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ORIGINAL ARTICLE
Year : 2014  |  Volume : 10  |  Issue : 2  |  Page : 284-293

Correlation of Computerized Tomography density patterns of lymph nodes with treatment results and outcome in head and neck cancer patients treated by 2 different chemoradiotherapy schedules


1 Department of Radiotherapy, MLN Medical College, Allahabad, Uttar Pradesh, India
2 Department of Radiodiagnosis, MLN Medical College, Allahabad, Uttar Pradesh, India

Date of Web Publication14-Jul-2014

Correspondence Address:
Virendra Singh
Department of Radiotherapy, L 9, M.L.N. Medical College Campus, Allahabad, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.136566

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 > Abstract 

Aims/Background: Tumor necrosis is visualized on CT scan as non enhancing hypodense area. Necrotic areas contain less oxygen and results in poor response of chemo-radiotherapy. Literature review (1) has shown that for hypodense lesions in head and neck cancer the complete response rate is lower than the isodense lesions. Locally advanced head and neck cancer require the addition of surgery but after a radical dose of radiation that is, 7000 cGy, surgery become difficult but there is no tool initially that can be used for selection of patients after delivery of 4500 cGy, that is the dose after which surgery can be performed without much difficulty. The hypothesis is that, hypodense lymph nodes even when they are small will show less response to various schedules of chemoradiotherapy so hypodensity of lymph nodes can be used as a tool to select patient, who will go for surgery after initial 4500 cGy of radiotherapy. Surgery is usually performed 2 to 3 weeks after radiotherapy, so primary can be treated to full dose while the skin in region of lymph nodes radiation field will recover from acute radiation reaction. Correlation of C T density patterns of lymph nodes in head and neck cancer patients with treatment results when two different chemoradiotherapy schedules are used is studied.
Materials and Methods: Eighty three patients with locally advanced head and neck cancer were treated with two schedules of concurrent chemoradiotherapy prospectively from August 2010 to July 2011. CT Scans of the entire neck region including primary were performed. An iodine based contrast material (150 ml) was injected intravenously starting with a bolus of 50ml (3ml/s), followed by a slow (1ml/s) infusion of the remaining dose. The total tumor volume of the primary and involved neck nodes was calculated as a cuboid volume using maximum dimension in each plane: Vc= (a x b x c). Nodal density was graded.
Results and Conclusion: No statistically significant association between recovery and CT density was found (X 2 = 0.306; P > 0.05).

 > Abstract in Chinese 

淋巴结的CT密度模式在2种不同放化疗方案治疗头颈部肿瘤的治疗结果相关性
摘要
目的/背景:肿瘤坏死可在CT非增强的低密度区。坏死区含氧少,对放化疗不敏感。文献综述(1)表明,头颈部肿瘤完全缓解率为低密度区低于等密度区。局部晚期头颈部肿瘤需要放疗后手术,而接受了辐射剂量是7000 cGy后,手术变得困难,而在照射了4500 cGy剂量后病人也别无选择,而这个剂量后手术量无多大困难。我们推测在低密度的淋巴结,甚至在他们很小的时候就显示了放化疗不敏感性,淋巴结密度可以作为放疗敏感性预测指标,当病人照射了4500 cGy剂量后选择手术。手术通常是放疗后2到3周,所以可以采用全剂量而在淋巴结中的辐射场区的皮肤会恢复急性放射反应。根据相关的C T密度模式的淋巴结,研究头颈部癌症患者进行治疗时使用的两种不同的放化疗方案。
材料与方法:2010年8月至2011年7月间的83例局部晚期头颈部肿瘤患者分别用前瞻性的两个计划进行同步放化疗。CT扫描整个颈部区域包括原发灶。通过对比剂碘(150毫升)静脉注射,开始注射50ml(3ml/s),然后缓慢(1ml/s)输注剩余剂量。计算总肿瘤体积和颈部淋巴结体积:取立方体最大值:VC =(a* B*C)。淋巴结密度分等级。
结果与结论:痊愈和CT密度没有统计学上的显著差异(X2 = 0.306;P<0.05)。
关键词:放化疗,CT密度,头颈癌,淋巴结,治疗结果


