Head and Neck ASTRO Refresher 2022

RT is mostly IMRT
NPC studies show better xerostomia

Kam et al randomized NPC chemorad study

Pow et al. randomized study in early stage NPC

  • PARSPORT

Pharyngeal SCC

  • UK study
  • up to 24 month s benefits in recovery of saliva with IMRT
  • improved dry mouth specific and global QoL scores
  • LC, OS, late toxicity unchanged at 24 months.

IC: pharynx SCC T1-T4, N0-N3


Tx: 60 or 65 Gy/ 30 fx parotid sparing IMRT
vs.
conventional RT


Result: IMRT improved xerostomia
12-mo xerostomia 38% vs 75%
24-mo xerostomia grade ≥2 29% vs 83%
QOL scores


Parotid sparing IMRT reduces xerostomia. 💦

Contouring

TG263 nomenclature (Mayo 2018)

OARs (Brouwer, Radiother Oncol 2015)

CTVp (Gregoire Radiother Oncol 2018)

CTVs (Lee, Radiother Oncol 2018)

Planning objectives and dose constraints (Lee IJROBP 2019)

Postop CTV (Gregoire, Radiother Oncol 2006)

Perineural invasion review (Bakst, IJROBP 2019)

Perineural CN guides (Anware PRO 2016; Biau, Radiother Oncol 2018; Ko PRO 2014; Mourad Oral Onc 2013)

Can we treat just 1 side of neck in OPC ca?

O'Sullivan Benefits and pitfalls of ipsi RT in carcinoma of tonsillar region

limited nodal involvement: N1 in jugular digastric. (level 2)

  • level of extension of tonsil cancer: must be 1cm or less into the soft palate or BOT to be considered lateralized.

Altered Fractionation?

  • Good for LRC
  • inferior to chemorad, No OS benefit in AFx

  • RTOG 90-03: BID regimen

RT alone
4 arms
* Standard
* Hyperfrac
* Split Course (AFX)
* Concominant boost

1) Conventional 70/35 fx in 2Gy vs.


2) 🏆 Hyperfx 81.6/68 fx in 7 wks in 1.2Gy BID vs.


3) Accel Split: 67.2/42 fx in 6 wks at 1.6Gy BID with 2-wk break at 38.4Gy vs.


4) Accel-con boost: 72Gy/42 fx in 6 wks at 1.8Gy and 1.5Gy
IMRT not allowed

5y and 10 y F/u: Hfx and AFx better for LRC

  • AFx can give several % points of improvement in LRC

  • DAHANCA 6: 6 days/week

RT only


  • DAHANCA 7

RT + nimorazole

  • glottic, supraglottic pharynx, oral cavity not receiving chemo, treated with primary RT
    • →5 fx per week
      vs.
      →🏆 6 fx per week

• 6th fraction given on weekend or
weekday (>6h after previous fx)
• T1 glottis: 62 Gy
• Primary or nodes < 4 cm: 66 Gy
• Primary or nodes > 4 cm: 68 G


66-68 Gy/ 33-34 fx, no chemo
Nimorazole for all except for glottic

  • 6 day per week fractions improved LRC and disease specific survival
    • no OS benefit

Oropharynx cancer

OPX Conclusions ✏

  • Surgery 🔪 or RT ☢ monotherapy is SOC for T1-2N0
  • Concurrent cisplatin CRT 💊 ☢is the SOC for locally or regionally advanced disease, or surgery 🔪 with adjuvant therapy ☢ can be considered if eminently operable (lateralized, no ENE)
  • Deintensification remains investigational for HPV-associated non- smoking-associated OPSCC
  • For HPV-negative OPSCC, intensification studies are ongoing
  • Induction chemotherapy has not shown oncologic benefit but can be considered in certain clinically desperate scenarios

