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Prospective Pilot Study Comparing the Need for Adaptive Radiotherapy in Unresected Bulky Disease and in Postoperative Patients With Head and Neck Cancer.

ABSTRACT: BACKGROUND:Adaptive radiotherapy is being used in few institutions in patients with head and neck cancer having bulky disease using periodic computed tomography imaging accounting for volumetric changes in tumor volume and/or weight loss. Limited data are available on ART in the postoperative setting. We aim to identify parameters that would predict the need for ART in patients with head and neck cancer and whether ART should be applied in postoperative setting. MATERIALS AND METHODS:Twenty patients with stage III-IV head and neck cancer were prospectively accrued. A computed tomography simulation was done prior to treatment and repeated at weeks 3 and 6 of concurrent intensity-modulated radiotherapy and chemotherapy. The final plan was coregistered with the subsequent computed tomography images, and dosimetric/volumetric changes at weeks 1 (baseline), 3, and 6 were quantified in high-risk clinical target volumes, low-risk clinical target volumes , right parotid , left parotid , and spinal cord . An event to trigger ART was defined as spinal cord maximum dose >45 Gy, parotid mean dose >26 Gy, and clinical target volume coverage <95%. RESULTS:Comparing the 2 groups, the proportion of patients with at least 1 event triggering ART was higher in bulky disease than in postoperative group: 72.7% versus 18.2% (P = .03) overall; 54.6% versus 1.8% (P = .064) at week 3; and 63.6% versus 18.2% (P = .081) at week 6. In the bulky disease group, 8 of 11 patients had events at week 3 and/or 6 as follows: overdose in spinal cord (n = 2), right parotid (n = 3), left parotid (n = 5), coverage < 95% seen in low-risk clinical target volumes (n = 3), and high-risk clinical target volumes (n = 5). In the postoperative group, 2 of 11 patients had events: spinal cord (n = 1) and low-risk clinical target volume (n = 1). CONCLUSION:Our study confirmed the need for ART in patients with head and neck cancer having bulky disease due to target under dosing and/or spinal cord/parotids overdosing in weeks 3 and 6. In contrast, the benefit of ART in postoperative patients is less clear.

SUBMITTER: Mahmoud O

PROVIDER: S-EPMC5762062 | biostudies-literature | 2017 Dec

REPOSITORIES: biostudies-literature

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Prospective Pilot Study Comparing the Need for Adaptive Radiotherapy in Unresected Bulky Disease and in Postoperative Patients With Head and Neck Cancer.

Mahmoud Omar O Reis Isildinha M IM Samuels Michael M MM Elsayyad Nagy N Bossart Elizabeth E Both Joseph J ELGhoneimy Ehsan E Moustafa Magda M AbdAllah Mohamed M Takita Cristiane C

Technology in cancer research & treatment 20170703 6

<h4>Background</h4>Adaptive radiotherapy is being used in few institutions in patients with head and neck cancer having bulky disease using periodic computed tomography imaging accounting for volumetric changes in tumor volume and/or weight loss. Limited data are available on ART in the postoperative setting. We aim to identify parameters that would predict the need for ART in patients with head and neck cancer and whether ART should be applied in postoperative setting.<h4>Materials and methods< ...[more]