Keywords: Chemoradiotherapy, CT density, head and neck cancer, lymph nodes, treatment results


How to cite this article:
Jaju S, Gupta S K, Pandey S, Singh V. Correlation of Computerized Tomography density patterns of lymph nodes with treatment results and outcome in head and neck cancer patients treated by 2 different chemoradiotherapy schedules. J Can Res Ther 2014;10:284-93

How to cite this URL:
Jaju S, Gupta S K, Pandey S, Singh V. Correlation of Computerized Tomography density patterns of lymph nodes with treatment results and outcome in head and neck cancer patients treated by 2 different chemoradiotherapy schedules. J Can Res Ther [serial online] 2014 [cited 2020 Oct 26];10:284-93. Available from: https://www.cancerjournal.net/text.asp?2014/10/2/284/136566


 > Introduction Top


Presence of tumor necrosis is visualized on CT scan as non enhancing hypodense area. Necrotic areas contain less oxygen and results in poor response of chemo-radiotherapy and non surgical treatment. Literature review [1] has shown that for hypodense lesions in head and neck cancer the complete response rate is lower than the isodense lesions. Locally advanced disease in head and neck require the addition of surgery but after radical dose of radiation that is 7000 cGy, surgery become difficult but there is no tool initially that can be used for selection of patients after delivery of 4500 cGy, that is the dose after which surgery can be performed without much difficulty. Hypodensity of lymph nodes is being studied as a tool to select patient who will go for surgery after initial 4500 cGy of radiotherapy to primary and nodes. Surgery is usually performed 2 to 3 weeks after radiotherapy, so that radiation field will recover from acute radiation reaction and surgery could be undertaken with ease. Chemo-radiotherapy+-salvage surgery has become the standard of care for loco-regionally advanced head and neck cancers. Nodal disease in the majority of advanced head and neck cancer patients fails to respond to standard chemo radiation regimes. This may result in difficulty in performing salvage surgery, in view of higher 70Gy radiation dose received by the patient. The use of CT feature of less than one third lymph node hypodensity as a measure of selecting patients for radical chemo radiation has not been studied in randomized trials. Literature review [1],[2] has shown that for hypodense lesions in head and neck cancer, the complete response rate is lower than the isodense lesions. Platinum based regimens are the most effective; although the benefits are proven with chemo-radiation, acute toxicities are markedly increased. The dose and delivery schedules of Cisplatin have ranged from intermittent higher dose [100 mg/m 2 ] every 3 weeks to low dose [6 mg/m 2 ] daily administration as well as weekly in various dose schedules and late cameo boost. At present there is no data indicating which regimen is superior. The association between CT density and recovery is evaluated in this study.


 > Material and methods Top


A total of 83 patients of Head and Neck cancer including oral cavity, oropharynx, hypopharynx and larynx (supraglotic, glottis and subglottic), who were registered between June 2010 to July 2011 were studied using two different chemo radiotherapy schedules. Inclusion criteria required that General condition should be fair enough to tolerate acute mucosal reaction (KPS >60); Biopsy proved cases of malignancy and included all advance stages (III and IV) head and neck malignancies (except M1 and malignancy of nasopharynx and Paranasal Sinuses (PNS)).

Exclusion Criteria included Poor general condition, Metastatic disease, Prior surgery or chemotherapy and Carcinoma nasopharynx and PNS.

