Cancer Res Treat.  2019 Apr;51(2):603-610. 10.4143/crt.2018.240.

Feasibility of Selective Neck Irradiation with Lower Elective Radiation Dose in Treating Nasopharynx Cancer Patients

Affiliations
  • 1Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. ahnyc@skku.edu
  • 2Department of Radiation Oncology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea.
  • 3Department of Radiation Oncology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea.

Abstract

PURPOSE
This study aimed to report the clinical outcomes following selective neck irradiation (SNI) with lower elective radiation therapy (RT) dose in treating nasopharyngeal cancer (NPC) patients.
MATERIALS AND METHODS
A total of 347 NPC patients received definitive RT according to our SNI policy and were retrospectively analyzed. The clinical target volumes (CTVs) were subdivided into CTV at high risk (CTV-HR) and CTV at low risk (CTV-LR). The typical doses to gross tumor volume (GTV), CTV-HR, and CTV-LR were 68.4-70.0 Gy, 54.0-60.0 Gy, and 36.0 Gy.
RESULTS
With the median follow-up of 68.1 months (range, 2.3 to 197.1 months), the 5-year rates of loco-regional control and progression-free survival in all the patients were 85.0% and 70.8%, respectively. Thirty patients developed regional failure and the regional control rates at 3 and 5 years were 92.6% and 91.4%, respectively. The sites of regional failure in relation to the target volume were exclusively inside GTV/CTV-HR in 20, inside and outside GTV/CTVHR in three, and exclusively outside GTV/CTV-HR in seven, which were 5.7%, 0.9%, and 2.0% of total patients, respectively.
CONCLUSION
The clinical outcomes by the current SNI policy were feasible and comparable to those following classic elective nodal irradiation policy.

Keyword

Nasopharyngeal carcinoma; Lymphatic irradiation; Radiotherapy

MeSH Terms

Disease-Free Survival
Follow-Up Studies
Humans
Lymphatic Irradiation
Nasopharyngeal Neoplasms*
Nasopharynx*
Neck*
Radiotherapy
Retrospective Studies
Tumor Burden

Figure

  • Fig. 1. The policy of selective neck irradiation with differential radiation dose plan employed in the current study is illustrated: (A) 66-72 Gy to gross tumor volume (GTV) of primary tumor and metastatic lymph nodes; (B) 54-60 Gy to clinical target volume at high risk (CTV-HR) that included 1.0-1.5 cm margin to nodal GTV; and (C) 36 Gy to clinical target volume at low risk (CTV-LR) that included 2-2.5 cm distal margin from CTV-HR.

  • Fig. 2. Patterns of failure in 100 patients.

  • Fig. 3. The sites of regional failures in relation to target volume and detail of seven patients who developed regional failure in or outside clinical target volume at low risk (CTV-LR). GTV, gross tumor volume; CTV-HR, clinical target volume at high risk. RT, radiotherapy; NED, no evidence of disease; DOD, dead of disease; M, male.


Cited by  3 articles

Development and Validation of Web-Based Nomograms to Precisely Predict Survival Outcomes of Non-metastatic Nasopharyngeal Carcinoma in an Endemic Area
Ji-Jin Yao, Li Lin, Tian-Sheng Gao, Wang-Jian Zhang, Wayne R. Lawrence, Jun Ma, Ying Sun
Cancer Res Treat. 2021;53(3):657-670.    doi: 10.4143/crt.2020.899.

Oncological and Functional Outcomes of Larynx-Preserving Surgery for Hypopharyngeal Cancer: A Comparison with Definitive Radiation-Based Treatment
Donghyeok Kim, Nalee Kim, Sungmin Koh, Man Ki Chung, Young-Ik Son, Dongryul Oh, Han-Sin Jeong, Yong Chan Ahn
Cancer Res Treat. 2022;54(1):84-95.    doi: 10.4143/crt.2020.1197.

Re-irradiation with Moderate Hypo-fractionation Using Intensity Modulated Photon or Proton Radiation Therapy in Locally Recurrent Squamous Cell Carcinoma of Nasopharynx
Heerim Nam, Yong Chan Ahn, Kyungmi Yang, Dongryul Oh, Jae Myoung Noh
Cancer Res Treat. 2022;54(1):96-108.    doi: 10.4143/crt.2020.1349.


