Concomitant infusional paclitaxel and fluorouracil, oral hydroxyurea, and hyperfractionated radiation for locally advanced squamous head and neck cancer

Randomized phase-III-trial of concurrent chemoradiation for locally advanced head and neck cancer comparing dose reduced radiotherapy with paclitaxel/cisplatin to standard radiotherapy with fluorouracil/cisplatin: The PacCis-trial

BACKGROUND AND PURPOSE

This multicenter, phase 3 trial investigates whether the incorporation of concurrent paclitaxel and cisplatin together with a reduced total dose of radiotherapy is superior to standard fluorouracil-cisplatin based CRT.

MATERIALS AND METHODS

Patients with SCCHN, stage III-IVB, were randomized to receive paclitaxel/cisplatin (PacCis)-CRT (arm A; paclitaxel 20 mg/m² on days 2, 5, 8, 11 and 25, 30, 33, 36; cisplatin 20 mg/m², days 1-4 and 29-32; RT to a total dose of 63.6 Gy) or fluorouracil/cisplatin (CisFU)-CRT (arm B; fluorouracil 600 mg/m²; cisplatin 20 mg/m², days 1-5 and 29-33; RT: 70.6 Gy). Endpoint was 3-year-disease free survival (3y-DFS).

RESULTS

A total of 221 patients were enrolled between 2010 and 2015. With a median follow-up of 3.7 years, 3y-DFS in the CisFU arm and PacCis arm was 58.2% and 48.4%, respectively (HR 0.82, 95% CI 0.56-1.21, p = 0.52). The 3y-OS amounted to 64.6% in the CisFU arm, and to 59.2% in the PacCis arm (HR 0.82, 95% CI 0.54-1.24, p = 0.43). In the subgroup of p16-positive oropharyngeal carcinomas, 3y-DFS and 3y-OS was 84.6% vs 83.9% (p = 0.653), and 92.3% vs. 83.5% (p = 0.76) in arm A and B, respectively. Grade 3-4 hematological toxicities were significantly reduced in arm A (anemia, p = 0.01; leukocytopenia, p = 0.003), whereas grade 3 infections were reduced in arm B (p = 0.01).

CONCLUSION

Paclitaxel/cisplatin-CRT with a reduced RT-dose is not superior to standard fluorouracil/cisplatin-CRT. Subgroup analyses indicate that a reduced radiation dose seems to be sufficient for p16+ oropharyngeal cancer or non-smokers.

CLINICAL TRIAL INFORMATION

NCT01126216; EudraCT Number 2005-003484-23.

Late toxicities among laryngopharyngeal cancers patients treated with different schedules of concurrent chemoradiation at a rural tertiary cancer care center

Background:

Concurrent chemoradiation is the treatment of choice for laryngeal-pharyngeal cancers. Apart from survival organ preservation remains major aims of the treatment. Advanced radiation techniques like VMAT have shown to reduce morbidity. The purpose of our study is to assess the late toxicities in patients treated with concurrent chemoradiation and its association with dose to organs at risk.

Aims:

Assessment of late toxicities following concurrent chemoradiation in patients with laryngopharyngeal cancers.

Materials and Methods:

Retrospective study at a tertiary cancer centre on patients with laryngeal and pharyngeal cancers treated with concurrent chemoradiation with VMAT upto a total dose of 69.3 -70 Gy in 33-35 fractions and concurrent chemotherapy with Cisplatin was done. Severe late toxicities and its association with demographic and clinical parameters and dose to OAR were studied. Data was analysed using EpiData analysis v2.2.2.182.

Results:

Of the 93 patients studied majority were males above 55 years. Oropharynx was the commonest site (58%) with T3 and N2 in majority. Late dysphagia and odynophagia was seen in 18(21%) and 23(27%) patients respectively. 16 (17%) had tube dependence and nine (9.6%) had aspiration pneumonia. D60, V50 and V60 along with site, node positivity and weight loss were found to be significantly associated with severe late toxicity.

Conclusion:

Oropharyngeal cancers, node positivity and weight loss were found to have significant grade III and above toxicities including tube dependency. Dose to larynx showed association with severe late toxicities, though dose to constrictors could not.

Comparing high-dose cisplatin with cisplatin-based combination chemotherapy in definitive concurrent chemoradiation setting for locally advanced head and neck squamous cell carcinoma (LAHNSCC)

BACKGROUND

High-dose cisplatin (Cis) is a preferred systemic agent for concurrent chemoradiation (CRT) in locally advanced head and neck squamous cell cancer (LAHNSCC) patients. As some patients are unable to tolerate Cis, this study compares the toxicity and efficacy of weekly cisplatin-paclitaxel (CP) regimen with Cis.

METHODS

Patients with LAHNSCC receiving definitive chemoradiation either with Cis (Cisplatin-100 mg/m² q3w x 3) or CP (Cisplatin-20 mg/m² ; Paclitaxel-30 mg/m² qw x7) were included.

RESULTS

Cis and CP groups were comprised of 114 and 111 subjects, respectively. Complete response for Cis versus CP groups was 88% versus 88%, respectively. Median follow-up for the study was 58.5 months. After adjusting for potential treatment selection bias, no significant differences were evident between Cis and CP groups for overall survival (hazard ratios [HR] 0.85, 95% CI 0.59-1.21, P = 0.36), progression free survival (HR 0.88, 95% CI 0.62-1.24, P = 0.46), locoregional control (HR 0.77, 95% CI 0.52-1.15, P = 0.21), and distant control (HR 0.87, 95% CI 0.61-1.23, P = 0.42). Patients in the CP group had less acute and chronic toxicities.

CONCLUSIONS

Weekly CP regimen can serve as an alternative systemic therapy with radiation in patients with LAHNSCC who are not fit for Cis.

