Altered Fractionation Intensity Modulated Radiotherapy with concurrent chemotherapy in head and neck cancer : a feseability study
Abstract
Purpose: To assess the loco regional response and toxicity of patients to concurrent chemo-radiation with 6 fractions/week using Intensity Modulated Radiotherapy in locally advanced head and neck cancers. (oropharynx and hypopharynx).
Materials and Methods: 20 patients with Stage III and stage IV , squamous cell carcinoma of Head and neck were enrolled. Target Volume Delinetion was done in accordence with Danish Head and Neck cancer group (DAHANCA) contouring guidelines. Differential radiation dose of 70 Gy, 63Gy and 56Gy in 35 fractions using IMRT, delivered to GTV, CTV1 and CTV2 with weekly cisplatin with weekly assessment of response and toxicity.
Results: The median age of the patients was 54 years ranging from 40 to 65 years. 14 and 6 patients had Hypopharyngeal and Oropharyngeal malignancy of squamous cell origin. 95 % of patients received 70 Gy in 35 fractions with 4 cycles of concurrent Cisplatin. 18 patients completed treatemnt within 45 days of OTT. 16 patients had complete response and 4 had partial response. Grade I, II dermatitis was observed in 70% and 30% of patients, respectively. 5 patienst developed Grade 2 and 1 patinet developed grade 3 leucopenia. 2 patients had weight loss of more than 10%. 85% oforopharyngeal cancers and 67% of hypopharyngeal cancers showed complete response. Nodal response was 100% complete in N1 & N2a, 92% and 0% in N2b and N3 lesions respicyively. TNM stage group wise the complete response rates were 100% in stage III, 92% & 0 % IVA & IVB.
Conclusion: Accelerated fractionation with IMRT and concurrent chemotherapy is a feasible in locoregionally adanced head and neck cancers with acceptable toxicities and good locoregional response rates.
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References
Ferlay J1, Shin HR, Bray F, Forman D, Mathers C, Parkin DM Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer. 2010 Dec 15; 127(12):2893-917.
National Cancer Registry Programme. Consolidated Report of the Population Based cancer Registries. 2001-2004. Indian Council of Medical Research. New Delhi. 2001.
WHO Cancer Report 2008.
National Comprehensive Cancer Network. Practice Guidelines: head and Neck cancer, version 1.2009. http://www.nccn.org/physician-gls/PDF/head-and-neck-pdf.
Withers HR, Taylor JM, Machiejewski B. The hazarad of accelerated tumor clonogen repopulation during radiotherapy. Acta Oncol.1998;27(2):131-146.
Fowler JF, Lindstrom MJ. Loss of local control with prolongation in radiotherapy. Int J Radiat Oncol Biol Phys. 1992;23(2):457-67.
Soren M. Bentzen, and Howard D. Thames: Clinical evidence for tumor clonogen regeneration: interpretations of the data. Radiother Oncol 1991; 22:161–166.
Steel GG. Basic Clinical Radiobiology. 3rd Edition. Hodder Arnold Pulishers; 2002.
Hall EJ, Giaccia AJ. Radiobiology for the Radiologist, 6thedition. LippincottWilliams and Wilkins Publishers; 2006.
Strandquist M: A study of the cumulative effect of fractionated x-ray treatment based on the experience mined at the Radium Hemmant with the treatment of 280 cases of carcinoma of the skin and lip. Acta Radiol 1944;55[suppl]:1-300.
Orton CG, Ellis F. A simplification in the use of the NSD concept in practical radiotherapy. Br J Radiol 1973;46:529-537.
Overgaard J, Hansen HS, Specht L, Overgaard M, Grai C, Andersen E et al. Five compared with six fractions per week of conventional radiotherapy of squamous cell car cinoma of the head and neck: DAHANCA 6 & 7 randomised controlled trial. Lancet 2003;362: 933-940.
