Clinical outcomes of patients receiving integrated PET/CT-guided radiotherapy for head and neck carcinoma

PURPOSE: We previously reported the advantages of (18)F-fluorodeoxyglucose-positron emission tomography (PET) fused with CT for radiotherapy planning over CT alone in head and neck carcinoma (HNC). The purpose of this study was to evaluate clinical outcomes and the predictive value of PET for patients receiving PET/CT-guided definitive radiotherapy with or without chemotherapy. METHODS AND MATERIALS: From December 2002 to August 2006, 42 patients received PET/CT imaging as part of staging and radiotherapy planning. Clinical outcomes including locoregional recurrence, distant metastasis, death, and treatment-related toxicities were collected retrospectively and analyzed for disease-free and overall survival and cumulative incidence of recurrence. RESULTS: Median follow-up from initiation of treatment was 32 months. Overall survival and disease-free survival were 82.8% and 71.0%, respectively, at 2 years, and 74.1% and 66.9% at 3 years. Of the 42 patients, seven recurrences were identified (three LR, one DM, three both LR and DM). Mean time to recurrence was 9.4 months. Cumulative risk of recurrence was 18.7%. The maximum standard uptake volume (SUV) of primary tumor, adenopathy, or both on PET did not correlate with recurrence, with mean values of 12.0 for treatment failures vs. 11.7 for all patients. Toxicities identified in those patients receiving intensity modulated radiation therapy were also evaluated. CONCLUSIONS: A high level of disease control combined with favorable toxicity profiles was achieved in a cohort of HNC patients receiving PET/CT fusion guided radiotherapy plus/minus chemotherapy. Maximum SUV of primary tumor and/or adenopathy was not predictive of risk of disease recurrence.     

PET/CT显像在头颈部肿瘤中的临床应用进展

头颈部肿瘤是常见的恶性肿瘤之一,由于其位置深在且复杂,临床上主要采用根治性放疗或同期放化疗.早期疗效评价对肿瘤治疗决策的制定具有重要的指导意义.传统的物理学技术已经不能够满足对疾病早期做出诊断的需求.PET/CT作为一种无创的功能成像技术,能够在解剖结构改变之前探测到包括增殖、凋亡及乏氧等在内的多种生物学信息的变化,在头颈部肿瘤中的应用日趋广泛.该研究综述了PET/CT显像在头颈部肿瘤中的临床应用进展.     

Nonrigid image registration for head and neck cancer radiotherapy treatment planning with PET/CT

PURPOSE: Head and neck radiotherapy planning with positron emission tomography/computed tomography (PET/CT) requires the images to be reliably registered with treatment planning CT. Acquiring PET/CT in treatment position is problematic, and in practice for some patients it may be beneficial to use diagnostic PET/CT for radiotherapy planning. Therefore, the aim of this study was first to quantify the image registration accuracy of PET/CT to radiotherapy CT and, second, to assess whether PET/CT acquired in diagnostic position can be registered to planning CT. METHODS AND MATERIALS: Positron emission tomography/CT acquired in diagnostic and treatment position for five patients with head and neck cancer was registered to radiotherapy planning CT using both rigid and nonrigid image registration. The root mean squared error for each method was calculated from a set of anatomic landmarks marked by four independent observers. RESULTS: Nonrigid and rigid registration errors for treatment position PET/CT to planning CT were 2.77 +/- 0.80 mm and 4.96 +/- 2.38 mm, respectively, p = 0.001. Applying the nonrigid registration to diagnostic position PET/CT produced a more accurate match to the planning CT than rigid registration of treatment position PET/CT (3.20 +/- 1.22 mm and 4.96 +/- 2.38 mm, respectively, p = 0.012). CONCLUSIONS: Nonrigid registration provides a more accurate registration of head and neck PET/CT to treatment planning CT than rigid registration. In addition, nonrigid registration of PET/CT acquired with patients in a standardized, diagnostic position can provide images registered to planning CT with greater accuracy than a rigid registration of PET/CT images acquired in treatment position. This may allow greater flexibility in the timing of PET/CT for head and neck cancer patients due to undergo radiotherapy.     

