Radiochemotherapy in locally advanced squamous cell carcinomas of the head and neck

Multidisciplinary Imaging Review Conference Improves Neuro-oncology Radiation Treatment Planning and Follow-up

Purpose: To review the impact of a weekly multidisciplinary neuroradiology imaging review on the management of patients undergoing radiotherapy.

Methods: A prospective study of the management of 118 patients (30=head and neck, 40=skull base, central nervous system=48) was conducted over a 12-month period from January 2018 through January 2019. After review of each patient’s history and relevant imaging, a radiation oncologist completed a form detailing the changes that were made in diagnosis and management. Imaging source (external and internal examinations), availability of outside reports, report timeliness, the value of reports, changes in interpretation, changes in clinical management, and changes in prognosis were documented. Changes in interpretation and management were designated as major or minor depending on the significance of the change. The managing radiation oncologist indicated whether the imaging review conference substituted for a peer-to-peer consultation with a neuroradiologist.

Results: Nearly half (47%) of all patients had a change in interpretation. Of those, 32% of patients had a major change in interpretation, while 14% had a minor change in interpretation. The existence of the multidisciplinary imaging review conference prevented a peer-to-peer consultation (interruption) by the radiation oncologists to the neuroradiologists in 90% of the cases presented. Further analysis was performed.

Conclusion: The involvement of neuroradiologists in a joint radiation oncology imaging review conference resulted in changes in diagnostic imaging interpretation that led to significant changes in management, expected prognosis, and workflow. 

Impact of Time Factors on Outcome in Patients with Head and Neck Cancer Treated with Definitive Radio(Chemo)Therapy

AIM

To evaluate treatment-related factors such as overall treatment time (OTT) and radiation treatment time (RTT) in head-and-neck cancer.

PATIENTS AND METHODS

A total of 216 patients with locoregionally advanced inoperable head and neck cancer were treated with definitive radio(chemo)therapy. Mean follow-up was 37 months.

RESULTS

Median time from diagnosis to start of radiotherapy (total waiting time) was 34 days, and comprised of referral waiting time and time for preparatory work. Median RTT was 40 days, and median OTT was 91 days. At 6, 12 and 24 months local recurrence-free survival (LRFS) was 75%, 65% and 60%; metastasis-free survival (MFS) was 84%, 77% and 70%; overall survival (OS) was 72%, 58% and 40%. Tumor stage, boost and chemotherapy were significant for OS, waiting time for preparatory work and RTT were significant for MFS, and referral waiting time and total radiotherapy dose for LRFS.

CONCLUSION

RTT ≤40 days was a prognostic factor for better MFS. Prolonged waiting time had a converse effect for radiotherapy with better outcome on MFS and LRFS.

Postradiation Matrix Metalloproteinase-20 Expression and Its Impact on Dental Micromorphology and Radiation-Related Caries

Recent evidence suggests that head-and-neck radiotherapy (HNRT) increases active forms of matrix metalloproteinase-20 (MMP-20) in human tooth crowns, degrading the dentin-enamel junction (DEJ) and leading to enamel delamination, which is a pivotal step in the formation of radiation-related caries (RRC). Additional participation of enzymatic degradation of organic matrix components in caries progression was attributed to MMP-20 in dentin. Therefore, the current study tested the hypothesis that MMP-20 is overexpressed in the DEJ, dentin-pulp complex components, and carious dentin of post-HNRT patients, leading to detectable micromorphological changes to the enamel and dentin. Thirty-six teeth were studied, including 19 post-HNRT specimens and 17 nonirradiated controls. Optical light microscopy was used to investigate the micromorphological components of the DEJ, dentin-pulp complex components, and carious dentin. The samples were divided into 2 subgroups: nondemineralized ground sections (n = 20) and demineralized histological sections (n = 16). In addition, immunohistochemical analysis using the immunoperoxidase technique was conducted to semiquantitatively assess MMP-20 expression in the DEJ, dentin-pulp complex components, and carious dentin. No apparent damage to the DEJ microstructure or other dentin-pulp complex components was observed and no statistically significant differences were detected in MMP-20 expression (p > 0.05) between the irradiated and control groups. This study rejected the hypothesis that MMP-20 is overexpressed in the DEJ, dentin-pulp complex components, and carious dentin of post-HNRT patients, leading to detectable micromorphological changes. Hence, direct effects of radiation may not be regarded as an independent factor to explain aggressive clinical patterns of RRC.

The role of recombinant epidermal growth factor and serotonin in the stimulation of tumor growth in a SCCHN xenograft model

One challenge of squamous cell carcinoma of the head and neck (SCCHN) chemotherapy is a small percentage of tumor cells that arrest in the G0 phase of the cell cycle and are thus not affected by chemotherapy. This could be one reason for tumor recurrence at a later date. The recruitment of these G0-arresting cells into the active cell cycle and thus, proliferation, may increase the efficacy of chemotherapeutic agents. The aim of this study was to investigate whether stimulation with recombinant epidermal growth factor (EGF) or serotonin leads to an increased tumor cell proliferation in xenografts. Detroit 562 cells were injected into NMRI-Foxn1nu mice. Treatment was performed with 15 µg murine or human EGF, or 200 µg serotonin. The control mice were treated with Lactated Ringer's solution (5 mice/group). Tumor size was measured on days 4, 8 and 12 after tumor cell injection. The EGF stimulated mice showed a significantly higher tumor growth compared to the serotonin-stimulated mice and the untreated controls. In the present study, we show that it is possible to stimulate tumor cells in xenografts by EGF and thus, enhance cell proliferation, resulting in a higher tumor growth compared to the untreated control group. In our future investigations, we plan to include a higher number of mice, an adjustment of the EGF dosage and cell subanalysis, considering the heterogeneity of SCCHN tumors.