A Comparative Study of Two Chemo-Radiation Regimens for the Cancer of Larynx

The region of head and neck is critical for respiration, nutrition, and speech. The management of laryngeal tumours can stimulate mutilations and cosmetic deformities and worsen the life. A “non-operative approach” is preferred for patients to whom radiation following surgery, possibly, will direct severe functional destruction predominantly in advanced stage patients having a bulk of carcinoma larynx. The case material for the study was selected from the cross-section of patients registered at the J. K. Cancer Institute, Kanpur. Histologically squamous cell carcinoma 64 patients were registered and equally and randomly placed into Arm I and Arm II. “Arm I” patients and “Arm II” was comprised of randomly selected 64 patients, having histopathologically proven squamous cell carcinoma of the larynx. All patients (32 patients) belonging to “Arm I” received concurrent chemoradiotherapy of Inj. Cisplatin 100 mg/m² for three-weekly underwent EBRT with 60 Co/LINAC and photon radiation of 70 Gy in 35 fractions for 7 weeks (2 parallel opposed fields). All the patients (32 patients) belongs to “Arm II” received chemo boost as Inj. Cisplatin 6 mg/m2 on last 15 fractions of treatment underwent EBRT with 60 Co/ LINAC photon radiation of 70 Gy in 35 fractions for 7 weeks. Radiotherapy was delivered in supine position by parallel opposing fields including the primary tumour, disease extension, and neck nodes. The study concluded that the loco-regional responses are analogous in Arm I and Arm 2, however Arm II had additional treatment allied toxicities and resulting from numerous of treatment breaks.

The detrimental effects of radiotherapy interruption on local control after concurrent chemoradiotherapy for advanced T-stage nasopharyngeal carcinoma: an observational, prospective analysis

Background

Previous studies have reported radiotherapy interruption (RTI) is associated with poor local control in two-dimensional radiotherapy (2DRT) era. However, it remains unclear whether RTI still affects local control for advanced T stage (T3–4) in the intensity-modulated radiation therapy (IMRT) era. We aim to evaluate whether RTI affects local control for T3–4 NPC treated with definitive IMRT.

Methods

In this observational prospective study, 447 T3–4 NPC patients treated with IMRT plus concurrent chemotherapy were included. All patients completed the planned radiotherapy course, and RTI was defined as the actual time taken to finish the prescribed course of radiotherapy minus the planned radiotherapy time. Receiver operating characteristic (ROC) curve was used for determined the cutoff point of RTI. The effects of RTI on local control were analyzed in multivariate analysis.

Results

At 5 years, the local relapse-free survival (LRFS) and overall survival (OS) rates were 93.7 and 85.7%, respectively. The cutoff RTI for LRFS was 5.5 days by ROC curve. Compared to patients with RTI >  5 days, patients with RTI ≤ 5 days had a significantly lower rate of LRFS (97% vs. 83%; P < 0.001). In multivariate analysis, RTI was a risk factor independently associated with LRFS (HR = 9.64, 95% CI, 4.10–22.65), but not for OS (HR = 1.09, 95% CI, 0.84–1.64).

Conclusions

The current analysis demonstrates a significant correlation between prolonged RTI and local control in NPC, even when concurrent chemotherapy is used. We consider that attention to RTI seems to be warranted for patients with advanced T-stage NPC in the era of IMRT.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4495-2) contains supplementary material, which is available to authorized users.

Induction docetaxel and S-1 followed by concomitant radiotherapy with low-dose daily cisplatin in locally advanced head and neck carcinoma

BACKGROUND

The purpose of this study was to assess the efficacy and safety of induction chemotherapy with docetaxel-S-1, and radiotherapy (RT) with concurrent daily cisplatin in locally advanced head and neck carcinoma.

METHOD

Fifty patients received 2 cycles of induction chemotherapy with induction chemotherapy with docetaxel and S-1, followed by 7 cycles of RT with concurrent daily cisplatin.

RESULTS

The most frequent grade 3 to 4 hematologic toxicity was neutropenia (14%). Forty of 50 patients who completed induction chemotherapy with docetaxel and S-1 subsequently started RT with concurrent daily cisplatin, all within 3 to 4 weeks after the start of the second cycle of induction chemotherapy with docetaxel and S-1. The best response to induction chemotherapy with docetaxel and S-1 and after completion of RT with concurrent daily cisplatin was partial response (PR) in 52.5% and complete response in 47.5%, respectively. With a median follow-up of 61 months, 5-year progression-free survival (PFS) and overall survival (OS) were 63.3% and 65.7%, respectively.

CONCLUSION

Administration of induction chemotherapy with docetaxel and S-1 before RT with concurrent daily cisplatin chemoradiotherapy (CRT) resulted in a high response rate with good tolerability, and did not compromise subsequent CRT. © 2016 Wiley Periodicals, Inc. Head Neck 38: E1653-E1659, 2016.

Systemic therapy for squamous cell carcinoma of the head and neck

The use of systemic therapy as part of curative treatment and palliation is an evolving paradigm for squamous cell cancer of the head and neck (SCCHN), which historically has been treated with local modalities. At present, the treatment armamentarium includes traditional cytotoxic therapy, targeted biological agents, and emerging immunotherapeutics. This article discusses the use of all of these systemic approaches for the curative and palliative treatment of SCCHN.

Comparison of swallowing function after intensity-modulated radiation therapy and conventional radiotherapy for head and neck cancer

BACKGROUND

Intensity-modulated radiotherapy (IMRT) is hoped to protect structures important for swallow function. We compared posttreatment swallow function in 7 pairs of patients with head and neck cancer treated with either IMRT or conventional radiotherapy (RT).

METHODS

Patients were matched on tumor characteristics. Swallowing function was evaluated with the modified barium swallow procedure pretreatment and at 3 and 6 months postcancer treatment completion. Swallows were analyzed for bolus transit times, bolus residues, laryngeal closure (LAC) duration, cricopharyngeal opening (CPO) duration, and oropharyngeal swallow efficiency (OPSE). Data were analyzed using multifactor repeated measures analysis of variance and adjusted for baseline function.

RESULTS

Main effect of radiation type was significant for all measures on at least 1 bolus type. Patients treated with IMRT demonstrated shorter bolus transit times, less oral and pharyngeal residue, longer LAC, and larger OPSE.

CONCLUSION

Patients treated with IMRT demonstrated faster, more efficient swallows, and greater airway protection.

Comparison of outcomes of locoregionally advanced oropharyngeal and non-oropharyngeal squamous cell carcinoma over two decades

BACKGROUND

Human papillomavirus (HPV) has emerged as a causative agent and positive prognostic factor for oropharyngeal (OP) head and neck squamous cell cancer (HNSCC). This prompts inquiry into whether therapy improvements or increasing incidence of HPV drives the apparent improvements in HNSCC outcomes observed in non-randomized clinical trials.

