Randomized Clinical Trial on Reduction of Radiotherapy Dose to the Elective Neck in Head and Neck Squamous Cell Carcinoma: Results on the Quality of Life.

PURPOSE: A randomized trial was initiated to investigate whether a reduction of the dose to the elective nodal sites would result in less toxicity and improvement in Quality of Life (QoL) without compromising tumor control. This paper aimed to compare QoL in both treatment arms. METHODS: Two-hundred head and neck cancer patients treated with radiotherapy (RT) or chemo-RT were randomized (all stages, mean age: 60 years, M/F: 82%/18%). The elective nodal volumes of patients randomized in the experimental arm were treated up to a 40 Gy equivalent dose. In the standard arm, the elective nodal volumes were treated up to a 50 Gy equivalent dose. The QoL data were collected using The European Organization for Research and Treatment of Cancer (EORTC) core questionnaire QLQ-C30 and the EORTC Head and Neck Cancer module (H&N35). RESULTS: A trend toward less decline in QoL during treatment was observed in the 40 Gy arm compared to the 50 Gy arm. Statistically significant differences for global health status, physical functioning, emotional functioning, speech problems, and trouble with social eating in favor of the 40 Gy arm were observed. A clinically relevant better outcome in the 40 Gy arm was found for physical functioning at the end of therapy. CONCLUSION: QoL during RT for head and neck cancer tends to be less impaired in the 40 Gy arm. However, reducing the dose only on the elective neck does not result in clinically relevant improvement of QoL. Therefore, additional treatment strategies must be examined to further improve the QoL of HNSCC patients.

Does intensity-modulated radiation therapy lower the risk of osteoradionecrosis of the jaw? A long-term comparative analysis.

The aim of this study was to analyze the impact of different radiation techniques on the long-term incidence of osteoradionecrosis in head and neck cancer. Risk factors and the occurrence of osteoradionecrosis were analyzed in a retrospective, comparative, observational study. Medical files and radiological images of 109 patients treated with primary intensity-modulated radiation therapy (IMRT) and 129 patients treated with primary three-dimensional conformal radiotherapy (3D-CRT) were evaluated. Proportional hazards models were used to analyse the effects of the radiation modality and patient characteristics on the necrosis risk. Twenty-two patients developed osteoradionecrosis (9.2%) during a mean follow-up of 4.3 years. A numerical difference was observed, with more osteoradionecrosis after 3D-CRT (n=18) than after IMRT (n=4). After correction for group differences and confounders, no statistical difference in risk was observed between the two treatment groups (P=0.37). Multivariate analysis showed evidence of a higher osteoradionecrosis risk for patients with a tumour of the oropharynx and for patients with tooth extraction after radiation therapy. Although the incidence of osteoradionecrosis tended to be lower after IMRT, due to the multifactorial aetiology it remains a severe problem and cannot be prevented by new radiotherapy techniques. Continuous efforts are necessary to control additional risk factors and avoid osteoradionecrosis.

Correlation of Patient- and Physician-Scored Dysphagia with Videofluoroscopies in Patients Treated with Radiotherapy for Head and Neck Cancer.

The aim of this study was to investigate the correlation between patient-scored dysphagia and physician-scored dysphagia in head and neck cancer patients treated with radiotherapy. Furthermore, we wanted to compare both patient- and physician-scored dysphagia with dysphagia evaluated on swallowing videofluoroscopies. Sixty-three patients from two different centers treated with radiotherapy for head and neck cancer were evaluated in the current study. Swallowing videofluoroscopies at baseline, 6, and 12 months following radiotherapy were evaluated by 2 observers using the Penetration Aspiration Scale (PAS) and Swallowing Performance Status Scale (SPS) and correlated with patient and physician scored dysphagia. We observed a significant association between physician and patient scored dysphagia (p < 0.01), pre-treatment and post-treatment. Furthermore, the risk of observing dysphagia on videofluoroscopies increased significantly with increasing scores of both physician as well as patient scored dysphagia, and this at all assessed time-points. Patient-scored dysphagia correlates better with dysphagia evaluated by the PAS. Physician-scored dysphagia, however, correlates better with dysphagia as evaluated using the SPS. Both physician- and patient-scored dysphagia correlate well with dysphagia evaluated on videofluoroscopies. Since patient-scored dysphagia correlates better with PAS and changes in the PAS score, and physician-scored dysphagia correlates better with SPS, we advocate to use both patient- and physician-scored dysphagia in future trials.

The incidence of hypothyroidism after radiotherapy for head and neck cancer.