Pre-treatment work up included Bio-social characteristics: Name, Age, sex, personal habit, socio-economic status, address. Complete history: Detailed history with particular emphasis on the presenting symptoms with onset, duration, personal habit, family history, past history, medical history and previous mode of treatment; if any. General examination: Pulse rate, respiratory rate, temperature, pallor, Icterus, blood pressure, lymphadenopathy. Examination of primary lesion was followed by Local examination, Anterior/posterior rhinoscopy, Indirect laryrngoscopy, Flexible endoscopic examination, where primary is not accessibly by indirect laryngoscopic examination; Local lymph node examination (Group of lymph node involved Ipsilateral/bilateral/contralateral, Size: <3 cm/3-6 cm/6 cm, Number of lymph node involved in a particular group, Margin: Defined/ill defined, Consistency: Soft/firm/hard/stony hard, Tender/non tender, Mobility, Fixity to deeper structure +/-, Skin over swelling fixed/free); Dental examination; Systemic examination: CVC, respiratory, GIT, CNS; Biopsy from primary; Histopathology; Routine blood counts: Hb, TLC, DLC, Platelets; Blood sugar, serum creatinine, blood urea, LFT and Radiological examination (X-ray chest, X-ray mandible lateral-oblique view or orthopentogram, CT scan of entire neck region including primary).

CT density is obtained by doing a CT scan of the entire neck region including primary. Iodine based contrast material (150 ml) was injected intravenously starting with a bolus of 50 ml (3 ml/s), followed by a slow (1 ml/s) infusion of the remaining dose. Total tumor volume of the primary and involved neck nodes was calculated as a carbide volume, using maximum dimension in each plane:

Vc = (a x b x c).

Nodal density was graded according to the criteria of the Institute Gustave Roussy, France [1] the density of nodes was compared to that of nuchal muscle at the same level. A node was classified as isodense if one third or less than one third of its cross- section consisted of hypodense zones and as hypodense, if more than one third of the node cross section was found to be hypo dense. The largest visible node of at least 2cm was chosen for grading purposes.

The staging was done according to the TNM classification immediately before starting radiotherapy.

Radiotherapy in a total dose of 65-7500 cGy was delivered in 6 1/2 - 7 weeks with 5 fractions per week as 200 cGy per day using orifit cast and compensator. Spinal cord was excluded from the beam after a total dose of 4600 cGy in 4 1/2 week has been delivered and rest of the dose was delivered with reduced fields excluding neck nodes, if not involved clinically and compensator was not used for this latter part of the treatment. When the nodes were lying outside the off cord field then TPS plan was done to include the node as well as primary so that we can spare the cord.

Chemotherapy is given in Arm1 (Control Group) as weekly injection Cisplatin 40 mg/m 2 IV over one hour infusion with premedication and maintenance of proper hydration over total 6-7 cycles, while in Arm2 (Study Group) Chemoboost was given as a daily infusion of injection Cisplatin 10 mg/m 2 per day IV and continuously infused 5-FU 400 mg/m 2 per day, on day 1-5 of weeks 5, 6 and 7 of radiation therapy (dose of 5 FU was reduced to 350 mg/m 2 from 400 mg/m 2 after the initial 2 patients developing severe skin reactions and mucositis).

During the course of radiation all the patients were observed weekly for mucosal and skin reactions, laryngeal edema, salivary gland reaction, tumor response. Grading was done according to RTOG criteria. Tumor response was assessed 4 weeks after completion of treatment.

Complete Response denoted Complete regression of tumor i.e. no clinically palpable or visible tumor. Partial Response was considered when there were more than 25% but less than 75% regression of tumor. No response included less than 25% tumor regression.

All the patients who developed severe mucosal reaction were given supportive IVF in the form of 5-10% dextrose with MVI or Amino drip if required.

Statistical analysis was performed using SPSS 13.0 (SPSS Inc., Chicago, IL, USA) software. Descriptions of the parameters are quoted as mean of SD and 95% confidence Intervals (CI). Differences between groups in response rate and incidence of toxicity were evaluated using the Fisher's exact test. P < 0.05 was considered to be statistically significant.


