Prognostic impact of total tumor volume and hemoglobin concentration on the outcome of patients with advanced head and neck cancer after concomitant boost radiochemotherapy

Tumour volume and radiotherapy prolongation in locally advanced head and neck cancer patients treated with radical IMRT

AIMS

The relationship of tumour volume, radiotherapy treatment time and other prognostic factors affecting prognosis was evaluated.

METHODS

184 patients with locally advanced head and neck cancer were treated with radical intensity modulated radiotherapy (IMRT) and compared retrospectively.

RESULTS

In the multivariate analysis the overall survival was dependent on gross tumour volume (GTV), clinical stage (CS), radiotherapy treatment time (RTT) and p16 status. Local control was influenced by GTV, overall RTT and age. DFS was significantly affected by GTV, CS, RTT, p16 status and concomitant chemotherapy (CHT).

CONCLUSIONS

The tumour volume and the radiotherapy treatment time were the most significant prognostic factors with the best outcomes in patients with GTV ≤ 55 cc and RTT ≤ 48 days (mean LC 8.1, DFS 7.1 and OS 6.4 years) and worst outcomes with GTV > 55 cc and RTT >48 days (mean LC 4.4, mean DFS 3.2 and mean OS 2.6 years).

Risk factors and their diagnostic values for ocular metastases in invasive ductal carcinoma

Invasive ductal carcinoma (IDC) is a major type of breast cancer. Ocular metastasis (OM) in IDC is rarely seen, but patients with OM often have a poor prognosis. Furthermore, OM is difficult to detect in the early stages by common imaging examinations. In the present study, we tried to figure out the risk factors of OM in IDC and evaluate their diagnostic values for early detection. There were 1192 IDC patients who were divided into two groups according to ocular metastasis involved in this study. Clinical parameters of those patients were used to detect differences. The binary logistic regression test was then used to determine the risk factors of OM in IDC. Furthermore, ROC curves of both single and combined risk factors were established to examine their diagnostic values. The incidence of axillary lymph node metastases was significantly higher in the OM group (p = 0.002). Higher carbohydrate antigen 153 (CA153), lower apolipoprotein A1 (ApoA1), and hemoglobin (Hb) were risk factors for OM in IDC (p < 0.001, p < 0.001, p = 0.038, respectively). In the single risk factor ROC analysis, cutoff values of CA153, ApoA1, and Hb were 43.3 u/mL (CI: 0.966-0.984, p < 0.001), 1.11 g/L (CI: 0.923-0.951, p < 0.001), and 112 g/L (CI: 0.815-0.857, p < 0.001), respectively. Among the ROC curves of combined risk factors, CA153+ApoA1+Hb had the best accuracy, with the sensitivity and specificity of 89.47% and 99.32%, respectively (CI: 0.964-0.983, p < 0.001). CA153, ApoA1, and Hb are risk factors for OM in IDC. In clinical practice, the three parameters could be used as predictive factors for the early detection of OM.

Risk factors for competing non-cancer mortality after definitive treatment for advanced-stage head and neck cancer

OBJECTIVE

Patients with head and neck cancer (HNC) can die of index tumor progression and second tumor or non-cancer causes. Here, we investigated the risk factors for competing non-cancer mortality (NCM) in a prospective cohort of patients with advanced-stage HNC.

MATERIALS AND METHODS

A prospective observational study was conducted with 604 patients who underwent definitive treatment for advanced-stage HNC between 2010 and 2015. Main outcomes were NCM and cancer mortality (CM) defined as death from non-cancer causes and HNC or second cancers, respectively. Cumulative incidence and cause-specific hazard functions were used to analyze the risk factors of NCM and CM.

RESULTS

Age, smoking, Charlson comorbidity index (CCI), performance status, body mass index, rural residence, education and hemoglobin level at diagnosis, and chemotherapy were significantly associated with NCM (all p < 0.05). Multivariate analyses showed that age, CCI, and hemoglobin were independent factors of NCM. Age (≥65 years), CCI (≥2), and hemoglobin (<11 g/dl) were related to 4.5-, 3.2-, and 2.7-fold increased adjusted risk of NCM, respectively.

CONCLUSIONS

Old age, comorbidity, and hemoglobin at diagnosis were independent predictors of NCM. The risk factors could be used to predict non-cancer death after definitive treatment for advanced-stage HNC.

Impact of initial tumor volume on radiotherapy outcome in patients with T2 glottic cancer

BACKGROUND

The aim of this study was to quantify the impact of initial tumor volume (TV) on radiotherapy (RT) outcome in patients with T2 glottic cancer.

MATERIALS AND METHODS

Initial TV was calculated for 115 consecutive patients with T2 glottic cancer who had been treated with definitive RT alone at a single institution.

RESULTS

The results showed strong correlations of TV with 3-year local tumor control (LTC) and disease-free survival (DFS). For TV ≤ 0.7 cm(3), 3-year LTC was 83%; for TV 0.7-3.6 cm(3) this was 70% and for TV 3.6-17 cm(3) 44%. Analysis of total dose vs. initial TV showed that larger T2 glottic tumors with a TV of around 5 cm(3) (2-2.5 cm in diameter with 10(10) cancer cells) need an extra 6.5 Gy to achieve similar 3-year LTC rates as for small tumors with a TV of 0.5 cm(3) (~1 cm in diameter with 10(9) cancer cells).

CONCLUSION

Although classification of tumors according to TV cannot replace TNM staging in daily practice, it could represent a valuable numerical supplement for planning the optimal dose fractionation scheme for individual patients.

The role of tumor volume in radiotherapy of patients with head and neck cancer

The assumption that the larger tumor contains a higher number of clonogenic cells what may deteriorate prognosis of patients treated with RT has been confirmed in many clinical studies. Significant prognostic influence of tumor volume (TV) on radiotherapy (RT) outcome has been found for tumors of different localizations including patients with head and neck cancer (HNC). Although TV usually is a stronger prognostic factor than T stage, commonly used TNM classification system dose not incorporate TV data. The aim of the paper is to refresh clinical data regarding the role of TV in RT of patients with HNC. At present somehow new meaning of TV could be employed in the aspect of modern RT techniques and combined treatment strategies. For larger TV more aggressive treatment options may be considered. In modern RT techniques escalated dose could be provided highly conformal or RT can be combined with systemic treatment increasing therapeutic ratio. In the study several reports estimating prognostic value of TV for patients with HNC treated with RT has been reviewed.Due to substantially various reported groups of patients as to tumor site, stage of disease or treatment strategies, precise cut-off value could not be establish in general, but the significant association between TV and treatment outcome had been found in almost all studies. There is a strong suggestion that TV should supplement clinical decision in the choice of optimal treatment strategy for patients with HNC.

