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Sharma R, Vats S, Seam R, Gupta M, Negi RR, Fotedar V, Singh K. A Comparison of the Toxicities in Patients With Locally Advanced Head and Neck Cancers Treated With Concomitant Boost Radiotherapy Versus Conventional Chemoradiation. Cureus 2023; 15:e38362. [PMID: 37266055 PMCID: PMC10230179 DOI: 10.7759/cureus.38362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 06/03/2023] Open
Abstract
PURPOSE To compare the objective and patient-reported toxicities of concomitant boost radiotherapy (CBRT) and concurrent chemoradiation (CRT) in patients with locally advanced head and neck cancers. METHODS AND MATERIAL In this prospective study, 46 patients with histologically proven stage III-IVA head and neck cancer were randomly assigned to receive either concurrent chemoradiation to a dose of 66 Gy in 33 fractions over 6.5 weeks with concurrent cisplatin (40 mg/m2 IV weekly; control arm) or accelerated radiotherapy with concomitant boost radiotherapy (study arm) to a dose of 67.5 Gy in 40 fractions in five weeks. Acute toxicity was evaluated using RTOG toxicity criteria. The assessment was done weekly after initiation of treatment, at the first follow-up (six weeks), and at three months. The four main patient-reported symptoms of pain, hoarseness of voice, dryness of mouth, and loss of taste were also compared between the two groups to assess patient quality of life during treatment. RESULTS The mean treatment duration was 37 days in the CBRT arm and 49 days in the CRT arm. Treatment-related interruptions were less in the study group,17.3% in the study, and 27.2% in the control with insignificant P-value. Grade III laryngeal toxicity was significantly higher in the study group (P=0.029). Other acute grade I-III toxicities (pharyngeal, skin, mucositis, and salivary) were comparable in both CRT and CBRT arms. Grade IV toxicities were seen only in the CBRT arm but were resolved at the first follow-up. Haematological toxicities and renal toxicities were significantly higher in the CRT arm, with significant P-values of 0.0004 and 0.018, respectively. CONCLUSION In patients with locally advanced head and neck cancer, concomitant boost radiotherapy is well tolerated with acceptable local toxicity and minimal systemic toxicity as compared to conventional chemoradiation. It is a feasible option for patients with locally advanced head and neck cancer not fit for concurrent chemoradiation.
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Affiliation(s)
- Ritu Sharma
- Department of Radiotherapy, Shri Lal Bahadur Shastri Government Medical College and Hospital, Mandi, IND
| | - Siddharth Vats
- Department of Radiotherapy, Indira Gandhi Medical College, Shimla, IND
| | - Rajeev Seam
- Department of Radiotherapy, Maharishi Markandeshwar Institiute of Medical Sciences and Research, Ambala, IND
| | - Manish Gupta
- Department of Radiotherapy, Indira Gandhi Medical College, Shimla, IND
| | - Ratti R Negi
- Department of Radiotherapy, Shri Lal Bahadur Shastri Government Medical College and Hospital, Mandi, IND
| | - Vikas Fotedar
- Department of Radiotherapy, Indira Gandhi Medical College, Shimla, IND
| | - Kaalindi Singh
- Department of Radiotherapy, Shri Lal Bahadur Shastri Government Medical College and Hospital, Mandi, IND
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Huynh M, Kempson I, Bezak E, Phillips W. Predictive modeling of hypoxic head and neck cancers during fractionated radiotherapy with gold nanoparticle radiosensitization. Med Phys 2021; 48:3120-3133. [PMID: 33818799 DOI: 10.1002/mp.14872] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 03/18/2021] [Accepted: 03/29/2021] [Indexed: 11/05/2022] Open
Abstract
PURPOSE Intrinsic radioresistance and increased proliferation rates in head and neck cancers (HNCs) are associated with negative radiotherapy (RT) treatment responses. The use of gold nanoparticles (AuNPs) as radiosensitizers could enable total radiation dose reduction and lowered radiation toxicity. AuNP radiosensitization may overcome hypoxia-induced radioresistance and treatment-induced accelerated repopulation of cancer cells in HNCs, improving radiotherapy outcomes. METHODS Tumor control was determined by considering individual cancer cell responses in probabilistic computational simulations using HYP-RT software for clinical radiotherapy doses and fractionation schedules along with three different nanoparticle administration schedules. Antagonistic tumor hypoxia and rapid tumor regrowth due to accelerated repopulation of cancers cells were taken into consideration. RESULTS Simulations indicate that tumors that are conventionally uncontrollable can be controlled with AuNP radiosensitization. In simulations where the absence of AuNPs required radiotherapy doses above standard clinical prescriptions, reoccurring AuNP administration allowed for radiation dose reductions below standard clinical dose prescriptions. For example, considering a 2 Gy per fraction radiotherapy schedule, tumor control was achieved with 57.2 ± 5.1 Gy (P = <0.0001) for weekly AuNP administration and 53.0 ± 4.0 Gy (P = <0.0001) for biweekly AuNP administration compared to 69.9 ± 5.8 Gy with no radiosensitization. CONCLUSIONS AuNPs decreased the predicted RT total doses required to achieve tumor control via total stem cell elimination, offering an optimistic prediction and method for which hypoxia-induced and rapidly growing radioresistant tumors are treated more effectively. Outcomes are also shown to be sensitive to the RT schedule with data for hyperfractionated RT indicating the greatest benefits from radiosensitization.
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Affiliation(s)
- Myxuan Huynh
- Cancer Research Institute, University of South Australia, Adelaide, SA, Australia
| | - Ivan Kempson
- Future Industries Institute, University of South Australia, Mawson Lakes, SA, 5095, Australia
| | - Eva Bezak
- Cancer Research Institute, University of South Australia, Adelaide, SA, Australia.,Department of Physics, University of Adelaide, North Terrace, Adelaide, SA, Australia
| | - Wendy Phillips
- Department of Physics, University of Adelaide, North Terrace, Adelaide, SA, Australia.,Department of Medical Physics, Royal Adelaide Hospital, Adelaide, SA, Australia
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Huynh M, Kempson I, Bezak E, Phillips W. In silico modeling of cellular probabilistic nanoparticle radiosensitization in head and neck cancers. Nanomedicine (Lond) 2020; 15:2837-2850. [DOI: 10.2217/nnm-2020-0301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background: The use of gold nanoparticles (AuNPs) as radiosensitizers may offer a new approach in the treatment of head and neck cancers; minimizing treatment-associated toxicities and improving patient outcomes. AuNPs promote localized dose deposition; permitting improved local control and/or dose reduction. Aim: This work aimed to address the theoretical optimization of radiation doses, fractionation and nanoparticle injection schedules to maximize therapeutic benefits. Materials & methods: Probabilistic nanoparticle sensitization factors were incorporated into the individual cell-based HYP-RT computer model of tumor growth and radiotherapy. Results: Total dose outcomes across all radiation therapy treatment regimens were found to be significantly reduced with the presence of AuNPs, with bi-weekly injections showing the most decrease. Conclusion: Outcomes suggest the need for regular AuNP administration to permit effective radiosensitization.
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Affiliation(s)
- Myxuan Huynh
- Cancer Research Institute, University of South Australia, Adelaide, South Australia, Australia
| | - Ivan Kempson
- Future Industries Institute, University of South Australia, Mawson Lakes 5095, South Australia, Australia
| | - Eva Bezak
- Cancer Research Institute, University of South Australia, Adelaide, South Australia, Australia
- Department of Physics, University of Adelaide, North Terrace, Adelaide, South Australia, Australia
| | - Wendy Phillips
- Department of Physics, University of Adelaide, North Terrace, Adelaide, South Australia, Australia
- Department of Medical Physics, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Kodaira T, Kagami Y, Shibata T, Shikama N, Nishimura Y, Ishikura S, Nakamura K, Saito Y, Matsumoto Y, Teshima T, Ito Y, Akimoto T, Nakata K, Toshiyasu T, Nakagawa K, Nagata Y, Nishimura T, Uno T, Kataoka M, Yorozu A, Hiraoka M. Results of a multi-institutional, randomized, non-inferiority, phase III trial of accelerated fractionation versus standard fractionation in radiation therapy for T1-2N0M0 glottic cancer: Japan Clinical Oncology Group Study (JCOG0701). Ann Oncol 2019; 29:992-997. [PMID: 29401241 DOI: 10.1093/annonc/mdy036] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Background We assessed the non-inferiority of accelerated fractionation (AF) (2.4 Gy/fraction) compared with standard fractionation (SF) (2 Gy/fraction) regarding progression-free survival (PFS) in patients with T1-2N0M0 glottic cancer (GC). Patients and methods In this multi-institutional, randomized, phase III trial, patients were enrolled from 32 Japanese institutions. Key inclusion criteria were GC T1-2N0M0, age 20-80, Eastern Cooperative Oncology Group performance status of 0-1, and adequate organ function. Patients were randomly assigned to receive either SF of 66-70 Gy (33-35 fractions), or AF of 60-64.8 Gy (25-27 fractions). The primary end point was the proportion of 3-year PFS. The planned sample size was 360 with a non-inferiority margin of 5%. Results Between 2007 and 2013, 370 patients were randomized (184/186 to SF/AF). Three-year PFS was 79.9% (95% confidence interval [CI] 73.4-85.4) for SF and 81.7% (95% CI 75.4-87.0) for AF (difference 1.8%, 91% CI-5.1% to 8.8%; one-sided P = 0.047 > 0.045). The cumulative incidences of local failure at 3 years for SF/AF were 15.9%/10.3%. No significant difference was observed in 3-year overall survival (OS) between SF and AF. Grade 3 or 4 acute and late toxicities developed in 22 (12.4%)/21 (11.5%) and 2 (1.1%)/1 (0.5%) in the SF/AF arms. Conclusion Although the non-inferiority of AF was not confirmed statistically, the similar efficacy and toxicity of AF compared with SF, as well as the practical convenience of its fewer treatment sessions, suggest the potential of AF as a treatment option for early GC. Clinical trials registration UMIN Clinical Trial Registry, number UMIN000000819.
