Cancer Res Treat.  2019 Apr;51(2):685-695. 10.4143/crt.2018.250.

Reduction of Target Volume and the Corresponding Dose for the Tumor Regression Field after Induction Chemotherapy in Locoregionally Advanced Nasopharyngeal Carcinoma

• Wang L
• Wu Z
• Xie D
• Zeng R
• Cheng W
• Hu J
• Huang S
• Zhou S
• Zhong R
• Su Y

• KMID: 2464414
• DOI: http://doi.org/10.4143/crt.2018.250

Abstract

PURPOSE
This study aims to investigate the feasibility of contouring target volume according to residual tumor and decreasing the dose to the tumor regression field after induction chemotherapy (IC) in locoregionally advanced nasopharyngeal carcinoma (NPC).
MATERIALS AND METHODS
From August 2009 to August 2013, patients with stage III-IVB NPC were treated with IC and concurrent chemoradiotherapy. Gross tumor volume of nasopharynx (GTVnx)-residual and gross tumor volume of cervical lymph node (GTVnd)-residual were contoured according to post-IC residual primary tumor and any N+ disease, respectively. The tumor regression field was included in CTVnx1/CTVnd1 and prescribed a dose of 60 Gy. Outcomes and toxicities of all patients were evaluated.
RESULTS
A total of 57 patients were enrolled. At a median follow-up of 68 months, three cases displayed locoregional recurrence and one case showed both distant metastasis and locoregional recurrence. All locoregional recurrences were in the GTVnx-residual/GTVnd-residual and in-field. The 5-year overall, locoregional relapse-free, distant metastasis-free, and progression-free survival rates were 82.2%, 87.7%, 85.8% and 80.3%, respectively.
CONCLUSION
After IC, contouring of GTVnx-residual/GTVnd-residual as residual tumor volume and distribution 60 Gy ofradiation dose to the tumorregression field may be feasible and need further investigation.

Keyword

Nasopharyngeal carcinoma; Induction chemotherapy; Intensity-modulated radiotherapy; Target volume; Dose distribution

MeSH Terms

Chemoradiotherapy
Disease-Free Survival
Follow-Up Studies
Humans
Induction Chemotherapy*
Lymph Nodes
Nasopharynx
Neoplasm Metastasis
Neoplasm, Residual
Radiotherapy, Intensity-Modulated
Recurrence
Tumor Burden

Figure

• 

  Fig. 1. (A) In MRI before IC, the primary tumor located in the bilateral roof and left wall of nasopharynx, spread to bilateral middle nasal turbinate and bilateral pterygopalatine fossa anteriorly (green arrow), laterally extended to left petrous apex, left carotid canal and posteriorly to left clivus (white arrow). (B) In MRI after IC, the tumor obviously regressed. Tumor enhancement signal could only be seen in anterior roof of nasopharynx, bilateral choanae and bilateral pterygopalatine fossa (green arrow in B), delineated as GTVnx-residual. Signal of skull base bone destruction became unapparent (white arrow in B). Left petrous apex, left carotid canal and left clivus partially recovered in the bone window of computed tomography scan (white arrow in C), delineated as CTVnx1 and prescribed 60 Gy. (D) Red line, purple line, and blue line indicate GTVnxresidual, CTVnx1, and CTV2, respectively. (E) Dose color wash (60 Gy). Yellow line, pink line, green line, light yellow line, blue line, and light blue line (arrow) indicate PGTVnx-residual, GTVnx-pre, PCTVnx1, PCTV2, brain stem, and optic chiasm, respectively. (F) DVH. Orange line, green line, blue line, and red line indicate PGTVnx-residual, PCTVnx1, brain stem, and optic chiasm, respectively. MRI, magnetic resonance imaging; IC, induction chemotherapy; GTVnx, gross tumor volume of nasopharynx; CTV, clinical target volume; PGTV, planning target volume of GTV; PCTV, planning target volume of CTV; DVH, dose volume histogram.

• 

  Fig. 2. (A) In MRI before IC, the tumor invaded ethmoidal cellules and orbital apex, with the right optic nerve suspiciously invaded (white arrow). The patient suffered with inflammation after wadding for nasopharynx bleeding (red arrow in A). (B, C) The tumor volume was reduced and no tumor signal was founded in MRI after IC (white arrow in B) and computed tomography after IC (white arrow in C) in the same slice as A. (D) Therefore, the tumor regressed region was outlined as CTVnx1, prescribed 60 Gy (pink line, CTVnx1; blue line, CTV2 in D). (E) Dose color wash (60 Gy). Orange line and red line indicate PCTVnx1 and optic chiasm, respectively. (F) DVH. Green line, red line, and blue line, indicated PCTVnx1, right optic nerve, and optic chiasm, respectively. MRI, magnetic resonance imaging; IC, induction chemotherapy; CTV, clinical target volume; PCTV, planning target volume of CTV; DVH, dose volume histogram.

• 

  Fig. 3. (A) Kaplan-Meier estimates of locoregional-free survival (5-year LRFS, 87.7%; 95% confidence interval [CI], 82.6 to 92.7). (B) Kaplan-Meier estimates of distant metastasis-free survival (5-year DMFS, 85.8%; 95% CI, 80.3 to 91.4). (C) KaplanMeier estimates of progression-free survival (5-year PFS, 80.3%; 95% CI, 73.0 to 87.6). (D) Kaplan-Meier estimates of overall survival (5-year OS, 82.2%; 95% CI, 75.9 to 88.5).

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