Astro 2015 Refresher Head Neck
Astro 2015 Refresher Head Neck
Astro 2015 Refresher Head Neck
Neck Cancers
Sue S. Yom, MD, PhD
University of California, San Francisco
Disclosure
Carvalho et al. Trends in incidence and prognosis for head and neck cancer in
the United States: a site specific analysis of the SEER database. 2005.
Major etiology (smoking) is in decline in
the U.S.
Basaloid SCC
Figure Legend:
Robotic Equipment Positioning
Central position of the endoscope flanked by 2 robotic trocars is shown.
RTOG 0022
Small, early trial of IMRT feasibility
For oropharyngeal cancer T1-T2, N0-N1
Prescribed to 66 Gy at 2.2 Gy/fraction over 6 weeks
with subclinical dose of 54-60 Gy
Not selected for HPV or p16 status
2 year locoregional control 91% at 2 years
All cases of LRF, metastasis, or second
primary cancer occurred among patients who
were current/former smokers
NCCN T1-T2 N0-N1 ALGORITHM
• Radiation: 70Gy/30fx
• ChemoRT: 70Gy + CDDP 100 mg/m2 in wk 1,4 and 7
• Split course chemoRT: 30Gy, break, 30-40 Gy +
CDDP 75mg/m2 and 5-FU 1 g/m2 x 4 days q 3 wk
– At break evaluate for resectability
Platinum based
Chemoradiotherapy
Estimated for
Bioradiotherapy
RT alone
CRT
Ang, JCO 28:15s, 2010 (suppl; abstr 5507); Ang NEJM 2010
RTOG 0129: HPV and p16 survival analyses
R* CLINICAL CR
E Low dose IMRT 54Gy/27fx** +
Key Eligibility Cisplatin 75mg/m2 D1
S Cetuximab weekly
1.OPSCC Paclitaxel 90mg/m2
2.HPV16 ISH + D1,8,15 P
and / or p16+ Cetuximab 250mg/m2 O
3.Resectable D1,8,15
stage III, IVA Q 21 days for 3 cycles
N CLINICAL PR /SD
S Full dose IMRT 69.3Gy/33fx** +
E Cetuximab weekly
*Response Assessment
: Direct visualization of primary **Uninvolved nodes get 51.3 Gy/27 fx
: Clinical exam of neck
: CT/MRI Courtesy of Barbara Burtness
RESULTS: PFS IN STANDARD AND LOW DOSE
RT ARMS
Progression-free Survival
1.0
Low-dose (n=62)
Std-dose (n=15)
All evaluable pts (n=80)
0.2
# at risk
6 mo 9 mo 12 mo
All eval 72 69 61
Low dose 57 55 48
Std dose 14 13 12
0.0
0 5 10 15 20 25 30
Time in months
Presented by: Courtesy of Barbara Burtness
ASCO 2012
ECOG 1308: 2-YEAR PRIMARY ENDPOINT
ASCO 2014
RESULTS IN INDUCTION CHEMOTHERAPY
+ CETUX-54 GY ARM AT 2 YEARS
ASCO 2014
PRINCESS MARGARET HOSPITAL:
RADIATION ALONE
PMH RADIOTHERAPY ALONE FOR P16+
AND <10 PY SMOKING: RT VS CRT
Eligibility R S R 60 Gy XRT (2Gy/fx)
OP SCCA
E T A
Central Declare in 6 weeks +
≤10 pack- G review R Intent N cisplatin 40 mg/m2
year I p16+ A Unilat
T1-T2 N1- S IHC
D weekly x 6 cycles
T vs
N2b T I Bilat O
T3 N0- E F Neck M
N2b XRT 60 Gy XRT (2 Gy/fx)
R Y I at 6 fractions/week
Z for 5 weeks
44% of RTOG 1016
population eligible E
WHAT EVER HAPPENED TO INDUCTION
ANYWAY?