The emerging role of cetuximab in head and neck cancer: a 2007 perspective

The integration of targeted therapies into clinical practice constitutes the paradigm of oncology treatment in the current era. Cetuximab, a recombinant human/mouse chimeric epidermal growth factor (EGFR) monoclonal antibody is a targeted agent that has seen expanding indication in recent years. Originally approved for colorectal cancer, its role in the treatment of squamous cell carcinoma of the head and neck has augmented treatment options for patients who are refractory to or cannot tolerate platinum. This article will review the science underlying cetuximab, data supportings its use in patients with locally advanced and recurrent/metastatic disease, common toxicities of therapy, and the integration of this treatment with radiation therapy.     

The role of split-course hypofractionated palliative radiotherapy in head and neck cancer

Aims

A significant proportion of patients with head and neck squamous cell carcinoma are unsuitable for radical treatment due to factors including tumour stage, performance status and co-morbidity. Palliative radiotherapy has a useful role in the control of local symptoms. This study documented the outcome with split-course hypofractionated radiotherapy.

Materials and methods

Thirty-three previously untreated patients with head and neck squamous cell carcinoma were treated with palliative intent with split-course radiotherapy, with an initial 20 Gy in five fractions over 1 week, a 2 week gap, and then a further 20 Gy in five fractions over 1 week at the Yorkshire Cancer Centre between January 2004 and December 2007. Data were collected retrospectively from case notes and radiotherapy records.

Results

Thirty (91%) patients had stage IV A-B disease. World Health Organization performance status was 2 or 3 in 19 (58%) patients. The median age was 76 years (range 48-91 years). Twenty-five (76%) patients were men. Symptomatic improvement was reported in 26 (79%) patients at 4-6 weeks of follow-up. Thirteen (39%) patients had a complete tumour response and 11 (33%) patients had a partial response as assessed clinically, and in some cases radiologically. The median overall survival was 9 months (range 3-43 months). Progression-free survival at 1 and 2 years was 35 and 25%, respectively. Overall survival at 1 and 2 years was 42 and 34%, respectively. Treatment was generally well tolerated; admission for nasogastric feeding and/or supportive care was required in only six patients. Radiation Therapy Oncology Group grade 3 toxicity was documented for skin in one patient, for mucosa in two patients and for oesophagitis in three patients.

Conclusion

Split-course hypofractionated radiotherapy is an effective palliative regimen with acceptable toxicity.     

Correlation of 18F-BPA and 18F-FDG uptake in head and neck cancers

Background and purposeThe aim of this study was to compare the accumulation of 4-borono-2-¹⁸F-fluoro-phenylalanine (¹⁸F-BPA) with that of ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) in head and neck cancers, and to assess the usefulness of ¹⁸F-FDG PET for screening candidates for boron neutron capture therapy (BNCT).Material and methodsTwenty patients with pathologically proven malignant tumors of the head and neck were recruited from March 2012 to January 2014. All patients underwent both whole-body ¹⁸F-BPA PET/CT and ¹⁸F-FDG PET/CT within 2 weeks of each other. The uptakes of ¹⁸F-BPA and ¹⁸F-FDG at 1 h after injection were evaluated using the maximum standardized uptake value (SUVmax).ResultsThe accumulation of ¹⁸F-FDG was significantly correlated with that of ¹⁸F-BPA. The SUVmax of ¹⁸F-FDG ⩾5.0 is considered to be suggestive of high ¹⁸F-BPA accumulation.Conclusions¹⁸F-FDG PET might be an effective screening method performed prior to ¹⁸F-BPA for selecting patients with head and neck cancer for treatment with BNCT.     

Advances in imaging in the work-up of head and neck cancer patients

Accurate staging at the time of the diagnosis of head and neck squamous cell carcinoma (HNSCC) is critical for selection of the appropriate treatment strategy. Therefore, optimizing pre-treatment imaging in the diagnostic work-up is of great importance. CT and MRI are the corner stones of diagnostic work-up. Technical improvements will increase the value of these techniques even further. PET and PET-CT became a standard imaging techniques for HNSCC patients. It may be helpful for the detection of occult primary tumours, but its sensitivity for the detection of occult lymph node metastases is too low. Alternatively, the sentinel node procedure may be sufficiently accurate to avoid elective treatment of the neck. Screening for distant metastases should be performed only in HNSCC patients with high risk factors by FDG-PET-CT.     

