Preliminary results of a phase I/II study of simultaneous modulated accelerated radiotherapy for nondisseminated nasopharyngeal carcinoma

Split-field versus extended-field step-and-shoot IMRT techniques in nasopharyngeal cancer: a report of acute and late toxicities

Aim:

This study aimed to evaluate acute and late toxicities in nasopharyngeal cancer (NPC) patients who were treated between split-field (SF) and extended-field (EF) step-and-shoot intensity-modulated radiotherapy (IMRT) techniques.

Materials and methods:

Between January 2011 and October 2011, 21 NPC patients with stage I-IVB (7th edition American Joint Committee on Cancer Staging) were randomly assigned to undergo radiotherapy with SF or EF step-and-shoot IMRT technique.

Results:

At a median follow-up time of 60 months (range 3–77), we reported the comparable acute and late toxicities between the two techniques. One patient (9%) in SF-IMRT arm developed grade 3 acute skin toxicity.

Findings:

Both SF and EF step-and-shoot IMRT techniques for NPC patients did not produce any statistically significant differences in both acute and late toxicities. Although no difference in toxicity was observed, technical problems due to field matching management were the obstacles in utilisation of SF-IMRT in our routine practice.

Reprint of Long-term survival and late toxicities of elderly nasopharyngeal carcinoma (NPC) patients treated by high-total- and fractionated-dose simultaneous modulated accelerated radiotherapy with or without chemotherapy

BACKGROUND

To analyse the survival and late toxicities of elderly nasopharyngeal carcinoma (NPC) patients treated by intensity-modulated radiotherapy (IMRT) with the high-total- and fractionated-dose simultaneous modulated accelerated radiation therapy (SMART) boost technique and to identify the effect of concurrent chemotherapy for these patients.

METHODS

Two hundred and fifty-four elderly patients (age ≥ 60.0) with newly diagnosed non-metastatic NPC were retrospectively analysed. Statistical analyses were performed using the SPSS software program.

RESULTS

The actual mean total and fractionated doses delivered to the gross tumour volume of the nasopharynx (GTVnx) were 74.55 Gy and 2.49 Gy, respectively. The 5-year locoregional recurrence-free survival (LRRFS), distant metastasis-free survival (DMFS), disease-specific survival (DSS) and overall survival (OS) of the whole cohort were 93.0%, 85.7%, 83.2% and 74.1%, respectively. No grade 4 acute or late radiotherapy-induced toxicities were observed. Of 247 patients with stage II-IVb disease, 89 patients received radiotherapy (RT) alone, and 158 patients received concurrent chemoradiotherapy (CCRT), and the 5-year LRRFS, DMFS, DSS and OS of the RT-alone group vs. the CCRT group were 94.0% vs. 92.2%, 83.5% vs. 86.2%, 81.8% vs. 83.1% and 74.0% vs. 72.8% (all P > 0.05), respectively. Multivariate analyses showed that CCRT was not an independent predictor for LRRFS, DMFS, DSS and OS (all P > 0.05).

CONCLUSION

High-total- and fractionated-dose SMART boost IMRT could obtain a satisfactory long-term outcome with mild late toxicity in elderly NPC patients. The role of CCRT needs to be further studied to optimize the treatment strategy and improve the overall survival.

Prognostic value of nutritional risk screening 2002 scale in nasopharyngeal carcinoma: A large-scale cohort study

Little is known about the value of the nutritional risk screening 2002 (NRS2002) scale in nasopharyngeal carcinoma (NPC). We conducted a large-scale study to address this issue. We employed a big-data intelligence database platform at our center and identified 3232 eligible patients treated between 2009 and 2013. Of the 3232 (12.9% of 24 986) eligible patients, 469 (14.5%), 13 (0.4%), 953 (29.5%), 1762 (54.5%) and 35 (1.1%) had NRS2002 scores of 1, 2, 3, 4 and 5, respectively. Survival outcomes were comparable between patients with NRS2002 <3 and ≥3 (original scale). However, patients with NRS2002 ≤3 vs >3 (regrouping scale) had significantly different 5-year disease-free survival (DFS; 82.7% vs 75.0%, P < .001), overall survival (OS; 88.8% vs 84.1%, P = .001), distant metastasis-free survival (DMFS; 90.2% vs 85.9%, P = .001) and locoregional relapse-free survival (LRRFS; 91.6% vs 87.2%, P = .001). Therefore, we proposed a revised NRS2002 scale, and found that it provides a better risk stratification than the original or regrouping scales for predicting DFS (area under the curve [AUC] = 0.530 vs 0.554 vs 0.577; P < .05), OS (AUC = 0.534 vs 0.563 vs 0.582; P < .05), DMFS (AUC = 0.531 vs 0.567 vs 0.590; P < .05) and LRRFS (AUC = 0.529 vs 0.542 vs 0.564; P < .05 except scale A vs B). Our proposed NRS2002 scale represents a simple, clinically useful tool for nutritional risk screening in NPC.

Outcome and long-term efficacy of four facio-cervical fields conformal radiotherapy for nasopharyngeal carcinoma

Purpose

To evaluate the outcomes of 255 patients with nasopharyngeal carcinoma (NPC) treated with four facio-cervical fields conformal radiotherapy (4F-CRT).

Results

In one patient's 3 different RT treatment modalities, the 4F-CRT techniques resulted in sharper of the dose-volume histograms (DVHs) for primary gross tumor volume (PGTVnx) and planning target volume (PTVnx), similar to the intensity modulated radiation therapy (IMRT). The median follow-up duration was 43 months. Locoregional relapse and distant metastases as the first treatment failure events occurred in 32 (32/255, 12.5%) and 20 (30/255, 11.8%) patients, respectively. The 3-year and 5-year local control, disease-free survival, and overall survival rates were 83.3%, 82%, 83.8%, and 76.1%, 73.2%, 76.3% respectively. Univariate analysis displayed that clinical stage, T-stage, N-stage, and tumor response were related to prognosis. Multivariate analysis indicated that age, T-stage, N-stage, and combined chemotherapy were independent prognosticators. The incidence of grade 1–2 acute mucositis and leukocytopenia were 93.7% and 91.0%, respectively, with no cases of grade 4 toxicity detected.

Materials and Methods

From November 2007 to December 2011, 255 patients with histologically diagnosed, non-metastatic NPC were enrolled into this study and received 4F-CRT. Magnetic resonance imaging scans of the nasopharynx were performed on every patient. All patients received definitive radiotherapy with 6 MV X-rays using conventional fractions at 2 Gy daily, 5 fractions per week, and 231 patients with stage IIb-IV received concurrent chemotherapy and cisplatin-based adjuvant chemotherapy. The accumulated survival was calculated according to the Kaplan-Meier method; the log-rank test was used to compare survival differences. Multivariate analysis was performed using Cox's proportional hazard model.

Conclusions

Compared with the conventional treatment plans, the 4F-CRT plan delivered more dose to cover the tumor volume and reduces the doses of the normal tissues including the parotid gland, TMJs and so on. The long-term efficacy of 4F-CRT is satisfactory and its toxicities are tolerable.

Suggestions for surveillance and radiation strategy in nasopharyngeal carcinoma treated with IMRT: Based on hazard-rate and patterns of recurrence

OBJECTIVE

The study was designed to appraise the locoregional recurrence patterns using conventional two-dimensional radiotherapy (2D-RT) and intensity modulated radiation therapy (IMRT) in nasopharyngeal carcinoma (NPC) in order to better establish the scenario of the modern radiotherapy and the duration of surveillance.

MATERIALS AND METHODS

We reviewed the institutional database to identify patients with pathologically confirmed, non-metastatic NPC who completed radical 2D-RT or IMRT at our center from 2000 to 2011. We collected data on clinicopathologic features, treatments and outcomes. Statistical analyses were performed using SPSS 20.0 or STATASE 14.0.