PATIENTS AND METHODS

We reviewed all locoregionally advanced HNSCC patients treated with chemotherapy and radiation in prospective institutional trials at a single institution. Patients were divided into three groups (1, 2, 3) according to treatment time period (1993-1998, 1999-2003, 2004-2010, respectively). We reasoned that if a favorable trend was observed over time in OP but not non-OP patients, HPV status may be confounding treatment effects, whereas this would be unlikely if both subgroups improved over time.

RESULTS

Four hundred and twenty-two patients were identified with OP (55.7%) and non-OP (44.3%) HNSCC. Five-year OP overall survival (OS) improved from 42.3% (group 1) to 72.5% (group 2), and 78.4% (group 3), adjusted P = 0.0084. Non-OP 5-year OS was 51.0% (group 1), 58.8% (group 2), and 66.3% (group 3), adjusted P = 0.51. Five-year recurrence-free survival (RFS) improved for OP groups from 42.3% to 68.4% to 75.8% (adjusted P = 0.017). Non-OP 5-year RFS was 42.9%, 53.6%, and 61.7% for sequential groups (adjusted P = 0.30). Five-year OP distant failure-free survival (DFFS) improved from 42.3% to 71.1% to 77.8% (adjusted P = 0.011). Five-year non-OP DFFS was 46.9%, 57.1%, and 66.0% for sequential groups (adjusted P = 0.38).

CONCLUSIONS

Over the past two decades, OP HNSCC outcomes improved significantly, while non-OP outcomes only trended toward improvement. Although our patients are not stratified by HPV status, improving OP outcomes are likely at least partly due to the increasing HPV incidence. These data further justify trial stratification by HPV status, investigations of novel approaches for carcinogen-related HNSCC, and current de-intensification for HPV-related HNSCC.

Concurrent therapy with taxane versus non-taxane containing regimens in locally advanced squamous cell carcinomas of the head and neck (SCCHN): a systematic review

BACKGROUND

Platinum compounds remain the most widely utilized systemic agents in combination with radiation for treating SCCHN in the concurrent setting. Despite recent interest in using taxanes in this setting, there is a lack of randomized clinical trials to support this approach. We conducted a systematic review of published clinical trials of taxane-containing versus standard non-taxane-based regimens used in definitive treatment of SCCHN.

METHODS

Trials published between 1994 and 2012 were identified by an electronic search of public databases (MEDLINE, EMBASE, Cochrane library). All prospective studies were independently identified by two authors for inclusion. Studies were excluded if induction therapy was part of the regimen or if targeted agents were used. Trials using cisplatin- or carboplatin-based regimens and paclitaxel or docetaxel were included. Demographic data, treatment response, locoregional failure free rate (LFFR), progression-free and overall survival (PFS, OS) and toxicities were extracted and analyzed using Comprehensive Meta Analysis software (Version 2.0). Outcome data were pooled and reported as weighted response rate (RR), PFS and OS.

RESULTS

A total of 790 studies were retrieved and 42 studies with 3120 patients were included: 804 patients were treated with taxanes (80% males, median age 57years) and 2316 with non-taxanes (86% males, median age 56years). Progression free survival was not different between the two groups. Weighted median survival was compared from those studies that reported these data; taxanes=36.7months (N=197) versus non-taxanes=25months (N=503), P<0.001. Toxicity (grade 3 and above) was higher in non-taxane containing trials.

CONCLUSIONS

The improved overall survival observed supports the choice of taxane-based regimens in the concurrent setting but may also reflect the predominance of single arm multi-agent phase II trials in the taxane arm. Our findings urge the need for better standardization of taxane-based regimens.

Phase III randomized trial of induction chemotherapy in patients with N2 or N3 locally advanced head and neck cancer

PURPOSE

Induction chemotherapy (IC) before radiotherapy lowers distant failure (DF) rates in locally advanced squamous cell carcinoma of the head and neck (SCCHN). The goal of this phase III trial was to determine whether IC before chemoradiotherapy (CRT) further improves survival compared with CRT alone in patients with N2 or N3 disease.

PATIENTS AND METHODS

Treatment-naive patients with nonmetastatic N2 or N3 SCCHN were randomly assigned to CRT alone (CRT arm; docetaxel, fluorouracil, and hydroxyurea plus radiotherapy 0.15 Gy twice per day every other week) versus two 21-day cycles of IC (docetaxel 75 mg/m(2) on day 1, cisplatin 75 mg/m(2) on day 1, and fluorouracil 750 mg/m(2) on days 1 to 5) followed by the same CRT regimen (IC + CRT arm). The primary end point was overall survival (OS). Secondary end points included DF-free survival, failure pattern, and recurrence-free survival (RFS).

RESULTS

A total of 285 patients were randomly assigned. The most common grade 3 to 4 toxicities during IC were febrile neutropenia (11%) and mucositis (9%); during CRT (both arms combined), they were mucositis (49%), dermatitis (21%), and leukopenia (18%). Serious adverse events were more common in the IC arm (47% v 28%; P = .002). With a minimum follow-up of 30 months, there were no statistically significant differences in OS (hazard ratio, 0.91; 95% CI, 0.59 to 1.41), RFS, or DF-free survival.

CONCLUSION

IC did not translate into improved OS compared with CRT alone. However, the study was underpowered because it did not meet the planned accrual target, and OS was higher than predicted in both arms. IC cannot be recommended routinely in patients with N2 or N3 locally advanced SCCHN.

Effects of 2 different swallowing exercise regimens during organ-preservation therapies for head and neck cancers on swallowing function

BACKGROUND

This study investigated the effects of 2 different swallowing exercise regimens performed during radiation therapy with/without chemotherapy on swallowing function.

METHODS

Fifty patients were recruited prospectively to 2 groups (the exercise group, n = 26 and the repetitive swallow group, n = 24). Functional Oral Intake Scale (FOIS) scores and percutaneous endoscopic gastrostomy (PEG) placements were compared at posttreatment and at 3 months.

RESULTS

The exercise group eliminated significantly more PEG tubes at 3 months posttreatment compared to the swallow group (16% vs 50%). Among patients who received both radiation and chemotherapy, the exercise group had significantly less PEG tubes immediately posttreatment as well as 3 months posttreatment (35% and 10%), compared to the swallow group (69% and 50%).

