Jacques Bernard Davis

IMRT using simultaneously integrated boost (SIB) in head and neck cancer patients

BackgroundPreliminary very encouraging clinical results of intensity modulated radiation therapy (IMRT) in Head Neck Cancer (HNC) are available from several large centers. Tumor control rates seem to be kept at least at the level of conventional three-dimensional radiation therapy; the benefit of normal tissue preservation with IMRT is proven for salivary function. There is still only limited experience with IMRT using simultaneously integrated boost (SIB-IMRT) in the head and neck region in terms of normal tissue response.The aim of this work was (1) to establish tumor response in HNC patients treated with SIB-IMRT, and (2) to assess tissue tolerance following different SIB-IMRT schedules.ResultsBetween 1/2002 and 12/2004, 115 HNC patients have been curatively treated with IMRT. 70% received definitive IMRT (dIMRT), 30% were postoperatively irradiated. In 78% concomitant chemotherapy was given.SIB radiation schedules with 5–6 × 2 Gy/week to 60–70 Gy, 5 × 2.2 Gy/week to 66–68.2 Gy (according to the RTOG protocol H-0022), or 5 × 2.11 Gy/week to 69.6 Gy were used.After mean 18 months (10–44), 77% of patients were alive with no disease. Actuarial 2-year local, nodal, and distant disease free survival was 77%, 87%, and 78%, respectively. 10% were alive with disease, 10% died of disease. 20/21 locoregional failures occurred inside the high dose area. Mean tumor volume was significantly larger in locally failed (63 cc) vs controlled tumors (32 cc, p <0.01), and in definitive (43 cc) vs postoperative IMRT (25 cc, p <0.05); the locoregional failure rate was twofold higher in definitively irradiated patients.Acute reactions were mild to moderate and limited to the boost area, the persisting grade 3/4 late toxicity rate was low with 6%. The two grade 4 reactions (dysphagia, laryngeal fibrosis) were observed following the SIB schedule with 2.2 Gy per session.ConclusionSIB-IMRT in HNC using 2.0, 2.11 or 2.2 Gy per session is highly effective and safe with respect to tumor response and tolerance. SIB with 2.2 Gy is not recommended for large tumors involving laryngeal structures.

Quality assurance of EORTC trial 22922/10925 investigating the role of internal mammary—medial supraclavicular irradiation in stage I-III breast cancer: the individual case review

To assess consistency among participants in an European Organisation for Research and Treatment of Cancer (EORTC) phase III trial randomising between irradiation and no irradiation of the internal mammary and medial supraclavicular (IM-MS) lymph nodes, all participating institutes were invited to send data from 3 patients in each arm as soon as they started accrual. The evaluation focused on eligibility, compliance with the radiotherapy guidelines, treatment techniques and dose prescription to the IM-MS region. Nineteen radiotherapy departments provided a total of 111 cases, all being eligible. Minor discrepancies were found in the surgery and pathology data in almost half the patients. Major radiotherapy protocol deviations were very limited: 2 cases of unwarranted irradiation of the supraclavicular region and a significant dose deviation to the internal mammary region in 5 patients. The most frequently observed minor protocol deviation was the absence of delineation of the target volumes in 80% of the patients. By detecting systematic protocol deviations in an early phase of the trial, recommendations made to all the participating institutes should improve the interinstitutional consistency and promote a high-quality treatment.

IMRT in hypopharyngeal tumors.