RESULTS

The median follow-up was 60.1 months. Of 2315 patients, 1289 (53%) were treated with 2D-RT and 1026 (47%) with IMRT. IMRT group achieved better locoregional control rate, with the 5-year locoregional relapse-free survival (LRRFS) were 84.9% and 87.7% among patients received 2D-RT and IMRT, respectively (P = 0.050). IMRT was superior to 2D technique in terms of local relapse-free survival (LRFS) (88.4% vs 91.1%, P = 0.047) and the advantage was only significant in T3-4 subgroup (81.6% vs 90.2%, P = 0.000). Similar neck control rates were observed using different RT techniques. And the recurrence time appeared to be postponed by IMRT, with peaks accounting for the year 1.5 and year 3-4 compared to which was predominant at the first two years using 2D-RT in nature.

CONCLUSIONS

IMRT provided an improved LRRFS in overall stage and LRFS in advanced T stage for NPC compared with 2D-RT. Annual hazard of recurrence also changed with RT techniques.

Surgical Management of Rathke Cleft Cysts

BACKGROUND

The diagnosis of Rathke cleft cysts (RCC) has increased in recent times as a result of improvements in imaging techniques; however, symptomatic patients are uncommon and accurate preoperative diagnosis may sometimes be difficult. The indications of surgical management protocol are evolving. We aim to provide a comprehensive review of clinical, imaging, and histopathologic features with operative management strategies along with outcome and prognosis in RCC.

METHODS

A retrospective analysis (2003-2015) was performed of 58 consecutive cases of RCC seen in a surgical unit. Twenty-seven surgically treated symptomatic RCCs were further evaluated for their clinical presentation, imaging characteristics, surgical approaches, and intraoperative findings.

RESULTS

Headache was the most common presenting complaint followed by visual deficit. Hormonal abnormality was observed in 13 patients. On magnetic resonance imaging, the characteristic intracystic nodule was identified in 6 patients. Transsphenoidal surgery for cyst excision was performed in all 27 patients with an endoscopic route in 25 patients and radical excision was performed in 17 patients. The pituitary stalk and the normal gland were preserved in all patients. Headache improved in 96% of patients and visual field defect resolved in all. Around 46% had improvement of the anterior pituitary axis. New permanent hormone deficiency was not observed. The recurrence rate was 3.7% after a minimum of 18 months follow-up.

CONCLUSIONS

RCCs are an uncommon disease with a wide spectrum of clinical and radiologic features. Endonasal endoscopic transsphenoidal surgery provides excellent clinical and endocrinologic improvement. We believe that radical excision does not necessarily result in endocrinologic impairment and may have a better impact on recurrence and cyst resolution.

Preliminary analysis of the sequential simultaneous integrated boost technique for intensity-modulated radiotherapy for head and neck cancers

The aim of this study was to compare three strategies for intensity-modulated radiotherapy (IMRT) for 20 head-and-neck cancer patients. For simultaneous integrated boost (SIB), doses were 66 and 54 Gy in 30 fractions for PTVboost and PTVelective, respectively. Two-phase IMRT delivered 50 Gy in 25 fractions to PTVelective in the First Plan, and 20 Gy in 10 fractions to PTVboost in the Second Plan. Sequential SIB (SEQ-SIB) delivered 55 Gy and 50 Gy in 25 fractions, respectively, to PTVboost and PTVelective using SIB in the First Plan and 11 Gy in 5 fractions to PTVboost in the Second Plan. Conformity indexes (CIs) (mean ± SD) for PTVboost and PTVelective were 1.09 ± 0.05 and 1.34 ± 0.12 for SIB, 1.39 ± 0.14 and 1.80 ± 0.28 for two-phase IMRT, and 1.14 ± 0.07 and 1.60 ± 0.18 for SEQ-SIB, respectively. CI was significantly highest for two-phase IMRT. Maximum doses (Dmax) to the spinal cord were 42.1 ± 1.5 Gy for SIB, 43.9 ± 1.0 Gy for two-phase IMRT and 40.3 ± 1.8 Gy for SEQ-SIB. Brainstem Dmax were 50.1 ± 2.2 Gy for SIB, 50.5 ± 4.6 Gy for two-phase IMRT and 47.4 ± 3.6 Gy for SEQ-SIB. Spinal cord Dmax for the three techniques was significantly different, and brainstem Dmax was significantly lower for SEQ-SIB. The compromised conformity of two-phase IMRT can result in higher doses to organs at risk (OARs). Lower OAR doses in SEQ-SIB made SEQ-SIB an alternative to SIB, which applies unconventional doses per fraction.

Simultaneous modulated accelerated radiotherapy in cervical cancer with retroperitoneal lymph node metastasis after radical hysterectomy and pelvic lymphadenectomy

OBJECTIVE

To compare the dosimetry, toxicity, and efficacy of simultaneous modulated accelerated radiotherapy (SMART) with 3-dimensional conformal radiotherapy (3DCRT) in cervical cancer with retroperitoneal lymph node metastasis after radical hysterectomy and pelvic lymphadenectomy.

METHODS

Total 32 patients who underwent SMART were retrospectively evaluated. Daily fractions of 2.2 to 2.4 Gy and 1.8 to 2 Gy were prescribed and delivered to gross tumor volume and clinical target volume to a total dose of 63.8 and 52.2 Gy, respectively. A 3DCRT plan was designed for the SMART group and planned to deliver the same prescribed dose. The doses of organs at risk (OARs) were compared. Thirty-six patients who received 3DCRT were used to compare the target dose, toxicities, and efficacy with 32 cases who received SMART.

RESULTS

The mean doses delivered to gross tumor volume and clinical target volume were significantly higher in the SMART group than in the 3DCRT group (63.8 vs 55.2 Gy [P < 0.01] and 52.5 vs 48.6 Gy [P < 0.01], respectively). For SMART plan, the doses of OARs were significantly lower than that of 3DCRT plans (small intestine: 25.1 vs 30.9 Gy [P < 0.01], bladder: 35.3 vs 46.3 [P < 0.01], and rectum: 31.7 vs 43.7 [P = 0.002], respectively). The patients experienced less acute and late toxicities in the SMART group (acute toxicities: enteroproctitis, P = 0.019; cystitis, P = 0.013; leukopenia, P = 0.025; late toxicities: enteroproctitis, P = 0.007; and cystitis, P = 0.026, respectively). No significant difference was found for 1-year survival (78.7% vs 67.7%, P = 0.222), but SMART group had a higher 2-year survival rate (2-year: 63.1% vs 39.1%, P = 0.029).

CONCLUSIONS

Simultaneous modulated accelerated radiotherapy plans yielded higher dose to the targets and better sparing of OARs than did 3DCRT in cervical cancer with retroperitoneal lymph node metastasis after radical hysterectomy and pelvic lymphadenectomy. Simultaneous modulated accelerated radiotherapy provided better clinical outcomes than did 3DCRT. Long-term follow-up and studies involving more patients are needed to confirm our results.

Treatment of nasopharyngeal carcinoma using simultaneous modulated accelerated radiation therapy via helical tomotherapy: a phase II study

Background

The aim of the study was to evaluate short-term safety and efficacy of simultaneous modulated accelerated radiation therapy (SMART) delivered via helical tomotherapy in patients with nasopharyngeal carcinoma (NPC).

Methods

Between August 2011 and September 2013, 132 newly diagnosed NPC patients were enrolled for a prospective phase II study. The prescription doses delivered to the gross tumor volume (pGTV_nx) and positive lymph nodes (pGTV_nd), the high risk planning target volume (PTV1), and the low risk planning target volume (PTV2), were 67.5 Gy (2.25 Gy/F), 60 Gy (2.0 Gy/F), and 54 Gy (1.8 Gy/F), in 30 fractions, respectively. Acute toxicities were evaluated according to the established RTOG/EORTC criteria. This group of patients was compared with the 190 patients in the retrospective P70 study, who were treated between September 2004 and August 2009 with helical tomotherapy, with a dose of 70-74 Gy/33F/6.5W delivered to pGTV_nx and pGTV_nd.