Chemotherapy advances in locally advanced head and neck cancer

The management of locally advanced unresectable head and neck squamous cell cancer (HNSCC) continues to improve. One of the major advances in the treatment of HNSCC was the addition of chemotherapy to radiation in the treatment of non-surgical patients. The majority of the data regarding chemotherapy in HNSCC involve cisplatin chemotherapy with concurrent radiation. However, several new approaches have included targeted therapy against epidermal growth factor receptor and several recent studies have explored the role of induction chemotherapy in the treatment of HNSCC. The purpose of this article is to provide an overview of the role of chemotherapy in the treatment of locally advanced HNSCC.     

光动力治疗消化道和头颈部肿瘤的临床观察

目的　探讨光动力疗法治疗消化道和头颈部肿瘤的疗效和安全性。方法　选取消化道肿瘤９例、头颈部复发转移癌７例行光动力治疗,其中早期４例,晚期１２例。具体治疗：静脉输注血卟啉３～５ｍｇ／ｋｇ,４８～７２ｈ在肿瘤表面或瘤体内行激光照射（输出波长６３０ｎｍ,输出功率６００～８００ｍＷ,能量密度为２００～３００Ｊ／ｃｍ２）。根据治疗后肉眼及内镜观察、Ｂ超和ＣＴ检查肿瘤缩小及症状缓解情况评价疗效。结果　所有患者治疗后随访１０～３９个月。４例早期患者均获ＣＲ,随访期间无复发;１２例晚期患者,获ＳＲ７例,ＭＲ４例,ＮＲ１例。全组患者的总有效率为９３.７％。主要毒副反应为暴露部位皮肤肤色加深,无严重并发症。结论　光动力疗法对于早期病灶局限的恶性肿瘤可达到局部根治的作用,对于晚期病例也能缓解症状并改善生存质量。     

Systematic dental management in head and neck irradiation

Preservation of teeth has been possible in 528 head and neck patients treated with irradiation at Centre Georges Leclerc, University of Dijon, by careful adherence to precise dental care. Careful initial dental evaluation with appropriate X rays, restoration of oral hygiene, atraumatic extraction technique where indicated, and institution of a program of topical fluoridation has resulted in an overall incidence of less than 3% post-irradiation dental decay and 2% osteoradionecrosis. In a small group of 22 patients who required extraction post-irradiation, precise, strict technique resulted in successful extraction in all but one patient who subsequently developed ostegnecrosis. Soft-based dental prostheses were well tolerated in nearly 90% of patients. Adherence to the described principles of dental care will virtually eliminate post-irradiation decay and osteoradionecrosis.     

Twice-daily fractionation schemes for advanced head and neck cancer

Eighty-five patients with advanced squamous cell carcinoma of the head and neck were treated with twice-a-day fractionation schedules between April 1972 and December 1980. Two types of treatment were distinguished: hyperfractionation, by which 65 patients (Group 1) were treated at a weekly dose rate of 1100 to 1200 rad (10 fractions of 110 to 120 rad) in 5 to $\text{6}\text{1}\text{2}$ weeks for either advanced primary disease (Group IA) and/or advanced neck metastases (Group 1B); and accelerated treatment, used to treat 20 patients (Group 2) who had fast-growing and usually massive neck nodes, at a weekly dose rate of 1300 to 1500 rad in 7 to 10 fractions, to a total dose of 6100 to 8000 rad in 4 to 6 weeks. The radiation portals for patients in Group 2 excluded the mucosa of mouth and throat for part of the treatment. The local control rate at 1 year in Groups 1A and 1B was 41 and 54%, respectively; the incidence of complications was 17%, 5% of them fatal. The local control rate in Group 2 was 80%. Seven patients in this group underwent a neck dissection 6 to 8 weeks following irradiation. Four specimens were negative for tumor. In two, only necrotic tumor cells were identified, and in one specimen morphologically intact tumor cells were seen. There were no fatal complications.