Five compared with six fractions per week of conventional radiotherapy of squamous-cell carcinoma of head and neck: DAHANCA 6 and 7 randomised controlled trial

Radiotherapy for early glottic carcinoma (T1N0M0): results of prospective randomized study of radiation fraction size and overall treatment time

PURPOSE

To investigate in a prospective randomized study the effect of radiation fraction size and overall treatment time on the local control of early glottic carcinoma.

METHODS AND MATERIALS

Between December 1993 and December 2001, 180 patients with early glottic carcinoma (T1N0M0) were treated at our department. The patients were randomly allocated to either treatment arm A (radiation fraction size 2 Gy, n = 89) or B (2.25 Gy, n = 91). The total radiation dose administered was 60 Gy in 30 fraction within 6 weeks for minimal tumors (two-thirds of the vocal cord or less) or 66 Gy in 33 fractions in 6.6 weeks for larger than minimal tumors (more than two-thirds of the vocal cord) in Arm A and 56.25 Gy in 25 fractions within 5 weeks for minimal tumor or 63 Gy in 28 fractions within 5.6 weeks for larger than minimal tumors in Arm B.

RESULTS

The 5-year local control rate was 77% for Arm A and 92% for Arm B (p = 0.004). The corresponding 5-year cause-specific survival rates were 97% and 100% (no significant difference). No significant differences were found between these two arms in terms of rates of acute mucosal reaction, skin reactions, or chronic adverse reactions.

CONCLUSION

Use of 2.25-Gy fractions with a shorter overall treatment time for Arm B showed superior local control compared with conventional use of 2-Gy fractions for Arm A without adverse reactions from the greater fraction.

Phase I and initial phase II results from a trial investigating weekly docetaxel and carboplatin given neoadjuvantly and then concurrently with concomitant boost radiotherapy for locally advanced squamous cell carcinoma of the head and neck

BACKGROUND

The current Phase I/II study assessed induction docetaxel/carboplatin given weekly for 4 weeks, followed by weekly docetaxel/carboplatin and concomitant boost radiotherapy (CB-XRT) for locally advanced head and neck squamous cell carcinoma.

METHODS

Twenty patients with Stage III or IV (M0) disease of the oropharynx, supraglottic larynx, or hypopharynx were enrolled. Patients initially received docetaxel 20 mg/m2 and carboplatin area under the curve (AUC) 2 weekly x 4. Patients with stable (SD) or responding disease subsequently received dose-escalated docetaxel (10-20 mg/m2 in sequential patient cohorts) and carboplatin AUC 1 weekly x 5 with CB-XRT (1.8 gray [Gy] every day x 15 days, followed by 1.8/1.5 Gy twice per day x 13 days).

RESULTS

All patients were evaluable, and 15 patients (5 patients with Stage III disease, 10 patients with Stage IV disease) completed all planned therapy. The target docetaxel dose level of 20 mg/m(2) weekly with radiotherapy was achieved with no dose-limiting toxicities. The most frequent maximum toxicities during chemoradiotherapy were Grade 3 mucositis, dysphagia, and/or pain. Primary site responses after induction included 4 patients with partial responses, 11 patients with SD, and 5 patients with disease progression. Fifteen patients (75%) continued to receive chemoradiotherapy, with 14 patients attaining a complete response (CR). Overall, a clinicopathologic neck CR after chemoradiotherapy was achieved in 9 of 10 patients. One patient had persistent primary disease and underwent salvage surgery, whereas another died of unrelated causes before neck assessment. Thirteen patients remain free of any disease event, with a median follow-up of 15 months (range, 3-29 months).

CONCLUSIONS

This regimen was feasible, safe, and particularly well tolerated. Early Phase II outcomes revealed promising activity in patients completing all treatment. Initial induction response results suggested that further investigation of this regimen with more aggressive induction therapy is warranted.

The possible role of TP53 mutation status in the treatment of squamous cell carcinomas of the head and neck (HNSCC) with radiotherapy with different overall treatment times

BACKGROUND AND PURPOSE

TP53-mutations have been shown to influence the radiosensitivity of HNSCC. Furthermore, HNSCC with mutated TP53, may have a higher proliferative potential caused by a lack of control in G1 checkpoint. Our aim of the study was to identify the role of TP53 mutations for the outcome of radiotherapy.