Volumetric stratification of cT4 stage head and neck cancer

BACKGROUND

Locoregionally advanced stage head and neck cancer (HNC) is known for unfavorable outcome with only ~ 40-50% 3-year overall survival (OS). Clinical T4 stage includes a wide range of tumor burden. The lack of further nonsurgical subgrouping of cT4 stage makes intercenter outcome of irradiated cohorts difficult. Aim of this analysis was to further stratify cT4 stage HNC using volumetric staging.

MATERIAL AND METHODS

Between January 2002 and January 2013, a total of 201 cT4 stage squamous cell cancer (SCC) HNC patients referred to our center for curative definitive radiation were consecutively irradiated. Radiation was performed using modulated techniques. Total gross tumor volumes (tGTV: primary+nodal tumor volume) of all patients have retrospectively been stratified using a prospectively evaluated volumetric staging system which bases on 3 cut-offs (15/70/130 ml), translating into 4 prognostic subgroups [V1: 1-15 ml (n=15), V2: 16-70 ml (108), V3: 71-130 ml (62), V4: >130 ml (16)]. OS, disease-free survival (DFS), locoregional control (LRC), and distant metastasis-free survival (DMFS) rates were calculated.

RESULTS

The mean/median follow-up was 31/23 months (range 1-116 months). The 3-year OS, DFS, LRC, and DMFS rates of the entire cohort were 63, 44, 48, and 77%, respectively. Volumetric staging revealed its potential to prognostically statistically significantly divide the cT4 cohort into 4 volume subgroups (V1/2/3/4): OS: 90%/72%/58%/18%; DFS: 83%/50%/39%/10%; LRC: 81%/53%/47%/15%; DMFS: 93%/90%/70%/41%, all p<0.0001.

CONCLUSION

Volumetric staging allowed a highly statistically significant stratification of cT4 HNC stages into prognostic subgroups, which offers the chance of better intercenter comparability of irradiated advanced stage HNC cohorts.

Comparing primary tumors and metastatic nodes in head and neck cancer using intravoxel incoherent motion imaging: a preliminary experience

OBJECTIVE

This study aimed to use intravoxel incoherent motion (IVIM) imaging for investigating differences between primary head and neck tumors and nodal metastases and to evaluate IVIM efficacy in predicting outcome.

METHODS

Sixteen patients with head and neck cancer underwent IVIM diffusion-weighted imaging on a 1.5-T magnetic resonance imaging scanner. The significance of parametric difference between primary tumors and metastatic nodes were tested. Probabilities of progression-free survival and overall survival were estimated using the Kaplan-Meier method.

RESULTS

In comparison with metastatic nodes, the primary tumors had significantly higher vascular volume fraction (f) (P < 0.0009) and lower diffusion coefficient (D) (P < 0.0002). Patients with lower SD for D had prolonged progression-free survival and overall survival (P < 0.05).

CONCLUSIONS

Pretreatment IVIM measures were feasible in investigating the physiologic differences between the 2 tumor tissues. After appropriate validation, these findings might be useful in optimizing treatment planning and improving patient care.

Prognostic value of gross tumor volume delineated by FDG-PET-CT based radiotherapy treatment planning in patients with locally advanced pancreatic cancer treated with chemoradiotherapy

Background

We aimed to assess whether gross tumor volume (GTV) determined by fusion of contrast-enhanced computerized tomography (CT) and 18F-fluoro-deoxy-D-glucose positron emission tomography-CT (FDG-PET-CT) based radiotherapy planning could predict outcomes, namely overall survival (OS), local-regional progression-free survival (LRPFS), and progression-free survival (PFS) in cases with locally advanced pancreas cancer (LAPC) treated with definitive concurrent chemoradiotherapy.

Methods

A total of 30 patients with histological proof of LAPC underwent 50.4 Gy (1.8 Gy/28 fractions) of radiotherapy concurrent with continuously infused 5-FU followed by 4 to 6 courses of maintenance gemcitabine. Target volume delineations were performed on FDG-PET-CT-based RTP. Patients were stratified into 2 groups: GTV lesser (GTV_L) versus greater (GTV_G) than cut off value determined by receiver operating characteristic (ROC) analysis, and compared in terms of OS, LRPFS and PFS.

Results

Median GTV delineated according to the FDG-PET-CT data was 100.0 cm³. Cut off GTV value determined from ROC curves was 91.1 cm³. At a median follow up of 11.2 months, median OS, LRPFS and PFS for the entire population were 10.3, 7.8 and 5.7 months, respectively. Median OS, LRPFS and PFS for GTV_L and GTV_G cohorts were 16.3 vs. 9.5 (p = 0.005), 11.0 vs. 6.0 (p = 0.013), and 9.0 vs. 4.8 months (p = 0.008), respectively.

Conclusions

The superior OS, LRPFS and PFS observed in GTV_L patients over GTV_G ones suggests a potential for FDG-PET-CT-defined GTV size in predicting outcomes of LAPC patients treated with definitive C-CRT, which needs to be validated by further studies with larger cohorts.

Definitive Radiotherapy versus Postoperative Radiotherapy of Patients with Oro- and Hypopharyngeal Cancer: Impact of Prognostic Factors

Purpose. To compare the impact of prognostic factors of patients treated with definitive radio(chemo)therapy versus patients treated with surgery and postoperative radiotherapy for squamous cell carcinoma of the oro- and hypopharynx. Patients and Methods. 162 patients treated with definitive radiotherapy and 126 patients treated with postoperative radiotherapy were retrospectively analysed. The impact of the prognostic factors gender, age, total tumor volume (TTV), pre-radiotherapy hemoglobin level (Hb-level), tumor site, T- and N-classification, radiotherapy interruptions >5 days, radiotherapy versus simultaneous radiochemotherapy, R-status and time interval between surgery and radiotherapy were investigated. Results. The median follow-up time for the censored patients treated with definitive radio(chemo)therapy was 28.5 months and for postoperative radiotherapy 36.5 months. On univariate analysis, the TTV, Hb-level, and simultaneous radiochemotherapy had a significant impact on the survival of patients treated with definitive radio(chemo)therapy. For patients treated with postoperative radiotherapy, only the TTV showed a statistical trend for the survival (P = 0.13). On multivariate analysis, the TTV and simultaneous radiochemotherapy maintained their statistical significance for patients treated with definitive raditherapy, and the TTV, the statistical trend for patients treated with postoperative radiotherapy (P = 0.19). Conclusions. The TTV was the predominant prognostic factor for both, patients treated with definitive or postoperative radiotherapy.