TPF PF
Response P Value
N=255 (95% CI) N=246 (95% CI)
ORR (ICT) 72% (65.8-77.2) 64% (57.9-70.2) 0.07
CR (ICT) 17% (12.1-21.6) 15% (10.8-20.1) 0.66
ORR (ICT+CRT) 77% (70.8-81.5) 72% (65.5-77.1) 0.21
CR (ICT+CRT) 35% (29.4-41.5) 28% (22.5-34.1) 0.08
90 90
Survival Probability (%)
60 60
50 50
40
TPF 67% 40
PF 54% TPF 53%
30 TPF 62% 30
PF 42%
20 PF 48% 20 TPF 49%
TPF (N=255) TPF (N=255)
10
PF (N=246)
10
PF (N=246)
PF 37%
0 0
0 6 12 18 24 30 36 42 48 54 60 66 72 0 6 12 18 24 30 36 42 48 54 60 66 72
Months Months
• TPF significantly improves survival and PFS compared with PF in an ICT regimen
followed by CRT
Posner. N Engl J Med. 2007;357:1705. Copyright © [2007] Massachusetts Medical Society. All rights
reserved.
Paradigm: Phase III Sequential Therapy Trial
in North America
ICT CRT
Carboplatin (every week)
CR Daily RT (days 1-5)
Docetaxel
R 7 weeks
Cisplatin
Paradigm A
N 5-FU
Stage III/IV SCCHN every 3 weeks, 3 cycles Docetaxel (every week for 4 wks)
D
• Oral cavity, O PR Daily/twice-daily RT (days 1-5)
oropharynx, M 6 weeks
hypopharynx, larynx I
• Expected N=330 Z Cisplatin (weeks 1, 4)
E Daily/twice-daily RT (days 1-5)
6 weeks
ICT CRT
R
A Docetaxel (day 1)
N Cisplatin (day 1)
DeCIDE
D 5-FU (days 1-5)
Chemotherapy and RT-
O every 3 weeks, 2 cycles Docetaxel (day 1)
naïve SCCHN
M 5-FU (days 0-4)
• Expected N=400 I Hydroxyurea (days 0-4)
Z Twice-daily RT (days 1-5)
E
every 2 weeks, 5 cycles
same CRT
Enrolled 280 patients
3y OS 73% vs 75% (p=0.70)
Cohen et al., DeCIDE: A phase III randomized trial of docetaxel (D),
cisplatin (P), 5-fluorouracil (F) (TPF) induction chemotherapy (IC) in
patients with N2/N3 locally advanced squamous cell carcinoma of the
head and neck (SCCHN).). ASCO 2012. Abstract #5501.
Defensible Induction Chemotherapy
Scenarios
1. Need to optimize patient’s medical status
2. Very high potential for metastasis, or
oligometastasis with plan to consolidate
3. Unavoidable delay in starting radiation
4. Impending local issue (airway, CNS) that is not well
addressed with surgery
5. Markedly advanced neck disease (dermal
infiltration, truly massive N3)
6. Markedly advanced primary disease (T4b)
* Consider 1-4% risk of mortality and effect on compliance with
subsequent CRT
Adapted from: Haddad and Shin, NEJM 2008
Basic IMRT Delineation for OPC
• GTV = All gross disease on imaging or exam
• CTV1 = “Microscopic margin”: GTV + 5-10 mm margin
(many use 7-8 mm)
• CTV2 = “High Risk” nodal volumes and mucosal sites
– Not defined consistently
– E.g. uninvolved level 3 nodes in base of tongue cancer with
involved level 2 nodes
• CTV3 = “Elective” uninvolved nodal regions at risk for
microscopic disease
– E.g. uninvolved level 4 nodes in base of tongue cancer with
involved level 2 nodes
styloid
Tonsil cancer
include some tongue base/GP sulcus
CTV stay
outside
bone
Come out
into neck
at C2
transverse
process
Tonsil cancer
CTV1 extends to just above hyoid
Make sure Follow
to cover lateral
vasculature pharyngeal
wall with
CTV1
Tonsil cancer
CTV2 covers lateral pharyngeal wall to just
above AE fold
AE fold
Don’t go
outside
platysma
Monroe, A.T., Reddy, S.C., and Peddada, A.V. Dorsal vagal complex of the brainstem:
Conformal avoidance to reduce nausea. Pract Radiat Oncol. 2014; 4: 267–271
Dose constraints
• Optic Chiasm & Optic Nerves: <54Gy max dose
• Oral cavity: ALARA, mean dose <40Gy or <34Gy
• Larynx: mean <35Gy (<25-30Gy preferred)
– Strongly consider low neck split field approach which
reduces dose to approximately 10 Gy
• Cervical Esophagus: ALARA, minimize 60Gy
• Posterior Neck: <35Gy (try to control the 30Gy to
reduce hair loss and long term cramping)
• Lens <5Gy or <10Gy if close to the target
• Brachial plexus: <60 Gy max dose (LOW PRIORITY)
Rosenthal DI, Int J Radiat Oncol Biol Phys. 2008 Nov 1;72(3):747-55.