Results

The median follow-up was 23.7 (12–38) months. Acute radiation related side-effects were mainly problems graded as 1 or 2. Only a small number of patients suffered from grade 4 leucopenia (4.5%) or thrombocytopenia (2.3%). The local relapse-free survival (LRFS), nodal relapse-free survival (NRFS), local-nodal relapse-free survival (LNRFS), distant metastasis-free survival (DMFS) and overall survival (OS) were 96.7%, 95.5%, 92.2%, 92.7% and 93.2%, at 2 years, respectively, with no significant difference compared with the P70 study.

Conclusions

Smart delivered via the helical tomotherapy technique appears to be associated with an acceptable acute toxicity profile and favorable short-term outcomes for patients with NPC. Long-term toxicities and patient outcomes are under investigation.

Intensity-modulated radiotherapy for lung cancer: current status and future developments

Radiotherapy plays an important role in the management of lung cancer, with over 50% of patients receiving this modality at some point during their treatment. Intensity-modulated radiotherapy (IMRT) is a technique that adds fluence modulation to beam shaping, which improves radiotherapy dose conformity around the tumor and spares surrounding normal structures. Treatment with IMRT is becoming more widely available for the treatment of lung cancer, despite the paucity of high level evidence supporting the routine use of this more resource intense and complex technique. In this review article, we have summarized data from planning and clinical studies, discussed challenges in implementing IMRT, and made recommendations on the minimum requirements for safe delivery of IMRT.

Value of the prognostic nutritional index and weight loss in predicting metastasis and long-term mortality in nasopharyngeal carcinoma

BACKGROUND

To evaluate the influence of the progonistic nutritional index (PNI) and weight loss on metastasis and long-term mortality in nasopharyngeal carcinoma (NPC).

METHODS

We retrospectively reviewed 694 newly diagnosed patients with non-disseminated, biopsy-proven NPC. Survival analysis was used to evaluate the predictive value of PNI and weight loss.

RESULTS

Multivariate analysis demonstrated that a low pre-therapy PNI (< 55.0) was an independent predictor of poor overall survival (OS) (P = 0.012), distant metastasis-free survival (DMFS) (P = 0.011) and progression-free survival (P = 0.012). High weight loss (HWL, weight loss during treatment ≥10 %) was an independent predictor of poor OS (P = 0.001) and DMFS (P = 0.014). Advanced stage disease, female gender, chemotherapy, high white blood cell count, high serum globulin concentration and pre-therapy body-mass index were predictors of HWL.

CONCLUSION

Pre-therapy PNI and weight loss have significant predictive value for metastasis and mortality in patients with NPC.

Patient- and therapy-related factors associated with the incidence of xerostomia in nasopharyngeal carcinoma patients receiving parotid-sparing helical tomotherapy

We investigated the incidence of moderate to severe patient-reported xerostomia among nasopharyngeal carcinoma (NPC) patients treated with helical tomotherapy (HT) and identified patient- and therapy-related factors associated with acute and chronic xerostomia toxicity. The least absolute shrinkage and selection operator (LASSO) normal tissue complication probability (NTCP) models were developed using quality-of-life questionnaire datasets from 67 patients with NPC. For acute toxicity, the dosimetric factors of the mean doses to the ipsilateral submandibular gland (Dis) and the contralateral submandibular gland (Dcs) were selected as the first two significant predictors. For chronic toxicity, four predictive factors were selected: age, mean dose to the oral cavity (Doc), education, and T stage. The substantial sparing data can be used to avoid xerostomia toxicity. We suggest that the tolerance values corresponded to a 20% incidence of complications (TD20) for Dis = 39.0 Gy, Dcs = 38.4 Gy, and Doc = 32.5 Gy, respectively, when mean doses to the parotid glands met the QUANTEC 25 Gy sparing guidelines. To avoid patient-reported xerostomia toxicity, the mean doses to the parotid gland, submandibular gland, and oral cavity have to meet the sparing tolerance, although there is also a need to take inherent patient characteristics into consideration.

A randomized phase II/III study of adverse events between sequential (SEQ) versus simultaneous integrated boost (SIB) intensity modulated radiation therapy (IMRT) in nasopharyngeal carcinoma; preliminary result on acute adverse events

BACKGROUND

To investigate acute and late toxicities comparing sequential (SEQ-IMRT) versus simultaneous integrated boost intensity modulated radiotherapy (SIB-IMRT) in nasopharyngeal carcinoma (NPC) patients.

METHODS

Newly diagnosed stage I-IVB NPC patients were randomized to receive SEQ-IMRT or SIB-IMRT, with or without chemotherapy. SEQ-IMRT consisted of two sequential radiation treatment plans: 2 Gy x 25 fractions to low-risk planning target volume (PTV-LR) followed by 2 Gy x 10 fractions to high-risk planning target volume (PTV-HR). In contrast, SIB-IMRT consisted of only one treatment plan: 2.12 Gy and 1.7 Gy x 33 fractions to PTV-HR and PTV-LR, respectively. Toxicities were evaluated according to CTCAE version 4.0.

RESULTS

Between October 2010 and November 2013, 122 eligible patients were randomized between SEQ-IMRT (54 patients) and SIB-IMRT (68 patients). With median follow-up time of 16.8 months, there was no significant difference in toxicities between the two IMRT techniques. During chemoradiation, the most common grade 3-5 acute toxicities were mucositis (15.4% vs 13.6%, SEQ vs SIB, p = 0.788) followed by dysphagia (9.6% vs 9.1%, p = 1.000) and xerostomia (9.6% vs 7.6%, p = 0.748). During the adjuvant chemotherapy period, 25.6% and 32.7% experienced grade 3 weight loss in SEQ-IMRT and SIB-IMRT (p = 0.459). One-year overall survival (OS) and progression-free survival (PFS) were 95.8% and 95.5% in SEQ-IMRT and 98% and 90.2% in SIB-IMRT, respectively (p = 0.472 for OS and 0.069 for PFS).

CONCLUSION

This randomized, phase II/III trial comparing SIB-IMRT versus SEQ-IMRT in NPC showed no statistically significant difference between both IMRT techniques in terms of acute adverse events. Short-term tumor control and survival outcome were promising.

The clinical importance of assessing tumor hypoxia: relationship of tumor hypoxia to prognosis and therapeutic opportunities

Tumor hypoxia is a well-established biological phenomenon that affects the curability of solid tumors, regardless of treatment modality. Especially for head and neck cancer patients, tumor hypoxia is linked to poor patient outcomes. Given the biological problems associated with tumor hypoxia, the goal for clinicians has been to identify moderately to severely hypoxic tumors for differential treatment strategies. The "gold standard" for detecting and characterizing of tumor hypoxia are the invasive polarographic electrodes. Several less invasive hypoxia assessment techniques have also shown promise for hypoxia assessment. The widespread incorporation of hypoxia information in clinical tumor assessment is severely impeded by several factors, including regulatory hurdles and unclear correlation with potential treatment decisions. There is now an acute need for approved diagnostic technologies for determining the hypoxia status of cancer lesions, as it would enable clinical development of personalized, hypoxia-based therapies, which will ultimately improve outcomes. A number of different techniques for assessing tumor hypoxia have evolved to replace polarographic pO2 measurements for assessing tumor hypoxia. Several of these modalities, either individually or in combination with other imaging techniques, provide functional and physiological information of tumor hypoxia that can significantly improve the course of treatment. The assessment of tumor hypoxia will be valuable to radiation oncologists, surgeons, and biotechnology and pharmaceutical companies who are engaged in developing hypoxia-based therapies or treatment strategies.

Clinical study of nasopharyngeal carcinoma treated by helical tomotherapy in China: 5-year outcomes

Background. To evaluate the outcomes of nasopharyngeal carcinoma (NPC) patients treated with helical tomotherapy (HT). Methods. Between September 2007 and August 2012, 190 newly diagnosed NPC patients were treated with HT. Thirty-one patients were treated with radiation therapy as single modality, 129 with additional cisplatin-based chemotherapy with or without anti-EGFR monoclonal antibody therapy, and 30 with concurrent anti-EGFR monoclonal antibody therapy. Results. Acute radiation related side effects were mainly grade 1 or 2. Grade 3 and greater toxicities were rarely noted. The median followup was 32 (3–38) months. The local relapse-free survival (LRFS), nodal relapse-free survival (NRFS), distant metastasis-free survival (DMFS), and overall survival (OS) were 96.1%, 98.2%, 92.0%, and 86.3%, respectively, at 3 years. Cox multivariate regression analysis showed that age and T stage were independent predictors for 3-year OS. Conclusions. Helical tomotherapy for NPC patients achieved excellent 3-year locoregional control, distant metastasis-free survival, and overall survival, with relatively minor acute and late toxicities. Age and T stage were the main prognosis factors.