PATIENTS AND METHODS

DNA extracted from 180 paraffin-embedded formalin-fixed pretreatment biopsies of HNSCC was screened for mutations in exon 4C-10 by denaturing high-pressure liquid chromatography (DHPLC) followed by sequencing. Treatment was 66-68Gy, 2Gy/fx with overall treatment times of 6.5 and 5.5 weeks according to the DAHANCA-guidelines. Endpoints were local control at T-site, disease-specific and crude survival.

RESULTS

125 of 180 carcinomas (69%) carried in total 176 mutations. 72 carcinomas were WT (40%) and 108 carcinomas (60%) carried mutations giving dysfunctional p53. Overall, mutations in TP53 were not associated with the endpoints. However, when dichotomising according to TP53 status and evaluating the effect of the overall treatment time then tumours with mutant TP53 did benefit from 6 instead of 5fx/wk regarding local control, P=0.005; RR: 0.33 (C.I 95%:0.15-0.75) whereas WT-tumours did not (P=0.9). These observations were also reflected in the disease-specific and crude survival.

CONCLUSIONS

If all patients were considered regardless of treatment schedule, then TP53-mutations were not related to local control or survival. However, mutations in TP53 may be associated with HNSCC that benefit of a reduced overall treatment time of radiotherapy.

Repopulation of cancer cells during therapy: an important cause of treatment failure

Radiotherapy and chemotherapy are given in multiple doses, which are spaced out to allow the recovery of normal tissues between treatments. However, surviving cancer cells also proliferate during the intervals between treatments and this process of repopulation is an important cause of treatment failure. Strategies developed to overcome repopulation have improved clinical outcomes, and now new strategies to inhibit repopulation are emerging in parallel with advances in the understanding of underlying biological mechanisms.

The influence of epidermal growth factor receptor and tumor differentiation on the response to accelerated radiotherapy of squamous cell carcinomas of the head and neck in the randomized DAHANCA 6 and 7 study

BACKGROUND AND PURPOSE

Reduction of the overall treatment time of radiotherapy has increased locoregional control and disease specific survival in squamous cell carcinomas of the head and neck (HNSCC), but the response is heterogeneous. EGFr is often overexpressed in HNSCC and has been related to the repopulation taking place during radiotherapy. The aim of the current study was to address the influence of EGFr and histopathological differentiation when the overall treatment time of radiotherapy was moderately reduced.

PATIENTS AND METHODS

Eight hundred and three patients with representative pretreatment tissue samples from the randomized DAHANCA 6 and 7 study of 5 vs. 6 fx/wk of radiotherapy. EGFr was visualized using immunohistochemistry and separated into high and low expression before correlation with clinical data.

RESULTS

Tumors with high EGFr (84%) responded better to moderately accelerated radiotherapy, than carcinomas with low EGFr, using locoregional control as endpoint and a similar pattern was seen, stratifying by well/moderate vs. poor tumor differentiation. Therefore, a combined parameter was constructed showing a more prominent separation of response: tumors with high EGFr and well/moderate differentiation did benefit from moderate acceleration of treatment regarding locoregional control, HR 0.54 (0.37-0.78), whereas such an effect was not seen in tumors with low EGFr and/or poor differentiation, HR 0.8 (0.51-1.25). These results reflected the disease specific survival as well and were confirmed in multivariable analyses.

CONCLUSIONS

Moderately accelerated fractionation is superior to conventional treatment in HNSCC but the response is heterogeneous and may be predicted by high expression of EGFr and well/moderate tumor differentiation.

The role of epidermal growth factor receptor and E-cadherin for the outcome of reduction in the overall treatment time of radiotherapy of supraglottic larynx squamous cell carcinoma

Reduction of the overall treatment time (OTT) of radiotherapy results in increased T-site control in squamous cell carcinomas of the head and neck (HNSCC). However, the response is heterogeneous and accelerated repopulation of clonogenic tumour cells during therapy may be one of the factors determining this response. The aim of the present study was to identify the influence of the epidermal growth factor receptor (EGFr) and E-cadherin for T-site control when the OTT was reduced and whether the markers add information to the histopathological grading in selecting patients for accelerated radiotherapy. A total of 209 patients from randomized DAHANCA-trials with supraglottic larynx squamous cell carcinomas treated with primary radiotherapy with different OTT of 9(1/2), 6(1/2), and 5(1/2) weeks. Available formalin-fixed paraffin embedded tumour tissues were re-evaluated for histopathological characteristics and stained for EGFr and E-cadherin. Data were correlated with patient and tumour characteristics and 5-year T-site control. EGFr and E-cadherin were not associated with patient or tumour characteristics except that EGFr correlated to carcinomas with a well to moderate histopathological feature. Tumours with high EGFr or low E-cadherin did benefit from reduced OTT, and the combination of the two (high EGFr and low E-cadherin) had the most significant acceleration of treatment effect, compared with tumours with other combinations of EGFr and E-cadherin expression. Tumours with high expression of EGFr and low expression of E-cadherin showed the most significant increase in T-site control when the overall treatment time of radiotherapy was reduced, and the markers may be useful for selecting patients who will benefit from accelerated radiotherapy.

