Acute mucosal reactions in patients with head and neck cancer. Three patterns of mucositis observed during radiotherapy.

PURPOSE: To investigate the individual pattern of acute mucosal radiation reactions (AMRR) in patients with head and neck cancer who were treated with radiotherapy alone. Reactions were evaluated daily on an individual basis according to the Dische scoring system. MATERIALS AND METHODS: Treatment of 87 head and neck cancer patients comprised either conventional fractionation- (CF; n = 33), accelerated fractionation (AF; n = 33), hyperfractionated- (HPEFX; n = 12) or hypofractionated (HPOFX; n = 9) radiotherapy with radical intent. Daily evaluation of AMRR progression was performed prospectively using a modified, morphologically functional Dische scoring system. The daily sums of the score parameters were subsequently used to construct an individual AMRR course curve for each patient. RESULTS: A latency period ranging from 3 to 14 days between the start of radiotherapy and the occurrence of the first AMRR symptom was observed in all patients. Based on the three different shapes of AMRR course curve observed during radiotherapy, three types of AMRR course can be described: (1) a continual increase in AMRR intensity until the completion of radiotherapy; (2) the incidence of a plateau phase following the increase in AMRR (increase-plateau course) and (3) decreasing AMRR intensity with a healing phase. A continual increase in AMRR intensity was observed in about 25 % of CF and AF patients and in more than 50 % of HPOFX treatments. This type of reaction was not observed in the HPEFX group. The increase-plateau course was noted in the majority of AF and CF patients; in almost half of those treated with HPOFX and in all HPEFX patients. A decreasing AMRR intensity course was observed in 23 % of all patients, although not observed at all in the HPEFX and HPOFX fractionation groups. CONCLUSION: The course of AMRR during radiotherapy can differ between individual patients. After the initial increase in AMRR intensity, a stabilization of the reaction--visible as a plateau phase on the course curve--is observed in the majority of patients. A proportion of the irradiated patients experience a continual increase in AMRR intensity up until the end of radiotherapy. A further group of patients exists in whom signs of AMRR healing are observed during the final stages of radiotherapy.

Acute mucosal radiation reactions in patients with head and neck cancer. Patterns of mucosal healing on the basis of daily examinations.

PURPOSE: The goal of this research was to evaluate the healing processes of acute mucosal radiation reactions (AMRR) in patients with head and neck cancer. MATERIALS AND METHODS: In 46 patients with oral and oropharyngeal cancer patients irradiated with conventional (n = 25) and accelerated (n = 21) dose fractionation AMRR was evaluated daily during and after radiotherapy. Complex of morphological and functional symptoms according to the Dische score were collected daily until complete healing. RESULTS: Duration of healing after the end of radiotherapy ranged widely (12-70 days). It was on the average 8 days longer for accelerated than for conventional radiotherapy (p = 0.016). Duration of dysphagia was also longer for accelerated irradiation (11 days, p = 0.027). Three types of morphological symptoms were observed as the last symptom at the end of AMRR healing: spotted and confluent mucositis, erythema, and edema. Only a slight correlation between healing duration and area of irradiation fields (r = 0.23) was noted. In patients with confluent mucositis, two morphological forms of mucosal healing were observed, i.e., marginal and spotted. The spotted form was noted in 71% of patients undergoing conventional radiotherapy and in 38% of patients undergoing accelerated radiotherapy. The symptoms of mucosal healing were observed in 40% patients during radiotherapy. CONCLUSION: The wide range of AMRR healing reflects individual potential of mucosa recovery with longer duration for accelerated radiotherapy. Two morphological forms of confluent mucositis healing were present: marginal and spotted. Healing of AMRR during radiotherapy can be observed in a significant proportion of patients.

[Unconventional accelerated irradiation of advanced pharyngolaryngeal cancer as an alternative treatment compare to surgery. The interim results of randomized clinical trial]. / Przyspieszona niekonwencjonalna radioterapia zaawansowanego raka krtani i gardla dolnego jako alternatywa dla leczenia operacyjnego. Wczesne wyniki kontrolowanego doswiadczenia klinicznego.

The paper presents preliminary results (3 year tumour control and survival) of clinical randomized trial comparing accelerated fractionation (7 fx a week) with conventional (5 fx a week) radiotherapy (RT) for advanced pharyngo-laryngeal cancer. Significant treatment gain (p < 0.001) and good tolerance associated with accelerated RT was noted (82% of disease-free and 79% of overall survival). These results are similar with combined (total laryngectomy + postoperative RT) policy and, additionally, accelerated RT offers a high chance of larynx preservation.

[The effectiveness of combined treatment for laryngeal cancer in Silesia region during the years 1987-1996]. / Ocena wyników skojarzonego leczenia raka krtani w materiale klinicznym Instytutu Onkologii w Gliwicach w latach 1987-1996.

Between 1987-1996, 484 patients with laryngeal cancer were treated by surgery and adjuvant radiotherapy. The 25-30% therapeutic gain was noted when to compare the first period of the study (1987-1992) with the second (1993-1996). The increment of effectiveness of combined treatment for larynx cancer is probably the result of better quality of surgical procedures and individualization of radiation treatment.

[[Radical radiotherapy in patients with laryngeal cancer in clinical material of Institute Oncology in Gliwice treated in year 1990-1996]. / Samodzielna radioterapia chorych na raka krtani w materiale klinicznym Instytutu Onkologii w Gliwicach w latach 1990-1996.