Comparison of 3D confromal radiotherapy and intensity modulated radiotherapy with or without simultaneous integrated boost during concurrent chemoradiation for locally advanced head and neck cancers

OBJECTIVE

Radiotherapy techniques have evolved from 3D conformal radiotherapy (3D-CRT) to intensity modulated radiotherapy (IMRT) where boost fields are delivered either sequentially (IMRTseq) or with a simultaneous integrated boost (IMRT+SIB). Our goal was to compare the outcomes of patients treated with IMRT+SIB to traditional standards.

METHODS

We analyzed the efficacy and toxicity of patients treated with concurrent chemoradiation using 3D-CRT, IMRTseq or IMRT+SIB. Between 1993 and 2012, 379 patients with non-metastatic Stage III-IV head and neck squamous cell cancer were treated with concurrent chemoradiation using 3D-CRT (n = 125), IMRTseq (n = 120) and IMRT+SIB (n = 134).

RESULTS

Patients treated with any technique had similar rates of 2y local control, 2y regional control, 2y progression free survival and 2y overall survival. Patients treated with IMRT+SIB had lower rates acute toxicity according to Grade 3 or greater mucositis (3D-CRT: 44.0% vs. IMRTseq: 36.7% vs. IMRT+SIB: 22.4%; P<.0001), dermatitis (3D-CRT: 44.0% vs. IMRTseq: 20.0% vs. IMRT+SIB: 7.5%; P<.0001) and feeding tube placement during radiotherapy (3D-CRT: 80.0% vs. IMRTseq: 50.8% vs. IMRT+SIB: 44.0%; P<.0001) as well as late toxicity as measured by feeding tube use (P<.0001) and tracheostomy use (P<.0001). On multivariate analysis, IMRT+SIB predicted for less mucositis, dermatitis and feeding tube use compared to 3D-CRT and for less dermatitis compared to IMRTseq.

CONCLUSIONS

Compared to 3D-CRT and IMRTseq, IMRT+SIB provided similar outcomes and potentially less toxicity indicating it is a feasible technique for chemoradiation in locally advanced head and neck cancer.

Conventional 2D (2DRT) and 3D conformal radiotherapy (3DCRT) versus intensity-modulated radiotherapy (IMRT) for nasopharyngeal cancer treatment

PURPOSE

Nasopharyngeal carcinoma represents a distinct entity as compared to other head and neck tumours. Radio-chemotherapy is the treatment of first choice in non-metastatic disease. Intensity-modulated radiation therapy (IMRT) allows the sparing of parotid glands, improving the toxicity profile. The aim of this study was to compare the results obtained with IMRT with those obtained with conventional 2D (2DRT) and 3D conformal radiation therapy (3DCRT) in terms of tumour control, survival, acute and late toxicity.

MATERIALS AND METHODS

We reviewed the clinical records of 52 patients with histologically proven carcinoma of the nasopharynx (stage I-IVB according to the 2002 American Joint Committee on Cancer staging system) treated with curative intent between January 2003 and August 2011: 26 patients were treated with 2D or 3D technique (arm A) and 26 with IMRT technique (arm B) with simultaneous integrated boost. Fifty patients (96 %) received chemotherapy. Local control (LC), locoregional control (LRC), disease-free survival (DFS), overall survival (OS), acute and late toxicity were retrospectively evaluated.

RESULTS

After a median follow-up of 37.6 months (69 months in arm A and 23 months in arm B), 69 % of patients were alive and disease-free, 10 % were alive with disease and 21 % died of disease, with an OS of 81 % at 2 years and 79 % at 5 years, a LC rate of 88 % at 2 years and 78 % at 5 years, a LRC rate of 80 % at 2 years and 73 % at 5 years and a DFS of 74 % at 2 years and 65 % at 5 years, with no statistically significant differences between IMRT and 2DRT/3DCRT. In multivariate analysis, the TNM stage and the volume treated at high dose correlated with DFS. No factor was found to be related to OS. Chronic toxicity was not statistically different in the two study groups and in particular ≥ G2 xerostomia rates were 67 and 41 % in arm A and B, respectively (p = 0.10).

CONCLUSIONS

The findings of this study confirm that IMRT associated with chemotherapy, even with moderately hypofractionated regimens, allows good disease control with better results in terms of late xerostomia, although without statistically significant differences compared to 2DRT and 3DCRT. The hypothesis of an impact of IMRT on survival has yet to be confirmed.

Recurrence of nasopharyngeal carcinoma in the parotid region after definitive intensity-modulated radiotherapy

PURPOSE

To discuss the clinical characteristics and management of periparotid recurrence of nasopharyngeal carcinoma after definitive intensity-modulated radiotherapy.

PATIENTS AND METHODS

The authors retrospectively reviewed the charts of 716 patients with nasopharyngeal carcinoma who underwent intensity-modulated radiotherapy at their center from January 2005 through December 2010. Disease recurred in a spared parotid gland in 10 patients (1.4%). After periparotid recurrence, 4 patients received surgery alone, 1 patient received radiotherapy alone, 2 patients received chemotherapy alone, 2 patients received surgery plus chemotherapy, and 1 patient received surgery plus radiotherapy.

RESULTS

After a median follow-up of 42.6 months (19.8 to 86.0 months), 4 patients died of tumor progression. The median survival time after periparotid recurrence was 25.1 months (5.0 to 74.5 months).

CONCLUSIONS

Periparotid recurrence is an uncommon pattern of failure after definitive intensity-modulated radiotherapy for nasopharyngeal carcinoma, and there were some long-term survivors in this patient population after salvage treatment.

Intensity-modulated radiation therapy for T4 nasopharyngeal carcinoma. Treatment results and locoregional recurrence

PURPOSE

The purpose of this work was to examine outcomes in patients with T4 nasopharyngeal carcinoma (NPC) treated with intensity-modulated radiation therapy (IMRT).

METHODS AND MATERIALS

Between 2007 and 2010, 154 patients with nonmetastatic T4 NPC were treated with IMRT to a total dose of 70 Gy in 33-35 fractions. In addition, 97% of patients received concurrent platinum-based chemotherapy. The median follow-up time was 52.8 months.

RESULTS

The rates of 5-year actuarial locoregional control, distant metastasis-free survival, progression free-survival, and overall survival (OS) were 81.2, 72.2, 61.9, and 78.1%, respectively. A total of 27 patients had locoregional recurrence: 85.2% in-field failures, 11.1% marginal failures, and 3.7% out-of-field failures. Fourteen patients with locoregional recurrence received aggressive treatments, including nasopharyngectomy, neck dissection, or re-irradiation, and the 5-year OS rate tended to be better (61.9%) compared to those receiving conservative treatment (32.0%, p=0.051). In patients treated with 1 course of radiotherapy, grade ≥3 toxicities of ototoxicity, neck fibrosis, xerostomia, epistaxis, and radiographic temporal lobe necrosis occurred in 18.2, 9.8, 6.3, 2.1, and 5.6% of patients, respectively. Increased ototoxicity, osteonecrosis, severe nasal bleeding, and temporal necrosis were observed in patients treated by re-irradiation.

CONCLUSION

IMRT offers good locoregional control in patients with T4 NPC. For patients with locoregional recurrence after definitive radiotherapy, aggressive local treatment may be considered for a better outcome.