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Affiliation(s)
- T Kodaira
- Department of Radiation Oncology, Aichi Cancer Center Hospital, Nagoya, Japan.
| | - Y Kagami
- Department of Radiation Oncology, Showa University, Tokyo, Japan
| | - T Shibata
- Japan Clinical Oncology Group Data Center/Operations Office, National Cancer Center Hospital, Tokyo, Japan
| | - N Shikama
- Department of Radiation Oncology, Juntendo University, Tokyo, Japan
| | - Y Nishimura
- Department of Radiation Oncology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
| | - S Ishikura
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - K Nakamura
- Japan Clinical Oncology Group Data Center/Operations Office, National Cancer Center Hospital, Tokyo, Japan
| | - Y Saito
- Department of Radiation Oncology, Saitama Cancer Center, Saitama, Japan
| | - Y Matsumoto
- Department of Radiation Oncology, Niigata Cancer Center Hospital, Niigata, Japan
| | - T Teshima
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Y Ito
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - T Akimoto
- Department of Radiation Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | - K Nakata
- Department of Radiology, Sapporo Medical University, Sapporo, Japan
| | - T Toshiyasu
- Department of Radiation Oncology, The Cancer Institute Hospital of JFCR, Tokyo, Japan
| | - K Nakagawa
- Department of Radiology, Tokyo University, Tokyo, Japan
| | - Y Nagata
- Department of Radiation Oncology, Hiroshima University, Hiroshima, Japan
| | - T Nishimura
- Department of Radiation Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - T Uno
- Department of Radiology, Chiba University Hospital, Chiba, Japan
| | - M Kataoka
- Department of Radiation Oncology, Shikoku Cancer Center, Matsuyama, Japan
| | - A Yorozu
- Department of Radiology, Tokyo Medical Center, Tokyo, Japan
| | - M Hiraoka
- Department of Radiation Oncology and Image-Applied Therapy, Kyoto University Hospital, Kyoto, Japan
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Shuryak I, Hall EJ, Brenner DJ. Optimized Hypofractionation Can Markedly Improve Tumor Control and Decrease Late Effects for Head and Neck Cancer. Int J Radiat Oncol Biol Phys 2019; 104:272-278. [DOI: 10.1016/j.ijrobp.2019.02.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 01/29/2019] [Accepted: 02/08/2019] [Indexed: 12/25/2022]
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Liu Y, Kou C, Bai W, Liu X, Song Y, Zhang L, Wang M, Zhang Y, You Y, Yin Y, Jiang X, Xin Y. Altered fractionation radiotherapy with or without chemotherapy in the treatment of head and neck cancer: a network meta-analysis. Onco Targets Ther 2018; 11:5465-5483. [PMID: 30233208 PMCID: PMC6129020 DOI: 10.2147/ott.s172018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Objectives A Bayesian network meta-analysis (NMA) was conducted in patients with head and neck cancers (HNCs) to estimate the efficacy and safety of treatment with conventional fractionation radiotherapy (CF), conventional fractionation chemoradiotherapy (CF_CRT), hyperfractionated radiotherapy (HF), hyperfractionated chemoradiotherapy (HF_CRT), accelerated fractionation radiotherapy, accelerated fractionation chemoradiotherapy, accelerated hyperfractionated radiotherapy (HART) or accelerated hyperfractionated chemoradiotherapy (HACRT) to identify superior treatments to aid in clinical decisions. Methods PubMed, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched for potentially eligible randomized controlled trials up to December 2016. Overall survival (OS), disease-free survival (DFS) and locoregional control (LRC) were considered efficacy outcomes, whereas acute toxicity and late toxicity on skin and mucosa were considered safety outcomes. The surface under the cumulative ranking curve (SUCRA) was calculated to rank each treatment in each index. Results Data from 72 trials with 21,868 participants were included in the analysis. Concerning OS, all treatments were associated with a significant advantage compared to CF alone, with HR effect sizes ranging from 0.64 to 0.83, and HACRT was significantly more effective than all the other treatments. The network comparisons of both HACRT vs HART and HF_CRT vs HF demonstrated a higher OS benefit, with an HR of 0.78 (95% credible interval [CrI]: 0.64–0.95) and 0.78 (95% CrI: 0.61–0.99), respectively. The results of SUCRA indicated that HACRT had the best ranking for OS and LRC, HF_CRT for DFS, HART for acute and late skin toxicity, CF_CRT for acute mucosal toxicity and HF_CRT for late mucosal toxicity. Conclusion The NMA results support the notion that HACRT is the preferable treatment modality for HNCs because it has better rankings in all three efficacy indexes, although it does present a high risk of acute mucosal toxicity.
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Affiliation(s)
- Yingyu Liu
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin, China
| | - Changgui Kou
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin, China
| | - Wei Bai
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin, China
| | - Xinyu Liu
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin, China
| | - Yan Song
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin, China
| | - Lili Zhang
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin, China
| | - Mohan Wang
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin, China
| | - Yangyu Zhang
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin, China
| | - Yueyue You
- Department of Epidemiology and Biostatistics, School of Public Health, Jilin University, Changchun, Jilin, China
| | - Yue Yin
- Department of Radiation Oncology, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Xin Jiang
- Department of Radiation Oncology, The First Hospital of Jilin University, Changchun, Jilin, China,
| | - Ying Xin
- Department of Pathology, School of Basic Medicine, Jilin University, Changchun, Jilin, China,
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Shuryak I, Hall EJ, Brenner DJ. Dose dependence of accelerated repopulation in head and neck cancer: Supporting evidence and clinical implications. Radiother Oncol 2018. [PMID: 29534828 DOI: 10.1016/j.radonc.2018.02.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND PURPOSE Accelerated repopulation (AR) can compromise tumor control after conventional radiotherapy for fast-growing tumors. Standard AR models assume it begins at a fixed time, with repopulation rates independent of the number of clonogens killed. We investigate the validity and significance of an alternative model where onset-time and rate of AR depend on the number of clonogens killed, and thus on dose and dose-fractionation. MATERIALS AND METHODS We analyzed tumor control (TCP) from randomized trials for head and neck cancer (HNC, 7283 patients), featuring wide ranges of doses, times, and fractionation-schemes. We used the linear-quadratic model with the standard dose-independent AR model, or with an alternative dose-dependent model, where AR onset and rate depend on clonogen killing. RESULTS The alternative dose-dependent model of AR provides significantly-improved descriptions of a wide range of randomized clinical data, relative to the standard dose-independent model. This preferred model predicts that, for currently-used HNC fractionation schemes, the last 5 fractions do not increase TCP, but simply compensate for increased accelerated repopulation. CONCLUSIONS The preferred dose-dependent AR model predicts that, for standard fractionation schemes currently used to treat HNC, the final week (5 fractions) could be eliminated without compromising TCP, but resulting in significantly decreased late sequelae due to the lower overall dose.
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Affiliation(s)
- Igor Shuryak
- Center for Radiological Research, Columbia University Medical Center, New York, USA.
| | - Eric J Hall
- Center for Radiological Research, Columbia University Medical Center, New York, USA
| | - David J Brenner
- Center for Radiological Research, Columbia University Medical Center, New York, USA
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Lacas B, Bourhis J, Overgaard J, Zhang Q, Grégoire V, Nankivell M, Zackrisson B, Szutkowski Z, Suwiński R, Poulsen M, O'Sullivan B, Corvò R, Laskar SG, Fallai C, Yamazaki H, Dobrowsky W, Cho KH, Beadle B, Langendijk JA, Viegas CMP, Hay J, Lotayef M, Parmar MKB, Aupérin A, van Herpen C, Maingon P, Trotti AM, Grau C, Pignon JP, Blanchard P. Role of radiotherapy fractionation in head and neck cancers (MARCH): an updated meta-analysis. Lancet Oncol 2017; 18:1221-1237. [PMID: 28757375 PMCID: PMC5737765 DOI: 10.1016/s1470-2045(17)30458-8] [Citation(s) in RCA: 173] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 05/29/2017] [Accepted: 05/31/2017] [Indexed: 01/30/2023]
Abstract
BACKGROUND The Meta-Analysis of Radiotherapy in squamous cell Carcinomas of Head and neck (MARCH) showed that altered fractionation radiotherapy is associated with improved overall and progression-free survival compared with conventional radiotherapy, with hyperfractionated radiotherapy showing the greatest benefit. This update aims to confirm and explain the superiority of hyperfractionated radiotherapy over other altered fractionation radiotherapy regimens and to assess the benefit of altered fractionation within the context of concomitant chemotherapy with the inclusion of new trials. METHODS For this updated meta-analysis, we searched bibliography databases, trials registries, and meeting proceedings for published or unpublished randomised trials done between Jan 1, 2009, and July 15, 2015, comparing primary or postoperative conventional fractionation radiotherapy versus altered fractionation radiotherapy (comparison 1) or conventional fractionation radiotherapy plus concomitant chemotherapy versus altered fractionation radiotherapy alone (comparison 2). Eligible trials had to start randomisation on or after Jan 1, 1970, and completed accrual before Dec 31, 2010; had to have been randomised in a way that precluded prior knowledge of treatment assignment; and had to include patients with non-metastatic squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx, or larynx undergoing first-line curative treatment. Trials including a non-conventional radiotherapy control group, investigating hypofractionated radiotherapy, or including mostly nasopharyngeal carcinomas were excluded. Trials were grouped in three types of altered fractionation: hyperfractionated, moderately accelerated, and very accelerated. Individual patient data were collected and combined with a fixed-effects model based on the intention-to-treat principle. The primary endpoint was overall survival. FINDINGS Comparison 1 (conventional fractionation radiotherapy vs altered fractionation radiotherapy) included 33 trials and 11 423 patients. Altered fractionation radiotherapy was associated with a significant benefit on overall survival (hazard ratio [HR] 0·94, 95% CI 0·90-0·98; p=0·0033), with an absolute difference at 5 years of 3·1% (95% CI 1·3-4·9) and at 10 years of 1·2% (-0·8 to 3·2). We found a significant interaction (p=0·051) between type of fractionation and treatment effect, the overall survival benefit being restricted to the hyperfractionated group (HR 0·83, 0·74-0·92), with absolute differences at 5 years of 8·1% (3·4 to 12·8) and at 10 years of 3·9% (-0·6 to 8·4). Comparison 2 (conventional fractionation radiotherapy plus concomitant chemotherapy versus altered fractionation radiotherapy alone) included five trials and 986 patients. Overall survival was significantly worse with altered fractionation radiotherapy compared with concomitant chemoradiotherapy (HR 1·22, 1·05-1·42; p=0·0098), with absolute differences at 5 years of -5·8% (-11·9 to 0·3) and at 10 years of -5·1% (-13·0 to 2·8). INTERPRETATION This update confirms, with more patients and a longer follow-up than the first version of MARCH, that hyperfractionated radiotherapy is, along with concomitant chemoradiotherapy, a standard of care for the treatment of locally advanced head and neck squamous cell cancers. The comparison between hyperfractionated radiotherapy and concomitant chemoradiotherapy remains to be specifically tested. FUNDING Institut National du Cancer; and Ligue Nationale Contre le Cancer.