Volumetric and MGMT parameters in glioblastoma patients: survival analysis

BACKGROUND

In this study several tumor-related volumes were assessed by means of a computer-based application and a survival analysis was conducted to evaluate the prognostic significance of pre- and postoperative volumetric data in patients harboring glioblastomas. In addition, MGMT (O6-methylguanine methyltransferase) related parameters were compared with those of volumetry in order to observe possible relevance of this molecule in tumor development.

METHODS

We prospectively analyzed 65 patients suffering from glioblastoma (GBM) who underwent radiotherapy with concomitant adjuvant temozolomide. For the purpose of volumetry T1 and T2-weighted magnetic resonance (MR) sequences were used, acquired both pre- and postoperatively (pre-radiochemotherapy). The volumes measured on preoperative MR images were necrosis, enhancing tumor and edema (including the tumor) and on postoperative ones, net-enhancing tumor. Age, sex, performance status (PS) and type of operation were also included in the multivariate analysis. MGMT was assessed for promoter methylation with Multiplex Ligation-dependent Probe Amplification (MLPA), for RNA expression with real time PCR, and for protein expression with immunohistochemistry in a total of 44 cases with available histologic material.

RESULTS

In the multivariate analysis a negative impact was shown for pre-radiochemotherapy net-enhancing tumor on the overall survival (OS) (p = 0.023) and for preoperative necrosis on progression-free survival (PFS) (p = 0.030). Furthermore, the multivariate analysis confirmed the importance of PS in PFS and OS of patients. MGMT promoter methylation was observed in 13/23 (43.5%) evaluable tumors; complete methylation was observed in 3/13 methylated tumors only. High rate of MGMT protein positivity (> 20% positive neoplastic nuclei) was inversely associated with pre-operative tumor necrosis (p = 0.021).

CONCLUSIONS

Our findings implicate that volumetric parameters may have a significant role in the prognosis of GBM patients. Furthermore, volumetry could help not only to improve the prediction of outcome but also the outcome itself by identifying patients at high risk of treatment failure and, thus, seek alternative treatment for these patients. In this small series, MGMT protein was associated with less aggressive tumor characteristics.

Prognostic significance of radiologically determined neck node volume in head and neck cancer: a systematic review

This systematic review addresses the prognostic significance of neck node volume in head and neck cancer. Primary tumor volume evolved as an independent significant factor for survival in head and neck cancer patients. Besides primary tumor volume, multiple prognostic features related to the regional lymph nodes were studied in literature. In literature, some authors showed the significance of total tumor volume/nodal volume for survival and loco-regional control. Articles reporting prognosis and survival in nodal tumor volumes were collected by systematically reviewing publications listed in the Pubmed and Embase databases. Publications were included when they at least reported on total tumor volume (TTV) or nodal volume and survival. In this systematic review we studied 21 articles. For measurement of nodal volume different formulas were used. Until now, there's no clear statistical evidence for the use of either TTV or nodal volume versus primary tumor volume to predict the individual loco-regional control or survival after treatment. There is wide variety of tumor measuring systems in the literature. The cut-off value for local tumor response also shows large variation. Firstly consensus should be accomplished on standardization of volume measurements, preferably automatic, and secondly large study groups are needed with identical treatment modalities to further unravel the role of neck node volume as separate staging tool.

Tumor volume as prognostic factor in chemoradiation for advanced head and neck cancer

BACKGROUND

Tumor volume is an important predictor of outcome in radiotherapy alone. Its significance in concomitant chemoradiation (CCRT) is much less clear. We analyzed the prognostic value of primary tumor volume for advanced head and neck squamous cell carcinoma (HNSCC) treated with CCRT.

METHODS

Three hundred sixty patients treated with definitive CCRT for advanced HNSCC were selected. The pretreatment MRI or CT scan was used to calculate the primary tumor volume. Median follow-up was 19.8 months.

RESULTS

The average primary tumor volume was 37.0 cm³ (range, 2.1-182.7 cm³; median, 28.7 cm³). Multivariate analysis showed a significant effect of tumor volume on local control. The hazard ratio for a local recurrence increased by 14% per 10 cm³ volume increase (95% CI, 8% to 21%). There was no significant independent effect of T and N status on local control.

CONCLUSION

For advanced HNSCC, tumor volume is more powerful for predicting outcome after CCRT than TNM status.

Dynamic contrast-enhanced magnetic resonance imaging as a predictor of outcome in head-and-neck squamous cell carcinoma patients with nodal metastases

PURPOSE

Dynamic contrast-enhanced MRI (DCE-MRI) can provide information regarding tumor perfusion and permeability and has shown prognostic value in certain tumors types. The goal of this study was to assess the prognostic value of pretreatment DCE-MRI in head and neck squamous cell carcinoma (HNSCC) patients with nodal disease undergoing chemoradiation therapy or surgery.

METHODS AND MATERIALS

Seventy-four patients with histologically proven squamous cell carcinoma and neck nodal metastases were eligible for the study. Pretreatment DCE-MRI was performed on a 1.5T MRI. Clinical follow-up was a minimum of 12 months. DCE-MRI data were analyzed using the Tofts model. DCE-MRI parameters were related to treatment outcome (progression-free survival [PFS] and overall survival [OS]). Patients were grouped as no evidence of disease (NED), alive with disease (AWD), dead with disease (DOD), or dead of other causes (DOC). Prognostic significance was assessed using the log-rank test for single variables and Cox proportional hazards regression for combinations of variables.

RESULTS

At last clinical follow-up, for Stage III, all 12 patients were NED. For Stage IV, 43 patients were NED, 4 were AWD, 11 were DOD, and 4 were DOC. K(trans) is volume transfer constant. In a stepwise Cox regression, skewness of K(trans) (volume transfer constant) was the strongest predictor for Stage IV patients (PFS and OS: p <0.001).

