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RE-IRRADIATION IN HEAD AND NECK CANCER
S 16
SYMPOSIUM
Saturday, February 26,201 1 Symposium Symposium 5: Global care of patients (social concern, family, cultural issues, psychosocial support, what do patients expect, treatment of acute and late toxicities 32 speaker NEW THOUGHTS ON TREATMENT RELATED MUCOSlTlS IN HEAD AND NECK CANCER PATIENTS N. Treister' MEDICALSCHOOL, BRIGHAMAND WOMEN'S HOSPITALAND HARVARD Boston, USA Oral mucositis affects nearly all patients undergoing curative radiation therapy for head and neck cancer. Pain and debilitation are often so severe that patients routinely require feeding tube placement, intensive pain management, and in some cases hospitalization, leading to unscheduled treatment breaks and dose reductions that can jeopardize treatment outcomes. Until recently, mucositis was believed to be an inevitable side effect of radiation therapy leading to dose-dependent basal epithelial destruction and tissue ulceration, with management options limited to palliation and nutritional support. The pathobiology of mucositis is now recognized to be highly complex with activation and expression of various pathways and mediators, many of which precede the onset of clinical signs and symptoms. These discoveries have facilitated the identification of a variety of potential targets for novel mechanistically-based therapies aimed at the prevention and attenuation of oral mucositis. This is an exciting era for translational mucositis research in a rapidly transforming oncology landscape where increasingly intensive and targeted treatment regimens continue to challenge the limits of supportive care. 33 speaker MORBIDITY AFTER SURGICAL TREATMENT S. Rogers' UNIVERSITY HOSPITALAINTREE, Department of Head and Neck, Liverpool, Merseyside, United Kingdom
'
In this presentation the key factors associated with morbidity following surgery for head and neck cancer will be discussed. Morbidity will be set in the context of social concern, family, and psychosocial support for late surgical toxicities. Post-operative morbidity as part of the post-surgical admission will not be discussed e.g infection, reconstruction failure, fistula. The focus will be on patient derived outcomes based on patient self completed questionnaires. Morbidity after surgical treatment will be considered in terms of 'physical function' involving chewing, swallowing, speech, taste, saliva and appearance, 2) 'social-emotional function' involving anxiety, mood, pain, activity, recreation and shoulder function. Also 'morbidity' will be explained in terms of what the patients concerns are when attending follow-up review appointments as identified by the Patient Concerns Inventory (PCI). 1.Rogers SN, Lowe D, Yueh B, Weymuller EA. The Physical function and Social-Emotional function subscales of the University of Washington Quality of Life questionnaire (UW-QOL). Arch Otolaryngol Head Neck Surg.2010; 136: 352-357. 2.Rogers SN, El-Sheikha J, Lowe D. The development of a Patients Concerns Inventory (PCI) to help reveal patients concerns in the head and neck clinic.Ora1 Oncol. 2009; 45: 555-561.
'
34 speaker ACUTE AND LATE RADIATION-INDUCED SWALLOWING DYSFUNCTION IN HEAD AND NECK RADIOTHERAPY H. Langendijk'
' UNIVERSITY MEDICALCENTER GRONINGEN/ UNIVERSITY OF GRONIN-
GEN,
Groningen, Netherlands
Introduction: The last decade, major progress has been made in the treatment of head and neck squamous cell carcinoma (HNSCC). There is growing evidence that more aggressive treatment regimens, either the delivery of radiotherapy with concomitant chemotherapy or altered fractionation schedules, improve tumour control and survival. However, these new treatment regimens have come to the expense of increased morbidity, in particular, an increase in radiation-induced swallowing dysfunction (RISD). As health-related quality of life is particularly affected by RISD, prevention of this side effect may improve the therapeutic ratio of treatment for HNSCC. One of the ways to prevent RISD is to reduce the dose to the anatomical structures involved in
SATURDAY, FEBRUARY 26,201 1 swallowing, i.e. the swallowing organs at risk (SWOARs). Which anatomical structures should be spared?: Several authors investigated the relationship between the dose distributions in potential SWOARs and RISD. These studies retrieved different results, which may be due to a number of methodological problems, including the relatively small number of patients in most of these studies, differences in eligibility criteria among the different studies, differences in study design and endpoints chosen and differences in the definition and delineation of the SWAORs. To overcome these problems, we performed a prospective cohort study in two centres including 360 patients in which all possible relevant pre-treatment, treatment and outcome determinants were prospectively collected according to well defined guidelines. The primary endpoint was grade 2 2 RlSD at 6 months after completion of (chemo) radiation ((CH) RT) according to