Justification for CDDP chemorad

positive result for chemoRT arms

  • much toxicity with CDDP ☣
  • 3x toxicity vs w/o

  • Intergroup Adelstein, JCO, 2003: Where Cisplatin 💊 comes from

  • randomized Stage III&IV OPX, HPX, OC, Lx
    N=295
  • RT: 70 Gy
  • 🏆ChemoRT: 70 Gy w/ CDDP 100mg/m2 in 1,4,7 week
  • Split course chemo RT: 30-40 Gy + CDDP 75mg/m2 and 5FU 1g/m2 x 4 days Q3wk (ignore)

OS ChemoRT: 3y 37%
OS RT: 3y 23%

☣ Acute Toxicity
OS ChemoRT: 3y 89%
OS RT: 3y 52%

  • GORTEC: Carbo/5FU also works

n=266
86% T3-T4

  • RT: 70 Gy in 35 fx
  • chemoRT: 70/35 + CHT
    • carbo 70mg/m2 x4
    • 5 FU 600 mg/m2 x4 on day 1,22,43

OS ChemoRT: 5y 22%
OS RT: 5y 16%

☣ Late Toxicity
ChemoRT: 5y 56%
RT: 5y 30%

Alternative CHT?

Carboplatin/paclitaxel

The data is conflicting on benefit vs. Cetuxumab

not a realistic alternative

2 studies

  • Xiang et al
  • Karivedu et al

Cetuxumab 🐘

Dealers Choice RT +/- Cetuximab

  • Stage III / IV
  • definitive Tx, no postop patients
  • RT only
  • RT & Cetuximab 🐘
    RT conventional 70 Gy, or hyperfrac 72-76.8 Gy/ 1.2 BID, or CCB 72 Gy/ 42 fx

most pts have AFx
were randomized w/ or w/o Cetuximab

LRC better in cetixumab arm
Median LC 24 vs. 15 mos
2-yr LC 50% vs 41%
median OS 49 vs. 29 mos
3-yr OS 55% vs 45%. Acneiform rash and infusion reactions more common, but otherwise not more toxic.
OS for grade 2-4 acneiform rash 69 mos vs 25 without
Favorable factors on analysis: oropharynx, EGFR >50%, hyperfx, CCB, node positive, age <65

Deintensification studies

focus on p16+ OPX

  • excellent outcomes in the past
  • high sensitivity to CHT and RT
    • focus on minimal smoking hx
    • nonbulky primary and nonextensive pattern of disease spread
  • in combo w/ CDDP
  • no positive primary endpoint
    • analysis showed p16+ OPX cancers into a low risk (for death) category.

HPV positive vs. negative has different prognosis.


3-yr OS by RPA group (see commentary for classes):
Low risk: 93%
Int risk: 71%
High risk: 46%


3-yr OS HPV+/HPV-: 82% vs. 57%
3-yr DM HPV+/HPV-: 9% vs. 15%
3-yr LRC HPV+/HPV-: 86% vs. 65%


"Good risk" HPV+ (T1-2N1-2b or T3N0-N2b, and ≤10 py):
8-yr LRF 86%, OS 81%, DM 8.3%


For RT regimens, No difference in 8-yr OS, PFS, LRF, DM, or toxicity

  • RTOG 1016 randomized ph3: Cetux is inferior

  • 1st head to head with Cisplatin vs. Cetuximab 🐘
    • for chemoRT
  • p16+ as surrogate for HPV
  • toxicity events considerable for Cetuximab 🐘 and CDDP
  • included all risk patients

HPV+ locally advanced oropharynx p16+. T1-2 N2a-3 or T3-4, any N

→RT 70 Gy in 6 weeks (DAHANCA) SIB 56 & 52.5 Gy with concurrent cisplatin
vs.
→cetuximab

5-yr OS 85% vs. 78%
5-yr PFS 78% vs. 67%
5-yr LRF 10% vs. 17%
5-yr DM 9% vs. 12%
Severe and acute toxicity similar

Cetuximab clearly inferior in LRC and OS

  • De-ESCaLATE-HPV

  • European study
    Stage III-IV (T3N0, T4N0, T1N1-T2N3) HPV+ oropharynx cancer. Excludes N2b, N2c, >10 PY