Contouring the plexus
• You can recognize BP
on low-res CT
– MR fusion not usually
helpful
– Practice will help C2 C2
• How I do it
– Identify C5, C6, C7 nerve C4
roots above VB
– Identify C8, T1 nerve
roots below VB
– Contour between ant and
middle scalenes
– 3-4 mm brush on axial
cuts
– Confirm using sagittal
plane images
– For postop cases, confirm
using contralat neck
“Dose Dump” into Hot Spots
Delineation of the neck node levels for head and neck tumors: a 2013
update. Radiotherapy and Oncology. 2014 Jan;110(1):172-81.
3. Ipsilateral radiation therapy
for tonsil T1-2, N0-N2a ?maybe N2b?
The ultimate
form of salivary
gland sparing!
Ipsilateral RT
N1 N2 N3 Total N Contralat failure
Al-Mamgani, 43 50 0 93 1 (1%)
Rotterdam
Jackson, British 54 7 16 77 3 (4%)
Columbia
Chronowski, MDACC 23 43 0 66 1 (2%)
T4 skull base
N2 neck nodes
T2 parapharyngeal
T4 skull base
N2 neck nodes
The search for better selection
algorithms continues in NPC just
as in other sites
NPC is fairly uncommon in Europe and the U.S.
(2/100,000)
NPC is extremely common in southern China
and Hong Kong (20-25/100,000) and accounts
for up to 18% of all cancer diagnoses
NPC has been called "the Cantonese cancer”
NPC is also common in Taiwan, Singapore,
Malaysia, Thailand, and Vietnam
NPC is seen in Africa, the Mediterranean, and
among the Alaskan Inuit
Area Incidence*
Chinese White
Hong Kong 1965-1969 24.7 --
Singapore 1960-1964 20.2 --
San Francisco-Oakland 1969 17.9 0.9
Hawaii 1960-1964 10.4 1.1
EBV+
HPV+
HPV+
EBV-HPV-
EBV-HPV-
HPV+
EBV+
EBV+
EBV-HPV-
HPV+
EBV-HPV-
Stenmark, IJROBP
Intergroup 0099 (RTOG 88-17)
S R
AJCC A RT
T T stage
1992 N alone
R N stage
stage (70 Gy)
III-IV A Performance D
T status O
M0
I Histology M RT (70 Gy)
F I Cisplatin x3
Y Z
E Cisplatin + 5FU x3
N = early closure at 193 147
FU = 2.7 yrs
Al Sarraf, J Clin Oncol 1998; 16:1310-1317
Intergroup 00-99
Results
RT only CRT + adj chemo
5 yr PFS 29% 58% p < 0.001
p=0.001
R RT ( ≥ 66 Gy)
A Weekly cisplatin
AJCC 1997 40 mg/m2
N
stage III-IV
M0 D
O RT ( ≥ 66 Gy)
Excluded Weekly cisplatin
T3-T4N0 M 40 mg/m2
I
Z
N = 508 Cisplatin + 5FU x3
E Chen et al, Lancet Oncology 2011 50
Chen et al., Concurrent chemoradiotherapy plus adjuvant chemotherapy versus concurrent
chemoradiotherapy alone in patients with locoregionally advanced nasopharyngeal carcinoma: a
phase 3 multicentre randomised controlled trial, Lancet 2012
category 2A
(previously category 1)
• Chemotherapy radiation
• Concurrent chemoradiation
T3 supraglottic SCCA, s/p T1 FOM WLE and
B neck dissection with left N2b with ECE
• GTV 7 mm to CTV 5 mm to
PTV to account for motion
• Daily soft tissue based CBCT to
align laryngeal tissues
• For oral cavity, cover levels 1A-
1B-2-3, ipsi level 4 for N+, ipsi
level 5 for N2b; bolus for ECE
• Cover bilateral 2-4 for larynx
cancers, ipsi level 5 for N2b, and
level 6 if he had subglottic or
hypopharyngeal extension
• RPs if he had post pharyngeal
wall or hypopharynx involvement
Organ Preservation
• Not a new debate
R PR Surgery
A
CR or PR
N (3rd Cycle Radiation
D of Chemo) Therapy
O
M CR
I Induction
Chemotherapy
Z (2 Cycles) < PR Surgery Radiation
E
S + RT CT + RT P
(N = 166) (N = 166) value
Recurrent Disease
Primary only 0 (0%) 21 (13%) .001