CONCLUSION

Our study shows that skewness of K(trans) was the strongest predictor of PFS and OS in Stage IV HNSCC patients with nodal disease. This study suggests an important role for pretreatment DCE-MRI parameter K(trans) as a predictor of outcome in these patients.

Accelerated fractionation radiotherapy and late intensification with 2 intra-arterial cisplatin infusions for locally advanced head and neck squamous cell carcinoma

BACKGROUND

This study was established to determine the maximum tolerated dose of intra-arterial cisplatin (IAC) concurrent with accelerated fractionation radiotherapy for locally advanced head and neck squamous cell carcinoma (HNSCC).

METHODS

We conducted a phase I study. Treatment consisted of 70 Gy/35 fractions/5.8 weeks and 2 weekly IAC infusions during the last 2 weeks.

RESULTS

Ten patients were recruited. Two patients had stage III, 1 had stage IVa, and 7 had stage IVb disease. Three patients received IAC at 100 mg/m(2), 3 at 125 mg/m(2), and 4 at 150 mg/m(2). Nine patients received both planned infusions. Dose-limiting toxicity occurred at 150 mg/m(2) as transient grade 4 leukopenia and prolonged grade 3 acute skin reactions. The maximum tolerated dose was 125 mg/m(2). Six patients survived disease-free at 39 to 67 months.

CONCLUSIONS

It was feasible to give IAC concurrent with accelerated fractionation radiotherapy for locally advanced HNSCC. The maximum tolerated dose of cisplatin was 125 mg/m(2).

Pretreatment prognostic factors of survival in patients with locally advanced nonmetastatic squamous cell carcinoma of the head and neck treated with radiation therapy with or without concurrent chemotherapy

BACKGROUND

Identification of pretreatment prognostic factors influencing overall survival (OS) in locally advanced squamous cell carcinoma of the head and neck is an important issue in head and neck oncology.

METHODS

A total of 289 patients were treated with standard fraction or hyperfractionated radiation therapy with or without concurrent low-dose daily chemotherapy.

RESULTS

Gender (P = 0.43) and age (P = 0.26) did not influence OS whereas Karnofsky Performance Status (KPS) (P < 0.0001), T stage (P < 0.0001), and N stage (P < 0.0001) did. Stage grouping was another factor that influenced OS (P < 0.001). Patients with larynx and nasopharynx fared better than those with other primaries (P = 0.0153). Finally, treatment significantly influenced OS. Multivariate analysis showed that KPS, T and N stage, and treatment were independent prognosticators of OS.

CONCLUSIONS

KPS, T and N stage, and treatment are independent prognosticators of OS in patients with locally advanced squamous cell carcinoma of the head and neck treated with radiation therapy with or without concurrent low-dose daily chemotherapy.

Volumetric staging (VS) is superior to TNM and AJCC staging in predicting outcome of head and neck cancer treated with IMRT

The UICC classification (TNM) represents the validated standard tool to describe tumor extent and includes prognostic information on the probability of disease control. The American Joint Committee on Cancer (AJCC) stage grouping is based on the evaluation of treatment and outcome. Gross tumor volume (GTV) might be more relevant than pure description (TNM) or stage grouping as prognostic factor for local control in head and neck cancer (HNC). Based on the observation of GTV-correlated outcome in our initial HNC patient cohort treated with IMRT, we tested the hypothesis that the GTV is the most reliable predictive tool in HNC outcome. A GTV based volumetric staging system (VS) was introduced, using two volumetric cut-off values (15 and 70 cm3). VS, TNM, and AJCC stages were assessed and correlated with outcome following primary radiation in 172 HNC patients. Analyses were based on Kaplan-Meier survival curves. VS proved to be superior to the TNM/AJCC in predicting outcome. In addition, VS enabled to stratify high- and low-risk patients in advanced TN stages. GTV represented the most important prognostic indicator in HNC treated with IMRT and is recommended to be considered for therapeutic decisions and estimation of outcome.

Prognostic significance of a pretreatment hematologic profile in patients with head and neck cancer

BACKGROUND

The purpose of this retrospective study was to test whether the pretreatment hematologic profile can predict the prognosis of patients with head and neck cancer.

METHODS

Medical records from 278 patients with head and neck cancer were reviewed, and 270 cases were evaluable. Clinical data including age, gender, stage, pretreatment hematologic profile (including white blood cell, platelet, and differential counts, and hemoglobin level) were recorded. Statistical analyses were performed to determine the prognostic effect of these hematologic indicators, as well as clinical variables. The association between the hematologic indicators and clinical factors was also analyzed.

RESULTS

Pretreatment monocytes >1,000 cells/microl (P = 0.028), hemoglobin <11.0 g/dl (P = 0.022), and platelet count >400 x 10(3) cells/microl (P = 0.017) were identified as independent prognostic factors in addition to the nodal status and metastasis. A significant correlation between T-stage/monocyte or platelet count and metastasis/platelet count were shown. Monocytosis, anemia, and thrombocytosis were demonstrated to have a cumulative effect on the prognosis of head and neck cancer patients (normal vs. abnormality in one lineage, P = 0.001; abnormality in one vs. more than one lineage, P = 0.005).

CONCLUSIONS

A pretreatment hematologic profile can be considered as a useful prognostic marker in patients with head and neck cancer.

Long-term results of a prospective multicenter phase II study to preserve the larynx function using concomitant boost radiochemotherapy with Carboplatin

PURPOSE

This prospective phase II study was undertaken to assess the feasibility of a larynx preservation protocol with simultaneous radiochemotherapy.

PATIENTS AND METHODS

Between 3/1998 and 10/2000, 42 patients with moderately advanced cancer of the larynx (n=25) and hypopharynx (n=17) eligible for total laryngectomy (LE) were treated in a prospective larynx preservation study. The study protocol scheduled 66Gy in 5 weeks using a concomitant boost technique and 70mg/m(2) Carboplatin on days 1-5 in weeks 1 and 5.

RESULTS

The median follow-up time of the censored study patients was 41 months (9-95 months). The 5-year overall survival was 0.66 (95% CI 0.48-0.84), the 5-year laryngectomy-free survival 0.60 (95% CI 0.42-0.78), and the laryngeal preservation rate at 5 years 0.67 (95% CI 0.49-0.85). Cox multivariate regression analysis showed the total tumor volume to be the only statistically significant factor on locoregional failure-free survival. Six of 23 tumor-free long-term survivors received a tracheotomy because of late laryngeal toxicity associated with dysphagia 30-79 months after radiochemotherapy.