🐘 Cetuximab vs CDDP

  • endpoint was toxicity ☣
    • reconfirmed RTOG 1016

→70 Gy in 7 weeks with
cisplatin
vs.
→cetuximab

2-yr OS 98% vs. 89%
2-yr any recurrence 16% vs. 6%
Severe and any grade toxicity similar

  • p16+ as surrogate for HPV
  • toxicity events considerable for Cetuximab 🐘 and CDDP
  • included low risk

TROG 12.01

  • Australian study
  • reconfirmed RTOG 1016

More Deintensification Studies

  • NRG-HN002: Interest in "de-intensification" within RT based context eg "The 60 Gy trial"

randomized phase II for p16+, non/low-smokers, LR advanced OPC

  • RT only- 60Gy / 5 wks
  • RT & CDDP - 60 Gy / 6 wks
  • ChemoRT arm had better PFS (91% vs 88%) and LRC

NRG HN005: Phase II/III deintensification RT for patients with early stage, p16+ nonsmoking OPC

  • ECOG 1308: Single arm phase II trial of Induction CHT followed by reduced dose and weekly cetuximab 🐘 in patients with HPV associated resectable OPSCC

  • older study
  • n = 80
  • can you give cetuximab, paclitaxel, cistplatin induction to complete response prior to RT with 54gy at primary?
  • PFS unimpressive 78%

Patients with

  • < 10 pk year smoking
  • <T4N2c by AJCC7
    • PFS was 95%

randomized phase II trial

  • in a specific arm: intermediate risk features.
    Resectable oropharynx cancer stage III-IVA AJCC 7, p16+, who undergo TORS

• Low risk (negative margins, no ECE, 0-1 nodes):
-observation


• Intermediate risk (close margin <3 mm, 2-4 nodes, ENE ≤1 mm):
-50 Gy vs. 60 Gy


• High risk (>1 mm ENE, positive margins, or ≥5 nodes):
-66 Gy RT weekly cisplatin

Int Randomized

  • 50 Gy PORT
  • 60 Gy PORT

2-yr PFS (1⁰ endpoint)
Low risk (obs): 97%
Int risk (50 Gy vs. 60 Gy): 95% vs. 96%
High risk (chemoRT): 91%


3-yr PFS
Low risk: 97%
Int risk: 95% and 93%
High risk: 91%
(no signficant differences between groups in exploratory comparisons)


Grade 5 toxicity in n=1


Decline in QOL and FACT-HN for all arms with recovery to baseline in low-int risk groups, however not for high-risk (P=0.005)

PATHOS

active European trial

  • same randomization for intermediate risk as ECOG 3311
  • 60 Gy/30 PORT
  • 50 Gy/25 PORT

High Risk arm randomized for CDDP with PORT vs. PORT alone

Going to a Phase III with an overall survival endpoint

Mayo DART trial 🎯

study also looked at PORT
p16+
Sx resectable 🔪
No DM

<10 pack-yr smoking 🚬

  • 30 Gy (BID) & docetaxol
  • 36 Gy (BID) & docetaxel

in phase 3 it was randomized to 60 Gy w/ or w/o CDDP

with patients with bilateral disease or ENE

  • PFS in the 50%s
  • raised concerns if this, or any deintensification study is adequate after TORS

Comparative study for Chemorad vs TORS upfront

ORATOR: randomized phase 2 of standard CRT vs TORS +adjuvant

  • Used MDADI swallow instrument for QoL
  • RT was superior at 1 year, statistically
    • clinically no difference
    • but this was the opposite of the expected endpoint (10 point favor to TORS)
  • PFS similar

  • ORATOR 2: randomized phase 2 of two deintensified platforms following NRG-HN002 and ECOG 3311

Resectable oropharynx cancer by TOS T1-T2, N0-N2, p16+ only
Phase II
→60 Gy IMRT (54 & 48 Gy SIB)
with weekly cis if N2 by AJCC 7th ed


vs.