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Affiliation(s)
- Benjamin Lacas
- Ligue Nationale Contre le Cancer Meta-Analysis Platform, Service de Biostatistique et d'Epidémiologie, Gustave Roussy Cancer Campus, INSERM U1018, CESP, Université Paris-Sud, Université Paris-Saclay, Villejuif, France
| | - Jean Bourhis
- Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Jens Overgaard
- Department of Experimental Clinical Oncology, Aarhus, Denmark
| | - Qiang Zhang
- NRG Oncology Statistics and Data Management Center (formerly RTOG), Philadelphia, PA, USA
| | - Vincent Grégoire
- Radiation Oncology Department, UCL-Cliniques Universitaires St-Luc, Brussels, Belgium
| | - Matthew Nankivell
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Björn Zackrisson
- Department of Radiation Sciences, Oncology, Umeå University, Umeå, Sweden
| | - Zbigniew Szutkowski
- Department of Radiotherapy, Cancer Center, Marie Curie-Sklodowska Memorial Institute, Warsaw, Poland
| | - Rafał Suwiński
- Radiotherapy and Chemotherapy Clinic and Teaching Hospital, Marie Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice, Poland
| | - Michael Poulsen
- Radiation Oncology Services, Mater Centre, Brisbane, QLD, Australia
| | - Brian O'Sullivan
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, ON, Canada
| | | | | | - Carlo Fallai
- Department of Radiotherapy, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Hideya Yamazaki
- Department of Radiation Oncology, Osaka Medical Center for Cancer and Cardiovascular Disease, Osaka, Japan
| | - Werner Dobrowsky
- Department of Clinical Oncology, Freeman Hospital, Newcastle, UK
| | - Kwan Ho Cho
- Proton Therapy Center, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Beth Beadle
- Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Johannes A Langendijk
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Celia Maria Pais Viegas
- Radiation Oncology Department, Instituto Nacional de Cancer, Brasil National Cancer Institute, Rio de Janeiro, Brazil
| | - John Hay
- Division of Radiation Oncology, British Columbia Cancer Agency, Vancouver, BC, Canada
| | - Mohamed Lotayef
- Radiation Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Mahesh K B Parmar
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Anne Aupérin
- Ligue Nationale Contre le Cancer Meta-Analysis Platform, Service de Biostatistique et d'Epidémiologie, Gustave Roussy Cancer Campus, INSERM U1018, CESP, Université Paris-Sud, Université Paris-Saclay, Villejuif, France
| | - Carla van Herpen
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Philippe Maingon
- European Organisation for Research and Treatment of Cancer, Radiation Oncology Group, Brussels, Belgium; Service d'Oncologie, Radiothérapie, Hôpitaux Universitaires Pitié Salpêtrière, Charles Foix, Paris, France
| | - Andy M Trotti
- Moffitt Cancer Center, Department of Radiation Oncology, Tampa, FL, USA
| | - Cai Grau
- Department of Experimental Clinical Oncology, Aarhus, Denmark
| | - Jean-Pierre Pignon
- Ligue Nationale Contre le Cancer Meta-Analysis Platform, Service de Biostatistique et d'Epidémiologie, Gustave Roussy Cancer Campus, INSERM U1018, CESP, Université Paris-Sud, Université Paris-Saclay, Villejuif, France.
| | - Pierre Blanchard
- Department of Radiation Therapy, Gustave Roussy Cancer Campus, INSERM U1018, CESP, Université Paris-Sud, Université Paris-Saclay, Villejuif, France
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Yamazaki H, Suzuki G, Nakamura S, Yoshida K, Konishi K, Teshima T, Ogawa K. Radiotherapy for laryngeal cancer-technical aspects and alternate fractionation. JOURNAL OF RADIATION RESEARCH 2017; 58:495-508. [PMID: 28898958 PMCID: PMC5569999 DOI: 10.1093/jrr/rrx023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 03/25/2017] [Indexed: 06/01/2023]
Abstract
Early laryngeal, especially glottic, cancer is a good candidate for radiotherapy because obvious early symptoms (e.g. hoarseness) make earlier treatment possible and with highly successful localized control. This type of cancer is also a good model for exploring the basic principles of radiation oncology and several key findings (e.g. dose, fractionation, field size, patient fixation, and overall treatment time) have been noted. For example, unintended poor outcomes have been reported during transition from 60Cobalt to linear accelerator installation in the 1960s, with usage of higher energy photons causing poor dose distribution. In addition, shell fixation made precise dose delivery possible, but simultaneously elevated toxicity if a larger treatment field was necessary. Of particular interest to the radiation therapy community was altered fractionation gain as a way to improve local tumor control and survival rate. Unfortunately, this interest ceased with advancements in chemotherapeutic agents because alternate fractionation could not improve outcomes in chemoradiotherapy settings. At present, no form of acceleration can potentially compensate fully for the lack of concurrent chemotherapy. In addition, the substantial workload associated with this technique made it difficult to add extra fractionation routinely in busy clinical hospitals. Hypofractionation, on the other hand, uses a larger single fractionation dose (2-3 Gy), making it a reasonable and attractive option for T1-T2 early glottic cancer because it can improve local control without the additional workload. Recently, Japan Clinical Oncology Group study 0701 reprised its role in early T1-T2 glottic cancer research, demonstrating that this strategy could be an optional standard therapy. Herein, we review radiotherapy history from 60Cobalt to modern linear accelerator, with special focus on the role of alternate fractionation.
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Affiliation(s)
- Hideya Yamazaki
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho Kawaramachi Hirokoji, Kamigyo-ku, Kyoto 602–8566, Japan
| | - Gen Suzuki
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho Kawaramachi Hirokoji, Kamigyo-ku, Kyoto 602–8566, Japan
| | - Satoaki Nakamura
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho Kawaramachi Hirokoji, Kamigyo-ku, Kyoto 602–8566, Japan
| | - Ken Yoshida
- Department of Radiology, Osaka Medical College, 2–7 Daigaku-machi, Takatsuki-City, Osaka, 569–8686, Japan
| | - Koji Konishi
- Department of Radiation Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, 133 Nakamichi, Higashinari, Osaka 537–8511, Japan
| | - Teruki Teshima
- Department of Radiation Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, 133 Nakamichi, Higashinari, Osaka 537–8511, Japan
| | - Kazuhiko Ogawa
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Yamadaoka 2–2, Suita, 565–0871 Osaka, Japan
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Szutkowski Z, Kawecki A, Jarząbski A, Laskus Z, Krajewski R, Michalski W, Kukołowicz P. Hypofractionated accelerated radiotherapy in T1-3 N0 cancer of the larynx: A prospective cohort study with historical controls. Rep Pract Oncol Radiother 2016; 21:537-543. [PMID: 27698593 DOI: 10.1016/j.rpor.2016.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Revised: 05/27/2016] [Accepted: 08/24/2016] [Indexed: 10/21/2022] Open
Abstract
AIM The goal of this prospective study was to assess the effectiveness of a hypofractionated accelerated regime in treatment of the larynx cancer. BACKGROUND Multiple radiotherapy delivery regimes are used for treatment of the larynx cancer. Hypofractionated regimes could provide similar results with reduced use of radiotherapy facilities. MATERIAL AND METHODS 223 patients with squamous cell carcinoma of the upper or middle larynx have been treated with 63 Gy delivered in 28 fractions of 2.25 Gy during 38 days, 5 fractions per week. The study endpoints were overall survival, progression-free survival, early and late treatment toxicity. Standard and accelerated radiotherapy groups from the study published by Hliniak et al.20 served as controls. RESULTS Five-year actuarial overall survival was 87.5% in the study group, 84.5% in the control group receiving accelerated radiotherapy (33 fractions of 2.0 Gy, 6 fractions per week) and 86.2% in the control group (33 fractions of 2.0 Gy, 5 fractions per week). Five-year progression-free survival was 73.6%, 77.2% and 66.2%, respectively. Overall, treatment toxicity and complication rates did not differ between the study group and the control groups. CONCLUSIONS The hypofractionated accelerated radiotherapy protocol using 5 fractions per week reduced the use of radiotherapy facilities. There was no significant difference in overall survival and progression-free survival between the study and control groups treated with accelerated or standard radiotherapy.