CONCLUSION

Findings indicate significant benefits of the exercise group's exercise regimen in reducing PEG dependence and oral intake difficulties.

Radiotherapeutic management of locally advanced head and neck cancer

Head and neck cancer management has undergone several paradigm shifts for several relevant reasons. From the dismal experience with the use of radiotherapy as the sole modality in the treatment of this group of patients with advanced disease, radiotherapy has been evaluated as an adjuvant for the same group of patients who had undergone successful surgery. Although there is no level 1 evidence to support postoperative adjuvant radiation, several studies have demonstrated that adjuvant radiotherapy reduces the local failures and, thereby, improves survival. Predictors of recurrence after surgical resection are: positive margins of resection; extranodal spread in involved nodes; perineural invasion; and presence of two or more involved regional lymph nodes. Realization of the advantages of a combination of chemotherapy with radiotherapy has had a major impact on the management of these cancers. There is emerging evidence for the use of adjuvant concurrent chemoradiotherapy in the group with high-risk features. Multiple organ conservation strategies in the management of locally advanced head and neck cancers have evolved over the years. However, the meta-analyses of impact of chemotherapy in various settings reveal that concomitant chemoradiotherapy is superior to any of the other regimens. Increasing use of computed tomography, magnetic resonance imaging and positron emission tomography scan images has resulted in better visualization of target volumes and critical structures. Delineation of these structures is of paramount importance and has resulted in a profound change in conformal treatment planning. Better understanding of the physical aspects of delivery of radiotherapy and the advent of modern treatment planning systems have led to the development of conformal techniques. Although the benefit of these techniques on survival have yet to be demonstrated, there is evidence to suggest that they reduce treatment-related toxicities significantly and facilitate dose escalation. Increased knowledge of radiobiology has led to the development of various altered fractionation regimens in the management of locally advanced head and neck cancers. Discovery of cell-cycle kinetics and signal transduction pathways has led to the unearthing of several potential targets for targeted therapy. The epidermal growth factor receptor gene has emerged as the most promising target. The role of biological radiation response modifiers is evolving. All of these approaches to improve the therapeutic gain would be incomplete without evaluating their effect on the quality of life of these patients.

Oral complications and management strategies for patients undergoing cancer therapy

With cancer survival rate climbing up over the past three decades, quality of life for cancer patients has become an issue of major concern. Oral health plays an important part in one's overall quality of life. However, oral health status can be severely hampered by side effects of cancer therapies including surgery, chemotherapy, radiotherapy, and hematopoietic stem cell transplantation. Moreover, prevention and treatment of these complications are often overlooked in clinical practice. The present paper aims at drawing health care professionals' attention to oral complications associated with cancer therapy by giving a comprehensive review. Brief comments on contemporary cancer therapies will be given first, followed by detailed description of oral complications associated with cancer therapy. Finally, a summary of preventive strategies and treatment options for common oral complications including oral mucositis, oral infections, xerostomia, and dysgeusia will be given.

Survival and selected outcomes of older adults with locally advanced head/neck cancer treated with chemoradiation therapy

OBJECTIVES

Chemoradiation therapy (CRT) remains a potentially curative treatment in patients with locally advanced head/neck cancer (LA-HNC). However, survival and other outcomes in older patients with head/neck cancer receiving chemoradiotherapy are not well established. This study was performed to elucidate selected outcomes in this patient population.

MATERIALS AND METHODS

Retrospective study of LA-HNC patients ≥ 70 years of age who had received 5-fluorouracil-hydoxyurea-based CRT with a minimum of 3 years of follow up after therapy initiation was performed. Pre-treatment patient- and cancer-related characteristics were recorded. Survival data in addition to gastrostomy tube utilization, swallowing function, and hematologic toxicity were captured.

RESULTS

Eighty-nine patients treated between 1997 and 2009 were eligible for analysis (median age, 76 years; range, 70-94; male, 61%; ECOG PS, 0-1 43%; stage IVA/B, 71%). 86 were evaluable for survival analysis. 5-year overall and event-free survival were both at 32% with a median follow-up time of 39.2 months. The majority (86.5%) were able to complete all planned treatment cycles. A significant proportion of patients, however, required gastrostomy tube during CRT (62%) and developed aspiration during swallowing evaluation post-treatment (44%). Several patients required hospice (9%) or skilled nursing facility (13%) referrals during treatment.

CONCLUSION

Select older adults with LA-HNC can still experience long-term benefits despite 5-year survival rates lower than those historically reported in younger patients undergoing identical CRT regimens although potentially at higher risk for acute toxicities. Assessment and selection of those who can tolerate more intense combined-modality strategies and their long-term outcomes merit further larger, prospective studies.

Quantification of the effect of treatment duration on local-regional failure after definitive concurrent chemotherapy and intensity-modulated radiation therapy for squamous cell carcinoma of the head and neck

BACKGROUND

The purpose of this study was to quantify the effect of treatment duration on locoregional progression after definitive concurrent chemoradiation (CCRT) for squamous cell carcinoma of the head and neck (SCCHN).

METHODS

We conducted a retrospective chart review of patients treated between 2004 and 2010. After a prior analysis, measures were taken to limit therapy beyond 7 weeks. Comparison of outcomes were made between cohorts 1 (2004-2007, n = 78) and 2 (2007-2010, n = 62).

RESULTS

Median therapy duration was statistically significantly different between cohorts as follows: 51 days, cohort 1 and 46 days, cohort 2 (p < .01). Locoregional progression in cohorts 1 and 2 was 19% and 5% (p = .01), respectively. On multivariate analysis, patients with prolonged treatment (≥57 days) had an 8-fold increase in risk of locoregional progression compared to patients who completed on time (p < .01).

CONCLUSION

Treatment duration was a significant predictor of locoregional progression in patients with SCCHN who received definitive CCRT.