CONCLUSIONS

Due to the late laryngeal toxicity observed the value of this regimen for larynx preservation is limited.

Prognostic Factors Affecting Locally Recurrent Rectal Cancer and Clinical Significance of Hemoglobin

PURPOSE

To investigate potential prognostic factors, including hemoglobin levels before and during radiotherapy, for associations with survival and local control in patients with unirradiated locally recurrent rectal cancer.

PATIENTS AND METHODS

Ten potential prognostic factors were investigated in 94 patients receiving radiotherapy for recurrent rectal cancer: age (<or=68 vs. >or=69 years), gender, Eastern Cooperative Oncology Group performance status (0-1 vs. 2-3), American Joint Committee on Cancer (AJCC) stage (<or=II vs. III vs. IV), grading (G1-2 vs. G3), surgery, administration of chemotherapy, radiation dose (equivalent dose in 2-Gy fractions: <or=50 vs. >50 Gy), and hemoglobin levels before (<12 vs. >or=12 g/dL) and during (majority of levels: <12 vs. >or=12 g/dL) radiotherapy. Multivariate analyses were performed, including hemoglobin levels, either before or during radiotherapy (not both) because these are confounding variables.

RESULTS

Improved survival was associated with better performance status (p<0.001), lower AJCC stage (p=0.023), surgery (p=0.011), chemotherapy (p=0.003), and hemoglobin levels>or=12 g/dL both before (p=0.031) and during (p<0.001) radiotherapy. On multivariate analyses, performance status, AJCC stage, and hemoglobin levels during radiotherapy maintained significance. Improved local control was associated with better performance status (p=0.040), lower AJCC stage (p=0.010), lower grading (p=0.012), surgery (p<0.001), chemotherapy (p<0.001), and hemoglobin levels>or=12 g/dL before (p<0.001) and during (p<0.001) radiotherapy. On multivariate analyses, chemotherapy, grading, and hemoglobin levels before and during radiotherapy remained significant. Subgroup analyses of the patients having surgery demonstrated the extent of resection to be significantly associated with local control (p=0.011) but not with survival (p=0.45).

CONCLUSION

Predictors for outcome in patients who received radiotherapy for locally recurrent rectal cancer were performance status, AJCC stage, chemotherapy, surgery, extent of resection, histologic grading, and hemoglobin levels both before and during radiotherapy.

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

OBJECTIVE

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

DESIGN

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

RESULTS

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

CONCLUSION

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

Prognostic significance of blood transfusions in patients with esophageal cancer treated with combined chemoradiotherapy

OBJECTIVE

Anemia occurs commonly in patients with esophageal cancer. This study evaluates the effect of blood transfusion on survival outcomes in patients with esophageal cancer treated with combined chemoradiotherapy (CRT).

PATIENTS AND METHODS

Fifty-six consecutive patients with unresectable esophageal cancer received 50 Gy in 25 fractions over 5 weeks concurrent with cycles 2 and 3 of cisplatin and 5-fluorouracil chemotherapy. Data on hemoglobin before and during radiation therapy (RT) and blood transfusion use were abstracted by chart review. Each patient had a blood count before every chemotherapy cycle, and the test was repeated if the blood count was low. Five-year Kaplan-Meier overall survival (OS) and relapse-free survival (RFS) estimates were compared according to pre-RT hemoglobin levels and transfusion use. Multivariate analysis using Cox regression modeling was performed to determine the prognostic significance of pre-RT hemoglobin and transfusion use on survival outcomes.

RESULTS

The 5-year OS and RFS rates were 30% and 37%, respectively. Seventeen patients (30%) received transfusions during CRT. Among 18 patients (32%) with a hemoglobin of < or =12 g/dL at the start of RT, 9 received transfusions. Pre-RT hemoglobin levels of < or =12 g/dL were strongly associated with the use of blood transfusions (P = 0.03). Five-year Kaplan-Meier OS was 65% versus 21% in patients treated with, versus without, a transfusion (P = 0.006). On multivariate analysis, the use of blood transfusion was associated with improved OS (hazard ratio, 0.26; 95% confidence interval, 0.09-0.75, P = 0.01).

CONCLUSIONS

The use of blood transfusion is a significant treatment-related factor associated with improved survival in patients undergoing CRT for esophageal cancer.

Hemoglobin levels do not predict biochemical outcome for localized prostate cancer treated with neoadjuvant androgen-suppression therapy and external-beam radiotherapy

PURPOSE

To investigate whether hemoglobin (Hb) levels affect outcome in men with localized prostate adenocarcinoma (LPA) treated with neoadjuvant androgen-suppression therapy (NAST) and external-beam radiotherapy (EBRT).

METHODS AND MATERIALS

A total of 563 men with LPA treated with NAST (median: 5.3 months) and EBRT who had Hb levels during treatment were retrospectively reviewed. Patient, tumor, and treatment variables, including the following Hb variables, were subjected to univariate and multivariable analyses to identify factors that predict biochemical control (bNED) and overall survival (OS): pre-EBRT Hb, Hb nadir during EBRT, and change in Hb from pre-EBRT to nadir during EBRT.

RESULTS

Median PSA follow-up was 4.25 years. Forty-nine percent of men were anemic during EBRT, with a median Hb of 13.4 g/dL, and 68% experienced a decline in Hb from pre-EBRT to during EBRT of median 0.6 g/dL. Five-year Nadir+2 bNED and OS rates were similar for anemic and nonanemic patients during EBRT. High percent-positive biopsies, PSA and Gleason score, and use of AA monotherapy predicted worse bNED. High stage and age predicted worse OS. Hb variables were not predictive of bNED or OS.

CONCLUSIONS

Anemia is a common side effect of NAST and is usually mild. Hb levels, however, do not predict biochemical control or survival.

Concomitant low-dose cisplatin and three-dimensional conformal radiotherapy for locally advanced squamous cell carcinoma of the head and neck: Analysis of survival and toxicity

BACKGROUND

Our center sought to implement a simple chemoradiotherapy schedule for patients with locally advanced squamous cell carcinoma of the head and neck (SCCHN) with minimal toxicity to achieve rates of overall survival comparable to other schedules.