Brizel DM, Albers ME, Fisher SR, Scher RL, Richtsmeier WJ, Hars V et al. Hyperfractionated irradiation with or without concurrent chemotherapy for locally advanced head and neck cancer. N Engl J Med. 1998; 338(25):1798-1804.
Jeremic B, Shibamoto Y, Milicic B, Nikolic N, Dagovic A, Aleksandrovic J et al.Hyperfractionated radiation therapy with or without concurrent low-dose daily cisplatin in locally advanced squamous cell carcinoma of the head and neck: a prospective randomized trial. J Clin Oncol. 2000 Apr,18(7):1458-64.
Wendt TG, Grabenbauer GG, Rodel CM, Thiel HG, Aydin H, Rohloff R et al.Simultaneous radiochemotherapy versus radiotherapy alone in advanced head and neck cancer: a randomized multicenter study. J Clin Oncol 1998; 16(4): 1318–1324.
Adelstein DJ, Li Y, Adams GL, Wagner H, Kish JA, Ensley JF et al. An intergroup Phase III comparison of standard radiation therapy and two schedules of concurrent chemoradiotherapy in patients with unresectable squamous cell head and neck cancer. J. Clin Oncol 2003; 21(1):92-98.
Forastiere AA, Goepfert H, Maor M, Pajak TF, Weber R, Morrison W et al.Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer. N Engl J Med 2003 Nov 27; 349(22):2091-8.
Denis F, Garaud P, Bardet E, Alfonsi M, Sire C, Germain T et al. Final results of the 94-01 French Head and Neck Oncology and Radiotherapy Group randomized trial comparing radiotherapy alone with concomitant radiochemotherapy in advanced-stage oropharynx carcinoma. J. Clin. Oncol 2004 Jan 1; 22(1):69-76.
Staar S, Rudat V, Stuetzer H, Dietz A, Volling P, Schroeder M et al. Intensified hyperfractionated accelerated radiotherapy limits the additional benefit of simultaneous chemotherapy: Results of a multicentric randomized German trial in advanced head-and-neck cancer. Int J Radiat Oncol Biol Phys 2001 Aug 1; 50(5): 1161–71.
Bourhis J, Overgaard J, Audry H, Ang KK, Saunders M, Bernier J et al. Hyperfractionated or accelerated radiotherapy in head and neck cancer: a metaanalysis. The Lancet 2006 Sep 2;368(9538):843–54.doi: https://doi.org/10.1016/S0140-6736(06)69121-6.
Budach V, Stuschke M, Budach W, Baumann W, Geismar D, Grabenbauer G et al. Hyperfractionated accelerated chemoradiation with concurrent fluorouracil mitomycin is more effective than dose-escalated hyperfractionated accelerated radiation therapy alone in locally advanced head and neck cancer: final results of the radiotherapy cooperative clinical trials group of the German Cancer Society 95-06 prospective randomized trial. J Clin Oncol 2005 Feb 20;.23(6):1125-35.
Dobrowsky W and Naude J. Continuous hyperfractionated accelerated radiotherapy with/ without mitomycin C in head and neck cancers. Radiother Oncol 2000 Nov; 57(2): 119–124.
Chao KS, Majhail N, Huang CJ, et al. Intensity-modulatedradiation therapy reduces late salivary toxicity without compromising tumor control in patients with oropharyngeal carcinoma:A comparison with conventional techniques. Radiother Oncol 2001 Dec;61(3):275-80.
Chao KS, Ozyigit G, Blanco AI, et al. Intensity-modulatedradiation therapy for oropharyngeal carcinoma: Impact of tumor volume. Int J Radiat Oncol Biol Phys 2004 May 1;59(1):43–50.
Pignon JP, Maitre AL, Maillard E, Bourhis J. Meta-analysis of chemotherapy in head and neck cancer (MACH-NC): An update on 93 randomised trials and 17,346 patients. Radiother Oncology 2009 Jul 92(1): 4–14.
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