Radiation Oncology/Head & Neck/General

General Information About H&N Cancers HPV Status Please also see the Oropharynx page DAHANCA 5 (1986-1990) Randomized. 414 pts w/ pharynx or supraglottic larynx ca. RT median 66 Gy. Randomized: 1) +/- Nimorazole. Pts with low hgb level underwent 2nd randomization: 2) +/- transfusion. HPV Response; 2009 19289615 -- "Effect of HPV-associated p16INK4A expression on response to radiotherapy and survival in squamous cell carcinoma of the head and neck." (Lassen P, J Clin Oncol. 2009 Apr 20;27(12):1992-8. Epub 2009 Mar 16.) Subset analysis. p16/HPV+ in 22% Outcome: 5-year LRC p16+ 58% vs p16- 28% (SS), DSS 72% vs 34% (SS), OS 62% vs 26% (SS). p16 remained strong predictor on MVA Conclusion: Expression of p16 has a major impact on treatment response and survival HPV & Hypoxia; 2010 19910068 -- "HPV-associated p16-expression and response to hypoxic modification of radiotherapy in head and neck cancer." (Lassen P, Radiother Oncol. 2010 Jan;94(1):30-5. Epub 2009 Nov 10.) Subset analysis. 331 patients with pretreatment tumor blocks, stained for p16. p16+ in 25% (oropharynx 37%, SGL 21%, others 10%) Outcome: Nimorazole improved LRC overall (HR 0.7, SS). p16- improved LRC overall (HR 0.4, SS). If p16-, nimorazole improved LRC (HR 0.7, SS), but if p16+, nimorazole did not improved LRC (HR 0.9, NS) Conclusion: Hypoxic modification improved outcome in HPV/p16 negative patients, but had no impact in HPV/p16 positive patients Lymphatic Risk MD Anderson; 1972 (1948-1965) 5031238 -- "Distribution of cervical lymph node metastases from squamous cell carcinoma of the upper respiratory and digestive tracts." (Lindberg R, Cancer. 1972 Jun;29(6):1446-9.) Retrospective. 2044 patients, previously untreated. Incidence and topographic distribution of neck LNs + Incidence of clinical nodal metastasesSite OverallT1T2T3T4   N0 N+ N0 N+ N0 N+ N0 N+ N0 N+ Oral tongue 65 35 86 14 70 30 52 48 23 77 Floor of mouth 70 30 89 11 71 29 56 44 46 54 Retromolar Trigone 55 45 88 12 62 38 46 54 32 78 Soft Palate 56 44 92 8 63 37 35 65 33 67 Tonsil 24 76 29 71 32 68 30 70 10 90 Base of tongue 22 78 30 70 29 71 25 75 15 85 Nasopharynx 13 87 7 93 15 85 11 89 17 83 Pharyngeal wall 41 59 75 25 70 30 33 67 24 76 Supraglottic larynx 45 55 61 39 58 42 35 65 41 59 Hypopharynx 25 75 37 63 30 70 21 79 26 74 University of Florida; 1995 7782203 -- "Retropharyngeal adenopathy as a predictor of outcome in squamous cell carcinoma of the head and neck." (McLaughlin MP, Head Neck. 1995 May-Jun;17(3):190-8.) Retrospective. 619 patients. Review of pretreatment CT and/or MRI to determine presence of retropharyngeal LNs Outcome: Highest incidence in NPC (74%) and pharyngeal wall (19%). Neck relapse and DM significantly higher, RFS and OS significantly worse if present Conclusion: Retropharyngeal adenopathy predictor of poor outcome + Incidence of CT/MRI retropharyngeal nodal metastasesSite Clinical Neck   Overall cN0 cN+ Nasopharynx 74 40 86 Pharyngeal wall 19 16 21 Soft palate 13 5 19 Tonsil 9 4 12 Pyriform sinus 5 0 9 Base of tongue 4 0 6 Supraglottic larynx 2 0 4 Washington University; 2002 (1997-2000) 12128118 -- "Determination and delineation of nodal target volumes for head-and-neck cancer based on patterns of failure in patients receiving definitive and postoperative IMRT." (Chao KS, Int J Radiat Oncol Biol Phys. 2002 Aug 1;53(5):1174-84.) Retrospective. 