S. Clavel

The Role of Computed Tomography in the Management of the Neck After Chemoradiotherapy in Patients With Head-and-Neck Cancer

PURPOSE The aim of this study was to describe the outcome in patients with head-and neck-squamous cell carcinoma (HNSCC) followed up without neck dissection (ND) after concomitant chemoradiotherapy (CRT) based on computed tomography (CT) response. The second objective was to establish CT characteristics that can predict which patients can safely avoid ND. METHODS AND MATERIALS Between 1998 and 2007, 369 patients with node-positive HNSCC were treated with primary CRT at our institution. After a clinical and a radiologic evaluation based on CT done 6 to 8 weeks after CRT, patients were labeled with a complete neck response (CR) or with a partial neck response (PR). RESULTS The median follow-up was 44 months. The number of patients presenting with N3, N2, or N1 disease were 54 (15%), 268 (72%), and 47 (13%), respectively. After CRT, 263 (71%) patients reached a CR, and 253 of them did not undergo ND. Ninety-six patients reached a PR and underwent ND. Of those, 34 (35%) had residual disease on pathologic evaluation. A regression of the diameter of ≥ 80% and a residual largest diameter of 15 mm of nodes had negative pathologic predictive values of 100% and 86%, respectively. The 3-year regional control and survival rates were not different between patients with CR who had no ND and patients with PR followed by ND. CONCLUSION Node-positive patients presenting a CR as determined by CT evaluation 6 to 8 weeks after CRT had a low rate of regional recurrence without ND. This study also suggests that lymph node residual size and percentage of regression on CT after CRT may be useful criteria to guide clinical decisions regarding neck surgery. Those results can help diminish the number of ND procedures with negative results and their associated surgical complications.

Simultaneous Integrated Boost Using Intensity-Modulated Radiotherapy Compared With Conventional Radiotherapy in Patients Treated With Concurrent Carboplatin and 5-Fluorouracil for Locally Advanced Oropharyngeal Carcinoma

PURPOSE To compare, in a retrospective study, the toxicity and efficacy of simultaneous integrated boost using intensity-modulated radiotherapy (IMRT) vs. conventional radiotherapy (CRT) in patients treated with concomitant carboplatin and 5-fluorouracil for locally advanced oropharyngeal cancer. METHODS AND MATERIALS Between January 2000 and December 2007, 249 patients were treated with definitive chemoradiation. One hundred patients had 70 Gy in 33 fractions using IMRT, and 149 received CRT at 70 Gy in 35 fractions. Overall survival, disease-free survival, and locoregional control were estimated using the Kaplan-Meier method. RESULTS Median follow-up was 42 months. Three-year actuarial rates for locoregional control, disease-free survival, and overall survival were 95.1% vs. 84.4% (p = 0.005), 85.3% vs. 69.3% (p = 0.001), and 92.1% vs. 75.2% (p < 0.001) for IMRT and CRT, respectively. The benefit of the radiotherapy regimen on outcomes was also observed with a Cox multivariate analysis. Intensity-modulated radiotherapy was associated with less acute dermatitis and less xerostomia at 6, 12, 24, and 36 months. CONCLUSIONS This study suggests that simultaneous integrated boost using IMRT is associated with favorable locoregional control and survival rates with less xerostomia and acute dermatitis than CRT when both are given concurrently with chemotherapy.

CONCURRENT CHEMORADIATION WITH CARBOPLATIN―5-FLUOROURACIL VERSUS CISPLATIN IN LOCALLY ADVANCED OROPHARYNGEAL CANCERS: IS MORE ALWAYS BETTER?

PURPOSE The optimal chemotherapy regimen remains undefined in the treatment of locally advanced oropharyngeal cancer by concomitant chemoradiation. This article compares two platinum-based chemotherapy regimens. METHODS AND MATERIALS In this retrospective study, we reviewed all consecutive patients treated for Stage III or IVA-B oropharyngeal cancer using either a combination of carboplatin and 5-fluorouracil (5FU) every 3 weeks or high-dose cisplatin every 3 weeks concomitant with definitive radiation therapy. RESULTS A total of 200 patients were treated with carboplatin-5FU and 53 patients with cisplatin. Median potential follow-up was 43 months. The 3-year overall survival rates for carboplatin-5FU and cisplatin respectively were 79.1% and 74.9% (p = 0.628), the 3-year disease-free survival rates were 76.0% and 71.3% (p = 0.799), and the 3-year locoregional control rates were 88.4% and 94.2% (p = 0.244). CONCLUSIONS We could not demonstrate differences between these two regimens, which both proved efficacious. Polychemotherapy and monochemotherapy therefore seem comparable in this retrospective analysis.