Reference

References

1. Lee AW, Tung SY, Chua DT, Ngan RK, Chappell R, Tung R, et al. Randomized trial of radiotherapy plus concurrent-adjuvant chemotherapy vs radiotherapy alone for regionally advanced nasopharyngeal carcinoma. J Natl Cancer Inst. 2010; 102:1188–98.
2. Ou SH, Zell JA, Ziogas A, Anton-Culver H. Epidemiology of nasopharyngeal carcinoma in the United States: improved survival of Chinese patients within the keratinizing squamous cell carcinoma histology. Ann Oncol. 2007; 18:29–35.
Article
3. Ho FC, Tham IW, Earnest A, Lee KM, Lu JJ. Patterns of regional lymph node metastasis of nasopharyngeal carcinoma: a meta-analysis of clinical evidence. BMC Cancer. 2012; 12:98.
Article
4. Lee AW, Sham JS, Poon YF, Ho JH. Treatment of stage I nasopharyngeal carcinoma: analysis of the patterns of relapse and the results of withholding elective neck irradiation. Int J Radiat Oncol Biol Phys. 1989; 17:1183–90.
Article
5. Fletcher GH. Elective irradiation of subclinical disease in cancers of the head and neck. Cancer. 1972; 29:1450–4.
Article
6. Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A. AJCC cancer staging handbook: from the AJCC cancer staging manual. New York: Springer;2011.
7. Jeong Y, Baek S, Park JW, Joo JH, Kim JS, Lee SW. Lymph node standardized uptake values at pre-treatment (18)F-fluorodeoxyglucose positron emission tomography as a valuable prognostic factor for distant metastasis in nasopharyngeal carcinoma. Br J Radiol. 2017; 90:20160239.
Article
8. Hoang JK, Vanka J, Ludwig BJ, Glastonbury CM. Evaluation of cervical lymph nodes in head and neck cancer with CT and MRI: tips, traps, and a systematic approach. AJR Am J Roentgenol. 2013; 200:W17–25.
Article
9. Lee NY, Zhang Q, Pfister DG, Kim J, Garden AS, Mechalakos J, et al. Addition of bevacizumab to standard chemoradiation for locoregionally advanced nasopharyngeal carcinoma (RTOG 0615): a phase 2 multi-institutional trial. Lancet Oncol. 2012; 13:172–80.
Article
10. Zhang F, Cheng YK, Li WF, Guo R, Chen L, Sun Y, et al. Investigation of the feasibility of elective irradiation to neck level Ib using intensity-modulated radiotherapy for patients with nasopharyngeal carcinoma: a retrospective analysis. BMC Cancer. 2015; 15:709.
Article
11. Chen JZ, Le QT, Han F, Lu LX, Huang SM, Lin CG, et al. Results of a phase 2 study examining the effects of omitting elective neck irradiation to nodal levels IV and Vb in patients with N(0-1) nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys. 2013; 85:929–34.
Article
12. Gao Y, Zhu G, Lu J, Ying H, Kong L, Wu Y, et al. Is elective irradiation to the lower neck necessary for N0 nasopharyngeal carcinoma? Int J Radiat Oncol Biol Phys. 2010; 77:1397–402.
Article
13. Lee AW, Ng WT, Pan JJ, Poh SS, Ahn YC, AlHussain H, et al. International guideline for the delineation of the clinical target volumes (CTV) for nasopharyngeal carcinoma. Radiother Oncol. 2018; 126:25–36.
Article
14. Withers HR, Peters LJ, Taylor JM. Dose-response relationship for radiation therapy of subclinical disease. Int J Radiat Oncol Biol Phys. 1995; 31:353–9.
Article
15. van den Bosch S, Dijkema T, Verhoef LC, Zwijnenburg EM, Janssens GO, Kaanders JH. Patterns of recurrence in electively irradiated lymph node regions after definitive accelerated intensity modulated radiation therapy for head and neck squamous cell carcinoma. Int J Radiat Oncol Biol Phys. 2016; 94:766–74.
Article
16. van den Bosch S, Vogel WV, Raaijmakers CP, Dijkema T, Terhaard CHJ, Al-Mamgani A, et al. Implications of improved diagnostic imaging of small nodal metastases in head and neck cancer: radiotherapy target volume transformation and dose de-escalation. Radiother Oncol. 2018; 128:472–8.
Article