126 patients treated with IMRT. System for nodal target volumes used. Median F/U 2.2 years. Patterns of failure analyzed. Outcome: persistent/recurrent nodal disease in 12% of definitive IMRT patients and 9% of postop IMRT patients Conclusion: Development of guidelines for nodal target volumes + Incidence of pathologic nodal metastasesSite Level ILevel II Level III Level IV Level V Retropharngeal*   N- N+ N- N+ N- N+ N- N+ N- N+ N- N+ Nasopharynx - 40 86 Oral tongue 14 39 19 73 16 27 311 00 - - FOM 16 72 12 51 7 29 211 05 - - Alveolar ridgeRMT 25 38 19 84 6 25 510 14 - - Base of tongue 4 19 30 89 22 22 710 018 06 Tonsil 0 8 19 74 14 31 914 512 412 Pharyngeal wall 0 11 984 1872 040 020 1621 Pyriform sinus 02 1577 857 023 022 09 Supraglottic larynx 62 1870 1848 917 216 04 Glottic larynx 09 2142 2971 724 72 -- *Radiologically enlarged retropharyngeal nodes. Table adapted from Chao 2002 (12128118) Incidence of contralateral and bilateral lymph nodes: >30% cN+ bilateral - pharyngeal wall (50%), pyriform sinus (49%), supraglottis (39%) cN- but pN+ bilateral - pyriform sinus (59%), BOT (55%), phar. wall (37%), oral tongue (33%), supraglottis (26%), FOM (21%), glottic larynx (15%) Adopted from Chao 2002 (12128118) Effect of surgery to radiotherapy interval (SRI) Higher dose may "make up for" prolonged treatment time MSKCC, 1990 - 2325418 — "Impact of the time interval between surgery and postoperative radiation therapy on locoregional control in advanced head and neck cancer." Schiff PB et al. J Surg Oncol. 1990 Apr;43(4):203-8. Patients receiving < 60 Gy had locoregional recurrence rate of 7% when SRI < 6 weeks vs 27% when greater than 6 weeks. However when doses > 60 Gy were given, failure rates were 15% and 12%, respectively. Recursive Partitioning Analysis RTOG RPA, 1996 - 8646692 — "Recursive partitioning analysis of 2105 patients treated in Radiation Therapy Oncology Group studies of head and neck cancer." Cooper JS et al. Cancer. 1996 May 1;77(9):1905-11. 2105 pts. For survival, most predictive factor was T stage. For T1-T2, next most important was tumor location, whereas for T3-T4, it was KPS. For LRC, N stage was most important; for N0, T stage was next most important, whereas for N+ number of treatment fractions was. Survival: Group 1) T2 or less, glottic, age < 75; 2) Group 1 but age >= 75; 3) T2 or less, not glottic, N0-2, KPS >= 80, age < 75; or T3-4 N0-2 site:NP,OP,SGL,sinus KPS 90-100; 4) T2 or less, not glottic, N3, KPS >=80; or T3-4, N0-2, KPS 90-100, oral cavity, hypopharynx, or glottis; or T3-4 N3 or Nx KPS < 90; 5) T2 or less, not glottic, KPS <80; or N3, T3-4, KPS 90-100, N3; or T3-4, N1-3, KPS < 90. Local control: 11443750 - "Validation of the RTOG recursive partitioning classification for head and neck tumors." Cooper et al. - Tested validity using a separate database from RTOG 85-27. 15672358, 2005 - "Comparison of the Radiation Therapy Oncology Group recursive partitioning classification and Union Internationale Contre le Cancer TNM classification for patients with head and neck carcinoma." 2166 pts classified both by RPA and TNM stage and compared overall survival and loco-regional DFS. No differences between the systems in terms of survival, but for locoregional control, RPA system depended on treatment and was not generalizable. Surgery + RT vs. Chemo-RT Singapore (1996-2000) Randomized. Stopped early due to slow accrual. 199 patients, resectable Stage III/IV SCHNC excluding NPC and salivary glands (larynx 32% (supraglottis 23%), oral cavity 27%, oropharynx 21%, hypopharynx 12%). T4 56%. Arm 1) surgery + adjuvant RT 60/30 vs. Arm 2) RT 66/33 + concurrent cisplatin 20 mg/m2 + 5-FU 1000 mg/m2 x2 cycles. 90% received at least 1 cycle of chemo 2005 16012523 -- "Surgery and adjuvant radiotherapy vs concurrent chemoradiotherapy in stage III/IV nonmetastatic squamous cell head and neck cancer: a randomised comparison." (Soo KC, Br J Cancer. 2005 Aug 8;93(3):279-86.) Median F/U 6 years Outcome: 3-year DFS: S+RT 50% vs. chemo-RT 40% (NS). Organ preservation (larynx/hypopharynx 68%, oropharynx 55%, oral cavity 21%). Chemo-RT group had poor surgical salvage of 47%, with no long-term survivors (possibly due to larger proportion of T4 and oral cavity cancers) Conclusion: Chemo-RT not superior to surgery+RT, but can be attempted for organ preservation in larynx, hypopharynx, and oropharynx. Poor organ preservation (and salvage) in oral cavity Reviews 3278390, 1988 - "Radiation Therapy Oncology Group (RTOG) studies in head and neck cancer." Prediction of Response MSKCC, 2007 17416856 -- "Identification of angiogenesis/metastases genes predicting chemoradiotherapy response in patients with laryngopharyngeal carcinoma." (Ganly I, J Clin Oncol. 