→TOS (TLM or TORS) of primary site with neck dissection with adjuvant RT based on risk features
int: 50 Gy (LVI, N2, close margin)
high: 60 Gy (+margins or ENE)

  • trial stopped w/ 2 deaths (hemorrhage, infection) in surgery arm
    • survival endpoint was not reached.
  • no deaths in RT arm #

HPV Negative disease

  • the opposite: Intensifications

HPV Intensification: JAVELIN head and neck 100: Chemoradiation combined with anti-PD-1 in LR advanced SCCHN

  • attempt at intensification
  • St. III & IVa or IVb SCC
    • OC
    • LRx
    • HPx
    • OPX p16-
  • T4, N2c, N3 p16+ OPX
  • CCDP + RT (70Gy/35)& avelumab
    • anti PDL1
  • CDDP + RT & placebo

avelumab underperformed in 1º EP (PFS)

Keynote 412

Concomitant and Maintenance Pembro

  • Event free survival, endpoint maturing

SMAC Mimetics

  • antitumor effects via caspase regulate apoptosis.
    • apoptosis proteins act on tumor cells
  • Randomized Phase 2 with CRT with Zuvinipant
  • met primary endpoint of locoregional control
  • PFS improved.

currently in phase III

Induction?

Phase 3 trials showed no benefit over CRT in OPC, Larynx, HPX

  • Induction is standard for NPC 👃🏽
  • can use induction for special circumstances.
    • optimizing for medical status, delays, local issues preventing surgery, very advanced disease.
    • associated with mortality and worse compliance with CRT

Paradigm: Phase III North America

  • randomized
    • Induction Docetaxel CDDP 5FU & CRT
      • randomized CRT CDDP vs. Docetaxel
    • CDDP CRT

OS not significant diff

early study termination due to low accrual

Decide: Phase III North America

  • TPF regimen induction w/ TPF CRT
  • TPF CRT

OS not significant diff

Post treatment Followup

  • PET-NECK

  • 84% OPX, n=564
  • 75% were p16+
  • PET-CT surveillance 💸
  • planned neck dissection
  • QoL similar
  • fewer neck diss. Cheaper 💸
  • PET is now standard
  • typically 12-14 weeks after RT
    • so no early false positive

HPV DNA f/u

  • in HPV +
  • emerging research, not std of care
  • promising assay
  • not yet worked out

  • MACH-NC: Metaanalysis for concurrent chemo: single agent CRT is the best

n = 19805
H&N SCC trials comparing local treatment with chemo or without
Meta-analysis of 107 randomized trials

concurrent chemo 5-yr OS benefit of +6.5%.


Concurrent chemo improves LRF
Induction and adjuvant improve DM


Efficacy decreases with increasing age and performance status
No OS improvement with induction chemo

Meta-analysis confirms an OS benefit with the addition of concurrent chemotherapy to RT in H&N tumors. There is no benefit with induction chemotherapy.

Laryngeal SCC

Larynx and HPX Conclusions

  • Hypofx RT alone for early stage glottis
    • supraglottis requires elective neck treatment
  • Locally advanced laryngeal SCC, chemoradiation-based organ preservation does not compromise survival
  • Larynx preservation better in CRT compared to induction-RT or RT alone but survival no different, due to late non-cancer-related deaths
  • Induction has a special role in larynx/hypopharynx trials esp as selection strategy for bulky tumors or impaired function
  • T4 tumors with extensive/complete cartilage invasion or significant BoT 👅 involvement should have primary laryngectomy followed by adjuvant therapy depending on pathology
  • Organ preservation: CRT 💊☢
  • 🔪Surgery only for very early or T4
  • T1 Tumors
    • LC 85-95%
      • Ultimate LC with surgical salvage ~ 95%
  • T2 Tumors
    • LC 65-85%
      • Ultimate LC with surgical salvage about 90%
      • Surgical salvage most often with total laryngectomy