Why to start the concomitant boost in accelerated radiotherapy for advanced laryngeal cancer in week 3

PURPOSE

We analyzed toxicity and the local control rates for advanced laryngeal cancer, treated with two accelerated fractionation schedules. The main difference between the schedules was the onset of the concomitant boost, in Week 3 or Week 4. Overall treatment time and total dose were equivalent.

METHODS AND MATERIALS

In a prospective, nonrandomized study of T3, T4, and advanced T2 laryngeal cancer, concomitant boost schedules were used in 100 patients. Thirty patients received a schedule of twice daily 1.2 Gy in Weeks 1-3, followed by twice daily 1.7 Gy in Weeks 4 and 5; total dose was 70 Gy (the hyperfractionated accelerated schedule [HAS] regimen). Seventy patients were treated with 5 times 2 Gy in Weeks 1 and 2, followed by daily 1.8 Gy and 1.5 Gy (boost) in Weeks 3-5; total dose 69.5 Gy (the accelerated schedule only [ASO] regimen). Distribution of T stage was 47%, 40%, and 12% for T2, T3, and T4, respectively. In 24% of the patients, lymph nodes were positive. Pretreatment tracheotomy or stridor or both occurred in 8 patients. The distribution of prognostic factors was not significantly different between the two fractionation schedules. Acute and late toxicity was assessed. Results were estimated by the use of actuarial methods. For late toxicity and local control univariate and multivariate analyses were performed. Tumor control probability analysis was used to model cure rate differences.

RESULTS

Overall acute mucositis score was equal for both schedules. Acute mucositis started and decreased significantly earlier in the HAS regimen. In all patients acute mucositis healed completely. The treatment was completed within 38 days in all patients. The regional control rate was 100% for clinical N0, and 75% for the clinical N+ patients. The 3-year local control rate was 59% and 78% for the HAS and ASO regimens, respectively (p = 0.05); the ultimate local control was 80% and 94%, respectively. In multivariate analysis, besides the fractionation schedule (relative risk [RR], 2.6 for HAS vs. ASO), pretreatment tracheotomy/stridor (RR 4.3, yes vs. no), and local tumor response 3-6 weeks after radiotherapy (RR 5.1, no vs. yes) were independent factors for local control. Tumor control probability analysis indicated that the onset of repopulation may be about 4-6 days earlier for the HAS regimen. The onset of repopulation in the HAS regimen is probably at the end of the second week or at the beginning of the third week. Severe late toxicity was observed in the HAS group and ASO group in, respectively, 11% and 16%. In multivariate analysis this toxicity related significantly to the field size and pretreatment tracheotomy/stridor.

CONCLUSIONS

In our study the timing of the boost in accelerated radiotherapy for advanced laryngeal cancer was an independent factor for local control, favoring the use of a concomitant boost in Week 3. This finding may indicate that accelerated repopulation of tumor cells starts early in the treatment phase.

Accelerated versus conventional fractionated postoperative radiotherapy for advanced head and neck cancer: results of a multicenter Phase III study

PURPOSE

To determine whether, in the postoperative setting, accelerated fractionation (AF) radiotherapy (RT) yields a superior locoregional control rate compared with conventional fractionation (CF) RT in locally advanced squamous cell carcinomas of the oral cavity, oropharynx, larynx, or hypopharynx.

METHODS AND MATERIALS

Patients from four institutions with one or more high-risk features (pT4, positive resection margins, pN >1, perineural/lymphovascular invasion, extracapsular extension, subglottic extension) after surgery were randomly assigned to either RT with one daily session of 2 Gy up to 60 Gy in 6 weeks or AF. Accelerated fractionation consisted of a "biphasic concomitant boost" schedule, with the boost delivered during the first and last weeks of treatment, to deliver 64 Gy in 5 weeks. Informed consent was obtained. The primary endpoint of the study was locoregional control. Analysis was on an intention-to-treat basis.