METHODS

The chemoradiotherapy schedule consisted of daily radiation to 70 Gy over 7 weeks with concurrent cisplatin 20 mg/m(2) during days 1 to 4 of weeks 1 and 5. Acute and late toxicities were recorded according to the Radiation Therapy Oncology Group (RTOG) and common toxicity criteria (CTC) grading. The overall, disease-specific, and locoregional recurrence-free survival were calculated using the STATA statistics package. Possible factors influencing these endpoints were analyzed.

RESULTS

Fifty-seven patients were treated, and 56 patients were evaluable for follow-up. Median follow-up of alive patients was 16.1 months. There was an 82% complete response rate to chemoradiotherapy. The 2-year Kaplan-Meier overall, disease-specific, and locoregional recurrence-free survival rates were 62%, 67%, and 63%. Acute grade 3 and 4 radiation toxicity was noted in 61% and 2%, respectively. Grade 3 or 4 hematologic toxicity was noted in 7% of patients. Factors influencing overall survival included: Karnofsky performance status, receiving more than 50% of planned chemotherapy, age, and initial hemoglobin level.

CONCLUSION

This regimen is tolerable and achieves overall survival and locoregional control rates comparable to other chemoradiotherapy schedules.

Das Nachsorgeprinzip beim metastasierten Prostatakarzinom

For advanced prostate cancer - not including intermittent strategies - the patient is in continual treatment. The effect of the therapy must be controlled so that its failure can be determined as soon as possible and a new regimen started. As in most cases the progression of the disease can not be stopped, the aim of the therapy is to provide the patient with the best possible quality of life. In order to carry out therapy, if possible in the patient's usual environment, supportive therapies should be used, such as compensation for anaemia or pain therapy as required. Skeletal complications can be prophylactically treated by the use of biphosphonates.

Prognostic factors in the nonsurgical treatment of esophageal carcinoma with radiotherapy or radiochemotherapy: the importance of pretreatment hemoglobin levels

BACKGROUND

The current study was performed to evaluate prognostic factors for overall survival (OS), distant metastasis (DM), and local failure (LF) in patients with Stage II/III esophageal carcinoma.

METHODS

The following potential prognostic factors were retrospectively investigated in 124 patients treated with radiotherapy (RT) alone or with radiochemotherapy: age, gender, performance status, tumor location, tumor length, histology, histologic grade, T classification, N classification, International Union Against Cancer stage, chemotherapy, RT dose, and pre-RT hemoglobin level.

RESULTS

Using univariate analysis (Kaplan-Meier method), pre-RT hemoglobin level, RT dose, tumor length, chemotherapy, and performance status were significantly associated with OS. Hemoglobin levels of 12.1-14.0 g/dL were associated with the best OS, followed by >/= 14.1 g/dL and </= 12.0 g/dL. DM was significantly influenced by tumor length, RT dose, N classification, and performance status. LF was significantly influenced by pre-RT hemoglobin level, RT dose, and tumor length. Using multivariate analysis (Cox proportional hazard model), pre-RT hemoglobin maintained significance for OS (P < 0.001) and LF (P < 0.001), RT dose for OS (P = 0.001), DM (P = 0.031), and LF (P < 0.001), tumor length for OS (P = 0.003), DM (P = 0.017), and LF (P = 0.033), and chemotherapy for OS (P = 0.027). N classification was of borderline significance for DM (P = 0.054). Performance status lost significance for OS (P = 0.73) and LF (P = 0.22).

CONCLUSIONS

The strongest predictors for outcome in Stage II/III esophageal carcinoma were RT dose, tumor length, pre-RT hemoglobin level, and chemotherapy. The pre-RT hemoglobin level was an independent prognostic factor significantly associated with OS and LF. A hemoglobin level of 12.1-14 g/dL resulted in a better prognosis than hemoglobin levels >/= 14 g/dL and </= 12 g/dL.

Darbepoietin Alfa Potentiates the Efficacy of Radiation Therapy in Mice with Corrected or Uncorrected Anemia

Darbepoietin alfa (DA) is a long-acting analogue of erythropoietin that has reduced receptor affinity and enhanced biological activity. Experiments were done to test the hypothesis that correction of anemia in tumor-bearing mice by DA would increase tumor oxygenation and potentiate radiation-induced tumor cell killing. A SCC VII tumor model was used to study tumor responses to fractionated radiation therapy in mice with anemia induced by total body irradiation. Administration of DA reduced the extent and duration of anemia and associated tumor hypoxia, protected the bone marrow cells and prevented the body weight loss from the effect of irradiation, and facilitated the recovery in a time-dependent manner, with the administration of DA prior to total body irradiation having the greatest protective effect. When combined with fractionated radiation therapy, DA increased the tumor growth delay time from 2.7 days for irradiation alone to 7.3 to 10.6 days for combination of DA and irradiation. The effect of DA on tumor responses to fractionated radiation therapy was observed when DA was given 18 to 4 days before starting radiation therapy, but DA was also equally effective as a radiosensitizer when given only 2 hours before fractionated irradiation therapy. Weekly dosing of DA was as efficacious for the enhancement of radiation responses of tumors as biweekly dosing. Similar results were obtained in the RIF-1 fibrosarcoma tumor model. These studies show that DA can effectively correct anemia in tumor-bearing mice and sensitize tumor cells to fractionated radiation therapy. Importantly, DA was also able to sensitize tumors to radiation in mice with uncorrected anemia and hypoxia, suggesting that the effect of DA on radiosensitivity was independent of these factors and a different mechanism of action may be responsible for this effect.

Optimal treatment of intermediate-risk prostate carcinoma with radiotherapy

The clinical heterogeneity of intermediate-risk prostate carcinoma presents a challenge to urologic oncology in terms of prognosis and management. There is controversy regarding whether patients with intermediate-risk prostate carcinoma should be treated with dose-escalated external beam radiotherapy (EBRT) (e.g., doses > 74 gray [Gy]), or conventional-dose EBRT (e.g., doses < 74 Gy) combined with androgen deprivation (AD). Data for this review were identified through searches for articles in MEDLINE and in conference proceedings, indexed from 1966 to 2004. Currently, the intermediate-risk prostate carcinoma grouping is defined on the basis of prostate-specific antigen (PSA), tumor classification (T classification), and Gleason score. Emerging evidence suggests that additional prognostic information may be derived from the percentage of positive core needle biopsies at the time of diagnosis and/or from the pretreatment PSA doubling time. Novel prognostic biomarkers include protein expression relating to cell cycle control, cell death, DNA repair, and intracellular signal transduction. Preclinical data support dose escalation or combined AD with radiation as a means to increase prostate carcinoma cell kill. There is Level I evidence that patients with intermediate-risk prostate carcinoma benefit from dose-escalated EBRT or AD plus conventional-dose EBRT. However, clinical evidence is lacking to support the uniform use of AD plus dose-escalated EBRT. Patients in the intermediate-risk group should be entered into well designed, randomized clinical trials of dose-escalated EBRT and AD with sufficient power to address biochemical failure and cause-specific survival endpoints. These studies should be stratified by novel prognostic markers and accompanied by strong translational endpoints to address clinical heterogeneity and to allow for individualized treatment.