Lateral Opposed Fields ☢

• If anterior 1⁄2 cord involved and the patient has a thin neck, use 5 mm bolus
• Make sure there is always anterior flash on skin
• I recommend using CT based planning with real bolus placed on the field
• Do not over-wedge or you risk anterior failures

Hypofractionated

IMRT for early stage

  • Advantage
    • Carotid sparing
  • Disadvantages
    • Geographical miss from contouring or intrafraction motion
    • Toxicity from dose inhomogeneity

Voice Quality After Treatment of Early Vocal Cord Cancer 🗣

  • Randomized trial
    • CO2 laser
    • RT to 66 Gy
  • 60 patients with T1a glottic SCCA in Finland
  • At 6 and 24 months, compared voice quality, roughness, breathiness, asthenia, strain, videolaryngostroboscopic findings, self-rated voice quality and impact on daily life
  • Overall voice quality was similar but RT patients showed improvement in breathiness over time, better glottal closure, and less inconvenience in their daily lives

• Conclusion: “Radiation therapy may be the treatment of choice when the requirements for voice quality are demanding.”

  • Stross says that this isnt a fair comparison if there are multip bx on the same VC. Need to educate patient.

Supraglottic Cancer

must cover nodes

  • any extension into the inferior larynx or hypopharynx, must cover into level 6, sometimes mediastinal nodes

Japanese T1N0 fractionation study

  • Std fx 66Gy/33
  • 63Gy/28fx 🏆

Local control 5 Y
77% vs 92%
Most Desquamation not an issue.
10% coval cord edema more than 6mo

T3 organ preservation options

  • Partial laryngectomy
    • Supracricoid
    • Supraglottic
    • Vertical hemilaryngectomy
  • Partial laryngectomy followed by post-op (chemo)radiation therapy
  • Chemotherapy with sequential radiation
  • Concurrent chemoradiation

Total Larrys are not popular
Partial Larrys are not done in the USA

VA Laryngeal Ca Study 1991

T34N+

  • 🔪Surgery (SOC) followed by RT ☢
  • Induction CHT 💊
    • CR or good PR : RT ☢
      • good PR: 🔪surgery
      • CR: nothing
    • <PR: 🔪Surgery then RT ☢
  • no diff 2 year survival – 68%
  • Larynx Preservation in 64% in CT-RT group with
    • Fewer Distant Metastases
    • Higher Local Recurrence
    • Salvage in 3/4
  • Long-term (10yr) Quality of Life Follow-Up
    • speech significantly better in CT-RT group
    • same incidence of swallowing difficulties in both groups
    • Less pain and depression with better global mental health

Surgery first = bad
Large volume T4a laryngeal cancers did not do well

RTOG 91-11

Sequential 🔪💊☢ vs. CRT 💊☢

loc: glottic or supraglot
T: 2, 3, early 4
N: 0,1,2,3
neck diss. for >3cm node or multiple nodes 8 wks s/p RT
exc: T4a

  • Neoadj CT 💊 + RT ☢
  • concurrent CRT CDDP 💊☢
  • RT only ☢
  • Different toxicities
  • Same OS
  • Concurrent: superior
    • larynx preservation
    • LRC

10 y followup shows nonsignificant decrease in OS at ~8 years.

  • could be toxicity related?
  • LRC and larynx preserve same at 10y

T4 🔪

T4: outer cortex of thyroid cartilage

  • Full thickness destruction of the thyroid cartilage or extension to BoT 👅, reflex 🔪total laryngectomy

  • Do poorly with failure of CRT and salvage laryngectomy



    T4: extralaryngeal extension

  • Consider pre-existing function (patient’s age)
  • Consider volume of tumor e.g. >12cc is concerning
  • Can consider CRT 💊☢ :

Induction for Larynx and HPX Ca

  • Survival not affected
  • May be reasonable as selection strategy when function impaired,
    considerable bulk
  • Unclear whether to do RT or chemo-RT afterwards 🤷🏻‍♂️– unique concerns about long-term toxicities in this population