Rathke's cleft cyst recurrence after transsphenoidal surgery: a meta-analysis of 1151 cases

Rathke's cleft cysts (RCC) arise from the development of the Rathke's cleft pouch. These commonly occurring cysts are typically asymptomatic, but sometimes present with headaches, endocrine dysfunction, and visual loss. Recurrence is common after either drainage or surgical removal. The purpose of this study was to review published outcomes for RCC management, and determine whether specific factors, including patient demographics, cyst pathology, radiologic parameters, or surgical techniques predispose to their recurrence. A systematic review of studies for RCC from 1990 to 2012 was conducted. Patients were identified using a Medline/PubMed search, and from the bibliographies of relevant articles obtained from the primary search. Relevant studies reporting recurrence rate were identified, and data were extracted regarding patient demographics, presenting symptoms, cyst characteristics, surgical treatment, and outcomes. A meta-analysis for recurrence rates was also performed. Twenty-eight journal articles comprising a total of 1151 RCC revealed an average follow-up of 38 months (range 16-79 months). In the studies reviewed, there was a relatively equal distribution of treatment approaches, with 35% subtotal resection, 33% gross total resection, and 32% complete drainage with wall biopsy. The microsurgical transsphenoidal approach was found to have a higher recurrence rate (14% versus 8%) and new endocrine dysfunction rate (25% versus 10%) compared to the endoscopic approach. The data demonstrates a notable overall recurrence rate for RCC (12.5%). However, there appears to be no conclusive evidence that more aggressive resection of the cyst wall results in lower rates of recurrence.

Current controversies in radiotherapy for nasopharyngeal carcinoma (NPC)

Radiotherapy has a good track record in the treatment of NPC, yet the late toxicity profile and local failure rate for locally advanced disease remain a concern. Modern RT techniques incorporating IMRT and IGRT have widened our potential in treating NPC more effectively, and shall be regarded as the standard of care. Out of the various dose fractionation regimens in IMRT, 70 Gy in 35 fractions or the mini-SIB proves to be safe in combination with chemotherapy, but any further attempt of dose escalation must be tried out with extreme caution to avoid severe toxicities. CT-MRI image fusion improves the accuracy of GTV delineation, whereas the role of PET-CT has yet to be verified. RTOG definition of the CTV provides a reasonable template for the inclusion of sites at risk of microscopic involvement, and fine tuning has to be made in the future based on careful analysis of the pattern of local failure with long term follow-up. Toxicity reduction via radiation volume or dose reduction is tempting, but once again it has to be tested under scrutiny. Retrospective data have emerged that suggest a benefit of using adaptive IMRT replanning in NPC, however the optimal timing or frequency of replanning is still unclear. Future prospective studies are thus required to evaluate the cost-effectiveness of adaptive RT and streamline the workflow logistics before it can be widely accepted in routine practice.

Critical analysis of locoregional failures following intensity-modulated radiotherapy for nasopharyngeal carcinoma

AIM

To analyze the patterns of locoregional failure following intensity-modulated radiotherapy (IMRT) for nasopharyngeal carcinoma (NPC) at our institution, as part of an internal quality assurance program. We aimed to investigate the potential existence of a correlation between any part of the IMRT process and clinical outcome.

METHODS & MATERIALS

A total of 106 non-metastatic NPC patients consecutively treated with IMRT (with or without chemotherapy) were analyzed. Radiotherapy was administered using a sequential or simultaneous integrated boost approach at the total prescribed dose of 66-70 Gy (2.00-2.12 Gy per fraction). MRI studies of recurrences were recorded with the planning computed tomography studies to identify volume of failure. Recurrence-related characteristics were analyzed with respect to the original treatment. Failures were classified as 'in-field', 'marginal' or 'out-field' if at least 95, 20-95 or less than 20% of the volume of failure, respectively, was within 95% of the total prescription dose.

RESULTS

With a median follow-up of 43.4 months, 5-years local control, regional control, locoregional control and overall survival rates were 87.7, 88.0, 83.5 and 81.3% respectively. A total of 21 failures were registered in 15 patients. In particular, ten failures (47.6%) were classified as 'in-field' (seven local failures and three regional failures [RFs]), nine failures (42.9%) as 'marginal' (five local failures and four RFs) and only two failures (9.5%) as 'out-field' (both RFs). The most relevant causes of failures were suboptimal target definition and target coverage as well as a longer than planned overall treatment time.

CONCLUSION

IMRT determines excellent outcome in NPC patients. However, great attention in all IMRT steps is necessary to reduce potential causes of failure.

Phase I/II study of induction chemotherapy plus concurrent chemotherapy and SMART-IMRT-based radiotherapy in locoregionally-advanced nasopharyngeal cancer

This study aimed to evaluate the efficacy, toxicity and tolerability of simultaneous modulated accelerated radiation therapy (SMART)-intensity modulated radiotherapy (IMRT) plus cisplatin and 5-fluorouracil (5-FU) chemotherapy for patients with advanced nasopharyngeal cancer (NPC). Forty-five patients with stage II–IV NPC, determined by the American Joint Committee on Cancer system, were treated with prescribed doses of 72 Gy total to the gross tumor volume, 60 Gy to the clinical target volume and metastatic nodal station, and 54 Gy to the clinically-negative neck region. Before radiotherapy, two cycles of cisplatin (30 mg/m²/day on days 1–3) plus 5-FU (400 mg/m²/day on days 1–5) were delivered every three weeks for two cycles. Patients received two cycles of cisplatin (30 mg/m² day on days 1–3) every three weeks during radiotherapy. In addition, two cycles of cisplatin and 5-FU were given after radiation. All patients completed the prescribed radiotherapy and all scheduled cycles of chemotherapy. Thirty of the 45 patients (66.6%) had a complete response at the end of treatment. Grade 3 mucositis occurred in 4/45 patients (8.8%) and grade 3 dermatitis occurred in 5/45 (11.1%) during radiotherapy. Grade 3 neutropenia occurred in 6/45 (13.3%) during concurrent chemotherapy. There was no treatment-related mortality. After a median follow-up time of 51 months, only three patients’ treatments had failed. Local and distant failure rates were 1.5 and 3.0%, respectively. SMART-IMRT plus cisplatin and 5-FU chemotherapy showed promising activity with manageable toxicity. It is a feasible regimen and improves locoregional disease control.

Clinical outcomes and patterns of failure after intensity-modulated radiotherapy for T4 nasopharyngeal carcinoma

The goal of this study is to study and report the clinical outcomes and patterns of failure after intensity-modulated radiotherapy (IMRT) for T4 nasopharyngeal carcinoma (NPC). A total of 70 patients treated with IMRT between 2004 and 2009 were eligible for study inclusion. According to the staging system of 2010 AJCC, all the primary tumors were attributed to T4 stage, while the distribution of disease by N stage was N0 in 2, N1 in 23, N2 in 39, N3a in 1, and N3b in 5. The location and extent of locoregional failures were transferred to the pretreatment planning computed tomography for dosimetry analysis. The median follow-up period was 26.8 (range, 4-78) months. The overall 2-year local failure-free survival, regional failure-free survival, distant failure-free survival, and overall survival rate was 82.1%, 92.3%, 73.8%, and 82.5%, respectively. Thirty-three patients had developed treatment failure. Of the 33 patients, 11, 2, and 15 had developed local failure, regional failure, and distant metastasis, respectively, 2 had developed locoregional failure, 1 had developed distant metastasis and failure at the primary, and 2 had developed distant metastasis and failure at the primary and nodal site. Eight of the locoregional failures were marginal. The results of treating T4 NPC with IMRT were excellent. Advanced T4 disease remained difficult to treat. One possible strategy is to lessen the dose constraint criteria of selected neurologic structures. Distant metastasis remains the most difficult treatment challenge for patients with T4 NPC at present, and more effective systemic chemotherapy should be explored.

Definitive intensity-modulated radiation therapy for nasopharyngeal carcinoma: long-term outcome of a multicenter prospective study

PURPOSE

To evaluate long-term outcome in nasopharyngeal carcinoma (NPC) treated with intensity-modulated radiation therapy.

METHODS

Between January 2006 and August 2008, 300 patients with histologically proven NPC were enrolled in this multicenter prospective study. All patients received definitive IMRT. Cisplatin-based concurrent chemotherapy was given to patients with stages III-IVb disease.