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Affiliation(s)
- Zbigniew Szutkowski
- Head and Neck Cancer Department, Cancer Center - M. Curie-Sklodowska Memorial Institute, ul. Roentgena 5, 02-781 Warsaw, Poland
| | - Andrzej Kawecki
- Head and Neck Cancer Department, Cancer Center - M. Curie-Sklodowska Memorial Institute, ul. Roentgena 5, 02-781 Warsaw, Poland
| | - Andrzej Jarząbski
- Head and Neck Cancer Department, Cancer Center - M. Curie-Sklodowska Memorial Institute, ul. Roentgena 5, 02-781 Warsaw, Poland
| | - Zofia Laskus
- Head and Neck Cancer Department, Cancer Center - M. Curie-Sklodowska Memorial Institute, ul. Roentgena 5, 02-781 Warsaw, Poland
| | - Romuald Krajewski
- Head and Neck Cancer Department, Cancer Center - M. Curie-Sklodowska Memorial Institute, ul. Roentgena 5, 02-781 Warsaw, Poland
| | - Wojciech Michalski
- Department of Biostatistics, Cancer Center - M. Curie-Sklodowska Memorial Institute, ul. Roentgena 5, 02-781 Warsaw, Poland
| | - Paweł Kukołowicz
- Medical Physics Department, Cancer Center - M. Curie-Sklodowska Memorial Institute, ul. Roentgena 5, 02-781 Warsaw, Poland
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Nyqvist J, Fransson P, Laurell G, Hammerlid E, Kjellén E, Franzén L, Söderström K, Wickart-Johansson G, Friesland S, Sjödin H, Brun E, Ask A, Nilsson P, Ekberg L, Björk-Eriksson T, Nyman J, Lödén B, Lewin F, Reizenstein J, Lundin E, Zackrisson B. Differences in health related quality of life in the randomised ARTSCAN study; accelerated vs. conventional radiotherapy for head and neck cancer. A five year follow up. Radiother Oncol 2016; 118:335-41. [PMID: 26777124 DOI: 10.1016/j.radonc.2015.12.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 12/22/2015] [Accepted: 12/27/2015] [Indexed: 11/12/2022]
Abstract
BACKGROUND AND PURPOSE Health related quality of life (HRQoL) was assessed in the randomised, prospective ARTSCAN study comparing conventional radiotherapy (CF) with accelerated radiotherapy (AF) for head and neck cancer. MATERIAL AND METHODS 750 patients with squamous cell carcinoma (of any grade and stage) in the oral cavity, oro-, or hypopharynx or larynx (except T1-2, N0 glottic carcinoma) without distant metastases were randomised to either conventional fractionation (2 Gy/day, 5 days/week in 49 days, total dose 68 Gy) or accelerated fractionation (1.1+2.0 Gy/day, 5 days/week in 35 days, total dose 68 Gy). HRQoL was assessed with EORTC QLQ-C30, QLQ-H&N35 and HADS at baseline, at end of radiotherapy (eRT) and at 3 and 6 months and 1, 2 and 5 years after start of treatment. RESULTS The AF group reported HRQoL was significantly lower at eRT and at 3 months for most symptoms, scales and functions. Few significant differences were noted between the groups at 6 months and 5 years. Scores related to functional oral intake never reached baseline. CONCLUSION In comparison to CF, AF has a stronger adverse effect on HRQoL in the acute phase.
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Affiliation(s)
- Johanna Nyqvist
- Department of Otolaryngology and Head and Neck Surgery, Skåne University Hospital, Lund, Sweden; Department of Clinical Science Otolaryngology and Head and Neck Surgery, Umeå University, Sweden.
| | | | - Göran Laurell
- Department of Clinical Science Otolaryngology and Head and Neck Surgery, Umeå University, Sweden; Department of Otolaryngology and Head and Neck Surgery, Uppsala University Hospital, Sweden
| | - Eva Hammerlid
- Department of Otolaryngology and Head and Neck Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Elisabeth Kjellén
- Department of Oncology and Radiation Physics, Skåne University Hospital, Lund University, Sweden
| | - Lars Franzén
- Department of Radiation Sciences, Oncology, Umeå University, Sweden
| | - Karin Söderström
- Department of Radiation Sciences, Oncology, Umeå University, Sweden
| | | | - Signe Friesland
- Department of Oncology, Karolinska University Hospital, Stockholm, Sweden
| | - Helena Sjödin
- Department of Oncology, Karolinska University Hospital, Stockholm, Sweden
| | - Eva Brun
- Department of Oncology and Radiation Physics, Skåne University Hospital, Lund University, Sweden
| | - Anders Ask
- Department of Oncology and Radiation Physics, Skåne University Hospital, Lund University, Sweden
| | - Per Nilsson
- Department of Oncology and Radiation Physics, Skåne University Hospital, Lund University, Sweden
| | - Lars Ekberg
- Department of Oncology and Radiation Physics, Skåne University Hospital, Lund University, Sweden
| | | | - Jan Nyman
- Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Britta Lödén
- Department of Clinical Oncology, Karlstad Central Hospital, Sweden
| | - Freddi Lewin
- Department of Oncology, Ryhov County Hospital, Jönköping, Sweden
| | | | - Erik Lundin
- Department of Oncology, Ryhov County Hospital, Jönköping, Sweden
| | - Björn Zackrisson
- Department of Radiation Sciences, Oncology, Umeå University, Sweden
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12
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Mature results from a Swedish comparison study of conventional versus accelerated radiotherapy in head and neck squamous cell carcinoma - The ARTSCAN trial. Radiother Oncol 2015; 117:99-105. [PMID: 26427805 DOI: 10.1016/j.radonc.2015.09.024] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 09/10/2015] [Accepted: 09/18/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND PURPOSE This report contains the mature five-year data from the Swedish ARTSCAN trial including information on the influence of p16 positivity (p16+) for oropharyngeal cancers. MATERIAL AND METHODS Patients with previously untreated squamous cell carcinoma without distant metastases of the oral cavity, oropharynx, larynx (except T1-2, N0 glottic cancers) and hypopharynx were included. Patients were randomised between accelerated fractionation (AF) (1.1Gy+2Gy per day, 5days/week for 4.5weeks, total dose 68Gy) and conventional fractionation (CF) (2Gy per day, 5days/week for 7weeks, total dose 68Gy). Human papillomavirus (HPV)-associated p16-expression was assessed retrospectively in tumour tissues from patients with oropharyngeal carcinoma. RESULTS There was no significant difference in loco-regional control (LRC) between AF and CF (log-rank test p=0.75). LRC at 5years was 65.5% for AF and 64.9% for CF. Overall survival (OS) was similar in both arms (p=0.99). The estimated cancer specific survival (CSS) at 5years was 62.2% (AF) and 63.3% (CF) (p=0.99). 206 specimens were analysed for p16 with 153 specimens (74%) identified as p16+. P16 status did not discriminate for response to AF vs. CF with regard to LRC, OS or CSS. Patients with p16+ tumours had a statistically significant better overall prognosis compared with p16- tumours. CONCLUSION This update confirms the results of the 2-year report. We failed to identify a positive effect resulting from AF with regards to LRC, OS and CSS. The addition of information on the HPV-associated p16 overexpression did not explain this lack of effect.
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13
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Lyhne NM, Primdahl H, Kristensen CA, Andersen E, Johansen J, Andersen LJ, Evensen J, Mortensen HR, Overgaard J. The DAHANCA 6 randomized trial: Effect of 6 vs 5 weekly fractions of radiotherapy in patients with glottic squamous cell carcinoma. Radiother Oncol 2015; 117:91-8. [PMID: 26255764 DOI: 10.1016/j.radonc.2015.07.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 07/02/2015] [Accepted: 07/02/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE The DAHANCA 6 trial evaluated tumor response and morbidity after moderate accelerated radiotherapy compared to conventional fractionated radiotherapy in patients treated for glottic squamous cell carcinoma (SCC). Further, the failure pattern and incidence of new primary tumors were explored. PATIENTS AND METHODS Six hundred and ninety-four patients with non-metastatic glottic SCC were randomized between six or five weekly fractions (fx/w) of radiotherapy to the same total dose. The median treatment time was 38 and 46days, respectively. The primary endpoint was loco-regional failure. RESULTS Median follow-up time was 14.5years. Of the 177 failures, 167 involved T-site. The cumulative incidence of loco-regional failure (LRF) was 21.6% in the 6fx/w group and 29.3% in the 5fx/w group and the corresponding hazard rate (HR) of LRF was 0.72 (CI: 0.53-0.97, p=0.04). The effect of acceleration on LRF was especially evident in well differentiated tumors (HR=0.42 (CI: 0.23-0.75) and in T1-2 tumors (HR=0.60 (CI: 0.41-0.89)). The HR of laryngectomy was 0.72 (CI: 0.50-1.04) in the 6fx/w group compared to the 5fx/w group. The hazards of disease-specific death, event-free survival, and overall survival were comparable between the two groups. Significantly more patients experienced severe acute mucositis in the 6fx/w group but the incidence of late morbidity was comparable between the groups. New primary tumors occurred in 22.5% of the patients. CONCLUSION Moderate accelerated radiotherapy significantly improved loco-regional control in patients with glottic SCC.
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Affiliation(s)
- Nina M Lyhne
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark.
| | - Hanne Primdahl
- Department of Oncology, Aarhus University Hospital, Denmark
| | | | - Elo Andersen
- Department of Oncology, Herlev Hospital, Copenhagen, Denmark
| | | | | | | | - Hanna R Mortensen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark
| | - Jens Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark
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14
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González Ferreira JA, Jaén Olasolo J, Azinovic I, Jeremic B. Effect of radiotherapy delay in overall treatment time on local control and survival in head and neck cancer: Review of the literature. Rep Pract Oncol Radiother 2015; 20:328-39. [PMID: 26549990 DOI: 10.1016/j.rpor.2015.05.010] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 03/31/2015] [Accepted: 05/24/2015] [Indexed: 11/25/2022] Open
Abstract
Treatment delays in completing radiotherapy (RT) for many neoplasms are a major problem affecting treatment outcome, as increasingly shown in the literature. Overall treatment time (OTT) could be a critical predictor of local tumor control and/or survival. In an attempt to establish a protocol for managing delays during RT, especially for heavily overloaded units, we have extensively reviewed the available literature on head and neck cancer. We confirmed a large deleterious effect of prolonged OTT on both local control and survival of these patients.