Larynx Preservation in Pyriform Sinus Cancer, Lefebvre

n = 202
stage III/IV

  • 🔪Surgery then PORT ☢
  • CDDP/5FU 💊 then
    • CR: RT 70Gy ☢

54% CR after induction

  • Local failure: not sig
  • region failure: not sig
  • distant mets: Surgery (36% vs. 25%
  • median OS: CHT: 44 mo vs. 24mo
  • 5y OS: not sig

Larynx preservation: 3y: 42%, 5y:35%

GORTEC Phase III, Pointreau 2009

more aggressive induction
Docetaxel/CDDP/5FU vs Cisplatin/5FU ICT in Organ preservation in HPX and larynx Ca.

  • two ICT regimens
    • responders get RT alone
    • nonresponders got surgery 🔪 then RT ☢

laryngeal preservation same

  • DFS and OS favor TPF

HPX SCC

Need widespread nodal coverage

  • superior to cover RP

Korean KROG 0201: T12N0 fractionation study

  • Hypofx
    • T1: 63Gy/28fx
    • T2: 67.5Gy/30fx
  • standard fx
    • T1: 66/33
    • T2: 70

Local PFS

Nasopharyngeal Ca

  • Uncommon in Europe and the U.S. (2/100,000)
  • Extremely common in southern China and Hong Kong (20-25/100,000) and accounts for up to 18% of all cancer diagnoses
  • "the Cantonese cancer” 👲🏼
    • Common in Taiwan, Singapore, Malaysia, Thailand, and Vietnam
      • NPC is seen in Africa, the Mediterranean, and among the Alaskan Inuit

Nodal involvement is common, prognostic, and relates to type
• Nodal mets at presentation
• 90% subclinically node +
• 70% clinically node +
• 50% bilateral node +
• Type of cancer impacts amount of lymph node spread
• 73% node + if WHO type I (“keratinizing”)
• 92% node + if WHO type IIA/IIB (endemic Chinese/Asian type, "poorly differentiated")
• 40% of pts with N3 dz present with mets, 75% will ultimately have mets

NPC conclusions

  • IMRT is standard of care.
  • Concurrent chemoradiation is standard for all but T1-2N0.
  • Induction/adjuvant chemotherapy is standard for all receiving CRT except possibly T3N0.
  • The contribution of adjuvant chemotherapy is in dispute given its high toxicity and data suggesting lack of benefit over concurrent CRT alone.
  • EBV DNA as a biomarker to personalize administration of adjuvant chemotherapy is in clinical trials. Role of HPV in this disease is undetermined.
  • Induction gem/cis chemotherapy has shown benefit over concurrent CRT alone but adds toxicity and is not personalized.

Intergroup 0099 (RTOG 88-17)

OG standard setting RT trial
NPX st. III/IV

  • RT 70 Gy
  • RT 70 Gy + CDDP
    • 3 cycles adjuvant CDDP/5FU

closed early

  • CRT: doubling PFS and OS

Taiwan Taichung Veterans Phase III: RT vs CRT

NPX st. III/IV

  • RT 70-74 Gy
  • RT 70-74 Gy + CDDP/5FU
    • no adjuvant

CRT PFS superior

Is adjuvant necessary?

Sun Yat Sen university, Guangzhou trial, Lancet 2012

NPX st. III/IV, M0
exc: T3-T4N0
n=508

  • RT +66Gy & CDDP weekly
  • RT +66Gy & CDDP weekly
    • adjv CDDP/5FU x 3

no difference in local or distant PFS, OS

is there a role for adjuvant among EBV status patients?

  • EBV DNA is prognostic
  • within a week, EBV DNA separates recurrence vs no recurrence
    • Lin NEJM 2004

is induction necessary?