Hydroxyurea: a key player in cancer chemotherapy

Hydroxyurea (HU) is a simple organic compound currently used as a cancer chemotherapeutic agent. It acts specifically on the S-phase of the cell cycle by inhibiting the enzyme ribonucleoside diphosphate reductase, thereby hindering the reductive conversion of ribonucleotides to deoxyribonucleotides and thus limiting de novo DNA synthesis. HU is employed in hemotological settings as a first-line treatment of myeloproliferative disorders, such as polycythemia vera, essential thrombocythemia and primary myelofibrosis, apart from having a vital role in combination therapy for management of malignant melanoma, head and neck cancers and brain tumors. It offers an advantage that the patient may take this drug on an ambulatory basis with minimum clinical toxicity, while some of its limitations include gastrointestinal disturbance and bone marrow depression. This review will summarize and present the overall effects of HU and its combination therapy as an anticancer agent.

Weekly paclitaxel and carboplatin induction chemotherapy followed by concurrent chemoradiotherapy in locally advanced squamous cell carcinoma of the head and neck

OBJECTIVE

To perform a phase II trial evaluating dose dense induction chemotherapy for locally advanced head and neck cancer.

PATIENTS AND METHODS

Thirty-five patients received 6 weekly doses of carboplatin (area under the curve=2) and paclitaxel (135 mg/m) followed by concurrent weekly paclitaxel (40 mg/m) and carboplatin (area under the curve=1) and daily radiation (66-72 Gy).

RESULTS

There was 1 induction death from neutropenic sepsis and 1 sudden death during chemoradiotherapy. The overall response rate with induction was 79%. With >40 months of follow-up, the 36-month overall survival was 67% and squamous cell carcinoma of the head and neck survival 84%. Patients undergoing biopsy of the primary tumor site after the therapies had 17/18 (94%) pathologic complete response rate. The locoregional relapse rate was 40% (24 mo 28%) and distant relapse rate was 8% with only 1 distant site.

CONCLUSIONS

Therapy was active but patients must be carefully selected and monitored. Compared with the historical controls, dose dense and intense induction chemotherapy decreased distant failure rate without compromising the locoregional control.

Prophylactic percutaneous endoscopic gastrostomy tube placement in treatment of head and neck cancer: a comprehensive review and call for evidence-based medicine

BACKGROUND

Patients with head and neck cancers (HNCs) are at increased risk of experiencing malnutrition, which is associated with poor outcomes. Advances in the treatment of HNCs have resulted in improved outcomes that are associated with severe toxic oral side effects, placing patients at an even greater risk of malnutrition. Prophylactic placement of percutaneous endoscopic gastrostomy (PEG) tubes before treatment may be beneficial in patients with HNC, especially those undergoing more intense treatment regimens. PEG tube placement, however, is not without risks.

METHODS

A comprehensive review of the literature was conducted.

RESULTS

Systematic evidence assessing both the benefits and harm associated with prophylactic PEG tube placement in patients undergoing treatment for HNC is weak, and benefits and harm have not been established.

CONCLUSIONS

More research is necessary to inform physician behavior on whether prophylactic PEG tube placement is warranted in the treatment of HNC.

Integrating systemic agents into multimodality treatment of locally advanced head and neck cancer

Although highly debated in the 1980s, randomized clinical trials have provided undeniable evidence that systemic chemotherapy, as part of a multimodality treatment collaboration, is effective in improving survival, organ preservation and local-regional control in locally advanced head and neck cancer (HNC). We are entering an exciting period in which new chemotherapy agents, new paradigms of treatment, new surgical and radiation technology, and new prognostic factors are rapidly becoming available. Information on how to integrate these new tools and on how they affect long-term outcomes are lacking, making decision making and treatment planning more difficult. With unprecedented survival and the changing demographics of HNC we must now consider long-term consequences in addition to survival and local and regional control as important factors in therapeutic decision making. The availability of different treatment plans that incorporate systemic chemotherapy, radiotherapy and surgery give us many tools with which to craft a treatment for each individual patient. Today, in this exciting and chaotic period, a multidisciplinary and collaborative approach for each HNC patient at the start of decision making and planning is a necessity and the absolute standard of medical treatment for excellent patient care.

Induction chemotherapy in head and neck cancer: a new paradigm

Five hundred and fifty thousand new head and neck cancer cases are diagnosed each year worldwide. They are mostly locally advanced squamous cell carcinoma with a poor prognosis in terms of locoregional and distant failure. A major challenge for patients with locally advanced squamous cell carcinoma is to achieve a high cure rate while preserving functions. Treatment strategies are designed according to the disease stage, primary site, operable status, patient age, and performance status. Surgery, radiation therapy, chemotherapy, and more recently molecular-targeted therapies are part of these strategies, but their sequence remains to be defined. Over the last 30 years, induction chemotherapy has attained an important position in the management of patients with locally advanced squamous cell carcinoma, particularly since the introduction of taxanes. The decision to deliver induction chemotherapy (and its intensification) must be considered in the light of other treatments aiming at better locoregional control (normofractioned radiotherapy, accelerated or hyperfractionated radiotherapy, addition of concurrent chemotherapy, or of targeted therapy) with or without adjuvant treatment. This review summarizes the rationale, these data, and perspectives on induction chemotherapy-based strategies.

[Principles of radiation therapy for malignant tumors of the orbit and the periorbital area]

Primary malignant tumors of the orbit and the orbital adnexal area are rare, variform and in the majority of cases need an interdisciplinary treatment. According to tumor entity, tumor localization, and tumor extent the complete spectrum of radiotherapeutic therapy options is necessary. In the majority of malignant tumors, such as those of the eyelids, lachrymal glands, orbit, metastases, sarcoma or lymphoma, radiotherapy is used as a high energy therapy by means of medical linear accelerators as so-called teletherapy. In addition, new therapy methods, such as stereotactic highly conformal radiation or intensity-modulated radiation therapy (IMRT) were developed to achieve a higher local tumor control by a better configuration of the radiotherapy fields to the tumor borders and to contribute to a reduction of acute and chronic side effects in normal tissue by blurring of the dose. The application of ionizing radiation sources, such as so-called interstitial brachytherapy can also be just as carefully as effectively used. Particle beam radiotherapy is limited only to specially licensed centers and light hydrogen ions as proton therapy or carbon ions as heavy ion radiotherapy are in use. This overview will show the options as well as important progress in the field of radiotherapy in the treatment of tumors of the orbit and periorbital area.