Prognostic impact of tumor volumetry in patients with locally advanced head-and-neck carcinoma (non-nasopharyngeal) treated by radiotherapy alone or combined radiochemotherapy in a randomized trial

PURPOSE

Tumor volume (TV) is one of the main reported factors determining the outcome of treatment in head-and-neck carcinomas. In this study, the prognostic impact of TV was explored in the context of a randomized trial with the patients assigned to receive standard radiotherapy (RT) alone or RT plus platinum compounds (RT alone, RT plus cisplatin, or RT plus carboplatin).

METHODS AND MATERIALS

The tumor outlines were traced and digitized on each pretreatment CT slice for each of the 101 patients studied. Taking into account the magnification factor of the scan and CT slice thickness, a computer with specifically designed software calculated the TV in cubic centimeters.

RESULTS

The median overall survival for the whole group of patients was 21.6 months (95% confidence interval, 13.0-30.2) and the 3-year survival rate was 40%. The addition of platinum compounds to RT (Groups 2 and 3) significantly improved the survival rate (RT alone vs. RT plus cisplatin, hazard ratio 0.36, p = 0.002; RT alone vs. RT plus carboplatin, hazard ratio 0.53, p = 0.029). In univariate analysis, the most significant parameters for survival were treatment group, total gross tumor volume (TGTV), complete response, nodal GTV, primary GTV, and performance status. In multivariate analysis, treatment group, TGTV, gender, and primary site were independent prognostic factors for survival. A prognostic threshold of 22.8 cm(3) was detected for TGTV. Patients with a TGTV of <22.8 cm(3) were more likely to achieve a complete response and had a median survival of 45.3 months, and those with a TGTV >22.8 cm(3) had a median survival of 12.3 months (log-rank test, p = 0.0102).

CONCLUSION

The prognostic significance of the TGTV was confirmed and a cutoff value of 22.8 cm(3) derived. Our data indicated that locally advanced head-and-neck carcinomas should not be treated by standard (once-daily) RT alone. Tumor size and disease subsite should be taken into account in future randomized trials to increase their statistical power.

Parameters that predict local control after definitive radiotherapy for squamous cell carcinoma of the head and neck

PURPOSE

To analyze parameters that may influence the likelihood of local control after definitive radiotherapy for head and neck cancer.

METHODS

Between April 1980 and January 2000, 404 patients were treated with definitive RT alone (358 patients) or combined with adjuvant chemotherapy (46 patients) at our institution and were followed up for 0.25 to 20.25 years (median, 3.5 years.) All living patients were followed up for at least 2 years. All patients had the primary tumor volume calculated on pretreatment CT. End points were local control after RT and local control after RT without a severe late complication. Parameters evaluated in multivariate analyses of these end points included primary site, T stage, primary tumor volume, N stage, histologic differentiation, fractionation schedule, adjuvant chemotherapy, and gender.

RESULTS

The rates of local control and local control without a severe late complication after RT were significantly influenced by primary tumor volume for patients with cancer of the supraglottic larynx and true vocal cord. In contrast, the rates of local control and local control without severe complications for patients with tumors of the oropharynx and hypopharynx were less influenced by tumor volume. Multivariate analysis of the overall population revealed that the only parameter that was significantly related to the probability of local control after RT was T stage. Multivariate analyses stratified by primary site revealed that tumor volume significantly influenced local control for patients with cancers of the supraglottis (p =.0220) and glottis (p =.0042) but not for those with lesions of the tonsillar fossa/posterior tonsillar pillar (p =.0892), base of tongue (p =.9493), anterior tonsillar pillar/soft palate (p =.5909), and hypopharynx (p =.2282).

CONCLUSIONS

The most important parameter that has an impact on local control after RT is T stage. Primary tumor volume also significantly influences the probability of local control in cancers of the supraglottis and glottis.

Initial decline in hemoglobin during neoadjuvant hormonal therapy predicts for early prostate specific antigen failure following radiation and hormonal therapy for patients with intermediate and high-risk prostate cancer

BACKGROUND

Declines in serum hemoglobin (Hgb) levels occur from the use of androgen suppression therapy (AST) in the treatment of prostate cancer patients. We studied whether time to prostate specific antigen (PSA) failure following external beam radiation therapy (RT) and AST could be predicted by the rate of decline in the Hgb level following the administration of neoadjuvant AST or by the Hgb level at presentation or at the start of RT.

METHODS

The study cohort comprised 110 intermediate or high-risk prostate cancer patients who were managed using three-dimensional conformal RT (70 Gy) and 6 months of AST (2 months neoadjuvant, concurrent, and adjuvant). A Cox regression multivariable analysis was performed to evaluate the ability of the rate of decline of the Hgb from baseline to the start of RT, baseline PSA level, Gleason score, percent positive biopsies, and T-category to predict time to PSA failure.

RESULTS

A decline in the Hgb level of 1 g/dL or more during the first month of AST was the only significant predictor of time to PSA failure (P = 0.02) on multivariable analysis. The relative risk of PSA failure (95% confidence interval) for patients with a decline in Hgb level during the first month (> or = 1 g/dL vs. < 1 g/dL) was 6.3 (2.4, 8.3) and the 3-year estimate of PSA outcome was 66% versus 82% (P = 0.04), respectively. There were no imbalances in the pretreatment prognostic factors or length of follow-up in each of these groups.

CONCLUSION

A decline of 1 g/dL or more in Hgb level during the first month of neoadjuvant AST was a predictor of early PSA failure following RT and AST in intermediate and high-risk prostate cancer patients.