PMID: 28671024

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Project description:No clear criteria have yet been established to guide decision-making for patient selection and the optimal timing of adaptive radiotherapy (ART) based on image-guided radiotherapy (IGRT). We have developed a novel protocol-the Best for Adaptive Radiotherapy (B-ART) protocol-to guide patient selection for ART. The aim of the present study is to describe this protocol, to evaluate its validity in patients with head and neck (HN) cancer, and to identify the anatomical and clinical predictors of the need for replanning. We retrospectively evaluated 82 patients with HN cancer who underwent helical tomotherapy (HT) and subsequently required replanning due to soft tissue changes upon daily MVCT. Under the proposed criteria, patients with anatomical changes >3 mm on three to four consecutive scans are candidates for ART. We compared the volumes on the initial CT scan (iCT) and the replanning CT (rCT) scan for the clinical target volumes (CTV1, referring to primary tumor or tumor bed and CTV2, metastatic lymph nodes) and for the parotid glands (PG) and body contour (B-body). The patients were stratified by primary tumor localization, clinical stage, and treatment scheme. The main reasons for replanning were: (1) a planning target volume (PTV) outside the body contour (n = 70; 85.4%), (2) PG shrinkage (n = 69; 84.1%), (3) B-body deviations (n = 69; 84.1%), and (4) setup deviations (n = 40; 48.8%). The replanning decision was made, on average, during the fourth week of treatment (n = 47; 57.3%). The mean reductions in the size of the right and left PG volumes were 6.31 cc (20.9%) and 5.98 cc (20.5%), respectively (p < 0.001). The reduction in PG volume was ≥30% in 30 patients (36.6%). The volume reduction in all of the anatomical structures was statistically significant. Four variables-advanced stage disease (T3-T4), chemoradiation, increased weight loss, and oropharyngeal localization-were significantly associated with the need for ART. The B-ART protocol provides clear criteria to eliminate random errors, and to allow for an early response to relevant changes in target volumes.

Project description:BackgroundFormer meta-analyses have shown a survival benefit for the addition of chemotherapy (CHX) to radiotherapy (RT) and to some extent also for the use of hyperfractionated radiation therapy (HFRT) and accelerated radiation therapy (AFRT) in locally advanced squamous cell carcinoma (SCC) of the head and neck. However, the publication of new studies and the fact that many older studies that were included in these former meta-analyses used obsolete radiation doses, CHX schedules or study designs prompted us to carry out a new analysis using strict inclusion criteria.MethodsRandomised trials testing curatively intended RT (> or =60 Gy in >4 weeks/>50 Gy in <4 weeks) on SCC of the oral cavity, oropharynx, hypopharynx, and larynx published as full paper or in abstract form between 1975 and 2003 were eligible. Trials comparing RT alone with concurrent or alternating chemoradiation (5-fluorouracil (5-FU), cisplatin, carboplatin, mitomycin C) were analyzed according to the employed radiation schedule and the used CHX regimen. Studies comparing conventionally fractionated radiotherapy (CFRT) with either HFRT or AFRT without CHX were separately examined. End point of the meta-analysis was overall survival.ResultsThirty-two trials with a total of 10 225 patients were included into the meta-analysis. An overall survival benefit of 12.0 months was observed for the addition of simultaneous CHX to either CFRT or HFRT/AFRT (p < 0.001). Separate analyses by cytostatic drug indicate a prolongation of survival of 24.0 months, 16.8 months, 6.7 months, and 4.0 months, respectively, for the simultaneous administration of 5-FU, cisplatin-based, carboplatin-based, and mitomycin C-based CHX to RT (each p < 0.01). Whereas no significant gain in overall survival was observed for AFRT in comparison to CFRT, a substantial prolongation of median survival (14.2 months, p < 0.001) was seen for HFRT compared to CFRT (both without CHX).ConclusionRT combined with simultaneous 5-FU, cisplatin, carboplatin, and mitomycin C as single drug or combinations of 5-FU with one of the other drugs results in a large survival advantage irrespective the employed radiation schedule. If radiation therapy is used as single modality, hyperfractionation leads to a significant improvement of overall survival. Accelerated radiation therapy alone, especially when given as split course radiation schedule or extremely accelerated treatments with decreased total dose, does not increase overall survival.