 > Results Top


The patient's characteristics are shown in [Table 1]. The commonest site was Oropharynx constituting nearly half of the cases in both the groups. All the patients had histologically proven Squamous cell carcinoma (SCC). The response is depicted in [Table 2],[Table 3],[Table 4],[Table 5],[Table 6],[Table 7],[Table 8] and [Table 9]. In Group A at the primary site, 42 patients had a complete response (CR), 5 had persistent disease; while in Group B, 26 patients had a CR and 4 had persistent disease. In the neck nodes, in GroupA, 38 had a clinical CR, 6 had persistent disease while in group B, these figures are 22 and 6. The histology of 4 of the 5 neck resections was negative in Group A for viable tumour. Thus, the complete response rate in the primary site was 42/51 = 82%, in the Neck 38/44 = 86% and the overall complete response rate 38/51 = 74% in the Group A while it is 26/32 = 81%, 22/28 = 78% and 22/32 = 68% in Group B. The median potential follow-up time [Table 10] for the whole group from commencing radiotherapy with the close-out date was a year. At the close-out date in Group A, 41 patients were alive: 31 patients with no evidence of disease, 8 with loco regional disease and 7 with no evidence of disease but lost to follow-up while 3 lost to follow up with disease before the close-out date and in Group B these figures are 19, 6, 4, 2 respectively. Two patients died in group A while 1 patient in group B. Local control is illustrated in [Table 11] and [Table 12]. In the Chemo boost arm local control (Loco regional relapse free rate) was 90% by a year, among complete responders when patients relapsing at primary or nodal site were considered as an event. When we included patients with residual disease at completion of treatment as event (their time to recurrence was the end of the treatment) then local control was 76% in late Chemoboost With radiotherapy as compare to the weekly chemoradiotherapy group, in which these were 70% and 88% respectively. Toxicity and supportive care are demonstrated in [Table 13],[Table 14] and [Table 15]. Skin, mucous membrane, pharynx, salivary gland and laryngeal toxicity were compared between two groups. Two patients developed grade IV skin reaction which caused a gap of maximum 17 and 14 days in the treatment in late chemo boost and weekly chemotherapy respectively.Thirteen patients in late chemo boost arm and 4 in weekly chemotherapy arm had moist desquamation but this didn't cause any gap in the treatment. Thirty three patients developed patchy mucositis and 14 progressed to confluent mucositis in late Chemo boost with radiotherapy as compare to weekly chemoradiotherapy group in which these were 17 and 09 respectivly. 80% of the patients got their mucositis healed within a month after completion of treatment. The median duration of mucositis, from the date of onset of patchy mucositis, to the date when mucositis healed was 2m. Grade III dysphagia was seen in 38 patients in group A while 07 patients in group B.Twelve patients had significant dysphagia, they were put on tube feeding in late chemo boost with radiotherapy as compare to weekly chemo radiotherapy group, in which these were 8. Two of them required it for more than 3 m in Group A as compared in weekly chemo radiotherapy group in which 1 patient required feeding for >3 m. One patient in each treatment group developed absolute dysphagia, so they underwent surgical intervention that is feeding Gastrostomy. Nineteen patients required extra nutritional support for > a month while in 5 patients hospital stay was prolonged by >30 days in late Chemo boost with radiotherapy as comparable to weekly chemo radiotherapy group in which these were 10 and 5 respectively. Almost all the patients developed xerostomia which was irreversible. Eighteen and 09 patients respectively in group A and group B developed grade III laryngeal reaction but none of them caused any mortality. Out of these 27 patients total 2 patients developed severe laryngeal oedema for which tracheostomy was done in each group. Hematological toxicity was not significant except for three patients who developed grade IV reactions in both arms. Patients were managed aggressively with G-CSF and blood transfusions and his counts came to normal within a week. There were borderline fluctuations in TLC, Neutrophils count, platelet count and hemoglobin level in majority of the patients but none of the patients required any break in the treatment in late Chemo boost with radiotherapy as well as in weekly chemoradiotherapy group. The results showed that there is no statistically significant association between recovery and CT density (X2 = 0.306; P > 0.05). On measuring the strength of association between CT density and recovery, it was observed that odd ratio is 1.662 (CI-lower limit-0.620; upper limit-4.424), which also indicates that there was no association between CT density and recovery. The response rate for hypodense lesion was less as compared to isodense but this was not statistically significant so hypodensity may not be taken as a tool to select the patients for surgical treatment after initial 4500 cGy radiotherapy.
Table 1

