difference in biological effective dose (BED) for the original schedule and the schedule including a treatment delay. Tables of extra fractions and extra dose per fraction required to account for a number of possible delays have been determined. It has been shown that for tumours with very short potential doubling times it is best to deliver the extra dose as an increase in dose per fraction rather than an increase in the number of fractions, while for tumours with moderately short potential doubling times (above 7 days) the reverse is true. The equivalent uninterrupted schedules, which would have delivered the same effects to the tumour, have also been determined.

Split-course accelerated hyperfractionation radiotherapy for advanced head and neck cancer: influence of split time and overall treatment time on local control

We analyzed 52 patients with stage III and IV head and neck cancer who were given split-course accelerated hyperfractionated radiotherapy with curative intent, focusing particularly on the influence of split-time on local control. An initial complete response was achieved in 16 patients (31%), and the rate of persistent local control at 3 years was 23%. The cause specific survival rate at 3 years was 29%. Univariate analysis of local control according to the split-time duration and overall treatment time showed that shorter duration (< or = 14 days or < or = 45 days, respectively) had a significantly positive impact on local control (P < 0.05). Multivariate analysis using local control as an endpoint also demonstrated that gender (women showing a better outcome than men) and split-time (< or = 14 days was better than > 14 days) were statistically significant factors for local control. These results suggest that shortening the split-time during radiotherapy might improve local control in accelerated hyperfractionation.