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Affiliation(s)
| | - Javier Jaén Olasolo
- Comprehensive Cancer Care Unit, Puerta del Mar and Puerto Real University Hospitals, Ana de Viya Avenue 21, 11009 Cádiz, Spain
| | - Ignacio Azinovic
- IMO-Group Medical Director, República Argentina Square 7, 28002 Madrid, Spain
| | - Branislav Jeremic
- Institute of Lung Diseases, Sremska Kamenica, Serbia ; BioIRC Centre for Biomedical Research, Kragujevac, Serbia
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15
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Effectiveness of chemotherapy and radiotherapy for laryngeal preservation in advanced laryngeal cancer: a meta-analysis and systematic review. Radiol Med 2015; 120:1153-69. [DOI: 10.1007/s11547-015-0547-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 04/28/2015] [Indexed: 10/23/2022]
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16
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[Long-term results and cause of failure analysis in larynx cancer patients irradiated conventionally and with accelerated fractionation schedules in 1995-1998]. Otolaryngol Pol 2014; 68:320-7. [PMID: 25441938 DOI: 10.1016/j.otpol.2014.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 04/29/2014] [Accepted: 05/21/2014] [Indexed: 11/22/2022]
Abstract
The clinical material consists of 217 patients with squamous cell carcinoma in supraglottic and glottic larynx in clinical stage T1-3N0M0 irradiated radically in Warsaw Oncology Centre in 1995-1998. All patients were treated with Co-60, according to two schedules of fractionation, with maintenance of the consistent therapeutic protocol. The same team of doctors worked on the treatment of patients and on the follow-up as well. The clinical material is a part of a three-phased clinical trial KBN 0295. In the course of observation, the progression of cancer was not observed in 157 patients, among whom, 66% were treated conventionally and 79% with accelerated fractionation method. 60 cases of loco-regional recurrences were noted, among which 55 were regional. The majority of failure cases was observed until the 30(th) of the month after the radiotherapy ended. In conventional fractionation treatment, recurrences in T1 were 8/31 (26%), in T2 22/59 (37%) and in T3 8/20 (40%). In patients treated with AF, recurrences were T1 5/39 (13%), T2 15/55 (27%) and T3 2/13 (15%) respectively. The percentage of primary site tumour recurrences for each localization and kind of treatment was analysed. In CF 28/78 (37%) of glottic tumour recurrences and 10/34 (29%) of supraglottic tumour, recurrences were observed. In AF, 12/71 (17%) and 10/36 (28%) were observed respectively. In 48 cases salvage surgery was used, and 12 patients were not qualified because of tumour massive progression or because they refused to have a surgery. Among 34 cases (16%) of the second primary tumour or distant methastases, 25 were observed with glottic cancer, among which 23 were observed in early stages, and 9 cases with supraglottic cancer, among which, 6 showed early stage of tumour. In only 3 cases out of all the patients, distant methastases were confirmed in histopatology examination. The main cause of failure in larynx cancer patients in stage T1 is that 3N0M0 are local recurrences. Second primary or distant methastases constitute 16% of the patients in this paper.
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Ahmed KA, Correa CR, Dilling TJ, Rao NG, Shridhar R, Trotti AM, Wilder RB, Caudell JJ. Altered fractionation schedules in radiation treatment: a review. Semin Oncol 2014; 41:730-50. [PMID: 25499633 DOI: 10.1053/j.seminoncol.2014.09.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Conventionally fractionated radiotherapy is delivered in 1.8- to 2.0-Gy fractions. With increases in understanding of radiation and tumor biology, various alterations of radiotherapy schedules have been tested in clinical trials and are now regarded by some as standard treatment options. Hyperfractionation is delivered through a greater number of smaller treatment doses. Accelerated fractionation decreases the amount of time over which radiotherapy is delivered typically by increasing the number of treatments per day. Hypofractionation decreases the number of fractions delivered by increasing daily treatment doses. Furthermore, many of these schedules have been tested with concurrent chemotherapy regimens. In this review, we summarize the major clinical studies that have been conducted on altered fractionation in various disease sites.
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Affiliation(s)
- Kamran A Ahmed
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Candace R Correa
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Thomas J Dilling
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Nikhil G Rao
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Ravi Shridhar
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Andy M Trotti
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Richard B Wilder
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Jimmy J Caudell
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL.
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Randomized trial of hyperfractionation versus conventional fractionation in T2 squamous cell carcinoma of the vocal cord (RTOG 9512). Int J Radiat Oncol Biol Phys 2014; 89:958-963. [PMID: 25035199 DOI: 10.1016/j.ijrobp.2014.04.041] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Revised: 03/26/2014] [Accepted: 04/23/2014] [Indexed: 11/22/2022]
Abstract
PURPOSE To compare hyperfractionation versus standard fractionation for T2N0 vocal cord carcinoma in a randomized controlled trial. METHODS AND MATERIALS Patients with T2 vocal cord cancer were stratified by substage (T2a vs T2b) and randomly assigned to receive either hyperfractionation (HFX) to 79.2 Gy in 66 fractions of 1.2 Gy given twice a day, or standard fractionation (SFX) to 70 Gy in 35 fractions given once a day. The trial was designed to detect a 55% reduction in the local failure hazard rate with 80% statistical power. RESULTS Between April 1996 and July 2003, a total of 250 patients were enrolled. Of 239 patients analyzable for outcomes, 94% were male, 83% had a Karnofsky performance status of 90-100, and 62% had T2a tumor. Median follow-up for all surviving patients was 7.9 years (range, 0.6-13.1 years). The 5-year local control (LC) rate was 8 points higher but not statistically significant (P=.14 for HFX [78%] vs SFX [70%]), corresponding to a 30% hazard rate reduction. The 5-year disease-free survival (DFS) was 49% versus 40% (P=.13) and overall survival (OS) was 72% versus 63% (P=.29). HFX was associated with higher rates of acute skin, mucosal, and laryngeal toxicity. Grade 3-4 late effects were similar with a 5-year cumulative incidence of 8.5% (3.4%-13.6%) after SFX and 8.5% (3.4%-13.5%) after HFX. CONCLUSIONS The 5-year local control was modestly higher with HFX compared to SFX for T2 glottic carcinoma, but the difference was not statistically significant. These results are consistent with prior studies of hyperfractionation showing a benefit in local control. Substaging by T2a versus T2b carries prognostic value for DFS and OS. For cost and convenience reasons other altered fractionation schedules have been adopted in routine practice.
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Harriss-Phillips WM, Bezak E, Yeoh EK. Altered fractionation outcomes for hypoxic head and neck cancer using the HYP-RT Monte Carlo model. Br J Radiol 2013; 86:20120443. [PMID: 23392195 DOI: 10.1259/bjr.20120443] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Altered fractionation radiotherapy is simulated on a set of virtual tumours to assess the total doses required for tumour control compared with clinical head and neck data and the doses required to control hypoxic vs well-oxygenated tumours with different radiobiological properties. METHODS The HYP-RT model is utilised to explore the impact of tumour oxygenation and the onset times of accelerated repopulation (AR) and reoxygenation (ROx) during radiotherapy. A biological effective dose analysis is used to rank the schedules based on their relative normal tissue toxicities. RESULTS Altering the onset times of AR and ROx has a large impact on the doses required to achieve tumour control. Immediate onset of ROx and 2-week onset time of AR produce results closely predicting average human outcomes in terms of the total prescription doses in clinical trials. Modifying oxygen enhancement ratio curves based on dose/fraction significantly reduces the dose (5-10 Gy) required for tumour control for hyperfractionated schedules. HYP-RT predicts 10×1.1 Gy per week to be most beneficial, whereas the conventional schedule is predicted as beneficial for early toxicity but has average-poor late toxicity. CONCLUSION HYP-RT predicts that altered radiotherapy schedules increase the therapeutic ratio and may be used to make predictions about the prescription doses required to achieve tumour control for tumours with different oxygenation levels and treatment responses. ADVANCES IN KNOWLEDGE Oxic and hypoxic tumours have large differences in total radiation dose requirements, affected by AR and ROx onset times by up to 15-25 Gy for the same fractionation schedule.
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Affiliation(s)
- W M Harriss-Phillips
- Department of Medical Physics, Royal Adelaide Hospital Cancer Centre, South Australia, Australia.
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20
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Kiprian D, Kawecki A, Jarząbski A, Michalski W, Pawłowska-Sendułka B. [The results and toxicity of organ preservation treatment for locoregionally advanced laryngeal and hypopharyngeal cancer]. Otolaryngol Pol 2011; 65:363-8. [PMID: 22078287 DOI: 10.1016/s0030-6657(11)70727-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Accepted: 05/01/2011] [Indexed: 10/15/2022]
Abstract
UNLABELLED The most frequent malignant tumor of the head and neck region is a squamous cell cancer of the larynx. Squamous cell cancer of the hypopharynx is diagnosed rarely, but it has poorer prognosis than laryngeal cancer. The surgical treatment, especially in advanced disease, is a laryngectomy with the definitive tracheostomy, what negatively influenced the quality of life. Therefore, oncologists have been interested in new alternative methods of conservative treatment from many years. THE AIM OF THE STUDY The evaluation of efficacy and toxicity of the organ preservation treatment in patients with locally advanced laryngeal and hypopharyngeal cancer. MATERIAL AND METHODS The patients with diagnosed squamous cell laryngeal and hypopharyngeal cancer in III and IVa clinical status were treated with concomitant radiochemotherapy with intention of the organ preservation. Conformal 3D radiotherapy and SIB-IMRT technique was applied in all cases. Concomitant chemotherapy consisted of cisplatin in daily dose100mg/m(2) given two times during irradiation (1 and 22 day of treatment) or once weekly in dose 40mg/m(2). Between January 2004 and November 2008 146 patients were treated with this method. There were 83 patients diagnosed with laryngeal cancer and 62 patients with hypopharyngeal cancer in this group. RESULTS The median follow up is 42 months. Five years overall survival is 75% and disease free survivak is 63%. Three years laryngectomy free survival (LFS) is 82% and 5-years LFS is 76%. This group of patients is alive with larynx preservations. In 17.3% patients local recurrence was observed (4.5% regional recurrence and 1.8% locoregional). Those patients underwent salvage surgery or were treated with palliative chemotherapy. No severe life risking early and late complications were observed. Only 7% of patients have required temporary tracheostomy because of difficulties in breathing due to larynx edema. CONCLUSION We can conclude that organ preservation treatment is a valuable alternative to surgical procedure in patients diagnosed with laryngeal and hypopharyngeal cancer in III and IVa clinical status.
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Affiliation(s)
- Dorota Kiprian
- Klinika Nowotworów Głowy i Szyi Centrum Onkologii - Instytut im Marii Skłodowskiej-Curie.
