A Single-institution Comparison of Cetuximab, Carboplatin, and Paclitaxel Induction Chemotherapy Followed by Chemoradiation (CRT) Versus CRT for Locally Advanced Squamous Cell Carcinoma of the Head and Neck (LA-SCCHN).

OBJECTIVES: Comparisons of induction chemotherapy (IC) against upfront chemoradiation (CRT) for locally advanced head and neck cancer (LA-HNSCC) have demonstrated no differences except greater toxicity with IC. Effective induction regimens that are less toxic are therefore warranted. To inform future efforts with IC, we present our institutional experience comparing a less toxic IC regimen to CRT. METHODS: We included patients with LA-HNSCC treated with organ-preservation CRT (+/-induction) between 2008 and 2011. Patients were of age above 18 years, ECOG performance status 0-1, and had minimum 6 months follow-up. IC consisted of 8 weekly cycles of cetuximab, carboplatin, and paclitaxel followed by CRT. The CRT regimen was platinum based, with cetuximab reserved for patients contraindicated to receive platinum. RESULTS: Of 118 patients, 24 (20%) received IC and 94 (80%) received CRT. Median follow-up was 17 (IC) and 19 (CRT) months (P=0.05). There were no differences in toxicity between the groups. IC patients were more likely male, with more advanced tumor and nodal stage. Even when controlling for these factors, IC was still associated with worse locoregional control (HR=3.6, P=0.02), distant metastasis-free survival (HR=5.3, P=0.02), and overall survival (HR=5.1, P<0.01). CONCLUSIONS: IC patients had greater disease burden than those receiving CRT. IC was well tolerated, but with significant rates of locoregional and systemic failures. Given the retrospective nature of the study, our findings are not meant to be definitive or conclusive, but rather suggestive in directing future efforts with IC. For now, we favor CRT as the standard option for treatment of inoperable LA-HNSCC.

Development and evaluation of an automatic interstitial catheter digitization tool for adaptive high-dose-rate brachytherapy.

PURPOSE: To develop and evaluate an automatic interstitial catheter digitization algorithm for use in adaptive high-dose-rate brachytherapy for gynecologic cancers using the Syed-Neblett template. METHODS AND MATERIALS: We developed an automatic catheter digitization tool, which uses a region growing algorithm in conjunction with a spline model of the catheters. Seed locations were selected in each catheter for the region growing algorithm. The region growing was constrained by a spline model of the catheters, which prevents intercatheter crossover or incorrect digitization due to air pockets. Plan reoptimization was performed on successive day computed tomography scans using dwell positions for the Day 1 computed tomography. This method was applied to 10 patients who had received high-dose-rate interstitial brachytherapy using the Syed-Neblett template. The prescribed dose was 18.75 or 20 Gy delivered in five fractions, twice daily, and more than 3 consecutive days. Dosimetric comparisons were made between automatically and manually digitized plans. RESULTS: The region growing algorithm was able to successfully digitize all catheters. The mean difference between automatic and manually digitized positions was 0.4 ± 0.2 mm. No significant difference was found in dosimetric parameters between the automatic and manually digitized plans. The mean D90% of the clinical target volume over all 3 days of treatment of the manual vs. reoptimized automatic plans was 94.3 ± 6.58% and 92.32 ± 8.34%, respectively (p = 0.50). CONCLUSIONS: The algorithm discussed in this article is the first developed for adaptive interstitial brachytherapy for a large number of catheters (14 on average). The algorithm has future potential in digitization quality assurance. A region growing algorithm was developed to automatically digitize interstitial catheters in high-dose-rate brachytherapy. This automatic digitization tool was shown to be accurate compared with manual digitization.

The use of proton therapy in the treatment of head and neck cancers.

External beam radiation therapy is a commonly utilized treatment modality in the management of head and neck cancer. Given the close proximity of disease to critical normal tissues and structures, the delivery of external beam radiation therapy can result in severe acute and late toxicities, even when delivered with advanced photon-based techniques, such as intensity-modulated radiation therapy. The unique physical characteristics of protons make it a promising option in the treatment of advanced head and neck cancer, with the potential to improve sparing of normal tissues and/or safely escalate radiation doses. Clinical implementation will require the continued development of advanced techniques such as intensity-modulated proton therapy, using pencil beam scanning, as well as rigorous methods of quality assurance and adaptive techniques to accurately adjust to changes in anatomy due to disease response. Ultimately, the widespread adaptation and implementation of proton therapy for head and neck cancer will require direct, prospective comparisons to standard techniques such as intensity-modulated radiation therapy, with a focus on measures such as toxicity, disease control, and quality of life.