RESULTS

From March 1994 to August 2000, 226 patients were randomized. At a median follow-up of 30.6 months (range, 0-110 months), 2-year locoregional control estimates were 80% +/- 4% for CF and 78% +/- 5% for AF (p = 0.52), and 2-year overall survival estimates were 67% +/- 5% for CF and 64% +/- 5% for AF (p = 0.84). The lack of difference in outcome between the two treatment arms was confirmed by multivariate analysis. However, interaction analysis with median values as cut-offs showed a trend for improved locoregional control for those patients who had a delay in starting RT and who were treated with AF compared with those with a similar delay but who were treated with CF (hazard ratio = 0.5, 95% confidence interval 0.2-1.1). Fifty percent of patients treated with AF developed confluent mucositis, compared with only 27% of those treated with CF (p = 0.006). However, mucositis duration was not different between arms. Although preliminary, actuarial Grade 3+ late toxicity estimates at 2 years were 18% +/- 4% and 27% +/- 6% for CF and AF, respectively (p = 0.10).

CONCLUSION

Accelerated fractionation does not seem to be worthwhile for squamous cell carcinoma of the head and neck after resection; however, AF might be an option for patients who delay starting RT.

Evaluating adherence to the Dutch guideline for diagnosis, treatment and follow-up of laryngeal carcinomas

BACKGROUND AND PURPOSE

An evidence-based clinical practice guideline for laryngeal carcinomas was introduced in the Netherlands late 1999. The objective of this guideline was to ensure uniformity in the diagnosis, treatment, and follow-up. We retrospectively evaluated whether clinical practice changed according to the recommendations of this guideline and whether it succeeded in its aim.

MATERIAL AND METHODS

In five out of eight Dutch university hospitals, chart data of 459 patients treated before the guideline introduction were compared to data of 363 patients treated after the guideline introduction.

RESULTS

Patient and tumour characteristics were comparable among both groups. In general, the guideline recommendations were properly complied with. The patients treated before the guideline introduction were actually also for a large part already treated according to the guideline's recommendations. After its introduction, several changes according to the guideline were observed: increased rates of reassessment of biopsy samples taken in local hospitals, psychological screening (although still only performed in 10.5% of patients), application of accelerated radiotherapy schedules, clinical trial treatments, function-preserving treatments, and decreased rates of total laryngectomy, and annual chest X-rays during follow-up.

CONCLUSIONS

Although a causal relationship cannot be established in this kind of observational studies, several positive changes were observed after the introduction of the guideline, and therefore the guideline seems to have contributed to more uniformity. The largest changes were seen for the guideline recommendations based on the highest levels of evidence.

A review on re-irradiation for recurrent and second primary head and neck cancer

The purpose of this paper is to review the results of studies regarding radiation as primary or adjuvant treatment modality for head and neck recurrences or second primary tumours (SPT) in previously irradiated areas, with emphasis on acute and late radiation induced morbidity, locoregional control and survival. The criteria for the studies to be included in this review were: (1) re-irradiation for locoregional recurrent disease or SPT in the head and neck region, (2) squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx and larynx, and (3) a minimum of 10 patients included in the study. Studies were divided in four categories, including (1) external beam re-irradiation, (2) re-irradiation with brachytherapy, (3) re-irradiation in combination with chemotherapy and (4) postoperative re-irradiation. Most studies were retrospective using heterogeneous treatment regimens and including heterogeneous groups of patients. A total number of 27 studies were included. Overall survival, locoregional control and acute and late radiation-induced morbidity are reported. High dose reirradiation as salvage treatment in case of recurrent or second primary head and neck cancer should be considered, particularly when salvage surgery is not feasible. Although long term survivors are reported is some studies, the relatively high incidence of treatment-related morbidity emphasize the need for further optimisation in order to improve locoregional control and reduce the risk on late morbidity.

Theragnostic imaging for radiation oncology: dose-painting by numbers

Theragnostic imaging for radiation oncology is the use of molecular and functional imaging to prescribe the distribution of radiation in four dimensions-the three dimensions of space plus time-of radiotherapy alone or combined with other treatment modalities in an individual patient. Several new imaging targets for positron-emission tomography, single-photon-emission CT, and magnetic resonance spectroscopy allow variations in microenvironmental or cellular phenotypes that modulate the effect of radiation to be mapped in three dimensions. Dose-painting by numbers is a strategy by which the dose distribution delivered by inverse planned intensity-modulated radiotherapy is prescribed in four dimensions. This approach will revolutionise the way that radiotherapy is prescribed and planned and, at least in theory, will improve the therapeutic outcome in terms of local tumour control and side-effects to unaffected tissue.