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Harriss-Phillips WM, Bezak E, Yeoh EK. Monte Carlo radiotherapy simulations of accelerated repopulation and reoxygenation for hypoxic head and neck cancer. Br J Radiol 2011; 84:903-18. [PMID: 21933980 DOI: 10.1259/bjr/25012212] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE A temporal Monte Carlo tumour growth and radiotherapy effect model (HYP-RT) simulating hypoxia in head and neck cancer has been developed and used to analyse parameters influencing cell kill during conventionally fractionated radiotherapy. The model was designed to simulate individual cell division up to 10(8) cells, while incorporating radiobiological effects, including accelerated repopulation and reoxygenation during treatment. METHOD Reoxygenation of hypoxic tumours has been modelled using randomised increments of oxygen to tumour cells after each treatment fraction. The process of accelerated repopulation has been modelled by increasing the symmetrical stem cell division probability. Both phenomena were onset immediately or after a number of weeks of simulated treatment. RESULTS The extra dose required to control (total cell kill) hypoxic vs oxic tumours was 15-25% (8-20 Gy for 5 × 2 Gy per week) depending on the timing of accelerated repopulation onset. Reoxygenation of hypoxic tumours resulted in resensitisation and reduction in total dose required by approximately 10%, depending on the time of onset. When modelled simultaneously, accelerated repopulation and reoxygenation affected cell kill in hypoxic tumours in a similar manner to when the phenomena were modelled individually; however, the degree was altered, with non-additive results. Simulation results were in good agreement with standard linear quadratic theory; however, differed for more complex comparisons where hypoxia, reoxygenation as well as accelerated repopulation effects were considered. CONCLUSION Simulations have quantitatively confirmed the need for patient individualisation in radiotherapy for hypoxic head and neck tumours, and have shown the benefits of modelling complex and dynamic processes using Monte Carlo methods.
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Affiliation(s)
- W M Harriss-Phillips
- Department of Medical Physics, Royal Adelaide Hospital Cancer Centre, Adelaide, SA, Australia.
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Two-year results from a Swedish study on conventional versus accelerated radiotherapy in head and neck squamous cell carcinoma – The ARTSCAN study. Radiother Oncol 2011; 100:41-8. [DOI: 10.1016/j.radonc.2010.12.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2010] [Revised: 12/27/2010] [Accepted: 12/30/2010] [Indexed: 11/20/2022]
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Baujat B, Bourhis J, Blanchard P, Overgaard J, Ang KK, Saunders M, Le Maître A, Bernier J, Horiot JC, Maillard E, Pajak TF, Poulsen MG, Bourredjem A, O'Sullivan B, Dobrowsky W, Andrzej H, Skladowski K, Hay JH, Pinto LHJ, Fu KK, Fallai C, Sylvester R, Pignon JP. Hyperfractionated or accelerated radiotherapy for head and neck cancer. Cochrane Database Syst Rev 2010; 2010:CD002026. [PMID: 21154350 PMCID: PMC8407183 DOI: 10.1002/14651858.cd002026.pub2] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Several trials have studied the role of altered fractionation radiotherapy in head and neck squamous cell carcinoma, but the effect of such treatment on survival is not clear. OBJECTIVES The aim of this individual patient data (IPD) meta-analysis was to assess whether this type of radiotherapy could improve survival. SEARCH STRATEGY We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; CENTRAL (2010, Issue 3); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The date of the most recent search was 8 August 2010. SELECTION CRITERIA We identified randomised trials comparing conventional radiotherapy with hyperfractionated or accelerated radiotherapy, or both, in patients with non-metastatic head and neck squamous cell carcinomas and grouped trials into three pre-specified treatment categories: hyperfractionated, accelerated and accelerated with total dose reduction. Trials were eligible if they began recruitment after 1969 and ended before 1998. DATA COLLECTION AND ANALYSIS We obtained updated individual patient data. Overall survival was the main outcome measure. The secondary outcome measures were local or regional control rates (or both), distant control rates and cause-specific mortality. MAIN RESULTS We included 15 trials with 6515 patients. The median follow up was six years. Tumour sites were mostly oropharynx and larynx; 5221 (74%) patients had stage III-IV disease (UICC 2002). There was a significant survival benefit with altered fractionation radiotherapy, corresponding to an absolute benefit of 3.4% at five years (hazard ratio (HR) 0.92, 95% CI 0.86 to 0.97; P = 0.003). The benefit was significantly higher with hyperfractionated radiotherapy (8% at five years) than with accelerated radiotherapy (2% with accelerated fractionation without total dose reduction and 1.7% with total dose reduction at five years, P = 0.02). There was a benefit in locoregional control in favour of altered fractionation versus conventional radiotherapy (6.4% at five years; P < 0.0001), which was particularly efficient in reducing local failure, whereas the benefit on nodal control was less pronounced. The benefit was significantly higher in the youngest patients (under 50 year old) (HR 0.78, 95% CI 0.65 to 0.94), 0.95 (95% CI 0.83 to 1.09) for 51 to 60 year olds, 0.92 (95% CI 0.81 to 1.06) for 61 to 70 year olds, and 1.08 (95% CI 0.89 to 1.30) for those over 70 years old; test for trends P = 0.007). AUTHORS' CONCLUSIONS Altered fractionation radiotherapy improves survival in patients with head and neck squamous cell carcinoma. Comparison of the different types of altered radiotherapy suggests that hyperfractionation provides the greatest benefit. An update of this IPD meta-analysis (MARCH 2), which will increase the power of this analysis and allow for other comparisons, is currently in progress.
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Affiliation(s)
- Bertrand Baujat
- Hôpital TenonService ORL‐CCF4 rue de la ChineParisFrance75020
| | - Jean Bourhis
- Institut Gustave RoussyDépartement de Radiothérapie39 rue Camille DesmoulinsVillejuif CedexFrance94805
| | - Pierre Blanchard
- Institut Gustave RoussyBiostatistics and Epidemiology Department39, rue Camille DesmoulinsVillejuif CedexFrance94805
| | - Jens Overgaard
- Aarhus University HospitalDepartment of Experimental Clinical OncologyNorrebrogade 44 Bldg 5AarhusDenmarkC DK‐8000
| | - Kian K Ang
- MD Anderson Cancer CenterRadiation Oncology Department1515 Holcombe Blvd Box 97HoustonTexasUSA77030
| | - Michelle Saunders
- Marie Curie Research Wing for OncologyRadiation Oncology DepartmentMount Vernon Centre for Cancer TreatmentRickmansworth RoadNorthwoodMiddlesexUKHA6 2RN
| | - Aurélie Le Maître
- Institut Gustave RoussyBiostatistics and Epidemiology Department39, rue Camille DesmoulinsVillejuif CedexFrance94805
| | - Jacques Bernier
- Clinique de GenoliaService de Radio‐OncologieGenolierSwitzerlandCH‐1272
| | | | - Emilie Maillard
- Institut Gustave RoussyBiostatistics and Epidemiology Department39, rue Camille DesmoulinsVillejuif CedexFrance94805
| | - Thomas F Pajak
- RTOGStatistical Headquarters1818 Market Street, Suite 1600PhiladelphiaPAUSA19103
| | - Michael G Poulsen
- Mater Queensland Radium InstituteRaymond Terrace, South BrisbaneBrisbaneAustralia4101
| | - Abderrahmane Bourredjem
- Institut Gustave RoussyBiostatistics and Epidemiology Department39, rue Camille DesmoulinsVillejuif CedexFrance94805
| | - Brian O'Sullivan
- Princess Margaret HospitalRadiation Oncology Department610 University AvenueTorontoONCanadaM5G 2M9
| | - Werner Dobrowsky
- Northern Centre for Cancer TreatmentNewcastle General HospitalWestgate roadNewcastle upon TyneUKNE4 6BE
| | | | - Krzystof Skladowski
- Centrum Onkologii‐Inst. M. CurieRadiotherapy ClinicWybrzeze Armii Krajowej 15GliwicePoland44‐101
| | - John H Hay
- Vancouver Cancer CenterDepartment of Radiation Oncology600 W, 10th AvenueVancouverBCCanadaV5Z 4E6
| | - Luiz HJ Pinto
- Instituto Nacional de CancerDepartamento de RadioterapiaRio de JaneiroBrazil20230
| | - Karen K Fu
- University of California San Francisco555 Laurel Ave Apt 508San MateoCAUSA94401‐4153
| | - Carlo Fallai
- Instituto Nazionale dei TumoriDipartimento di RadiotherapiaVia Venezian 1MilanoItaly20133
| | - Richard Sylvester
- European Organisation for Research and Treatment of CancerData CenterAvenue E Mounier 83 ‐ Bte 11BrusselsBelgium1200
| | - Jean Pierre Pignon
- Gustave Roussy Cancer CampusPlateforme LNCC de Méta‐analyse en Oncologie et Service de Biostatistique et d’EpidémiologieVillejuifFrance
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Michiels S, Le Maître A, Buyse M, Burzykowski T, Maillard E, Bogaerts J, Vermorken JB, Budach W, Pajak TF, Ang KK, Bourhis J, Pignon JP. Surrogate endpoints for overall survival in locally advanced head and neck cancer: meta-analyses of individual patient data. Lancet Oncol 2009; 10:341-50. [DOI: 10.1016/s1470-2045(09)70023-3] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Langendijk JA, Doornaert P, Rietveld DHF, Verdonck-de Leeuw IM, Leemans CR, Slotman BJ. A predictive model for swallowing dysfunction after curative radiotherapy in head and neck cancer. Radiother Oncol 2009; 90:189-95. [PMID: 19167120 DOI: 10.1016/j.radonc.2008.12.017] [Citation(s) in RCA: 136] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2008] [Revised: 12/30/2008] [Accepted: 12/31/2008] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Recently, we found that swallowing dysfunction after curative (chemo) radiation (CH) RT has a strong negative impact on health-related quality of life (HRQoL), even more than xerostomia. The purpose of this study was to design a predictive model for swallowing dysfunction after curative radiotherapy or chemoradiation. MATERIALS AND METHODS A prospective study was performed including 529 patients with head and neck squamous cell carcinoma (HNSCC) treated with curative (CH) RT. In all patients, acute and late radiation-induced morbidity (RTOG Acute and Late Morbidity Scoring System) was scored prospectively. To design the model univariate and multivariate logistic regression analyses were carried out with grade 2 or higher RTOG swallowing dysfunction at 6 months as the primary (SWALL(6months)) endpoint. The model was validated by comparing the predicted and observed complication rates and by testing if the model also predicted acute dysphagia and late dysphagia at later time points (12, 18 and 24 months). RESULTS After univariate and multivariate logistic regression analyses, the following factors turned out to be independent prognostic factors for SWALL(6months): T3-T4, bilateral neck irradiation, weight loss prior to radiation, oropharyngeal and nasopharyngeal tumours, accelerated radiotherapy and concomitant chemoradiation. By summation of the regression coefficients derived from the multivariate model, the Total Dysphagia Risk Score (TDRS) could be calculated. In the logistic regression model, the TDRS was significantly associated with SWALL(6months) ((p<0.001). Subsequently, we defined three risk groups based on the TDRS. The rate of SWALL(6months) was 5%, 24% and 46% in case of low-, intermediate- and high-risk patients, respectively. These observed percentages were within the 95% confidence intervals of the predicted values. The TDRS risk group classification was also significantly associated with acute dysphagia (P<0.001 at all time points) and with late swallowing dysfunction at 12, 18 and 24 months (p<0.001 at all time points). CONCLUSION The TDRS is a simple and validated measure to predict swallowing dysfunction after curative (CH) RT for HNC. This classification system enables identification of patients who may benefit from strategies aiming at prevention of swallowing dysfunction after curative (CH) RT such as preventive swallowing exercises during treatment and/or emerging IMRT techniques aiming at sparing anatomical structures that are involved in swallowing.