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Table 2: Tumor response

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Table 3: Tumor response according to stage

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Table 4: Tumor response according to tnm classification (n=83)

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Table 5: Tumor response according to total tumor volume (n=83)

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Table 6: Tumor response according to nodal density (n=83)

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Table 7: Tumour response according to primary location

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Table 8: Gradewise comparison of tumour response according to histopathology

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Table 9: Comparison of tumour response according to various other prognostic factors in both weekly chemoradiotherapy and late chemoboost groups

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Table 10: Follow up status of patients at close out date

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Table 11:

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Table 12:

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Table 13:

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Table 14:

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Table 15:

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 > Discussion Top


The commonest site of head and neck involved by malignancy is reported to be larynx; other sites are base tongue, laryngopharynx, tonsil, lip, alveolus, cheek, palate etc. [3] In our study maximum numbers of cases were of carcinoma larynx. The present study is based on MD Anderson hospital concomitant boost technique using a similar 2 regimens in terms of treatment schedule, response, local control and toxicity profile. Median age was 55 years and disease is less common below 20 years; this may be because of lesser time of exposure to addictive agents. In this study only 3% patients had no addiction history and rest of the 97% patients were either addicted to tobacco, smoking, pan masala or alcohol intake. Histology in majority is Squamous cell carcinoma. [4] In our study incidence of squamous cell carcinoma Grade-I (well differentiated) was approximately 62%. Squamous cell carcinoma Grade-II (moderately differentiated) was 28%. Squamous cell carcinoma Grade III (poorly differentiated) was 7% and Grade IV (undifferentiated) was 3% [Table 1]. In our study overall incidence of lymph node involvement was around 86% [Table 1]b.

Stage III and stage IV disease patients are included in varying proportions in studies of locally advanced head and neck cancer, which makes retrospective comparisons with other treatment modalities very difficult. Local control rates with surgery alone depend on sub-site and stage, but in this poor prognosis group they are of the order of 25-30%. [5],[6],[7]] Addition of post-operative radiation therapy improves loco regional control to 36-77%. [8],[9] Regimens using accelerated radiation therapy have been somewhat disappointing in that although loco regional control rates may be improved, there has been unacceptable acute and late toxicity. [10],[11],[12] Hyperfractionated radiation regimens have shown improved loco regional control compared to conventional radiation therapy, [13] which may be further enhanced with concurrent chemotherapy, [14] but this doubles radiation machine workloads. It is now accepted that chemotherapy is more effective when given concurrently rather than sequentially with radiation therapy. However, randomized concurrent regimens published to date, have employed either small daily doses of chemotherapy or given chemotherapy in the first and last weeks of radiation therapy. [14] All patients (except patients who deteriorated after the start of radiotherapy, two patients who refuse chemotherapy and two patients who expired) completed their combined therapies. Mean total treatment time was 51.6 days +/- 4.26 (SD) and mean gap during treatment was 2.7 days +/- 4.25 (SD). Most of the gaps during treatment were because of holidays or power failures [Table 9], [Table 11] and [Table 12]. Maximum gap was of 17 days in one patient because of grade 4 skin and grade 3 mucosal reactions. A high complete response rate of 75% (at primary response was 90% and nodal response was also 87%) was seen. In 25% of patient there was partial response and none of the patient was non responsive to this Chemoboost regimen [Table 9]. Disease free survival at 9m was 70% and overall survival was 90% in late chemoboost + Radiotherapy group. This control rate is comparable to concomitant boost-radiation alone trial and other chemoboost trials and concurrent weekly chemoradiotherapy which were 88%, 80% and 88% respectively [Table 10].