The incidence of hypothyroidism after radiotherapy for head and neck cancer. OBJECTIVES: To identify the incidence of radiation-induced hypothyroidism (HT) after head and neck radiotherapy.Furthermore, we wanted to correlate patient and treatment characteristics with the incidence of HT in order to identify predictive factors for radiation-induced HT. METHODOLOGY: We examined the values of thyrotropin, i.e., the thyroid-stimulating hormone (TSH), in head and neck cancer patients who received a combination treatment of radiotherapy and chemotherapy between 2005 and 2012. HT was defined as having a TSH value of > 10 mIU/L or whenever the patient started to take substitution therapy after treatment. We correlated the radiotherapy mean dose to the thyroid gland (Dmean), the pretreatment volume of the thyroid gland, sex, age, type of concomitant treatment, tumour localization, and T and N classification with the incidence of HT. RESULTS: We were able to obtain data from 72 patients. From these 72 patients, 48 (66%) had a normal thyroid function and 25 (34%) had developed HT. The mean follow-up for these patients was 55 months (range: 21 to 103 months). Out of the 25 patients with HT, 8 (32%) were diagnosed within the first year of follow-up. Increasing Dmean is a significant risk factor for developing HT. Increasing thyroid volume, on the other hand, was correlated with less HT in our patient cohort. CONCLUSIONS: In our study, the incidence of HT is 34%. We also noticed that HT can even develop shortly after treatment. Patients with a higher Dmean to the thyroid gland and lower pretreatment thyroid gland volumes are more at risk.

HPV-positive head and neck tumours, a distinct clinical entity.

A worldwide rise in the incidence of oropharyngeal squamous cell cancer has been recorded over the past decade. This rise has been attributed to an increase in oncogenic human papilloma virus (HPV) infections. The biology of HPV-positive oropharyngeal cancer is distinct; it includes p53 degradation, retinoblastoma pathway inactivation, and p16 upregulation. The best method for detecting HPV in tumour material is controversial; both in-situ hybridisation and PCR are commonly used. However, p16 can serve as a potential surrogate marker, and therefore, p16 immunohistochemistry is widely used in clinical practice. Compared to HPV-negative cancers, HPV-positive oropharyngeal cancer appears to be more responsive to chemotherapy and radiotherapy. Thus, p16 can serve as a prognostic marker for enhanced overall survival and disease-free survival. In this review, we aimed to highlight the current understanding of the epidemiology, biology, detection, and management of HPV-related oropharyngeal head and neck squamous cell carcinoma.

Intensity-modulated radiotherapy vs. parotid-sparing 3D conformal radiotherapy. Effect on outcome and toxicity in locally advanced head and neck cancer.

BACKGROUND AND PURPOSE: Intensity-modulated radiotherapy (IMRT) has rapidly become standard of care in the management of locally advanced head and neck squamous cell carcinoma (HNSCC). In this study, our aim was to retrospectively investigate the effect of the introducing IMRT on outcome and treatment-related toxicity compared to parotid-sparing 3D conformal radiotherapy (3DCRT). MATERIAL AND METHODS: A total of 245 patients with stage III and IV HNSCC treated with primary radiotherapy between January 2003 and December 2010 were included in this analysis: 135 patients were treated with 3DCRT, 110 patients with IMRT. Groups were compared for acute and late toxicity, locoregional control (LRC), and overall survival (OS). Oncologic outcomes were estimated using Kaplan-Meier analysis and compared using a log-rank test. Acute toxicity was analyzed according to the Common Terminology Criteria for Adverse Events v3.0 and late toxicity was scored using the RTOG/EORTC late toxicity scoring system. RESULTS: Median follow-up was 35 months in the IMRT group and 68 months in the 3DCRT group. No significant differences were found in 3-year LRC and OS rates between the IMRT group and 3DCRT group. Significantly less acute mucositis ≥ grade 3 was observed in the IMRT group (32% vs. 44%, p = 0.03). There was significantly less late xerostomia ≥ grade 2 in the IMRT group than in the 3DCRT group (23% vs. 68%, p < 0.001). After 24 months, there was less dysphagia ≥ grade 2 in the IMRT group although differences failed to reach statistical significance. CONCLUSION: The introduction of IMRT in the radiotherapeutic management of locally advanced head and neck cancer significantly improved late toxicity without compromising tumor control compared to a parotid-sparing 3D conformal radiotherapy technique.

Uniform talc delivery during video-assisted thoracoscopic pleurodesis.

Video-assisted thoracoscopic talc pleurodesis is a highly effective technique to manage recurrent pneumothorax or pleural effusion. However, inhomogenous talc delivery might be a cause of failure. We report a simple and inexpensive technique for uniform talc dispersion with complete covering of the pleural space during video-assisted thoracoscopic pleurodesis.