La préservation laryngée, état de la question

Larynx preservation in advanced pharyngolaryngeal cancers has been a major challenge in clinical research over the past two decades. Subtotal surgery (endoscopic laser surgery, supracricoid partial laryngectomies and hemilaryngopharyngectomies) has allowed reducing the indications of the so-called "mutilating" surgery. On the other hand, the modification of fractionation has notably improved the results of definitive irradiation (but most probably for supraglottic tumors). The main clinical research has been carried out with either sequential or concurrent chemo-irradiation. Induction chemotherapy followed by irradiation in good responders or by surgery in poor responders allowed to preserve the larynx in around half the cases without deleterious impact on overall survival. Concurrent chemo-irradiation trials suggested that the larynx preservation rates could be increased but overall survival remained unchanged and mucositis was a notable side effect. The next step could be the combination of induction chemotherapy followed by concurrent chemo-irradiation in good responders. Finally, the place of new drugs (taxanes, targeted therapies) is to be explored in this context.

Strategies to overcome accelerated repopulation and hypoxia--what have we learned from clinical trials?

Accelerated repopulation and tumor hypoxia are significant causes of treatment failure following radiotherapy for locally advanced head and neck squamous cell carcinoma (HNSCC). Accelerated fractionation schedules were designed to counter accelerated repopulation. Review of the randomized trials of accelerated fractionation reveals that the best results have been obtained with regimens that deliver the full conventional dose with a modest degree of acceleration by use of either a concomitant boost or 6 days/week treatment. However, the role of accelerated fractionation when chemoradiation is used has not been established. Although tumor hypoxia is an established adverse prognostic factor in head and neck cancer treated with radiotherapy, progress has been hampered by the lack of a widely available and reproducible method of hypoxia detection and by the limitations of previous treatments designed to overcome hypoxia. The advent of noninvasive hypoxic imaging with positron emission tomography (PET), and new treatment approaches, such as accelerated radiotherapy with carbogen and nicotinamide (ARCON) and hypoxic cytotoxins, has led to renewed optimism that hypoxia can be overcome or exploited to improve the outcomes in locally advanced head and neck cancer.

Current clinical outcomes demand new treatment options for SCCHN

Head and neck cancer can be a devastating disease. The mainstays of treatment for early stage disease are either radiotherapy or surgery. However, although disease responds well at this stage, the risk of a second primary cancer is high, with a development rate of about 4% per year. Advanced diseases are treated either by surgery with postoperative radiotherapy or by definitive radiotherapy, with surgery in reserve for salvage if necessary. Over the past two decades major advances have been made in surgery (reconstructive surgery, non-mutilating surgery). Either definitive or postoperative, radiotherapy is an integral part of the treatment for the majority of non-metastatic stages of disease and ways of improving the effects of radiotherapy are constantly being explored. Good activity has been reported for the use of altered radiation fractionation regimens, which allow the delivery of intensified radiation doses. In addition, in recent years randomized trials and meta-analyses have confirmed the survival benefit of adding chemotherapy to radiotherapy in a number of different settings. Cisplatin-based regimens have been identified as the most active and are now standard treatment choices. The survival benefits of chemotherapy appear to be limited to concomitant administration and do not extend to neoadjuvant administration, although this has demonstrated clinical utility in preserving organ function. Platinum-based combination chemotherapy is by many clinicians considered the standard approach to the treatment of recurrent/metastatic disease for patients who are able to tolerate such regimens, but the prognosis for these patients remains poor; this is particularly true for those whose disease progresses on such therapy. This paper discusses current approaches and recent advances in the treatment of head and neck cancer, specifically squamous cell carcinoma, and suggests future management aims for the different disease stages.