This paper presents influence of selected prognostic factors on results of laryngeal cancer radiotherapy used as the only treatment in 541 patients irradiated in Centre of Oncology-Institute in Gliwice between 1990-1996. The 3-year actuarial disease-free survival was 47.5% for supraglottic cancer and 67% for glottic cancer. Primary tumour localisation in glottis correlates with more favourable prognosis than that in supraglottic. For extralaryngeal involvement the most favourable prognosis was infiltration of cartilages and the worst one for the hypopharyngeal and oropharyngeal involvement. Pretreatment tracheostomy significantly correlates with the worst results.

Randomized clinical trial on 7-day-continuous accelerated irradiation (CAIR) of head and neck cancer - report on 3-year tumour control and normal tissue toxicity.

PURPOSE: To evaluate tumour and normal tissues 3-year response to 7-day-a-week continuous accelerated irradiation (CAIR) compared to a conventional treatment (5 days per week) in a randomized trial. MATERIALS AND METHODS: One hundred patients with squamous cell carcinoma of the head and neck in stage T(2-4)N(0-1)M(0) were entered into the trial between December 1, 1993 and June 30, 1996. Dose per fraction of 2.0 Gy (to the end of 1994), and 1.8 Gy (since January 1, 1995) was the same in both arms and delivered once a day at regular 24-h intervals to total dose in the range of 66-72 Gy (depending on tumour stage). The only difference was overall treatment time being 5 weeks in the CAIR and 7 weeks in control arm. RESULTS: Actuarial 3-year local tumour control was 82% in the CAIR and 37% in the control group (P<0.0001) with reduction in local recurrence rate of 83%. Actuarial 3-year overall survival was 78 and 32% (P<0.0001), respectively. Confluent mucositis was significantly more severe and lasted longer in the CAIR than in control arm. After 2.0 Gy fractions five of 23 patients (22%) in the CAIR developed early necroses over a period of 2-4 months of follow-up which can be considered as a consequential to severe protracted acute mucosal reactions (CLE). For this reason dose per fraction was lowered to 1. 8 Gy and the CLE was not observed again until now. Thus the overall rate of CLE decreased to 10%. CONCLUSIONS: The gain in tumour control is likely the effect of shortening of overall treatment time by 14 days and regular continuous dose delivery during the whole course of radiation therapy including weekends. A 7-day schedule produces more severe acute mucosal reactions lasting longer than in conventional fractionation, however tolerable by patients. Relatively high rate (22%) of CLE in the 7-day arm observed during the first year of the study was eliminated by decreasing dose per fraction from 2.0 Gy to 1.8 Gy.

Comparative estimation of cure rates for supraglottic and glottic cancer in radiotherapy.

There are some clinical evidences, that the same types of tumors originated from neighboring anatomical structures can significantly differ in their response to radiation therapy. Squamous cell cancer of supraglottis and glottis could be good examples of this phenomenon. The purpose of the study was to compare the radiocurability of cancers localized in the upper and medium level of the larynx. From 1985 to the end of 1989, 544 patients with squamous cell cancer of the larynx were treated by radiotherapy alone. There were 388 patients with supraglottic cancer and 156 patients with glottic cancer. The total dose was in the range of 59-74 Gy. The end-point criteria were overall (OS) and disease-free survival (DFS). Generally, 5-year overall and disease-free survival rates were significantly more favorable for glottic cancer patients than for supraglottic cancer (67 and 63% vs. 40 and 36%, respectively). Significant differences in both disease-free and overall survival between supraglottic and glottic cancer in aspect of several analyzed clinical prognostic factors were found for: male sex, age, pattern of tumor growth, clinical performance status, radiation total dose lower than 70 Gy, fraction doses and overall treatment time. In all these prognostic categories 5-year survival rates were lower for supraglottic cancer patients. This tendency disappeared when the treatment results were compared in aspect of tumor stage (T). Tumor cure doses for 50% probability of local control (TCD50) in supraglottic cancer were estimated as: 61 Gy (T(1+2)) and 66 Gy (T3). In glottic cancer the lower TCD50 values of 54.5 Gy (T(1+2)) and 61 Gy (T3) were found in comparable treatment time. The comparative estimation of cure rates (i.e. OS and DFS) of laryngeal cancer treated by radiation alone showed that in aspect of almost all analyzed prognostic factors the greater risk of treatment failure was significantly associated with supraglottic origin.

[The effect of primary tumor localization on radiotherapy for supraglottic and glottic cancer]. / Wplyw pierwotnej lokalizacji nowotworu na wyniki radioterapii chorych na raka górnego i srodkowego pietra krtani.

In the group of 544 patients with squamous cell cancer of supraglottic and glottic larynx the effect of primary tumour localisation on the response to radiotherapy was analysed. There were 156 patients with glottic cancer T1-T3 N0-N2 and 388 patients with supraglottic cancer with T1-T4 N0-N3. The most common site of extralaryngeal involvement was piriform fossa. All patients were treated with the use of external megavoltage beam. The total dose was in range 59-80 Gy. The 5-year actuarial disease-free survival was 36% for supraglottic cancer and 63% for glottic cancer. Primary tumour localisation in glottis correlates with more favourable prognosis than that in supraglottic. Extension from supraglottis to glottis worsened the prognosis more than that in opposite direction. For extralaryngeal involvement the most favourable prognosis was the infiltration of lingual-epiglottidean fossa and the worst one for the base of tongue involvement.