Project description:Highlights • Paired holidays in the publicly funded Canadian healthcare system are significant predictors in local recurrence.• Treatment interruption or prolongation due to civic holidays results in poor oncologic outcomes in local recurrence.• Patients with early post-operative recurrences had poor oncologic outcomes, regardless of overall treatment time. Background Delays in starting postoperative radiotherapy (PORT) have been established as negative predictors for clinical outcomes in head and neck squamous cell carcinomas (HNSCC). Our study aimed to examine the effect of delays during PORT, and the impact of national holidays in Canada, a publicly funded system, on oncologic outcomes such as Overall Survival (OS) and Local Recurrence (LR). Methods The provincial cancer registry was queried to obtain demographic, pathologic, and outcomes data from cancer patients treated for all squamous cell carcinomas of the head and neck region treated between January 1, 2007 and November 30, 2019. All extracted information was cross-referenced and supplemented by chart review of patient electronic medical records. Extracted data were analyzed for OS and LR, in the context of Canadian national holidays causing delays during PORT. Results 1433 patients treated for HNSCCs were identified, of whom 338 were treated curatively with surgery followed by PORT. 68.6% of patients experienced at least one day of interruption during treatments due to holidays. LR was 15.4% and OS was 59.6% at 5 years. Treatment interruptions by holidays were predictive of local recurrence (HR, 2.38; 95% CI 1.17–4.83; p = 0.017). Patients that developed early recurrence prior to PORT had very poor oncologic outcomes. Conclusion Our findings were consistent with previously published studies in limiting the interval between surgery and PORT. We identified the novel finding of paired holidays as a significant predictor in determining LR, suggesting the importance of modifying RT delivery schedules and timing.

Project description:PurposeA planning strategy was developed and the utility of online-adaptation with the Ethos CBCT-guided ring-gantry adaptive radiotherapy (ART) system was evaluated using retrospective data from Head-and-neck (H&N) patients that required clinical offline adaptation during treatment.MethodsClinical data were used to re-plan 20 H&N patients (10 sequential boost (SEQ) with separate base and boost plans plus 10 simultaneous integrated boost (SIB)). An optimal approach, robust to online adaptation, for Ethos-initial plans using clinical goal prioritization was developed. Anatomically-derived isodose-shaping helper structures, air-density override, goals for controlling hotspot location(s), and plan normalization were investigated. Online adaptation was simulated using clinical offline adaptive simulation-CTs to represent an on-treatment CBCT. Dosimetric comparisons were based on institutional guidelines for Clinical-initial versus Ethos-initial plans and Ethos-scheduled versus Ethos-adapted plans. Timing for five components of the online adaptive workflow was analyzed.ResultsThe Ethos H&N planning approach generated Ethos-initial SEQ plans with clinically comparable PTV coverage (average PTVHigh V100% = 98.3%, Dmin,0.03cc = 97.9% and D0.03cc = 105.5%) and OAR sparing. However, Ethos-initial SIB plans were clinically inferior (average PTVHigh V100% = 96.4%, Dmin,0.03cc = 93.7%, D0.03cc = 110.6%). Fixed-field IMRT was superior to VMAT for 93.3% of plans. Online adaptation succeeded in achieving conformal coverage to the new anatomy in both SEQ and SIB plans that was even superior to that achieved in the initial plans (which was due to the changes in anatomy that simplified the optimization). The average adaptive workflow duration for SIB, SEQ base and SEQ boost was 30:14, 22.56, and 14:03 (min: sec), respectively.ConclusionsWith an optimal planning approach, Ethos efficiently auto-generated dosimetrically comparable and clinically acceptable initial SEQ plans for H&N patients. Initial SIB plans were inferior and clinically unacceptable, but adapted SIB plans became clinically acceptable. Online adapted plans optimized dose to new anatomy and maintained target coverage/homogeneity with improved OAR sparing in a time-efficient manner.

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Prospective Pilot Study Comparing the Need for Adaptive Radiotherapy in Unresected Bulky Disease and in Postoperative Patients With Head and Neck Cancer.

Publications

Prospective Pilot Study Comparing the Need for Adaptive Radiotherapy in Unresected Bulky Disease and in Postoperative Patients With Head and Neck Cancer.

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