Concomitant radiochemotherapy or accelerated radiotherapy: Analysis of two randomized trials of the French Head and Neck Cancer Group (GORTEC)

In the early 1990s, when conventional radiotherapy (RT) was the standard of care in patients with locally advanced head and neck squamous cell carcinoma (HNSCC), two main options were being tested to improve the efficacy and the therapeutic ratio of RT. The first approach evaluated the effect of adding chemotherapy (CT) simultaneously to RT (RT-CT), while the second approach assessed the effect of modified fractionated RT. To answer these two questions, in 1994, the French Group for Head and Neck Oncology Radiotherapy (GORTEC) initiated two randomized trials. A total of 494 patients were entered in these two parallel phase III multicenter trials comparing conventional RT (70 Gy in 35 fractions) either with concomitant RT-CT (226 patients; 70 Gy in 35 fractions with three cycles of a 4-day regimen comprising carboplatin and 5-fluorouracil [5FU]) or with very accelerated RT (268 patients) delivering 64 Gy in 3 weeks. The 5-year overall survival (OS), specific disease-free survival (DFS), and local-regional control rates were improved in favor of simultaneous RT-CT, whereas local-regional control was significantly improved with accelerated RT, along with a marginal effect on OS and DFS. This increased antitumor efficacy was in both cases associated with a marked increase in acute RT-induced toxicity, which was more pronounced with accelerated RT, whereas late effects were marginally increased with the addition of CT and not influenced by accelerated RT. We conclude that both concomitant RT-CT and accelerated RT improved tumor control rates, as compared to conventional RT, along with increased but manageable toxicity. The two regimens are currently being tested in an ongoing randomized study and also being compared to moderately accelerated RT and concomitant CT.

Investigation of relationship between change in locoregional control and change in overall survival in randomized controlled trials of modified radiotherapy in head-and-neck cancer

PURPOSE

To establish whether a relationship exists between improvement in locoregional control (LRC) and improvement in overall survival (OS) in trials of modified radiotherapy for head-and-neck cancer and to attempt to quantify the relationship.

METHODS AND MATERIALS

A systematic review of the literature was performed for randomized controlled trials of radiotherapy for head-and-neck cancer involving the use of altered fractionation or hypoxic sensitizers. The changes in LRC at 2 years and OS at 5 years were recorded for each trial. Regression analysis was used to investigate the relationship between the two variables.

RESULTS

Nineteen relevant trials were identified. Fourteen reported sufficient data for analysis. Linear regression analysis showed a statistically significant correlation between LRC and OS with a slope of 0.67 (95% confidence interval, 0.38-0.96, p = 0.00017).

CONCLUSIONS

We have demonstrated a relationship between a change in LRC and a change in OS in randomized trials of modified radiotherapy for head-and-neck cancer. A 10% improvement in the 2-year LRC is predicted to lead to a 6.7% improvement in the 5-year OS. This type of analysis may have applications in other tumor sites.

Hyperfractionated accelerated radiochemotherapy (HFA-RCT) with mitomycin C for advanced head and neck cancer

To investigate efficacy and feasibility of hyperfractionated accelerated radiotherapy combined with mitomycin C, patients with locally advanced unresectable squamous cell carcinomas of the head and neck region were administered 64-66 Gy in four weeks and mitomycin C (20 mg/m(2)) on day five. Twenty-one consecutive patients were included between November 1997 and June 1999 (median age: 57 years). All tumours were stage T3-4 and 18/21 were N2-3. Eighteen patients experienced grade 3 and three patients grade 2 mucosal toxicity. With median follow up for surviving patients of 42 months, loco-regional control was 55% at three years, overall survival was 33% at three years. This treatment is at the edge of local tolerability, but there is a good curative chance even for very advanced localised tumours, provided a complete remission is induced at primary treatment.

Simultaneous integrated boost intensity-modulated radiotherapy for locally advanced head-and-neck squamous cell carcinomas: II—clinical results

PURPOSE

To perform a Phase I radiation dose-escalation trial to determine the maximal tolerable dose (MTD) deliverable to the gross tumor volume (GTV) using an accelerated fractionation with simultaneous integrated boost intensity-modulated radiotherapy regimen with parotid gland sparing as the sole therapy in the treatment of locally advanced head-and-neck squamous cell carcinoma. The primary objective was the definition of the MTD using established criteria of quantifying acute dose-limiting toxicity (DLT). Secondary objectives included analysis of failure patterns, tumor control rates, and toxicity.