Nodes (+ prim) 15 (9%) 27 (16%) .001
Distant Mets 30 (18%) 20 (12%) .004
VAH Laryngeal Carcinoma Study
Cause of Death – similar in the end
Cause S + RT CT + RT
(N = 166) (N = 166)
* Supraglottic Laryngectomy
VA larynx, long term QOL: significant
differences in mental health and pain
< T4 29%
T4 56% p = 0.001
RTOG 91-11 selection criteria
• Patient selection
– T3
– Limited T4
• Patient exclusions
– Large volume T4a
• Extending through thyroid cartilage
• Greater than 1 cm extension into base of tongue
RTOG 91-11
Phase III Trial to Preserve the Larynx
N = 547 stage III/IV
R Arm 1 : Neoadjuvant CT + RT
S Location:
CR, PR Cis + 5-FU RT
A
T Glottic x 1 Cycle
Supraglottic N
R Cis + 5-FU X 2 Cycles
T Stage: D
A
T2 O NR Surgery RT
T T3 M
I Early T4
I Arm 2 : RT + cisplatin
F N Stage: Z
Y N0, N1 Arm 3 : RT Alone
E
N2, N3
Neck dissections for all pts with node > 3cm or
multiple nodes, 8 weeks after RT
RTOG 91-11 at 3 years
Arm LPR LRC OS G3/4 (G5)
Percentage
60 60
P (Log-rank test)=0.096
40 40
P (Log-rank test)=0.105
20 Induction TPF (N=108) 20 Induction TPF (N=108)
Induction PF (N=112) Induction PF (N=112)
0 0
0 6 12 18 24 30 36 42 0 6 12 18 24 30 36 42
Months Months
100 Larynx Preservation*
80
Percentage
• DFS and OS trends favor TPF but 60
are not statistically significant
40 P (Log-rank test)=0.036
Last 2 wks
CCB
NOT STATISTICALLY
SIGNIFICANT
EORTC & RTOG - Combined data
30%
reduction
in risk of
death
RTOG 9501: 10 year followup
• No overall benefit for LRC or OS from postop
chemoradiation at 10 years
– LRC still better for ECE or pos margins
• Multiple nodes without ECE or pos margin: shows
no LRC benefit from postop CRT
– Analysis of patients with up to 6 involved nodes
• Conclusion: Multiple nodes is not an indicator in
itself for postoperative CRT
– Faint suggestion of unexplained non-cancer related deaths in
patients who received chemo in absence of ECE/+marg
RTOG 1216: Phase II-III Randomized Trial of
Surgery Followed by Chemoradiation
for High Risk SCCHN
N=475
Register:
p16 and EGFR
R 60-66 Gy/6 wks
A CDDP 40mg/m2 wkly
Stratify by:
Tumor Site N
Zubrod D 60-66 Gy/6 wks
EGFR level O Docetax 15mg/m2 wkly
M
High Risk:
Positive margins I 60-66 Gy/6 wks
Extranodal extension Z wkly Cetuximab
E wkly Docetaxel
Intermediate Risk: Using
Targeted Therapy
RTOG 0920 for intermediate (NOT HIGH
RISK) cancers
OC, larynx,
OPX p16+/- R
RT: 60 Gy in 30 fractions
A
Intermediate
risk factors: N
cT2-3, N0-2 D
(minimal T4a)
Stage III-IVA O RT: 60 Gy in 30 fractions
PNI M Cetuximab 400 mg/m2
LVSI I loading, 250 mg/m2 x 10
Close <5mm cycles
>5mm deep Z
E
Open and accruing, goal is 700+ pts
CTVs for T3N0 oral tongue with close
inferior margin at FOM
• Refused chemotherapy
• 66 Gy (red) at area of inferior
close margin
• 60 Gy (blue) to remainder of
postop bed and flap
• Bilateral necks radiated
electively given midline
tumor location including level
1A and bilateral 1B
• No PNI, so did NOT cover V3
to base of skull
For oral cavity cases, assess status of:
1) lingual nerve, 2) hypoglossal nerve and
3) inferior alveolar nerve
Inferior alveolar nerve (V3) foramen
infiltration into mandible
T1-weighted MRI
V3 invasion easily
travels to skull base –
for major PNI, cover
pathway along
masticator space to
foramen ovale