17. Gunderson LL, Winter KA, Ajani JA, Pedersen JE, Moughan J, Benson AB 3rd, et al. Long-term update of US GI intergroup RTOG 98-11 phase III trial for anal carcinoma: survival, relapse, and colostomy failure with concurrent chemoradiation involving fluorouracil/mitomycin versus fluorouracil/cisplatin. J Clin Oncol. 2012; 30:4344–51.
Article
18. Bedi M, Firat S, Semenenko VA, Schultz C, Tripp P, Byhardt R, et al. Elective lymph node irradiation with intensity-modulated radiotherapy: is conventional dose fractionation necessary? Int J Radiat Oncol Biol Phys. 2012; 83:e87–92. .
Article
19. Salama JK, Stenson KM, Kistner EO, Mittal BB, Argiris A, Witt ME, et al. Induction chemotherapy and concurrent chemoradiotherapy for locoregionally advanced head and neck cancer: a multi-institutional phase II trial investigating three radiotherapy dose levels. Ann Oncol. 2008; 19:1787–94.
Article
20. Nevens D, Duprez F, Daisne JF, Dok R, Belmans A, Voordeckers M, et al. Reduction of the dose of radiotherapy to the elective neck in head and neck squamous cell carcinoma; a randomized clinical trial. Effect on late toxicity and tumor control. Radiother Oncol. 2017; 122:171–7.
Article
21. Kong F, Ying H, Du C, Huang S, Zhou J, Chen J, et al. Patterns of local-regional failure after primary intensity modulated radiotherapy for nasopharyngeal carcinoma. Radiat Oncol. 2014; 9:60.
Article
22. Wolden SL, Chen WC, Pfister DG, Kraus DH, Berry SL, Zelefsky MJ. Intensity-modulated radiation therapy (IMRT) for nasopharynx cancer: update of the Memorial Sloan-Kettering experience. Int J Radiat Oncol Biol Phys. 2006; 64:57–62.
Article
23. Wong FC, Ng AW, Lee VH, Lui CM, Yuen KK, Sze WK, et al. Whole-field simultaneous integrated-boost intensity-modulated radiotherapy for patients with nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys. 2010; 76:138–45.
Article
24. Wang R, Wu F, Lu H, Wei B, Feng G, Li G, et al. Definitive intensity-modulated radiation therapy for nasopharyngeal carcinoma: long-term outcome of a multicenter prospective study. J Cancer Res Clin Oncol. 2013; 139:139–45.
Article
25. Au KH, Ngan RK, Ng AW, Poon DM, Ng WT, Yuen KT, et al. Treatment outcomes of nasopharyngeal carcinoma in modern era after intensity modulated radiotherapy (IMRT) in Hong Kong: a report of 3328 patients (HKNPCSG 1301 study). Oral Oncol. 2018; 77:16–21.
Article
26. Pow EH, Kwong DL, Sham JS, Lee VH, Ng SC. Can intensitymodulated radiotherapy preserve oral health-related quality of life of nasopharyngeal carcinoma patients? Int J Radiat Oncol Biol Phys. 2012; 83:e213–21. .
Article
27. Yang H, Chen X, Lin S, Rong J, Yang M, Wen Q, et al. Treatment outcomes after reduction of the target volume of intensity-modulated radiotherapy following induction chemotherapy in patients with locoregionally advanced nasopharyngeal carcinoma: a prospective, multi-center, randomized clinical trial. Radiother Oncol. 2018; 126:37–42.
Article
28. Hawkins PG, Lee JY, Mao Y, Li P, Green M, Worden FP, et al. Sparing all salivary glands with IMRT for head and neck cancer: longitudinal study of patient-reported xerostomia and head-and-neck quality of life. Radiother Oncol. 2018; 126:68–74.
Article
29. Nuyts S, Lambrecht M, Duprez F, Daisne JF, Van Gestel D, Van den Weyngaert D, et al. Reduction of the dose to the elective neck in head and neck squamous cell carcinoma, a randomized clinical trial using intensity modulated radiotherapy (IMRT): dosimetrical analysis and effect on acute toxicity. Radiother Oncol. 2013; 109:323–9.
Article
30. Maguire PD, Neal CR, Hardy SM, Schreiber AM. Single-arm phase 2 trial of elective nodal dose reduction for patients with locoregionally advanced squamous cell carcinoma of the head and neck. Int J Radiat Oncol Biol Phys. 2018; 100:1210–6.
Article
Full Text Links
  • CRT
Actions
Cited
CITED
export Copy
Close
Share
  • Twitter
  • Facebook
Similar articles
Copyright © 2024 by Korean Association of Medical Journal Editors. All rights reserved.     E-mail: koreamed@kamje.or.kr