METHODS AND MATERIALS

Between July 1999 and June 2002, eligible patients with bulky Stage II to Stage IVB head-and-neck squamous cell carcinoma, excluding laryngeal primaries, were enrolled. Intensity-modulated radiotherapy was delivered with 6-MV photons using a "sliding-window" technique. Enrollment of 6 patients for each dose level was planned; if DLTs were seen in >2 of 6 patients, the previous dose was to be expanded by an additional 6 patients to confirm that dose level as the MTD. All schedules administered a total of 30 fractions, but with escalating doses per fraction (2.27, 2.36, and 2.46 Gy) to achieve a total dose to the GTV of 68.1, 70.8, and 73.8 Gy, respectively. The remaining target tissues were constrained to receive the same dose in all patients regardless of the GTV dose level. The clinical target volume, defined as tissue within 1 cm around the GTV (at high risk of subclinical disease), received 60 Gy in 30 fractions of 2.0 Gy. The electively irradiated target volume, defined as the clinically uninvolved lymph node-bearing tissues, received 54 Gy in 30 fractions of 1.8 Gy. The parotid glands were spared to the degree possible without compromising target coverage. Acute toxicity was scored weekly using National Cancer Institute Common Toxicity Criteria. DLT was defined as any Grade 4 acute toxicity or any acute toxicity requiring either a dose reduction or a treatment break of >5 treatment days.

RESULTS

Of 18 men and 2 women (average age, 57 years; range, 37-80 years), 17 presented with oropharyngeal primary tumors, and 1 each with squamous cell carcinoma of the oral cavity, nasopharynx, and hypopharynx. None of the 6 patients at dose level 1, and 2 of the 6 patients initially enrolled at dose level 2, developed DLT. Both patients treated at dose level 3 required a 3-day treatment break and dose reduction after rapid development of Grade 3 toxicity (by Day 15). Six additional confirmatory patients subsequently enrolled at dose level 2 completed treatment without DLT. At least 50% of the total parotid gland volume received <30 Gy in 14 patients (average, 54% of volume), with an average mean dose of 32 Gy. In contrast, >/=50% of the distal parotid gland volume received <25 Gy in 15 patients (average, 63% of volume), with an average mean dose of 24 Gy. With a median follow-up of 20 months from the date of enrollment and 28 months for surviving patients, the actuarial 2-year local control (primary site), regional control (nodal sites), and distant control rate was 76.3%, 66.7%, and 71.8%, respectively.

CONCLUSION

Dose level 2, 70.8 Gy in 30 fractions of 2.36 Gy, was defined as the MTD deliverable to the GTV using this accelerated fractionation with simultaneous integrated boost intensity-modulated radiotherapy regimen with parotid gland sparing as the sole treatment for locally advanced head-and-neck squamous cell carcinoma. Adequate parotid sparing was achievable in most cases. Early toxicity, tumor control, and survival rates compared favorably with the outcomes after other accelerated regimens.

Molecular profiles as predictive marker for the effect of overall treatment time of radiotherapy in supraglottic larynx squamous cell carcinomas

BACKGROUND AND PURPOSE

Reduction of the overall treatment time of radiotherapy increases the probability of local tumour control, but it does not benefit all patients. Identification of molecular marker profiles may aid in the selection of patients likely to benefit from accelerated radiotherapy.

PATIENTS AND METHODS

Two hundred and nine patients with SCC of the supraglottic larynx received primary radiotherapy in the randomised DAHANCA trials to 66-68 Gy, 2 Gy/fx but with different overall treatment times of 9.5 week, 6.5 week and 5.5 week. Formalin-fixed paraffin embedded tumour slides were assessed by immunohistochemistry for expression of EGFr, E-cadherin, KI-67 and Bcl-2 and the TP53 mutation profile was determined using PCR-amplification, DHPLC and sequencing. The profiles were established using a hierarchical clustering algorithm with a Bayesian information criterion for cluster number optimisation.

RESULTS

Full data-set were available for 158 patients and four almost equally sized clusters were identified. One of these clusters differed significantly with respect to local control compared to the other clusters: the cluster (n=36) characterised by wild type TP53, low expression of E-cadherin and Bcl-2, moderate KI-67 and EGFr, was not influenced by a reduction in the overall treatment time (P=0.6) whereas the other clusters showed an increase in local control when the overall treatment time of radiotherapy was reduced. This was also partially seen with disease specific survival as the endpoint.

CONCLUSIONS

Molecular marker profiling may aid in the selection of patients that will benefit of a reduction in overall treatment time of radiotherapy in SCC of the supraglottic larynx.

Multidisciplinary approaches in the management of advanced head and neck tumors: state of the art

PURPOSE OF REVIEW

Head and neck cancer remains a significant cause of morbidity worldwide, with approximately 400,000 new cases per year. Ongoing advances in multidisciplinary management of this complex and multivaried disease process are resulting in improved function, quality of life, and survival. This review presents selected advances in primary research in head and neck cancer during the year 2003.