RESULTS

Median follow-up time was 47.1 months (range 11-68 months). Median survival time was not reached. For all patients, the 4-year local control (LC), regional control (RC), distant metastasis-free survival (DMFS), and overall survival (OS) were 94.0, 95.1, 85.0, and 86.1 %, respectively. Thirty-five patients experienced locoregional failures: 18 were local only, 15 were regional only, and 2 were both local and regional. Forty-two patients developed distant metastasis. Of these, 32 patients had single organ metastasis, and 10 patients had multiple organ metastasis. The most common acute toxicities were mucositis, dermatitis, and xerostomia. Grade 0-2 mucositis, dermatitis, and xerostomia occurred in 200 patients (66.7 %), 288 patients (96.0 %), and 286 patients (95.3 %), respectively. Grade 3 mucositis, dermatitis, and xerostomia were seen in 100 patients (33.3 %), 12 patients (4.0 %), and 14 patients (4.7 %), respectively. No Grade 4 acute toxicities were observed. The most common late toxicity for 284 patients who survived for more than 2 years was xerostomia. At 3 months after treatment, 16.2 % of patients had Grade 1, 73.6 % had Grade 2, and 10.2 % had Grade 3 xerostomia. However, the severity of xerostomia decreased over time. At 24 months, only 12.3 % of patients had Grade 2 xerostomia, and none had Grade 3 or 4 xerostomia.

CONCLUSIONS

IMRT for NPC patients achieved excellent long-term locoregional control (LRC) and OS, with acceptable acute and late toxicities. After the treatment, xerostomia was improved over time. Distant metastasis remained the main cause of failure. More effective systemic therapy is demanding for reducing the risk of distant metastasis.

Pretreatment lifestyle behaviors as survival predictors for patients with nasopharyngeal carcinoma

BACKGROUND

Lifestyle behaviors have been widely reported to influence the survival of patients with head and neck cancer. However, the relationship between pretreatment lifestyle behaviors and survival among patients with nasopharyngeal carcinoma (NPC) is unclear.

METHODS

A prospective cohort study was designed to determine the relationship between lifestyle behaviors and survival in 1,533 NPC patients recruited from October 2005 to October 2007. Pretreatment lifestyle behaviors (such as body-mass index [BMI], smoking, alcohol, diet) of the patients were investigated. Univariate and multivariate proportional-hazards models were used to assess the impact of lifestyle behaviors on patient survival.

RESULTS

Smoking was a predictor of survival; both current smokers (hazard ratio [HR] = 1.88; 95% CI, 1.33 to 2.65) and heavy smokers (≥ 25 Pack-years; HR = 1.84; 95% CI, 1.30 to 2.60) showed associations with poor survival. Higher BMI was significantly associated with a lower risk of death (P(trend) = 0.002). Compared with under/normal-weight patients (BMI less than 22.99 kg/m(2)), the multivariate HR for survival was 0.66 (95% CI, 0.48 to 0.90) and 0.47 (95% CI, 0.23 to 0.97) for overweight and obese patients, respectively. No alcohol intake and high fruit intake were associated with favorable survival in the univariate analysis but lost significance in the multivariate model.

CONCLUSION

Our findings indicate that pretreatment lifestyle behaviors, especially smoking status and BMI, as easily available data, provide prognostic value for survival in NPC patients.

A benchmark study on 883 nasopharyngeal cancer patients treated in two Italian centres from 1977 to 2000. Part I: Evolving technical choices and survival

PURPOSE

The authors sought to define treatment results according to the different accrual periods and clinical-therapeutic features in a large series of nasopharyngeal cancer (NPC) patients treated in two Italian centres over more than two decades.

MATERIALS AND METHODS

A total of 883 patients consecutively treated with radiotherapy between 1977 and 2000 at the Florence (FLO) and Brescia (IRA) Radiation Oncology centres were studied. Five-year overall (OS) and disease-specific (DSS) actuarial survival rates in the different pathological, clinical and therapeutic subgroups were calculated, along with the actuarial local-regional control (LRC) probability.

RESULTS

At univariate analysis, survival and local control rates were significantly better in the more recent accrual periods and in the more favourable disease presentations; treatment-related parameters mainly affect LRC. At multivariate analysis, patient- and disease-related factors had a more evident prognostic effect than did therapeutic factors, although dose to the nasopharynx and treatment technique had a marginally significant impact on DSS and OS.

CONCLUSIONS

Results of this benchmark study may be useful for understanding the development of new radio-therapy techniques for NPC, such as three-dimensional conformal radiotherapy (3D-CRT) and particularly intensity-modulated radiotherapy (IMRT).

A benchmark study on 883 nasopharyngeal cancer patients treated in two Italian centres from 1977 to 2000. Part II: Evolving technical choices and toxicity patterns

PURPOSE

The authors sought to define toxicity patterns according to the different accrual periods and clinical-therapeutic features in a large series of nasopharyngeal cancer (NPC) patients treated in two Italian centres over more than two decades.

MATERIALS AND METHODS

A total of 883 patients consecutively treated with radiotherapy from 1977 to 2000 at the Florence (FLO) and Brescia (IRA) radiation oncology centres were studied. The crude incidence of late treatment toxicity in the different subgroups of patients was calculated and compared.

RESULTS

Higher total and fractional doses and the "older" treatment techniques were related with an increased incidence of the main late effects of treatment. More recently treated patients experienced less treatment-related complications.

CONCLUSIONS

Results of this benchmark study may have implications for understanding and developing new radiotherapy techniques, such as three-dimensional conformal radiotherapy (3D-CRT) and, in particular, intensity-modulated radiotherapy (IMRT) for NPC patients.

Clinical observation of 73 nasopharyngeal carcinoma patients treated by helical tomotherapy: the China experience

The preliminary short-term clinical outcome of 73 nasopharyngeal carcinoma (NPC) patients treated with helical tomotherapy at our cancer institute has been evaluated. Between September 2007 and September 2009, 73 newly diagnosed NPC patients were treated with helical tomotherapy. The distributions of clinical stages according to the UICC 2002 Staging System were: 6, 27, 24, and 16 for Stage I, IIa-b, III, and IVa-b, respectively. The prescription dose was 70-74 Gy/33F to planning gross tumor volume containing the primary tumor and positive lymph nodes, with 60-62.7 Gy/33F to high risk planning target volume, while delivering 52-56 Gy/33F to low risk planning target volume. Twenty-four patients were treated with radiation therapy as single modality, 25 with concurrent cisplatin-based chemotherapy with or without anti-EGFR monoclonal antibody therapy, and 24 with concurrent anti-EGFR monoclonal antibody therapy. Setup errors were analyzed. Side-effects were evaluated with the established RTOG/EORTC criteria. Average beam-on-time was 468.8 sec/F (396.7-696.1 sec). The setup errors in the lateral, longitudinal and vertical directions were 0.00 ± 1.79 mm, -0.55± 2.17 mm and 0.38 ± 1.43 mm, corresponding to 3.80 mm, 4.20 mm, and 2.46 mm as the CTV-PTV margin in these directions. The grade 0, 1, 2 and 3 acute skin toxicity was 2.7%, 76.7%, 13.8% and 6.8%; the grade 0, 1, 2 and 3 acute mucositis was 1.4%, 32.9%, 60.2% and 5.5%; and the grade 0, 1, 2 and 3 acute xerostomia was 4.0%, 45.3%, 50.7% and 0, respectively. Only 5 patients suffered from grade 3 or 4 leucopenia. Xerostomia resolved with passing of time and no grade 2 or more xerostomia was noted one year after radiation therapy. Concurrent chemotherapy significantly increased incidence of severe acute toxicities. One month after radiation therapy the remission rates of primary tumor and positive lymph nodes were 91.8% and 98.1%, respectively. The median follow-up was 14.8 months. The one-year relapse-free survival, distant metastasis-free survival and overall survival was 95.6%, 97.2% and 94.8%, respectively. In conclusion, the incidence of severe acute toxicities and late xerostomia was relatively infrequent for NPC patients treated with helical tomotherapy. The long-term clinical outcome for these patients is under investigation.

