Radiochemotherapy in head and neck cancer

Glutamine for prevention and alleviation of radiation-induced oral mucositis in patients with head and neck squamous cell cancer: Systematic review and meta-analysis of controlled trials

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) that investigated glutamine efficacy in preventing and alleviating radiation-induced oral mucositis (OM) among patients with head and neck (H&N) cancer. We screened five databases from inception till February 4, 2021 and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We included 11 RCTs, comprising 922 patients (458 and 464 patients were assigned to glutamine and control group, respectively). The incidence and onset of radiation-induced OM of any grade did not substantially differ between both groups. However, glutamine substantially reduced the severity of radiation-induced OM, as reflected by the reduced incidence of severe OM and reduced mean maximal OM grade score. Additionally, glutamine significantly decreased the rates of analgesic opioid use, nasogastric tube feeding, and therapy interruptions. Oral glutamine supplementation demonstrated various therapeutic benefits in preventing and ameliorating radiation-induced OM among patients with H&N cancer.

Future chemotherapy and radiotherapy options in head and neck cancer

Chemoradiation is a standard approach to advanced unresectable head and neck cancer, although the optimum combination regimen remains controversial. However, in the past few years, chemoradiation has been successfully extended from the treatment of unresectable disease to the postsurgical therapy of high-risk patients and its value as an organ preservation procedure is under evaluation. More recently, molecular-targeted therapies have emerged, which interfere with mechanisms of chemo- and radioresistance, and preliminary data are promising. Their use in the combined treatment of head and neck cancer will hopefully further improve the value of chemoradiation in the clinical setting.

Isolated head drop triggered by neck surgery following concomitant chemoradiotherapy

Dropped head syndrome (DHS) is characterized by severe weakness of neck extension that occurs in isolation or association with a generalized neuromuscular disorder. Multietiologies may be responsible for DHS, including radiotherapy, which may cause a delayed form of DHS. However, DHS acutely triggered by neck surgery after chemoradiotherapy is rare. The author reports a case of acute onset of isolated DHS following selective neck dissection surgery after concomitant chemoradiotherapy for laryngeal cancer.

Treatment of Advanced Head and Neck Cancer with Cetuximab

Cetuximab is a monoclonal antibody targeting the transmembrane receptor HER-1 (epidermal growth factor receptor, EGFR). In theory, inhibition of EGFR may influence tumor behavior since the receptor regulates many important tumor cell activities including tumor growth, angiogenesis, and inhibition of the apoptotic response to chemotherapy and radiotherapy. Available experimental data suggest that cetuximab may enhance the activity of chemotherapy and radiotherapy, reverse resistance to some anticancer drugs, and has itself anticancer activity. Early clinical data support the experimental results. This paper reviews the published findings on cetuximab in the treatment of advanced head and neck cancer and points out the future objectives of the clinical research on this drug.

Double-blinded, placebo-controlled trial on intravenous l-alanyl-l-glutamine in the incidence of oral mucositis following chemoradiotherapy in patients with head-and-neck cancer

PURPOSE

We performed this double-blinded, placebo-controlled study to determine the safety and efficacy of L-alanyl-L-glutamine in the prevention of mucositis in patients with head-and-neck cancer.

METHODS AND MATERIALS

Thirty-two patients with head-and-neck cancer were treated with chemoradiotherapy (CRT) (radiotherapy daily up to 70 Gy plus cisplatin/5-fluoruracil once a week) and were asked to participate. Twenty-nine patients received the CRT schedule and were double-blindly assigned to receive either intravenous L-alanyl-L-glutamine 0.4 g/kg weight/day or an equal volume of saline (placebo) during chemotherapy days.

RESULTS

Fourteen patients received L-alanyl-L-glutamine and 15 received placebo. Mucositis was assessed by the Objective Mucositis Score (OMS) and the World Health Organization (WHO) grading system. There was a significant difference in incidence of mucositis developed in patients receiving placebo compared with those who received L-alanyl-L-glutamine (p = 0.035). The number of patients with severe objective mucositis (OMS >1.49) was higher in the placebo group compared with the L-alanyl-L-glutamine group (67% vs. 14%, p = 0.007). L-alanyl-L-glutamine patients experienced less pain (three highest Numeric Rating Scale scores of 1.3/10 vs. 6.3/10 respectively, p = 0.008) and need for feeding tubes (14% vs. 60% respectively, p = 0.020) compared with placebo patients. No adverse effects related to the drug or the infusions were noted in either group.

CONCLUSION

For patients with head-and-neck cancer receiving CRT, intravenous L-alanyl-L-glutamine may be an effective preventive measure to decrease the severity of mucositis.

Alternating Chemotherapy and Radiotherapy in Locally Advanced Head and Neck Cancer: An Alternative?

Rapidly alternating chemotherapy and radiotherapy (ACR) is a minor variation of concurrent chemoradiation (CCR). This scheduling has been tested in advanced head and neck cancer and has shown superiority over standard radiation in some randomized trials with only marginally greater toxicity. This paper reviews ACR in advanced head and neck cancer. The hypothesis that this approach could have a better toxicity profile than CCR is discussed in light of the published clinical data. Efficacy is also discussed on the basis of available phase III trials. Published data indicate that rapidly alternating chemoradiation adds to toxicity less than CCR and results in comparable 3-year overall survival rates. In conclusion, ACR could be as active as, and possibly less toxic than, CCR. Comparative trials are highly recommended.