Influence of tumor volume on survival in patients irradiated for non-small-cell lung cancer

PURPOSE

To investigate the importance of CT-defined total tumor volume (TTV) on overall survival (OS) in patients with unresectable or medically inoperable non-small-cell lung carcinoma (NSCLC).

METHODS AND MATERIALS

Between 1991 and 1998, 150 evaluable patients with Stage I-IIIB NSCLC were treated with three-dimensionally planned conformal radiotherapy and curative intent at Duke University Medical Center. On the treatment-planning CT, the primary tumor and nodal volumes were identified and subsequently combined to form the TTV. The TTV was compared with the stage and outcome with respect to OS, local progression-free survival, and distant failure-free survival using the Kruskall-Wallis analysis of variance and Kaplan-Meier actuarial method. To account for the potentially confounding effects of therapeutic and patient-specific covariates on survival, the Cox proportional hazard regression model was used.

RESULTS

The TTVs in patients with Stage I disease (median 19 cm3) were smaller than in patients with Stage II (median 80 cm3) or Stage III (median 97 cm3; p <0.001) disease. The Stage II TTVs were not significantly different from those of Stage III (post-hoc test according to Bonferroni). Prolonged OS was independently associated with a small TTV (<80 vs. >80 cm3 [median]; p = 0.01), young age (<60 vs. > or =60 years; p = 0.03), high Karnofsky performance status (< o r =70 vs. >70; p = 0.04), and female gender (p = 0.04). Both stage (p = 0.7) and T stage (p = 0.06) were of less importance for OS than was the TTV, according to multivariate modeling. Increased local progression-free survival (p = 0.001) and distant failure-free survival (p = 0.03) were independently associated with a small TTV (i.e., <80 cm3). The results were unchanged if the TTV was analyzed as a continuous variable.

CONCLUSION

A strong independent association between a small CT-defined TTV and prolonged survival in patients with NSCLC selected for curative/definitive RT was found. Future therapeutic studies in NSCLC should consider stratifying/adjusting for differences in TTV to avoid confounding effects on survival from variations in the TTV at baseline.

Treatment resistance of solid tumors: role of hypoxia and anemia

Hypoxia is a characteristic property of locally advanced solid tumors, resulting from an imbalance between the supply and consumption of oxygen. Major pathogenetic mechanisms for the development of hypoxia are (1) structural and functional abnormalities of the tumor microvasculature, (2) increased diffusion distances, and (3) tumor-associated and therapy-induced anemia. The oxygenation status is independent of clinical tumor size, stage, grade, and histopathological type, but is affected by the hemoglobin level. Hypoxia is intensified in anemic patients, especially in tumors with low perfusion rates. Hypoxia and anemia (most probably via worsening of tumor hypoxia) can lead to therapeutic problems, as they make solid tumors resistant to sparsely ionizing radiation and some forms of chemotherapy. In addition to more direct mechanisms involved in the development of therapeutic resistance, there are also indirect machineries that can cause barriers to therapies. These include hypoxia-driven proteome and genome changes and clonal selection. These, in turn, can drive subsequent events that are known to further increase resistance to therapy (in addition to critically affecting long-term prognosis). Treatment resistance in anemic patients can be, at least partially, prevented or overcome by anemia correction, resulting in better locoregional tumor control and overall survival of patients.

Epithelial cells in the peripheral blood of patients with cancer of the head and neck: incidence, detection and possible clinical significance

In this study amplification of cytokeratin-19 mRNA by Reverse transcriptase-polymerase chain reaction (RT-PCR) was used to detect circulating tumor cells in the peripheral blood of patients with cancer of the head and neck before, during and after radiation therapy. Detection of cytokeratin-19-positive cells coincided with local failure, distant metastasis and anemia.

Short-time ultrasound of head and neck squamous cell carcinoma under radiotherapy

To evaluate the efficacy of ultrasonography for patients with head and neck squamous cell carcinoma before and during radiotherapy (RT), consecutive patients with macroscopic lesions were examined before and during RT. Each scan was performed percutaneously in a short time (less than 5 min). The demonstration rate of primary tumors and the largest node of previously known metastatic cervical nodes were measured. Of all 190 patients, 91 primary tumors were detected (47.9%). Primary tumors in oral cavity, oropharynx, hypopharynx and cervical esophagus were determined in over 70% and, for those of nasopharynx and larynx, the demonstration rates were 30% or less. Nodal metastases were visualized in 78 of 80 patients with regional metastases (97.5%). Using the above information, 73 patients (38.4%) received the benefit of radiation therapy. Short-time sonography is a valuable modality for patients with selected sites of head and neck cancers.

Role of multimodal treatment in oropharynx, larynx, and hypopharynx cancer

Due to recent advances in radiation fractionation, radiochemotherapy, and conservative surgical techniques, the concept of multimodal therapy in head and neck cancer is currently changing. The recently published RTOG Phase III trial 9003, with 1,113 patients accrued, showed that hyperfractionation and accelerated fractionation with concomitant boost are more efficacious than standard fractionation for locally-advanced head and neck cancer. Acute, but not late, toxicity was also increased. Three meta-analyses have suggested that the impact of chemotherapy in head and neck cancer is small but is highly associated with the timing of therapy. Concomitant administration of radiation therapy and chemotherapy led to an absolute benefit in 5-year survival of about 10%. This finding has been further supported by recently published randomized prospective trials comparing concomitant radiochemotherapy with radiotherapy alone in advanced head and neck cancer. There is now clear evidence that radiochemotherapy provides a substantial and statistically significant improvement in survival and local-regional control, as compared to radiotherapy alone. Radiochemotherapy should be considered an accepted standard of care in cancers of the oropharynx, particularly for patients with locally-advanced disease who have a good performance status. Two randomized studies conducted by the Department of Veterans' Affairs and the EORTC, with a total of 534 patients accrued, showed that induction chemotherapy followed by radiotherapy of responders yields survival rates equal to those of total laryngectomy with postoperative radiotherapy. After 4 years, one-half to two-thirds of survivors of the chemotherapy arm retained a functional larynx. Larynx preservation using induction chemotherapy can now be regarded as feasible but still investigational. Current phase II studies show excellent larynx preservation rates using a primary concomitant radiochemotherapy with an altered fractionation regimen. More clinical and laboratory research is required to further evaluate the different treatment options of the multimodality concept, and to develop prognostic models that will allow individualization of the therapy.