Docetaxel, cisplatin and 5-fluorouracil-based induction chemotherapy followed by intensity-modulated radiotherapy concurrent with cisplatin in locally advanced EBV-related nasopharyngeal cancer

BACKGROUND

This monocentric study evaluates the activity and tolerability of docetaxel (Taxotere), cisplatin and 5-fluorouracil (5-FU) (TPF) induction chemotherapy followed by intensity-modulated radiotherapy (IMRT) concurrent with high-dose cisplatin in Epstein-Barr virus -related locally advanced undifferentiated nasopharyngeal cancer.

PATIENTS AND METHODS

We retrospectively reviewed the records of patients who received induction docetaxel 75 mg/m(2) and cisplatin 75 mg/m(2) on day 1, and 5-FU 750 mg/m(2)/day (96-h continuous infusion). Following induction, patients received full doses of IMRT concurrently with cisplatin 100 mg/m(2) every 21 days for three cycles.

RESULTS

Thirty patients received three TPF cycles (median). Induction was well tolerated; the main toxicity was neutropenia (33%, grade 3-4). During chemoradiotherapy, neutropenia (40%) and mucositis (43%) were the most frequent grade 3-4 adverse events. Mean dose of IMRT was 68.8 Gy. Worst late toxicity was xerostomia. Complete response rate was 93%. At 35 months, two patients had locoregional recurrence, three had distant metastases, and one had both. Three-year progression-free survival and overall survival were 79% [95% confidence interval (CI) 64% to 94%] and 87% (95% CI 74%- to 100%), respectively.

CONCLUSIONS

In this high-stage nonendemic cancer population, TPF followed by high-dose cisplatin IMRT was promising; this treatment approach deserves evaluation in randomized trials.

Feasibility and efficacy study of weekly cisplatin with concurrent intensity-modulated radiation therapy for nasopharyngeal carcinoma: preliminary results

The aim of this study was to assess the feasibility and efficacy of a weekly cisplatin 40 mg/m(2) regimen in patients with nasopharyngeal carcinoma treated concurrently with definitive intensity-modulated radiation therapy (IMRT). The primary endpoints were treatment compliance and acute toxicities. Twenty-two patients with newly diagnosed NPC were recruited in this phase II trial. All patients received definitive IMRT concurrently with weekly cisplatin 40 mg/m(2) for six cycles. The treatment technique was split-field IMRT (SF-IMRT) before August 2009 and whole-field IMRT (WF-IMRT) thereafter. The median follow-up time was 15.1 months (range, 1.5-30 months). No patients experienced regional recurrence or distant metastasis. One patient developed local recurrence. One patient died of non-malignant disease. For all patients, the 1-year overall survival, local recurrence-free survival, regional recurrence-free survival, and distant metastasis-free survival were 95.5%, 95.5%, 100%, and 100%, respectively. All patients received the full dose of RT. Twenty-one patients (95.5%) completed all six cycles of chemotherapy (CHT). Three patients experienced treatment delay. Of them, one had CHT delay, and the other two had IMRT delay. No treatment-related death was found. Acute toxicities were generally mild or moderate. Grade 3 and 4 toxicities accounted for less than 10% of overall occurrence in each corresponding category except for a relatively higher rate in stomatitis (Grade 3, 27%). Renal function impairment was not found. Weekly cisplatin with concurrent IMRT appears to be feasible and effective in treating NPC patients and these findings warrant further investigation.

Cognitive function before and after intensity-modulated radiation therapy in patients with nasopharyngeal carcinoma: a prospective study

PURPOSE

To evaluate the effects of radiation therapy (RT) on neurocognitive function in patients with nasopharyngeal carcinoma (NPC).

METHODS AND MATERIALS

Thirty patients with NPC treated with intensity-modulated RT were included. Dose-volume histograms of the temporal lobes were obtained in every patient. Neurocognitive tests were administered individually to each patient 1 day before initiation of RT and at least 12 months after completion of RT. Cognitive functioning status was evaluated as change in scores over time.

RESULTS

Among the total of 30 patients, 23 patients (76.7%) had significantly lower post-RT cognitive functioning scores compared with their pre-RT scores (p = 0.033). The cognitive functioning scores had significantly declined in the domains of short-term memory, language abilities, and list-generating fluency (p = 0.020, 0.023, and 0.001, respectively). Compared with patients with a mean dose to the temporal lobes of 36 Gy or less, patients with a mean dose of greater than 36 Gy had a significantly greater reduction in cognitive functioning scores (p = 0.017). Patients in whom V60 of the temporal lobes (i.e., the percentage of the temporal lobe volume that had received >60 Gy) was greater than 10% also had a greater reduction in cognitive functioning scores than those in whom V60 was 10% or less (p = 0.039).

CONCLUSIONS

The results of our study indicated that RT could have deleterious effects on cognitive function in patients with NPC. Efforts should be made to reduce the radiation dose and irradiated volume of temporal lobes without compromising the coverage of target volume.

Whole-field simultaneous integrated-boost intensity-modulated radiotherapy for patients with nasopharyngeal carcinoma

PURPOSE

To retrospectively review the outcomes of our patients with newly diagnosed nondisseminated nasopharyngeal carcinoma treated with intensity-modulated radiotherapy using a whole-field simultaneous integrated-boost technique.

METHODS AND MATERIALS

A total of 175 patients treated with WF-SIB between mid-2004 and 2005 were eligible for study inclusion. The distribution of disease by stage was Stage IA in 10.9%, Stage IIA in 2.3%, Stage IIB in 21.7%, Stage III in 41.1%, Stage IVA in 14.9%, and Stage IVB in 9.1%. Of the 175 patients, 2 (1.2%), 10 (5.7%), and 163 (93.1%) had World Health Organization type I, II, and III histologic features, respectively. We prescribed 70 Gy, 60 Gy, and 54 Gy delivered in 33 fractions within 6.5 weeks at the periphery of three planning target volumes (PTV; PTV70, PTV60, and PTV54, respectively). Of the 175 patients, 46 with early T-stage disease received a brachytherapy boost, and 127 with advanced local or regional disease received chemotherapy.

RESULTS

The median follow-up period was 34 months. The overall 3-year local failure-free survival, regional failure-free survival, distant failure-free survival, and overall survival rate was 93.6%, 93.3%, 86.6%, and 87.2%, respectively. Cox regression analysis showed Stage N2-N3 disease (p = .029) and PTV (p = .024) to be independent factors predicting a greater risk of distant failure and poor overall survival, respectively. Grade 3 acute mucositis/pharyngitis occurred in 23.4% of patients, and Stage T4 disease was the only significant predictor of mucositis/pharyngitis (p = .021).

CONCLUSION

Whole-field simultaneous integrated-boost intensity-modulated radiotherapy with a dose >70 Gy achieved excellent locoregional control, without an excess incidence of severe, acute mucositis/pharyngitis, in the present study. Strategies for using such highly conformal treatment for patients with a large tumor and late N-stage disease are potential areas of investigation for future studies.

High dose three-dimensional conformal boost using the real-time tumor tracking radiotherapy system in cervical cancer patients unable to receive intracavitary brachytherapy

PURPOSE

The purpose of this study is to evaluate the clinical results of treatment with a high dose of 3-dimensional conformal boost (3DCB) using a real-time tracking radiation therapy (RTRT) system in cervical cancer patients.

MATERIALS AND METHODS

Between January 2001 and December 2004, 10 patients with cervical cancer were treated with a high dose 3DCB using RTRT system. Nine patients received whole pelvis radiation therapy (RT) with a median dose of 50 Gy (range, 40-50 Gy) before the 3DCB. The median dose of the 3DCB was 30 Gy (range, 25-30 Gy). Eight patients received the 3DCB twice a week with a daily fraction of 5 Gy. The determined endpoints were tumor response, overall survival, local failure free survival, and distant metastasis free survival. The duration of survival was calculated from the time of the start of radiotherapy.