Evaluating and reporting dysphagia in trials of chemoirradiation for head-and-neck cancer

PURPOSE

Reporting long-term toxicities in trials of chemoirradiation (CRT) of head-and-neck cancer (HNC) has mostly been limited to observer-rated maximal Grades >or=3. We evaluated this reporting approach for dysphagia by assessing patient-reported dysphagia (PRD) and objective swallowing dysfunction through videofluoroscopy (VF) in patients with various grades of maximal observer-reported dysphagia (ORD).

METHODS AND MATERIALS

A total of 62 HNC patients completed quality-of-life questionnaires periodically through 12 months post-CRT. Five PRD items were selected: three dysphagia-specific questions, an Eating-Domain, and "Overall Bother." They underwent VF at 3 and 12 months, and ORD (Common Terminology Criteria for Adverse Events) scoring every 2 months. We classified patients into four groups (0-3) according to maximal ORD scores documented 3-12 months post-CRT, and assessed PRD and VF summary scores in each group.

RESULTS

Differences in ORD scores among the groups were considerable throughout the observation period. In contrast, PRD scores were similar between Groups 2 and 3, and variable in Group 1. VF scores were worse in Group 3 compared with 2 at 3 months but similar at 12 months. In Group 1, PRD and VF scores from 3 through 12 months were close to Groups 2 and 3 if ORD score 1 persisted, but were similar to Group 0 in patients whose ORD scores improved by 12 months.

CONCLUSIONS

Patients with lower maximal ORD grades, especially if persistent, had similar rates of PRD and objective dysphagia as patients with highest grades. Lower ORD grades should therefore be reported. These findings may have implications for reporting additional toxicities besides dysphagia.

Concomitant vinorelbine and radiation in head and neck squamous cell carcinoma in vitro

Concomitant chemoradiotherapy has been used for locally advanced head and neck squamous cell carcinoma (HNSCC) particularily with cisplatin, 5-FU, methotrexate, bleomycin and taxanes. Vinorelbine is a semisynthetic vinca alcaloid, which causes a block in the G2/M phase of the cell cycle. HNSCC cell lines have previously been reported to be sensitive to vinorelbine in nanomolar concentrations. In the current study the effect of vinorelbine as a radiosensitizer in vitro was studied and eight recently established head and neck SCC cell lines of the UT-SCC-series were tested. Vinorelbine concentrations of 0.4-1.6 nM were used, corresponding to the IC70, IC50 and IC30 values of each cell line, resulting in 30%, 50% and 70% inhibition in clonogenic survival. The desired concentrations of vinorelbine were added to the medium and the cells were plated in 96-well culture plates in this solution. The plated cells were irradiated 24 h later with 4MeV photons generated by a linear accelerator and incubated at 37 degrees C with 5% CO2 for 4 weeks. Thereafter, the number of wells containing coherent, living colonies, consisting of 32 cells or more, was counted. The plating efficiency was calculated and the fraction survival data were fitted to the linear quadratic model [F = exp[-(alphaD + betaD2)]]. An additive effect of combining vinorelbine and irradiation could be demonstrated. The dose-dependent decrease in survival was seen at vinorelbine doses of 0.4-1.6 nM in all cell lines tested.

Clinical practice guidance for radiotherapy planning after induction chemotherapy in locoregionally advanced head-and-neck cancer

PURPOSE

The use of induction chemotherapy (IC) for locoregionally advanced head-and-neck cancer is increasing. The response to IC often causes significant alterations in tumor volume and location and shifts in normal anatomy. Proper determination of the radiotherapy (RT) targets after IC becomes challenging, especially with the use of conformal and precision RT techniques. Therefore, a consensus conference was convened to discuss issues related to RT planning and coordination of care for patients receiving IC.

METHODS AND MATERIALS

Ten participants with special expertise in the various aspects of integration of IC and RT for the treatment of locoregionally advanced head-and-neck cancer, including radiation oncologists, medical oncologists, and a medical physicist, participated. The individual members were assigned topics for focused, didactic presentations. Discussion was encouraged after each presentation, and recommendations were formulated.

RESULTS

Recommendations and guidelines emerged that emphasize up-front evaluation by all members of the head-and-neck management team, high-quality baseline and postinduction planning scans with the patient in the treatment position, the use of preinduction target volumes, and the use of full-dose RT, even in the face of a complete response.

CONCLUSION

A multidisciplinary approach is strongly encouraged. Although these recommendations were provided primarily for patients treated with IC, many of these same principles apply to concurrent chemoradiotherapy without IC. A rapid response during RT is quite common, requiring the development of two or more plans in a sizeable fraction of patients, and suggesting the need for similar guidance in the rapidly evolving area of adaptive RT.

Induction chemotherapy: to use or not to use? That is the question

The intensification of radiation, induction chemotherapy, and concomitant chemoradiotherapy has been extensively investigated over the past 2 decades for the nonsurgical management of locally advanced, nonmetastatic squamous cell head and neck cancer (HNC). Concurrent chemoradiation has emerged as the standard of care, with the majority of its benefit resulting from improvements in locoregional disease control. Distant failure has become a more prominent problem in conjunction with these improvements. Concurrent chemotherapy provides suboptimal adjuvant treatment for distant disease. Multiagent induction chemotherapy holds more promise especially with the use of taxane-based regimens. Induction chemotherapy followed by concurrent chemoradiation (sequential chemoradiation) is now under investigation. The rationale and evidence supporting the choice to use or not to use a sequential program are discussed.

Metastasis to the submandibular gland in oral cavity squamous cell carcinomas: pathologic analysis

CONCLUSION

This study demonstrates that the incidence of submandibular gland metastasis in oral cavity squamous cell carcinoma (SCC) is extremely rare and its involvement is through direct extension from a primary lesion. Therefore, if the primary lesion of the oral cavity carcinoma is not in close proximity and hence does not provide suspicion of direct extension, it may be safe to preserve the submandibular gland.

OBJECTIVES

Radiotherapy may lead to injury to the salivary glands resulting in xerostomia. This study aimed to determine whether and how the submandibular gland is involved in metastases of SCC of the oral cavity and to provide an oncological basis for preservation of the submandibular gland.

PATIENTS AND METHODS

This study reviewed the records and pathologic specimens of 201 patients who were diagnosed as having oral cavity SCC and underwent surgery at our institution, from 1991 to 2006, and pathologic metastasis to submandibular gland was evaluated.

