Preoperative intensity-modulated and image-guided radiotherapy with a simultaneous integrated boost in locally advanced rectal cancer: report on late toxicity and outcome.

BACKGROUND AND PURPOSE: The addition of chemotherapy to preoperative radiotherapy has been established as the standard of care for patients with cT3-4 rectal cancer. As an alternative strategy, we explored intensity-modulated and image-guided radiotherapy (IMRT-IGRT) with a simultaneous integrated boost (SIB) in a prospective phase II study. Here, we report outcome and late toxicity after a median follow-up of 54 months. METHODS AND MATERIALS: A total of 108 patients were treated preoperatively with IMRT-IGRT, delivering a dose of 46 Gy in fractions of 2 Gy. Patients (n=57) displaying an anticipated circumferential resection margin (CRM) of less than 2mm based on magnetic resonance imaging received a SIB to the tumor up to a total dose of 55.2 Gy. RESULTS: The absolute incidence of grade ≥3 late gastrointestinal and urinary toxicity was 9% and 4%, respectively, with a 13% rate of any grade ≥3 late toxicity. The actuarial 5-year local control (LC), progression-free survival (PFS) and overall survival (OS) were 97%, 57%, and 68%. On multivariate analysis, R1 resection and pN2 disease were associated with significantly impaired OS. CONCLUSIONS: The use of preoperative IMRT-IGRT with a SIB resulted in a high 5-year LC rate and non-negligible late toxicity.

Reduction of the dose to the elective neck in head and neck squamous cell carcinoma, a randomized clinical trial using intensity modulated radiotherapy (IMRT). Dosimetrical analysis and effect on acute toxicity.

BACKGROUND AND PURPOSE: A randomized trial was initiated to investigate whether a reduction of the dose to the elective nodal sites and the swallowing apparatus delivered by IMRT would result in a reduction of acute and late side effects without compromising tumor control. The aim of this paper is to report on dosimetrical analysis and acute toxicity. MATERIALS & METHODS: Two-hundred patients were randomized. In the standard arm, elective nodal volumes (PTVelect) were irradiated up to an equivalent dose of 50Gy. In the experimental arm an equivalent dose of 40Gy was prescribed to the PTVelect. The dose to the swallowing apparatus was kept as low as possible without compromising therapeutic PTV (PTVther) coverage. RESULTS: No significant difference was seen between both arms concerning PTVther coverage. The median D95 of the PTVelect was significantly lower in the experimental arm (39.5 vs 49.8Gy; p<0.001). Concerning the organs at risk, the dose to swallowing structures and spinal cord was significantly reduced. There was no significant difference in acute toxicity. Three months after radiotherapy there was significantly less grade ⩾3 dysphagia in the experimental arm (2% vs 11%; p=0.03). With a median follow-up of 6months no significant differences were observed in locoregional control, disease free survival or overall survival. CONCLUSIONS: Using IMRT we were able to significantly reduce the dose to the PTVelect and several organs at risk without compromising PTVther coverage. This resulted in a significant reduction of severe dysphagia 3months after radiotherapy. Further follow-up is necessary to investigate whether these observations translate into a benefit on late treatment related dysphagia without affecting treatment outcome.

Outcome after re-irradiation of head and neck cancer patients.

PURPOSE: To retrospectively report the outcome of head and neck cancer patients following re-irradiation. PATIENTS AND METHODS: A total of 51 patients with recurrent or second primary head and neck cancer received re-irradiation at Leuven University Hospital. Survival and locoregional control were calculated. Doses to organs at risk were retrieved from dose-volume histograms. Radiation-related toxicities were reported. RESULTS: The 2-year actuarial overall survival rate was 30%. On univariate analysis, surgery before re-irradiation and high radiation dose were associated with superior survival. Grade 3 acute and grade 3 or more late toxicity occurred in respectively 29.4% and 35.3% of the patients. CONCLUSION: Re-irradiation in head and neck cancer patients is feasible with acceptable late toxicity, although the survival remains poor.

Brachial plexopathy after chemoradiotherapy for head and neck squamous cell carcinoma.

PURPOSE: To evaluate late brachial plexopathy after primary chemoradiotherapy for locally advanced head and neck squamous cell carcinoma. PATIENTS AND METHODS: Consecutive 43 disease-free patients were evaluated by a specifically developed 26-item questionnaire. Retrospectively, the brachial plexus was delineated and the dose-volume histograms were calculated. RESULTS: After a median follow-up of 24 months, no radiation-induced brachial plexopathy was reported in these 43 patients. CONCLUSION: No radiation-induced brachial plexopathy was seen in the patient group, although 72.1% of the brachial plexuses received doses > 60 Gy. These findings should prompt further prospective studies and also stress the importance of trying to keep the doses to the brachial plexus as low as possible while covering the target volumes well.

Dysphagia in head and neck cancer patients treated with chemoradiotherapy.

Dysphagia is a very common complaint of head and neck cancer patients and can exist before, during, and after chemoradiotherapy. It leads to nutritional deficiency, weight loss, and prolonged unnatural feeding and also has a major potential risk for aspiration. This has a significant negative impact on the patient's entire quality of life. Because treatment of dysphagia in this setting is rarely effective, prevention is paramount. Several strategies have been developed to reduce dysphagia. These include swallowing exercises, treatment modification techniques such as intensity-modulated radiotherapy, selective delineation of elective nodes, reducing xerostomia by parotid-sparing radiotherapy, and adding of radioprotectors. However, more research is needed to further decrease the incidence of dysphagia and improve quality of life.