A study report [15] reveal that when oropharyngeal and nasopharyngeal carcinoma (T2-T4) were treated were concomitant boost technique and received a total dose of 69-72 Gy in 6 weeks. The main finding of their study was that the overall 2 year locoregional control was 74% and the optimal timing for the concomitant boost is during the last 2 to 2 1 / 2 week of basic treatment rather than first 2 to 2 1 / 2 week of the treatment.

A Chemoboost trial [16] reported 90% complete response at the primary site and 57% complete response at nodal site. One year primary control was 82% and 74% patients showed freedom from relapse at one year. This study demonstrates that full doses of chemotherapy can be administered with radical dose of radiotherapy. Although follow up is relatively short the complete response rate was well sustained and only 4 patients relapse locoregionally at neck and none of the patients showed relapse at primary -site. The toxicity is manageable with appropriately and timely medical support. In particular adequate attention to patient nutrition and treatment of infection was required. There were no deaths related to treatment toxicity, two patients expired after completion of treatment one because of cardiovascular disease and for other exact cause of death is not known. (Responses to Chemoboost according to various prognostic factors like Total tumor volume (TTV), Nodal Density (ND), Age, T stage, N stage, Primary site, type of growth whether infiltrative or Exophytic, average weekly haemoglobin level and gap in treatment were as follows: Total tumor volume (TTV), Nodal Density (ND), Primary site, type of growth and treatment gap were found to significantly affecting treatment outcome in terms of complete response, disease free survival and local control in chemoboost arm [Table 11] and [Table 12]. Exophytic lesions respond better and their locoregional control rate is also better than the infiltrative lesions (P < 0.05). Mean duration of gap was 2.7 days +/- 4.25 (SD) in this study. After subdividing the sample into two groups, that is gap size of more than 3 days and less than 3 days we found gap size was significantly affecting the treatment outcome in terms of' complete response and local control (P < 0.05) [Table 11] and [Table 12].

There is no significant difference in outcome according to primary site for complete response (P > 0.05), Lesions of larynx and oropharynx responded better than the oral cavity cancers [Table 11] and [Table 12].

A recent study [17] reported the influence of volume and the response to accelerated RT in a group of 73 patients with advanced SCC of the head and neck. After incorporation of the variable volume in the final Cox model, other variables like T and N category and age, lost their significance with respect to the end point, local tumor control. A study [18] examined the volume in 37 glottic and supraglottic tumors treated by Radiotherapy alone. The mean volume of controlled cases was 8.9 ml and for those that failed the mean volume was 21.3 ml. According to few previous studies, [19],[20] patients in T3 stage grouping could be divided into two groups with significantly different outcome. They split patients with T3 stage into two subgroups primarily based on TTV.OS was better in patients with TTV of less than or equal to 25 cm 3 (77.4% at 28 m) when compared with TTV of more than 25 cm 3 (61.5% at 28 m). The difference was statistically significant, there was trend toward improvement in Local relapse free survival with low tumor volume in T3 stage but the difference was statistically not significant. Within same T stage we can have tumors with different tumor volumes having varied response to treatment. Data derived from the CT images in this study demonstrated significant outcome difference between small (<30 cc) and large (>30 cc) volume head and neck cancers in chemoboost arm. This was further confirmed by multivariate analysis, which showed the independent influence of total tumor volume when confounding variables were considered [Table 12]. Other studies support our findings, although detailed primary tumor volume analyses of head and neck sites are limited in number. Two laryngeal tumor studies using precision CT images to define primary tumor volumes reviewed. [18],[19] 37 glottic and supraglottic, tumors (Stage T2- T4) managed by radiotherapy using volume measurement techniques similar to the methodology of our study. The mean volume of controlled cases was 8.86 cm 3 and 21.8 cm 3 for those that failed. Multivariate techniques identified tumor volume as the most important outcome predictor followed by N- stage and sex. The authors noted the problem of bulky volume T2 tumors and small volume T4 tumors. A study [20] examined supraglottic tumors and found that CT-derived tumor volume estimates were predictive of local control for treatment with radiotherapy alone. Tumor control was achieved in 83% of those with volumes <6 cm 3 vs 46% of those with volumes 2.6 cm 3 .