Background and Purpose:Intensity-modulated radiation therapy (IMRT) data on hypopharyngeal cancer (HC) are scant. In this study, the authors report on early results in an own HC patient cohort treated with IMRT. A more favorable outcome as compared to historical data on conventional radiation techniques was expected.Patients and Methods:29 consecutive HC patients were treated with simultaneous integrated boost (SIB) IMRT between 01/2002 and 07/2005 (mean follow-up 16 months, range 4–44 months). Doses of 60–71 Gy with 2.0–2.2 Gy/fraction were applied. 26/29 patients were definitively irradiated, 86% received simultaneous cisplatin-based chemotherapy. 60% presented with locally advanced disease (T3/4 Nx, Tx N2c/3). Mean primary tumor volume measured 36.2 cm3 (4–170 cm3), mean nodal volume 16.6 cm3 (0–97 cm3).Results:2-year actuarial local, nodal, distant control, and overall disease-free survival were 90%, 93%, 93%, and 90%, respectively. In 2/4 patients with persistent disease (nodal in one, primary in three), salvage surgery was performed. The mean dose to the spinal cord (extension of > 5–15 mm) was 26 Gy (12–38 Gy); the mean maximum (point) dose was 44.4 Gy (26–58.9 Gy).One grade (G) 3 dysphagia and two G4 reactions (laryngeal fibrosis, dysphagia), both following the schedule with 2.2 Gy per fraction, have been observed so far. Larynx preservation was achieved in 25/26 of the definitively irradiated patients (one underwent a salvage laryngectomy); 23 had no or minimal dysphagia (G0–1).Conclusion:Excellent early disease control and high patient satisfaction with swallowing function in HC following SIB IMRT were observed; these results need to be confirmed based on a longer follow-up period. In order to avoid G4 reactions, SIB doses of < 2.2 Gy/fraction are recommended for large tumors involving laryngeal structures.Hintergrund und Ziel:Daten zur Behandlung des Hypopharynxkarzinoms (HC) mittels intensitätsmodulierter Radiotherapie (IMRT) sind rar. Die Autoren berichten hier über erste eigene Ergebnisse ihres IMRT-Kollektivs konsekutiv behandelter HC-Patienten. Erwartet wurden eine bessere Tumorkontrolle und verbesserte Therapietoleranz bei HC-Patienten nach IMRT gegenüber historischen Kollektiven nach konventioneller Radiotherapietechnik.Patienten und Methodik:29 konsekutive HC-Patienten wurden zwischen 01/2002 und 07/2005 mit IMRT mit simultan integriertem Boost (SIB) behandelt. Die mittlere Verlaufsbeobachtung betrug 16 Monate (4–44 Monate). Es wurden Herddosen von 60–71 Gy mit 2,0–2,2 Gy/Sitzung verabreicht. 26/29 Patienten wurden primär definitiv bestrahlt, 86% erhielten eine simultane Cisplatin-basierte Chemotherapie. In gut 60% bestand ein lokal fortgeschrittenes Leiden (T3/4 Nx, Tx N2c/3, Tabelle 1). Das mittlere Tumorvolumen betrug 36,2 cm3 (4–170 cm3), das mittlere Lymphknotenvolumen 16,6 cm3 (0–97 cm3).Ergebnisse:Die aktuarischen 2-Jahres-Überlebensraten für die Primärtumor-, Lymphknoten- und Fernkontrolle lagen bei 90%, 93% und 93% (Abbildungen 1a bis 1c); das krankheitsfreie Gesamtüberleben betrug 90%. Vier Patienten zeigten eine Tumorpersistenz; in zwei dieser Fälle konnte eine Salvage-Operation durchgeführt werden. Die mittlere Dosis auf das expandierte Myelon (Sicherheitssaum > 5–15 mm) betrug 26 Gy (12–38 Gy), die durchschnittliche maximale Punktdosis 44,4 Gy (26–58,9 Gy).Bislang entwickelte ein Patient eine Grad(G)-3-Dysphagie und zwei Patienten G4-Reaktionen (Dysphagie, Larynxfibrose); beide G4-Ereignisse traten nach 2,2 Gy/Fraktion auf. Bei 25/26 primär bestrahlten Patienten konnte eine Organerhaltung erreicht werden; 23 Patienten sind betreffend Dysphagie beschwerdefrei oder minimal symptomatisch (G0–1).Schlussfolgerung:Sehr gute frühe Ergebnisse hinsichtlich der Krankheitskontrolle und eine hohe Patientenzufriedenheit in Bezug auf die Schluckfunktion wurden beobachtet; diese Resultate müssen mit einer längeren Verlaufsbeobachtung bestätigt werden. Einzeldosen ≥ 2,2 Gy werden im Hinblick auf die beobachteten G4-Reaktionen bei ausgedehnten Tumoren mit Befall laryngealer Strukturen empfohlen.