SYS induction trial, Chen JCO 2021

  • induction gem/CDDP then RT/CDDP x3
  • no induction

Induction superior
High compliance

  • better 3yr distant mets (recurrence) by 7%
  • OS by 4%
  • ASCO 2021 NPC Guidelines: NPX cancer, if not induction, then offer Adjuvant CRT

For patients with Stage III-IVA (except T3N0) (AJCC 8th) NPC who do not receive induction chemotherapy plus concurrent chemoradiotherapy, then concurrent chemoradiotherapy plus adjuvant chemotherapy should be offered.

NRG HN001: Phase II/III Trial of Individualized treatment for Nasopharynx Ca, based on EBV DNA

  • post CDDP and RT
  • Phase III: those undetectable are randomized
    • Adjuvant CDDP/5FU
    • observation 🔭
  • Phase II: detectable
    • non resistant consolidation: gem/paclitaxel
    • CDDP/5FU
  • this will give us the value of observation in low risk patients

HPV is also prognostic

  • Stenmark IJROBP 2014
  • prognosis is worse than EBV
  • double negative EBV HPV is related to loss of locoregional control.
  • for EBV we are concerned with metastases
  • for HPV we are concerned with locoregional control

IMRT

Spare optics and temporal lobe

• Entire nasopharynx
• Ant: posterior 1/3 of nasal
cavity/maxillary sinuses (or greater if
anterior extension)
• Post: anterior 1/2 of clivus (entire clivus
if involved)
• Sup: Inferior 1/2 of sphenoid (entire if
T3/4, including cavernous sinus)
• Inf: Palate (or greater to ensure
adequate inferior margin below GTV)
• Skull base (rotundum, ovale, lacerum) • Pterygoid
• Parapharyngeal space

🏮
For NPC
• Cover bilateral level IB-5 and RP nodes in
CTV2 (60 Gy) or CTV3 (54 Gy)
• May drop level 1B unless involvement of
the anterior nasal cavity or level II nodes
with ENE or > 2 cm or bilateral
• Like OPC, may drop contralateral 1B if
contralateral levels 1-2 are not involved
• Omission of level 4 in uninvolved side of
the neck if neck contains no nodes

NRG-HN009 ongoing trial

  • P16+/-
    • weekly CDDP vs high dose CDDP

can weekly be proven adequate in definitive chemoRT setting?

IMRT delineation

  • GTV: all gross dz
  • CTV1: microscopic margin off GTV (+ 5-10mm)
  • CTV2: HR nodal volumes/mucosal sites
  • CTV3: LR nodal volumes at risk for micro disease
    • PTV: 3-5mm off CTV

SIB dose sched.

RT only

  • 30 Fx
    • CTV1: 66Gy
    • CTV2: 60Gy
    • CTV3: 54Gy

CRT

  • 33-35 Fx
    • CTV1: 70Gy
    • CTV2: 59-63Gy
    • CTV3: 54-57Gy

PORT

  • 30-33 Fx
    • CTV1: 60-66Gy
    • CTV2: 56-60Gy
    • CTV3: 54Gy

Unilat RT inappropriate ⛔
• < 1 cm involvement of base of tongue
• < 1 cm involvement of soft palate
• T2 stage
• N1 stage
• N2c stage

Radonc tables Oral Boards
2D traditional: (in context of new CTV guidelines, traditional fields may be anachronistic)
Opposed lat,
sup=thyroid notch
inf=bottom of cricoid
ant=flash
post=ant VB
Some rotate gantry to make posterior border non-divergent or place isocenter at anterior edge of vertebral body


Wedge
Bolus only if AC involved/bolus if lesion is anterior


Treatment Planning Slides:
ISO mid thyroid cart. 4-6MV opp lat
5-10mm above thyroid notch
10mm behind thyroid cartilage
inferior edge of cricoid cart
1cm flash ant
T1: 5x5cm box, posterior edge ant to VB
T2: 6x6cm box posterior edge splitting VB
GTV, GTV + 2cm to guide block edge, PTV: GTV + 1cm
95% of PTV gets Rx, No less than 90% dose to PTV


T1: 63/28
T2: 65.25/29

EORTC 22851


  • late severe functional damage ☣
    • 7 cases of permanent peripheral neuropathy

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