A prospective study of the clinical impact of a multidisciplinary head and neck tumor board

OBJECTIVE

There have been no studies undertaken on the effect of the multidisciplinary head and neck tumor board on treatment planning. The objective of this study was to determine the efficacy of the multidisciplinary tumor board in altering diagnosis, stage, and treatment plan in patients with head and neck tumors.

STUDY DESIGN

Case series with planned data collection.

SETTING

Comprehensive cancer center and tertiary academic hospital.

SUBJECTS AND METHODS

A prospective study of the discussions concerning 120 consecutive patients presented at a multidisciplinary head and neck tumor board was performed. As each patient was presented, a record was made of the "pre-conference" diagnosis, stage, and treatment plan. After case discussion, the "post-conference" diagnosis, stage, and treatment plan were recorded. Results are compared between malignant and benign tumor cohorts.

RESULTS

The study population comprised 120 patients with new presentations of head and neck tumors: 84 malignancies and 36 benign tumors. Approximately 27 percent of patients had some change in tumor diagnosis, stage, or treatment plan. Change in treatment was significantly more common in cases of malignancy, occurring in 24 percent of patients versus six percent of benign tumors (P = 0.0199). Changes in treatment were also noted to be largely escalations in management (P = 0.0084), adding multi-modality care.

CONCLUSION

A multidisciplinary tumor board affects diagnostic and treatment decisions in a significant number of patients with newly diagnosed head and neck tumors. The multidisciplinary approach to patient care may be particularly effective in managing malignant tumors, in which treatment plans are most frequently altered.

The role of split-course hypofractionated palliative radiotherapy in head and neck cancer

AIMS

A significant proportion of patients with head and neck squamous cell carcinoma are unsuitable for radical treatment due to factors including tumour stage, performance status and co-morbidity. Palliative radiotherapy has a useful role in the control of local symptoms. This study documented the outcome with split-course hypofractionated radiotherapy.

MATERIALS AND METHODS

Thirty-three previously untreated patients with head and neck squamous cell carcinoma were treated with palliative intent with split-course radiotherapy, with an initial 20 Gy in five fractions over 1 week, a 2 week gap, and then a further 20 Gy in five fractions over 1 week at the Yorkshire Cancer Centre between January 2004 and December 2007. Data were collected retrospectively from case notes and radiotherapy records.

RESULTS

Thirty (91%) patients had stage IV A-B disease. World Health Organization performance status was 2 or 3 in 19 (58%) patients. The median age was 76 years (range 48-91 years). Twenty-five (76%) patients were men. Symptomatic improvement was reported in 26 (79%) patients at 4-6 weeks of follow-up. Thirteen (39%) patients had a complete tumour response and 11 (33%) patients had a partial response as assessed clinically, and in some cases radiologically. The median overall survival was 9 months (range 3-43 months). Progression-free survival at 1 and 2 years was 35 and 25%, respectively. Overall survival at 1 and 2 years was 42 and 34%, respectively. Treatment was generally well tolerated; admission for nasogastric feeding and/or supportive care was required in only six patients. Radiation Therapy Oncology Group grade 3 toxicity was documented for skin in one patient, for mucosa in two patients and for oesophagitis in three patients.

CONCLUSION

Split-course hypofractionated radiotherapy is an effective palliative regimen with acceptable toxicity.

Can synchronous chemotherapy be added to accelerated hypofractionated radiotherapy in patients with base of tongue cancer?

AIM

To evaluate the tolerability of synchronous chemotherapy and accelerated hypofractionated radiotherapy in patients with locally advanced squamous cell carcinoma of the base of the tongue.

MATERIALS AND METHODS

Between 1999 and 2004, 43 patients with stage II-IV squamous cell carcinoma of the base of the tongue were treated with a combined modality of radiotherapy (prescribed 55 Gy in 20 fractions), synchronous chemotherapy and in some cases surgical neck dissection. End points were acute and late toxicity, 3 year locoregional control, overall survival, cancer-specific survival and compliance.

RESULTS

The median follow-up for surviving patients was 3.9 years. All patients completed radiotherapy and 30% received neoadjuvant chemotherapy. The median time for the completion of treatment was 27 days (range 25-36). Overall, only 42% completed the prescribed synchronous chemotherapy. However, compliance increased to 60% in patients who did not receive neoadjuvant chemotherapy. Grade 3 mucositis developed in 90% of patients. Prolonged grade 3 mucositis (>4 weeks) was seen in 24/43 (56%) and none developed grade 4 mucositis. There were no toxic deaths. Feeding tube dependency at 1 year was 14%. The 3 year locoregional control, overall survival and cancer-specific survival were 70, 60 and 60%, respectively. Clinical T staging was most significantly associated with poor overall survival, cancer-specific survival and local control. Distant metastases occurred in 6/43 patients (14%), 5/6 without locoregional recurrence.

CONCLUSION

The addition of synchronous chemotherapy to accelerated hypofractionated radiotherapy consistently led to grade 3 mucositis. Tumour control rates compare well with published outcomes. Higher mucosal toxicity and lower synchronous chemotherapy compliance compared with other series may suggest that this approach is at the limit of patient tolerability. However, the tumour site investigated and the choice of synchronous chemotherapy agent may also be important. Compliance may be improved using intensity-modulated radiotherapy and agents that do not enhance mucosal toxicity. Longer fractionation will probably increase compliance with chemotherapy, particularly when induction is used before synchronous treatment.