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Affiliation(s)
- Johannes A Langendijk
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands.
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Skladowski K, Maciejewski B, Golen M, Tarnawski R, Slosarek K, Suwinski R, Sygula M, Wygoda A. Continuous accelerated 7-days-a-week radiotherapy for head-and-neck cancer: long-term results of phase III clinical trial. Int J Radiat Oncol Biol Phys 2006; 66:706-13. [PMID: 17011446 DOI: 10.1016/j.ijrobp.2006.05.026] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2006] [Revised: 05/24/2006] [Accepted: 05/24/2006] [Indexed: 11/19/2022]
Abstract
PURPOSE To update 5-year results of a previously published study on special 7-days-a-week fractionation continuous accelerated irradiation (CAIR) for head-and-neck cancer patients. METHODS AND MATERIALS One hundred patients with squamous cell carcinoma of head and neck in Stage T(2-4)N(0-1)M(0) were randomized between two definitive radiation treatments: accelerated fractionation 7 days a week including weekends (CAIR) and conventional 5 days a week (control). Hence the overall treatment time was 2 weeks shorter in CAIR. RESULTS Five-year local tumor control was 75% in the CAIR group and 33% in the control arm (p < 0.00004). Tumor-cure benefit corresponded with significant improvement in disease-free survival and overall survival rates. Confluent mucositis was the main acute toxicity, with the incidence significantly higher in CAIR patients than in control (respectively, 94% vs. 53%). When 2.0-Gy fractions were used, radiation necrosis developed in 5 patients (22%) in the CAIR group as a consequential late effect (CLE), but when fraction size was reduced to 1.8 Gy no more CLE occurred. Actuarial 5-year morbidity-free survival rate was similar for both treatments. CONCLUSIONS Selected head-and-neck cancer patients could be treated very effectively with 7-days-a-week radiation schedule with no compromise of total dose and with slight 10% reduction of fraction dose (2 Gy-1.8 Gy), which article gives 1 week reduction of overall treatment time compared with standard 70 Gy in 35 fractions over 47-49 days. Although this report is based on the relatively small group of patients, its results have encouraged us to use CAIR fractionation in a standard radiation treatment for moderately advanced head-and-neck cancer patients.
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Affiliation(s)
- Krzysztof Skladowski
- Department of Radiation Oncology, Center of Oncology-Maria Sklodowska-Curie Memorial Institute, Gliwice, Poland.
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27
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Bourhis J, Overgaard J, Audry H, Ang KK, Saunders M, Bernier J, Horiot JC, Le Maître A, Pajak TF, Poulsen MG, O'Sullivan B, Dobrowsky W, Hliniak A, Skladowski K, Hay JH, Pinto LHJ, Fallai C, Fu KK, Sylvester R, Pignon JP. Hyperfractionated or accelerated radiotherapy in head and neck cancer: a meta-analysis. Lancet 2006; 368:843-54. [PMID: 16950362 DOI: 10.1016/s0140-6736(06)69121-6] [Citation(s) in RCA: 661] [Impact Index Per Article: 36.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Several trials have studied the role of unconventional fractionated radiotherapy in head and neck squamous cell carcinoma, but the effect of such treatment on survival is not clear. The aim of this meta-analysis was to assess whether this type of radiotherapy could improve survival. METHODS Randomised trials comparing conventional radiotherapy with hyperfractionated or accelerated radiotherapy, or both, in patients with non-metastatic HNSCC were identified and updated individual patient data were obtained. Overall survival was the main endpoint. Trials were grouped in three pre-specified categories: hyperfractionated, accelerated, and accelerated with total dose reduction. FINDINGS 15 trials with 6515 patients were included. The median follow-up was 6 years. Tumours sites were mostly oropharynx and larynx; 5221 (74%) patients had stage III-IV disease (International Union Against Cancer, 1987). There was a significant survival benefit with altered fractionated radiotherapy, corresponding to an absolute benefit of 3.4% at 5 years (hazard ratio 0.92, 95% CI 0.86-0.97; p=0.003). The benefit was significantly higher with hyperfractionated radiotherapy (8% at 5 years) than with accelerated radiotherapy (2% with accelerated fractionation without total dose reduction and 1.7% with total dose reduction at 5 years, p=0.02). There was a benefit on locoregional control in favour of altered fractionation versus conventional radiotherapy (6.4% at 5 years; p<0.0001), which was particularly efficient in reducing local failure, whereas the benefit on nodal control was less pronounced. The benefit was significantly higher in the youngest patients (hazard ratio 0.78 [0.65-0.94] for under 50 year olds, 0.95 [0.83-1.09] for 51-60 year olds, 0.92 [0.81-1.06] for 61-70 year olds, and 1.08 [0.89-1.30] for over 70 year olds; test for trends p=0.007). INTERPRETATION Altered fractionated radiotherapy improves survival in patients with head and neck squamous cell carcinoma. Comparison of the different types of altered radiotherapy suggests that hyperfractionation has the greatest benefit.
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Affiliation(s)
- Jean Bourhis
- Radiation Oncology Department, Institut Gustave Roussy, Villejuif, France
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28
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Bourhis J, Lapeyre M, Tortochaux J, Rives M, Aghili M, Bourdin S, Lesaunier F, Benassi T, Lemanski C, Geoffrois L, Lusinchi A, Verrelle P, Bardet E, Julieron M, Wibault P, Luboinski M, Benhamou E. Phase III randomized trial of very accelerated radiation therapy compared with conventional radiation therapy in squamous cell head and neck cancer: a GORTEC trial. J Clin Oncol 2006; 24:2873-8. [PMID: 16782926 DOI: 10.1200/jco.2006.08.057] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE With the aim to increase the dose intensity of radiation therapy (RT), and subsequently the locoregional control rate, a very accelerated RT regimen was compared with conventional RT in a series of patients with head and neck squamous cell carcinoma (HNSCC). PATIENTS AND METHODS Between 1994 and 1998, 268 patients with T3 or T4, N0 to N3 HNSCC (staged by 1997 International Union Against Cancer criteria) that was not eligible for surgery were randomly assigned to receive either conventional RT, delivering 70 Gy in 7 weeks to the primary tumor and 35 fractions of 2 Gy over 49 days, or to receive very accelerated RT, delivering 62 to 64 Gy in 31 to 32 fractions of 2 Gy over 22 to 23 days (2 Gy/fraction bid). RESULTS The most common tumor site was the oropharynx and most of the patients (70%) had T4 and N1 to N3 tumors in 72% of patients. The main patient and tumor characteristics were well-balanced between the two arms. The median total doses were 63 Gy (accelerated) and 70 Gy (conventional), with a median overall time of 22 days and 48 days, respectively. Acute mucositis was markedly increased in the accelerated-RT arm (P < .001). The locoregional control rate was improved by 24% at 6 years with accelerated RT. In contrast, disease-free survival and overall survival were not significantly different between the two arms. There was no difference in late effects between the two arms. CONCLUSION The very accelerated RT regimen was feasible and provided a major benefit in locoregional control but had a modest effect on survival.
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Affiliation(s)
- Jean Bourhis
- Institut Gustave Roussy, Radiation Oncology, Head and Neck Statistics Department, Villejuif, France.
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29
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Lindholm P, Valavaara R, Aitasalo K, Kulmala J, Laine J, Elomaa L, Sillanmäki L, Minn H, Grénman R. Preoperative hyperfractionated accelerated radiotherapy and radical surgery in advanced head and neck cancer: A prospective phase II study. Radiother Oncol 2006; 78:146-51. [PMID: 16307813 DOI: 10.1016/j.radonc.2005.11.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2005] [Revised: 10/13/2005] [Accepted: 11/07/2005] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND PURPOSE To evaluate whether preoperative hyperfractionated accelerated radiotherapy (RT) combined with major radical surgery is feasible and successful in the treatment of advanced primary head and neck cancer. PATIENTS AND METHODS Ninety four patients with histologically confirmed head and neck squamous cell cancer (HNSCC) in the oral cavity (41/96; 43%), supraglottis (14/96; 15%), glottis (5/96; 5%), oropharynx (16/96; 17%), nasal cavity/paranasal sinuses (8/96; 8%), nasopharynx (3/96; 3%), hypopharynx (7/96; 7%) and two (2%) with unknown primary tumour and large cervical lymph nodes entered into the study. 21/96 patients (22%) had stage II, 17/96 (18%) stage III and 58/96 patients (60%) stage IV disease. The patients received preoperative hyperfractionated RT 1.6 Gy twice a day, 5 days a week to a median tumour dose of 63 Gy with a planned break for 11 days (median) after the median dose of 37 Gy. Then, after a median of 27 days the patients underwent major radical surgery of the primary tumour and metastatic lymph nodes including reconstructions with pedicled or microvascular free flaps when indicated as a part of the scheduled therapy. 12/96 patients had only ipsilateral or bilateral neck dissections. RESULTS After a median follow-up time of 37.2 mos 77/96 (80.2%) patients had complete locoregional control. All but 2 patients had complete histological remission after surgery. 40/96 pts were alive without disease, two of them after salvage surgery. 32/96 patients had relapsed; 15 had locoregional and 13 distant relapses, 4 patients relapsed both locoregionally and distantly. Fifty patients have died; 29 with locoregional and/or distant relapse, eight patients died of second malignancy, and 19 had intercurrent diseases. Disease-specific and overall survival at 3 years was 67.7 and 51%, respectively. Acute grade three mucosal reactions were common, but transient and tolerable. Late grade 3-4 adverse effects were few. CONCLUSIONS Preoperative hyperfractionated accelerated RT can be successfully combined with major radical surgery in the treatment of HNSCC. The amount of serious late adverse effects was not increased.