RESULTS

All patients were alive at the time of analysis and the median follow-up was 17.6 months (range, 4.9-27.3 months). Complete response was achieved in nine patients and one patient had a partial response. The 1- and 2-year local failure free survival was 78.8% and 54%, respectively. The 1- and 2-year distant metastasis free survival was 90% and 72%, respectively. Late toxicity of a grade 2 rectal hemorrhage was seen in one patient. A subcutaneous abscess was encountered in one patient.

CONCLUSION

The use of the high dose 3DCB in the treatment of cervical cancer is safe and feasible where intracavitary brachytherapy (ICBT) is unable to be performed. The escalation of the 3DCB dose is currently under evaluation.

Intensity-modulated radiation therapy with simultaneous integrated boost technique following neoadjuvant chemotherapy for locoregionally advanced nasopharyngeal carcinoma

BACKGROUND

Our aim was to evaluate the feasibility and efficacy of intensity-modulated radiation therapy (IMRT) with simultaneous integrated boost (SIB) technique following neoadjuvant chemotherapy for locoregionally advanced nasopharyngeal cancer (NPC).

METHODS

Between April 2004 and December 2006, 25 patients with stage IIB to IVB NPC underwent 3 cycles of neoadjuvant chemotherapy followed by IMRT using SIB technique. Neoadjuvant chemotherapeutic regimens were 5-fluorouracil and cisplatin in 11 patients; docetaxel, 5-fluorouracil, and cisplatin in 8; and paclitaxel and cisplatin in 6. Dose prescription of IMRT was as follows: 67.5 Gy at 2.25 Gy/fraction to postchemotherapy gross tumor, 54 to 60 Gy at 1.8 to 2 Gy/fraction to subclinical disease, and 48 Gy at 1.6 Gy/fraction to elective neck. Seventeen patients received weekly cisplatin during the course of radiation therapy as well.

RESULTS

With a median follow-up of 29 months for survivors (range, 14-39), the 3-year local progression-free, regional progression-free, and distant metastasis-free survival rates were 89.6%, 87.2%, and 80.4%, respectively. Treatment was well tolerated despite the grade 3 mucositis (16%) and/or pharyngitis (16%). With follow-up, the frequency of xerostomia decreased. At 3 months after IMRT, the proportions of Radiation Therapy Oncology Group grades 0, 1, and 2 xerostomia were 13%, 38%, and 50%, respectively. At 24 months, the corresponding figures were 36%, 46%, and 18%, respectively.

CONCLUSION

IMRT with SIB technique for locoregionally advanced NPC was feasible and effective regarding locoregional control and development of xerostomia, even after neoadjuvant chemotherapy. Definition of gross tumor volume by postchemotherapy extent of disease was also feasible.

Radiobiological basis and clinical results of the simultaneous integrated boost (SIB) in intensity modulated radiotherapy (IMRT) for head and neck cancer: A review

The simultaneous integrated boost (SIB)-IMRT technique allows the simultaneous delivery of different dose levels to different target volumes within a single treatment fraction. The most significant aspect associated with SIB-IMRT is related to the fractionation strategy, concerning two time-dose parameters: (1) the shortening of the overall treatment time (OTT); (2) the increase of fraction size (FS) to the boost volume. The SIB-IMRT technique represents, therefore, a new way to investigate the accelerated fractionation in definitive treatment of head and neck (H&N) cancers. The aims of this paper are the following: (1) to briefly review the influence of OTT and FS on H&N tumors and on acutely and late responding normal tissues; (2) to review the results of clinical studies of accelerated radiotherapy not employing IMRT in H&N cancer; (3) to review the clinical experiences of the SIB-IMRT technique and to compare the different SIB regimes in terms of radiobiological efficacy.

Multi-institutional comparison of intensity modulated radiation therapy (IMRT) planning strategies and planning results for nasopharyngeal cancer

The intensity-modulated radiation therapy (IMRT) planning strategies for nasopharyngeal cancer among Korean radiation oncology facilities were investigated. Five institutions with IMRT planning capacity using the same planning system were invited to participate in this study. The institutions were requested to produce the best plan possible for 2 cases that would deliver 70 Gy to the planning target volume of gross tumor (PTV1), 59.4 Gy to the PTV2, and 51.5 Gy to the PTV3 in which elective irradiation was required. The advised fractionation number was 33. The planning parameters, resultant dose distributions, and biological indices were compared. We found 2-3-fold variations in the volume of treatment targets. Similar degree of variation was found in the delineation of normal tissue. The physician-related factors in IMRT planning had more influence on the plan quality. The inhomogeneity index of PTV dose ranged from 4 to 49% in Case 1, and from 5 to 46% in Case 2. Variation in tumor control probabilities for the primary lesion and involved LNs was less marked. Normal tissue complication probabilities for parotid glands and skin showed marked variation. Results from this study suggest that greater efforts in providing training and continuing education in terms of IMRT planning parameters usually set by physician are necessary for the successful implementation of IMRT.

Further improvement in outcomes of nasopharyngeal carcinoma with optimized radiotherapy and induction plus concomitant chemotherapy: an update of the Milan experience

PURPOSE

To report the outcome of a consecutive series of patients with nonmetastatic nasopharyngeal carcinoma (NPC), focusing on the impact of treatment-related factors.

METHODS AND MATERIALS

Between 2000 and 2006, 87 patients with NPC were treated with either conventional (two- or three-dimensional) radiotherapy (RT) or with intensity-modulated RT (IMRT). Of these patients, 81 (93%) received either concomitant CHT (24%) or both induction and concomitant chemotherapy (CHT) (69%). Stage was III in 36% and IV in 39% of patients. Outcomes in this study population were compared with those in the previous series of 171 patients treated during 1990 to 1999.

RESULTS

With a median follow-up of 46 months, actuarial rates at 3 years were the following: local control, 96%; local-regional control, 93%; distant control (DC), 90%; disease-free survival (DFS), 82%; overall survival, 90%. In Stage III to IV patients, distant control at 3 years was 56% in patients treated with concomitant CHT only and 92% in patients treated with both induction and concomitant CHT (p = 0.014). At multivariate analysis, histology, N-stage, RT technique, and total RT dose had the strongest independent impact on DFS (p < 0.05). Induction CHT had a borderline effect on DC (p = 0.07). Most dosimetric statistics were improved in the group of patients treated with IMRT compared with conventional 3D technique. All outcome endpoints were substantially better in the study population compared with those in the previous series.

CONCLUSIONS

Outcome of NPC has further improved in the study period compared with the previous decade, with a significant effect of RT technique optimization. The impact of induction CHT remains to be demonstrated in controlled trials.

Concurrent chemoradiotherapy in locally advanced nasopharyngeal carcinoma: a treatment paradigm also applicable to patients in Southeast Asia

The majority of nasopharyngeal carcinoma (NPC) patients present at locally advanced stage. The poor prognosis has led to increasing interests in exploring the use of chemotherapy (CT). Intergroup-0099 trial was the first randomized trial comparing concurrent chemoradiotherapy (CCRT) with radiotherapy (RT) alone. Its outcome established the treatment standard in the United States as standard of care for locally advanced NPC. However, criticism has been arisen, particularly about its reproducibility and applicability in Southeast Asia where NPC is an endemic disease. Subsequently, new evidence has been provided by a large number of publications from various centers. In this article, through comprehensively analyzing recent meta-analyses and randomized controlled trials performed in Asian centers, we conclude that CCRT as a treatment paradigm is also applicable to patients in Southeast Asia and should be standard of practice in locally advanced disease. However, the CT regimen varied markedly among those trials, and the optimal regimen and scheduling remains to be determined. Moreover, a number of patients experienced toxicities and the treatment compliance was generally poor. With the emergence of new RT techniques such as intensity-modulated radiotherapy (IMRT) and image-guided radiotherapy (IGRT), the role of concurrent CT with these new techniques needs to be tested. New chemotherapeutics have been investigated in the recurrent or metastatic disease. However, their effectiveness in previously untreated NPC is unclear. Previous efforts have been made for immunotherapy and targeted therapy in palliative setting. Their role in newly diagnosed NPC should be evaluated, particularly when they are combined with CT or RT.