It was shown [21] that patients with low tumor volume had 69% survival and 67% tumor control at 3 years among patients receiving concurrent chemoradiotherapy while it was 22% and 23% with large tumor volume.

Toxic effects for most patients were significant but acceptable. The rate of confluent mucositis was comparable seen in concomitant boost radiation-only experience. [15] This study [15] also reported confluent mucositis in 69% patients in concomitant boost group. Nine percent of patients developed severe mucositis lasted more than 6 weeks [Table 13] and [Table 15]. Forty three patients (84%) had nutritional support during their therapy [Table 14].

In our study, the incidence of confluent mucositis was 30% and all of them were healed by 6 weeks. Seventy percent of these patients took a median duration of 3m to heal. A total of 21% patients was having severe mucositis for more than 6 weeks. Rate of prolongation of mucositis was slightly more severe in our study but in all patients mucositis was healed by 4 th m. In 21% of patients Grade III skin reactions were evident which was manageable with occlusive dressings [Table 13]. Twenty four percent of patients required tube feeding and 54% of patients required nutritional support. Median in patient stay post-completion of treatment was 12 days. All patients were discharged from the hospital within one week of completion of treatment except in one patient who was admitted for 34 days post treatment for nutritional support (because of severe grade 4 skin reaction and grade 3 mucositis) [Table 14]. This regimen of radiation with Concurrent late chemotherapy intensification (Chemoboost) is being assessed in two ongoing trials, one being a three - arm RTOG 97-03 randomized trial, along with two other novel concurrent chemotherapy-radiation regimens, one evaluating concurrent 5FU and hydroxyurea and the other evaluating weekly paclitaxel and cisplatin. Other trial evaluating Chemoboost regimen along with the combination of cisplatin, tripazamine and radiation therapy is going on in a multi- institutional randomized phase II study of the Trans-Tasman Radiation Oncology Group. Our study shows that good complete response rates can be achieved using conventional radiation therapy with the novel addition of chemotherapy in the final phase of radiation treatment [Figure 1] and [Figure 2]. Response to both these treatment regimen was again didn't differ statistically significant, when it was compared in terms of different T and N stages. Although follow-up is relatively short, the complete response rate was well sustained with only 5 patients relapsing locoregionally after the initial complete response. Loco regional control in this poor prognosis group is good, with only 25% estimated to fail locally by a year. This novel way of combining chemotherapy and radiation therapy in the management of locally advanced head and neck cancer is particularly suitable for poor patients, who can initially be treated with radiotherapy alone on outdoor basis and require some time for arranging resources for concurrent chemoradiotherapy. The response rate for hypodense lesion was less as compared to isodense but this was not statistically significant so hypodensity may not be taken as a tool to select the patients for surgical treatment after initial 4500 cGy radiotherapy. Late chemoboost regimen achieved a good complete response rate as well as locoregional control at a year in patients with a poor initial prognosis. There is no statistically significant association [Table 16]a and b between recovery and CT density and difference in response, relapse free survival and toxicities in 2 chemoradiotharepy schedules. The present study seeks to see the association between CT images of lymph-nodes and response but there is no gold standard of comparison for response in any case. The potential use of CT Scan density for patients who cannot afford PET CT before the start of radical treatment need to be investigated on a larger scale. Presently, in the era of PET CT, responses to therapy may be more reliably quantified, albeit a couple of months after (chemo) -radiotherapy to decide on the need for lymph node salvage surgery.
Figure 1: (Before treatment) Pre-Treatment CT Scan showing growth at base of tongue and lymph nodes

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Figure 2: (After treatment) Post treatment CT Scan showing complete response

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Table 16:

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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13], [Table 14], [Table 15], [Table 16]



 

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