Xerostomia in patients treated for oropharyngeal carcinoma: Comparing linear accelerator–based intensity‐modulated radiation therapy with helical tomotherapy

In comparison to sliding‐window intensity‐modulated radiation therapy (sw‐IMRT), we hypothesized that helical tomotherapy (HT) would achieve similar locoregional control and, at the same time, decrease the parotid gland dose, thus leading to a xerostomia reduction.

Induction Chemotherapy Followed by Concomitant Chemoradiation in Head and Neck Squamous Cell Carcinoma: A Single Institution Experience

Objective: Phase 3 studies are underway to compare induction chemotherapy (IC) followed by concomitant chemoradiation (CRT) with CRT alone in advanced head and neck cancer. The purpose is to report the outcome of patients with advanced head and neck cancer treated at Centre Hospitalier de l’Universite de Montreal (CHUM) with IC followed by CRT. Methods: From March 1998 to December 2007, 56 consecutive patients were treated for advanced squamous cell carcinoma of the head and neck with high-dose IC followed by CRT. Sixteen patients with carcinoma of the nasopharynx, paranasal sinuses or nasal cavity were excluded. Patients presented with either T4 (60%) or N3 (60%) disease. Outcomes were computed using Kaplan-Meier curves. The number of IC cycles were compared with logrank tests. Results: The 2 year estimates of OS, DFS, LRC and DMFS rates were 58%, 46%, 78% and 75% respectively. At last follow-up, we observed 17 patients with relapse of which 10 were at a distant site. When stratified by the number of IC cycles, a DMFS rate of 87% was observed for 1-2 cycles vs 49% for 3 cycles, p=0.05. Conclusions: Despite intensive treatment with platinum based IC and CRT, prognosis for this highly advanced population of T4 or N3 cancers is poor. The number of IC cycles seem to influence the rate of DM. Further trials are needed to answer the question regarding IC followed by CRT vs CRT alone. Targeted therapies might also yield more promising results.

A cancer care electronic medical record highly integrated into clinicians' workflow: users' attitudes pre‐post implementation

&NA; The purpose was to study users’ attitudes towards an electronic medical record (EMR) closely integrated into the clinicians’ cancer care workflow. The EMR, implemented in an ambulatory cancer care centre, was designed as a care pathway information system providing real‐time support to the coordination of shared care processes involving all the care personnel. Mixed method pre‐post study design was used. The study population consisted of all care personnel. A survey measured the quality attributes of the EMR, the clinical information it produces, the perceived usefulness of the system for supporting clinical data management tasks and the perceived impacts in terms of access and quality of care. The survey shows that users’ attitudes towards the EMR (response rate of 71%) measured after the go‐live were positive ranging from 3.42 to 3.95 on a 5‐point scale. Besides, the content analysis of 33 pre‐post interviews revealed five main themes: magnitude of the changes caused by the EMR; its innovative potential; its positive benefits; an ongoing growth in users’ expectancies; and the burden associated with the time required to operate the EMR. In sum, the study shows that users can largely apply innovative uses of information technologies that automate their clinical processes.

Role of CT in Head and Neck Cancer Following Chemoradiation

orly located goiters were found in 29% of cases. The goiter was on the left side in 57%, on right side in 31% and involving both sides in 12% of cases. Most of the right sided goiters were located posteriorly within the mediastinum. Histopathologically, the goiter was benign in 94% of patients and was resected completely through the cervical approach. The remaining 6% of cases were malignant that required an adjuvant intrathoracic approach. CONCLUSION: Cervical approach is optimum for benign retrosternal goiters reaching level I and level II whether situated anteriorly or posteriorly in the mediastinum. Malignant retrosternal goiters are better approached through intrathoracic approaches.