RESULTS

In all, 44 cases (21.9%) were found to show ipsilateral level I metastasis on pathologic examination. Only two cases (1%) had carcinoma involvement in the submandibular gland. Both these two cases had direct extension from a primary lesion (retromolar trigone and floor of mouth) and no submandibular glands showed pathologic evidence of isolated metastasis or local extension of metastatic lymph nodes.

Long-term outcomes and toxicity of concurrent paclitaxel and radiotherapy for locally advanced head-and-neck cancer

PURPOSE

To report the long-term outcomes and toxicity of a regimen of infusion paclitaxel delivered concurrently with radiotherapy in patients with locally advanced squamous cell carcinoma of the head and neck.

PATIENTS AND METHODS

Between 1995 and 1999, 35 patients with nonmetastatic, Stage III or IV squamous cell carcinoma of the head and neck were treated with three cycles of paclitaxel as a 120-h continuous infusion beginning on Days 1, 21, and 42, concurrent with radiotherapy. The initial 16 patients received 105 mg/m(2)/cycle, and the subsequent 19 patients received 120 mg/m(2)/cycle. External beam radiotherapy was delivered to a dose of 70.2-72 Gy at five fractions weekly. Patients were followed to evaluate the disease outcomes and late toxicity of this regimen.

RESULTS

The median follow-up for all patients was 56.5 months. The median survival was 56.5 months, and the median time to local recurrence was not reached. Of the 35 patients, 15 (43%) developed hypothyroidism. Of the 33 patients who underwent percutaneous endoscopic gastrostomy tube placement, 11 were percutaneous endoscopic gastrostomy tube dependent until death or their last follow-up visit. Also, 5 patients (14%) required a tracheostomy until death, and 3 (9%) developed a severe esophageal stricture. All evaluated long-term survivors exhibited salivary hypofunction. Fibrosis in the radiation field occurred in 24 patients (69%).

CONCLUSION

The results of our study have shown that concurrent chemoradiotherapy with a 120-h infusion of paclitaxel provides long-term local control and survival in patients with squamous cell carcinoma of the head and neck. Xerostomia, hypothyroidism, esophageal and pharyngeal complications, and subcutaneous fibrosis were common long-term toxicities; however, the vast majority of toxicities were grade 1 or 2.

Surgical treatment of squamous cell carcinoma of the maxilla and nasal sinuses

PURPOSE

In the treatment of oral squamous cell carcinoma of the maxilla and paranasal sinuses, radical surgery and reconstruction with free flaps is accepted among many clinics. Nevertheless, the treatment protocols vary considerably. This study was performed to present our experience in the treatment of maxillary squamous cell carcinoma with surgical means alone, and to try to identify crucial prognostic factors for the patients' survival.

PATIENTS AND METHODS

Thirty-six patients with primary resectable squamous cell carcinoma were included in the study. The mean age was 63 years (43-87 years) and 50% presented in advanced tumor stage (T4). Five patients (14%) already had cervical metastases. All patients were treated by radical surgery alone, and the resulting defects were closed by means of local or free flaps or the use of an obturator, respectively.

RESULTS

The overall 5-year survival rate was 64%; the recurrence rate was 33%. Only patients who presented in T3 or T4 stages or had no free resection margins died during the follow-up period. Sixty-nine percent of the patients who died passed away within the first 12 months of follow-up. The 5 patients with cervical metastases received therapeutic neck dissection and showed no regional recurrence. In cases of R1 resection, adjuvant radiotherapy was applied.

CONCLUSIONS

The sole surgical treatment of squamous cell carcinomas of the maxillary region led to good results, and can therefore be seen as a valuable strategy. Free resection margins and early detection of the tumor are the most important factors for success.

Radiotherapy for the management of locally advanced squamous cell carcinoma of the head and neck

BACKGROUND

Squamous cell carcinomas of the head and neck (SCCHN) affect approximately 35 000 people in the United States yearly. Although survival has improved with advances in therapy, patients with advanced stages of SCCHN continue to have a poor prognosis. An understanding of rationale for treatment selection, newer developments in therapy, and treatment toxicity is critical.

METHODS

Standard methods of treating locally advanced SCCHN are reviewed. Advances in medical and radiotherapeutic management are discussed and the toxicities of therapy are described.

RESULTS

Postoperative chemoradiation is used in patients with high-risk characteristics. Induction chemotherapy and altered fractionation radiation treatment have been evaluated as alternatives to definitive chemo-radiotherapy. Targeted agents such as cetuximab may prove to increase survival with minimal increase in toxicity profile. Technological improvements such as the use of intensity-modulated radiation treatment have proven to decrease some debilitating side effects from radiation treatment.

CONCLUSIONS

Locally advanced SCCHN continues to present a therapeutic challenge. Survival, local control, and quality of life are all goals of treatment. The optimal method of treating locally advanced SCCHN is the subject of ongoing research. Long-term side effects can be minimized with the use of newer technologies and with careful treatment planning.

Rehabilitation of dysphagia following head and neck cancer

Patients who have cancers of the oral cavity, pharynx, or larynx may be treated with surgery, radiotherapy, chemotherapy, or a combination of these modalities. Each treatment type may have a negative impact on posttreatment swallowing function; these effects are presented in this article. A number of rehabilitative procedures are available to the clinician to reduce or eliminate swallowing disorders in patients treated for cancer of the head and neck. The various procedures-including postures, maneuvers, modifications to bolus volume and viscosity, range-of-motion exercises, and strengthening exercises-and their efficacy in patients treated for head and neck cancer are discussed.

Functional organ preservation with definitive chemoradiotherapy for T4 laryngeal squamous cell carcinoma

BACKGROUND

Randomized trials established chemoradiotherapy as standard treatment for advanced laryngeal cancer. Patients with large-volume T4 disease (LVT4) were excluded from these trials. The purpose of this study was to report T4 laryngeal cancer patient outcome, including those with LVT4 disease, treated with chemoradiotherapy.

PATIENTS AND METHODS

This study is a retrospective subset analysis of 32 patients with T4 laryngeal carcinoma including LVT4 tumors treated on three consecutive protocols investigating paclitaxel (Taxol), 5-fluorouracil, hydroxyurea, and 1.5-Gy twice daily (BID) radiotherapy (TFHX).