2007 Apr 10;25(11):1369-76.) Gene arrays. Correlation of 277 genes (angiogenesis and/or mets) to locoregional control MDM2 and erbB2 are predictors of locoregional failure in patients treated with chemo-RT Patterns of failure M.D.Anderson, Hong, 1985 - 4027864 — "Patterns of relapse in locally advanced head and neck cancer patients who achieved complete remission after combined modality therapy." Hong WK et al. Cancer. 1985 Sep 15;56(6):1242-5. 103 pts treated with induction chemotherapy followed by surgery and/or RT. 71 pts were free of disease. 5-year recurrence rate was 51% (39% local and 26% distant failure). Relapse patterns were affected by: site (oral cavity more likely to fail locally, hypopharynx more likely to have DM); type of treatment (surgery + RT had lower local failure); TN stage (T3-4N3 had higher risk of local and distant failure); oropharynx (higher local + distant failure). Planned Neck Dissection General consensus suggests that adjuvant neck dissection is not necessary for patients with N1 neck and CR after chemo-RT Historically, ipsilateral neck recurrence was lower for N2/N3 disease after primary RT + adjuvant neck dissection than either modality alone The necessity of adjuvant neck dissection after chemo-RT is controversial ~25% of patients with clinical/radiographic CR who undergo neck dissection have residual disease 30-40% of patients with clinical/radiographic detectable disease who undergo neck dissection have no residual disease Thus, overall accuracy of neck response by clinical/radiographic evaluation is ~60% PET shows promise, and appears more accurate than clinical, CT, or MRI neck evaluation It may be reasonable to observe patients with clinical/radiographic CR, and negative PET 12 weeks after completing chemo-RT It is not clear what negative PET means in setting of clinical/radiographic detectable disease TROG 98.02 subset analysis suggests that after chemo-RT, ipsilateral failure is low in patients with clinical/radiographic CR RTOG 98.02 Subset analysis. TROG 98.02 is Phase II randomized trial of RT 70/35 with Arm 1) concurrent cisplatin/tirapazamine vs. Arm 2) concurrent cisplatin/5-FU. Subset patients with initial N2-3 disease, who achieved complete clinical/radiological CR at 12 weeks (N2 63%, N3 40%) and no planned neck dissection was performed 2008 18286488 -- "N2-N3 neck nodal control without planned neck dissection for clinical/radiologic complete responders-Results of Trans Tasman Radiation Oncology Group Study 98.02." (Corry J, Head Neck. 2008 Feb 19 [Epub ahead of print]). Median F/U 4.3 years Outcome: First failure: local 4%, locoregional 2%, distant 28%, locoregional + distant 6%. No patients with neck-only failure Conclusion: Patients with CR do not need planned neck disection Radiation Injury Please see Radiation Oncology/Toxicity/Head & Neck Other histologic types Sarcomatoid carcinoma - also called spindle cell carcinoma MDACC; 1998 9591559 -- "Radiation therapy for early stage (T1-T2) sarcomatoid carcinoma of true vocal cords: outcomes and patterns of failure." (Ballo MT, Laryngoscope. 1998 May;108(5):760-3.) 5-yr LC 94% for T1 and 54% for T2. 10-year DSS 92%, OS 63% Conclusion: similar control rates to typical squamous cell carcinoma. The histologic diagnosis of sarcomatoid carcinoma by itself should not influence the decision to treat a patient with early stage glottic disease with irradiation. Other Resources eContouring Webinar - Head and Neck with Kenneth Hu, M.D. ASTRO/ARRO Journal Club Webinar 2012 - "RT + Cetuximab for Locoregionally Advanced Head and Neck Cancer: 5 Year Update" with Alexander Lin, M.D. To Add add: hypopharynx - randomized surgery vs chemo/rt