RECENT FINDINGS

Successful management of head and neck cancer now requires a cooperative approach among a broad group of medical disciplines that includes head and neck surgery, radiation oncology, medical oncology, medical imaging, clinical pathology and lab medicine, social work, nutrition, and others. Translation of continued advances in these fields by cooperative work will continue to yield incremental advances in diagnosis, staging, treatment, follow-up, supportive care, and quality of life. Accordingly, this review aims to include facets of each individual field. Diagnosis and staging continue to evolve with the inclusion of nuclear medicine and in vivo molecular imaging based on the technology of positron emission tomography and single photon emission computed tomographic scanning. Multimodality approaches remain the forefront of intervention for patients with advanced disease. Facets that continue to be defined and studied include the best treatment order of the three disciplines of surgery, radiation, and chemotherapy; the refinement of radiation by altering fraction dose, sequence, and time course; radiosensitization by chemo- and biologic therapy; and the addition of novel, biologically targeted agents to these disciplines. Following from the side effects of these intensive treatments to a functionally critical part of the body are ongoing advances in supportive care and quality of life.

SUMMARY

Head and neck cancer represents a collection of diseases that, although seemingly united by location and histology, on closer inspection represent a diverse collection of subcategories that often differ in pathogenesis, tumor biology, sublocation within the head and neck region, diagnosis, prognosis, treatment, and effect on quality of life. Given this complexity, it is not surprising that clinical management is also complicated and requires a cooperative effort among multiple subspecialties. This review of the current standard of care for patients with head and neck cancer aims to assist this diverse group of practitioners in caring for this complex group of patients.

Altered fractionated radiotherapy in the management of head and neck carcinomas: advantages and limitations

PURPOSE OF REVIEW

This article provides an overview of randomized studies of altered fractionated radiotherapy (RT) in Head and Neck squamous cell carcinoma.

RECENT FINDINGS

Both hyperfractionated RT and accelerated RT may improve tumor control probability as compared to conventional RT, along with increased but manageable toxicity and a modest improvement in survival.

SUMMARY

Altered RT is a tool that can improve the results obtained with conventional RT in Head and squamous cell carcinoma.

Accelerated postoperative radiotherapy with weekly concomitant boost in patients with locally advanced head and neck cancer

BACKGROUND AND PURPOSE

To assess the feasibility and efficacy of accelerated 66-Gy postoperative radiotherapy (PORT) using a single-fraction regimen from Mondays to Thursdays and a concomitant boost on Friday afternoon sessions in patients with locally advanced head and neck cancer (LAHNC).

PATIENTS AND METHODS

Between December 1997 and June 2002, 89 consecutive patients with pT1-pT4 and/or pN0-pN3 LAHNC were included. PORT was indicated in patients with positive surgical margins, T4 tumors, or extracapsular nodal infiltration. RT consisted of 66 Gy (2 Gy/fr) in 5 weeks and 3 days. Median follow-up was 21 months (range 2-59).

RESULTS

Acute morbidity was acceptable: grade 3 mucositis in 20 (22%) patients, grade 3 dysphagia in 22 (25%) patients, and grade 3 skin erythema in 18 (20%) patients. Median weight loss was 2 kg (range 0-14.5). No grade 4 toxicity was observed. Late effects included grade 3 xerostomia in 6 (7%) patients, and grade 3 edema in 2 (2%) patients. Median time to locoregional relapse was 10 months (range 2-21). Two-year overall, cause-specific, and disease-free survival rates were 70% (95% confidence interval (CI) 59-81), 75% (95% CI 64-86), and 63% (95% CI 52-74), respectively. The 2-year actuarial locoregional control rate was 80% (95% CI 70-90). Distant metastasis probability at 4 years was 38% (95% CI 20-56). Multivariate analysis revealed that pT-classification (pT1-2 vs. pT3-4) and extranodal extension (0, 1 vs. 2 or more) were the two factors independently influencing the outcome.

CONCLUSIONS

We conclude that reducing the overall treatment time using an accelerated PORT schedule including a once-weekly concomitant boost (six fractions per week) is easily feasible with excellent local control. Acute and late RT-related morbidity is acceptable. Given the disease progression pattern (distant metastases), adjuvant chemotherapy should be considered.