RESULTS

Median follow-up is 43 months. Four-year locoregional control (LRC), disease-free survival (DFS), overall survival (OS), and laryngectomy-free survival (LFS) was 71%, 67%, 53%, and 86%, respectively. Four patients required laryngectomy for recurrent or persistent disease. Of disease-free patients with >or=1 year follow-up, 90% demonstrated normal or understandable speech. None required laryngectomy for complications. Among LVT4 patients, 4-year LRC, DFS, OS, and LFS was 71%, 65%, 56%, and 81%, respectively. Induction chemotherapy improved 4-year LRC (90% versus 46%, P = 0.03) and DFS (84% versus 42%, P = 0.03).

CONCLUSIONS

Promising control and functional outcomes are achieved with TFHX for T4 laryngeal patients. LVT4 disease had outcomes similar to patients with less advanced disease treated on Radiation Therapy Oncology Group 91-11. Induction chemotherapy improved outcomes, warranting further investigation.

Clinical trial design limitations in head and neck squamous cell carcinomas

PURPOSE OF REVIEW

The present article reviews the randomized trials contributing to the establishment of current standards for the treatment of head and neck cancer. It provides critical analysis of their methodology in order to facilitate future trial design.

RECENT FINDINGS

From a prognosis perspective, head and neck cancers are a heterogeneous group of diseases. Following a number of randomized clinical trials evaluating the role of chemotherapy in the induction, concomitant and adjuvant settings, there has been considerable improvement in the treatment of locally advanced head and neck cancers during the last decade. It is, however, difficult to interpret and compare the results optimally and to build on efficient trial designs as most of the trials included patients with different levels of essential prognostic factors.

SUMMARY

All key randomized trials will be reviewed according to eligibility criteria, subgroup issues, trial power and historical controls. Methodological interpretation and possible plans for the next generation of clinical trials will be presented.

Standard, and novel cytotoxic and molecular-targeted, therapies for HNSCC: an evidence-based review

(1) Head and neck squamous cell carcinoma is the sixth most frequently occurring cancer worldwide.(2) Chemotherapy has shown some success as part of multimodal treatment schedules for locally advanced, nonmetastatic head and neck squamous cell carcinoma, and too a much lesser extent for metastatic head and neck squamous cell carcinoma.(3) A recent meta-analysis of 32 studies involving >10,000 patients concluded that chemotherapy added to radiotherapy produces a large survival advantage relative to radiotherapy alone.(4) Concurrent or alternate chemoradiotherapy, with a schedule based on cisplatin, has an established place in the management of locally advanced nonmetastatic head and neck squamous cell carcinoma.

The chemoradiation paradigm in head and neck cancer

In this article, we use the example of head and neck cancer to show how concurrent chemoradiotherapy is used to treat a cancer where locoregional control is central for treatment success. The advent of concurrent chemoradiation has significantly contributed to the curability of head and neck cancer, including locoregionally advanced disease. Preserving organ function and reducing toxic effects are increasingly the focus of clinical trials. We review the available chemoradiotherapy platforms used for head and neck cancer, with initial discussions focused on single-agent cytotoxic-based regimens. We then assess the literature on multiagent-based regimens and include a discussion of the integration of novel agents, such as EGFR inhibitors, and antiangiogenic drugs into treatment platforms. Although single-agent cisplatin-based chemoradiotherapy is still widely used as a standard therapy, we propose that evidence increasingly shows that multiagent-based chemoradiotherapy, and EGFR-inhibitor-based treatments, offer distinct advantages. We provide guidance for clinicians based on current clinical trial evidence on how to choose appropriate treatment platforms for their patients.

Safety and effectiveness of prophylactic gastrostomy tubes for head and neck cancer patients undergoing chemoradiation

BACKGROUND

We would like to assess the safety and effectiveness of prophylactic percutaneous endoscopic gastrostomy (PEG) tube feedings during concurrent chemoradiation for head and neck cancer.

METHODS

Patients who underwent chemotherapy and radiation for head and neck malignancies were evaluated for their ability to resume oral feeding following treatment. All patients underwent PEG tube placement prior to the treatment because of the expected mucositis. Gastrostomy tubes were removed following treatment when the patients were able to resume oral feedings without aspiration.

RESULTS

Between March 1999 and 2006, 104 patients with locally advanced head and neck cancer underwent concurrent chemotherapy and radiation. One patient declined placement of gastrostomy tube. Ninety patients (86%) developed grade 3-4 mucositis during chemoradiation. Five patients died during treatment from aspiration pneumonia and sepsis. One hundred two patients lost weight during treatment. The mean and median weight loss during concurrent therapy was, respectively, 8.5 and 8 kg (1-23.5 kg). Following treatment, tube feedings were continued 1-41 months (mean: 8 months; median: 5 months) because of continued weight loss, chronic dysphagia, or aspiration. At a median follow-up of 19 months (1-62 months), no patient developed serious complications from tube feedings.

CONCLUSION

Dysphagia resulting from the severe mucositis produced severe weight loss, despite tube feedings. Gastrostomy tube feedings are safe. Gastrostomy tubes should be placed prophylactically for patients undergoing chemoradiation for head and neck cancer.

Relationship between swallow motility disorders on videofluorography and oral intake in patients treated for head and neck cancer with radiotherapy with or without chemotherapy

BACKGROUND

Current research demonstrates that swallow function is impaired after treatment with organ-sparing chemoradiotherapy. Few studies, however, have related observed swallowing disorders with the patient's oral intake and diet in a large cohort of patients.

METHODS

Swallowing function was examined using the modified barium swallow (MBS) procedure in 170 patients treated with radiotherapy with or without chemotherapy for cancer of the head and neck at 5 evaluation points: pretreatment and at 1, 3, 6, and 12 months posttreatment. Fisher's exact test was used to examine the relationship between swallow motility disorders and oral intake or diet consistencies.

RESULTS

Limitations in oral intake and diet during the first year after cancer treatment were significantly related to reduced laryngeal elevation, reduced cricopharyngeal opening, and rating of nonfunctional swallow on at least 1 swallow of any bolus type.

CONCLUSIONS

Swallow motility disorders had a significant impact on the eating ability of patients after treatment for head and neck cancer with radiotherapy with or without chemotherapy.