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Affiliation(s)
- Paula Lindholm
- Department of Oncology and Radiotherapy, University of Turku, Turku, Finland.
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30
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Groome PA, O'Sullivan B, Mackillop WJ, Jackson LD, Schulze K, Irish JC, Warde PR, Schneider KM, Mackenzie RG, Hodson DI, Hammond JA, Gulavita SPP, Eapen LJ, Dixon PF, Bissett RJ. Compromised local control due to treatment interruptions and late treatment breaks in early glottic cancer: Population-based outcomes study supporting need for intensified treatment schedules. Int J Radiat Oncol Biol Phys 2006; 64:1002-12. [PMID: 16414205 DOI: 10.1016/j.ijrobp.2005.10.010] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2005] [Revised: 10/18/2005] [Accepted: 10/18/2005] [Indexed: 11/17/2022]
Abstract
PURPOSE This population-based study describes the treatment of early glottic cancer in Ontario, Canada and assesses whether treatment variations were associated with treatment effectiveness. METHODS AND MATERIALS We studied 491 T1N0 and 213 T2N0 patients. Data abstracted from charts included age, sex, stage, treatment details, disease control, and survival. RESULTS The total dose ranged from 50 to 70 Gy, and the daily dose ranged from 1.9 to 2.8 Gy. In 90%, treatment duration was between 25 and 50 days. Field sizes, field reductions, beam arrangement, and beam energy varied. Late treatment breaks occurred in 13.6% of T1N0 and 27.1% of T2N0 cases. Local control was comparable to other reports for T1N0 (82% at 5 years), but was only 63.2% in T2N0. Variables associated with local failure in T1N0 were age less than 49 years (relative risk [RR], 3.21; 95% confidence interval [CI], 1.49-6.90) and >3 treatment interruption days (RR, 2.43; 95% CI, 1.00-5.91). In T2N0, these were field reduction (RR, 2.33; 95% CI, 1.23-4.42) and late treatment breaks (RR, 2.19; 95% CI, 1.09-4.41). CONCLUSION Some aspects of treatment for early glottic cancer were associated with worse local control. Problems with protracted treatment are of particular concern, underscoring the need for randomized studies to intensify radiotherapy.
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Affiliation(s)
- Patti A Groome
- Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Queen's University, Kingston, ON, Canada.
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Wilson GD, Saunders MI, Dische S, Daley FM, Buffa FM, Richman PI, Bentzen SM. Pre-treatment proliferation and the outcome of conventional and accelerated radiotherapy. Eur J Cancer 2006; 42:363-71. [PMID: 16386890 DOI: 10.1016/j.ejca.2005.10.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2005] [Revised: 10/07/2005] [Accepted: 10/09/2005] [Indexed: 11/28/2022]
Abstract
This study investigated the influence of pre-treatment proliferation characteristics, assessed by Ki-67 staining, in patients treated in the CHART trial of accelerated radiotherapy in head and neck cancer. Histological material from 402 patients was collected and stained for the presence and pattern of Ki-67 staining. Locoregional control and overall survival were the main clinical endpoints. Increasing Ki-67 positivity was associated with decreasing differentiation (P < 0.001) and increasing N-stage (P < 0.004). Increasing N-stage was also associated with the progression of proliferation pattern from marginal to random (P < 0.001). Using a multivariate model, a trend was seen towards a greater benefit from CHART in the lower Ki-67 tumours (P = 0.08); this became significant by pooling the low and intermediate Ki-67 groups in comparison with the high Ki-67 group (P = 0.032). Tumours with marginal proliferation pattern showed a lower hazard ratio with CHART versus conventional for locoregional control (P = 0.005). The data presented in this study do not support that a high pre-treatment Ki-67 is associated with a therapeutic benefit from accelerated radiotherapy.
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Affiliation(s)
- George D Wilson
- Gray Cancer Institute, Mount Vernon Hospital, Northwood, Middlesex HA6 2JR, UK.
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Eriksen JG, Steiniche T, Overgaard J. 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. Radiother Oncol 2005; 74:93-100. [PMID: 15816106 DOI: 10.1016/j.radonc.2004.12.018] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Jesper G Eriksen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
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Eriksen JG, Steiniche T, Overgaard J. 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. Acta Oncol 2005; 44:50-8. [PMID: 15848906 DOI: 10.1080/02841860510007396] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Jesper Grau Eriksen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark.
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Corry J, Rischin D. Strategies to overcome accelerated repopulation and hypoxia--what have we learned from clinical trials? Semin Oncol 2005; 31:802-8. [PMID: 15599858 DOI: 10.1053/j.seminoncol.2004.09.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- June Corry
- Head and Neck Radiation Oncology Unit, Division of Radiation Oncology, University of Melbourne, Peter MacCallum Cancer Centre, Melbourne, Australia
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Wadsley JC, Bentzen SM. 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. Int J Radiat Oncol Biol Phys 2004; 60:1405-9. [PMID: 15590171 DOI: 10.1016/j.ijrobp.2004.05.049] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2003] [Revised: 05/17/2004] [Accepted: 05/19/2004] [Indexed: 11/17/2022]
Abstract
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.
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Eriksen JG, Buffa FM, Alsner J, Steiniche T, Bentzen SM, Overgaard J. Molecular profiles as predictive marker for the effect of overall treatment time of radiotherapy in supraglottic larynx squamous cell carcinomas. Radiother Oncol 2004; 72:275-82. [PMID: 15450725 DOI: 10.1016/j.radonc.2004.07.014] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2004] [Revised: 06/26/2004] [Accepted: 06/28/2004] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- Jesper G Eriksen
- Department of Experimental Clinical Oncology, University Hospital of Aarhus, Noerrebrogade 44, build. 5, 8000 Aarhus C, Denmark
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Bourhis J, Etessami A, Wilbault P, Lusinchi A, Calais G, Lapeyre M, Pignon JP. Altered fractionated radiotherapy in the management of head and neck carcinomas: advantages and limitations. Curr Opin Oncol 2004; 16:215-9. [PMID: 15069315 DOI: 10.1097/00001622-200405000-00004] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Jean Bourhis
- Institut Gustave Roussy, Radiation Oncology & Statistic Departments, Villejuif, France.
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Zouhair A, Azria D, Pasche P, Stupp R, Chevalier J, Betz M, Mirimanoff RO, Ozsahin M. Accelerated postoperative radiotherapy with weekly concomitant boost in patients with locally advanced head and neck cancer. Radiother Oncol 2004; 70:183-8. [PMID: 15028406 DOI: 10.1016/j.radonc.2003.11.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2003] [Revised: 11/06/2003] [Accepted: 11/13/2003] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Abderrahim Zouhair
- Department of Radiation Oncology, Centre Hospitalier Universitaire Vaudois, Bugnon 46, CH-1011 Lausanne, Switzerland
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Overgaard J, Hansen HS, Specht L, Overgaard M, Grau C, Andersen E, Bentzen J, Bastholt L, Hansen O, Johansen J, Andersen L, Evensen JF. 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. Lancet 2003; 362:933-40. [PMID: 14511925 DOI: 10.1016/s0140-6736(03)14361-9] [Citation(s) in RCA: 474] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Although head and neck cancer can be cured by radiotherapy, the optimum treatment time for locoregional control is unclear. We aimed to find out whether shortening of treatment time by use of six instead of five radiotherapy fractions per week improves the tumour response in squamous-cell carcinoma. METHODS We did a multicentre, controlled, randomised trial. Between January, 1992, and December, 1999, of 1485 patients treated with primary radiotherapy alone, 1476 eligible patients were randomly assigned five (n=726) or six (n=750) fractions per week at the same total dose and fraction number (66-68 Gy in 33-34 fractions to all tumour sites except well-differentiated T1 glottic tumours, which were treated with 62 Gy). All patients, except those with glottic cancers, also received the hypoxic radiosensitiser nimorazole. Analysis was by intention to treat. FINDINGS More than 97% of the patients received the planned total dose. Median overall treatment times were 39 days (six-fraction group) and 46 days (five-fraction group). Overall 5-year locoregional control rates were 70% and 60% for the six-fraction and five-fraction groups, respectively (p=0.0005). The whole benefit of shortening of treatment time was seen for primary tumour control (76 vs 64% for six and five fractions, p=0.0001), but was non-significant for neck-node control. Six compared with five fractions per week improved preservation of the voice among patients with laryngeal cancer (80 vs 68%, p=0.007). Disease-specific survival improved (73 vs 66% for six and five fractions, p=0.01) but not overall survival. Acute morbidity was significantly more frequent with six than with five fractions, but was transient. INTERPRETATION The shortening of overall treatment time by increase of the weekly number of fractions is beneficial in patients with head and neck cancer. The six-fractions-weekly regimen has become the standard treatment in Denmark.
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Affiliation(s)
- Jens Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Nørrebrogade 44, Building 5, DK-8000 C, Aarhus, Denmark.
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Glaholm J, Watkinson JC. Developments in radiotherapy and adjuvant chemotherapy for head and neck cancer. CLINICAL OTOLARYNGOLOGY AND ALLIED SCIENCES 2003; 28:1-4. [PMID: 12580871 DOI: 10.1046/j.1365-2273.2003.00659.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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