the RTOG late morbidity criteria (SWALMG). The prevalence of SWAL-M6 was 40%. The most important predictive factors were the mean dose to the superior pharyngeal constrictor muscle (PCM), the mean dose to the supraglottic area (SG) and the presence of swallowing problems at baseline. The predictive model consisting of these 3 variables had a good performance with an Area Under the Curve (AUC) of 0.79. This model also predicted acute RED and RlSD beyond 6 months. Different SWOARs were involved in the development of different aspects of swallowing problems. Problems with solid food are mainly determined by the mean dose in the PCM superior and inferior, problems with soft food by the dose in the middle PCM, age and tumour site, problems with swallowing liquids are mainly determined by the mean dose in the SG, while aspiration was associated with the mean dose in the SG and the esophageal inlet muscle (EIM). Can we prevent RlSD by swallowing sparing radiation techniques?: In order to see if RED can be prevented by swallowing sparing IMRT (SWIMRT), we performed an in-silico planning comparative study. In this study, we analysed if standard IMRT, aiming at sparing of the parotid glands, could be further developed into SWIMRT by sparing the dose in the aforementioned SWOARs, including the superior, middle and inferior PCM, the SG and the EIM. Based on the results of this in silico study, we expect that the incidence of SWAL-M6, problems with swallowing solid, soft and liquid food and aspiration can be relatively reduced by 29%, 13%. 15%, 23% and 16% respectively. It should be noted that the amount of reduction varies widely among individual patients. Clinical validation: Currently, we are carrying out a prospective cohort study in which patients are actually treated with SWIMRT to validate the assumptions from the prior studies. The first results of this study will be presented during the meeting. 35 speaker THE VIEW POINT OF THE ADVOCACY GROUP ON PATIENT MANAGEMENT M. Brooks Abstract not received.
Symposium 6: Metastatic / recurrent disease 36 speaker RE-IRRADIATION IN HEAD AND NECK CANCER E. Lartigau'
' CENTREOSCARLAMBRET,Lille, France
Recurrences are frequent in head and neck cancers and retreatment is a difficult issue. Today's reference treatments are surgery or brachytherapy but are rarely applicable (< 20 % of the patients). Chemotherapy and targeted treatments may be palliative but without real local control. Re-irradiation is an option which has been recently demonstrated to be improved by new technologies (IMRT, SBRT&). As example, treatments with stereotactic body radiotherapy can demonstrate good local control. In our department, 80 patients have been re-irradiated between June 2007 and October 2010. Total dose administered was 36 Gy in 6 fractions of 6 Gy to the 80.85% isodose line on 11 to 12 days. Local control rate > 70% at 18 months with very few toxicity. Preliminary results suggest that fractionated stereotactic radiotherapy is an effective salvage treatment for recurrent HNC in previously irradiated areas. This treatment is feasible and safe with acceptable acute toxicities. Longer follow-up is necessary to evaluate late toxicities, disease free survival and overall survival. Other data will be presented.
SYMPOSIUM
Saturday, February 26,201 1 Symposium Symposium 5: Global care of patients (social concern, family, cultural issues, psychosocial support, what do patients expect, treatment of acute and late toxicities 32 speaker NEW THOUGHTS ON TREATMENT RELATED MUCOSlTlS IN HEAD AND NECK CANCER PATIENTS N. Treister' MEDICALSCHOOL, BRIGHAMAND WOMEN'S HOSPITALAND HARVARD Boston, USA Oral mucositis affects nearly all patients undergoing curative radiation therapy for head and neck cancer. Pain and debilitation are often so severe that patients routinely require feeding tube placement, intensive pain management, and in some cases hospitalization, leading to unscheduled treatment breaks and dose reductions that can jeopardize treatment outcomes. Until recently, mucositis was believed to be an inevitable side effect of radiation therapy leading to dose-dependent basal epithelial destruction and tissue ulceration, with management options limited to palliation and nutritional support. The pathobiology of mucositis is now recognized to be highly complex with activation and expression of various pathways and mediators, many of which precede the onset of clinical signs and symptoms. These discoveries have facilitated the identification of a variety of potential targets for novel mechanistically-based therapies aimed at the prevention and attenuation of oral mucositis. This is an exciting era for translational mucositis research in a rapidly transforming oncology landscape where increasingly intensive and targeted treatment regimens continue to challenge the limits of supportive care. 33 speaker MORBIDITY AFTER SURGICAL TREATMENT S. Rogers' UNIVERSITY HOSPITALAINTREE, Department of Head and Neck, Liverpool, Merseyside, United Kingdom
'
In this presentation the key factors associated with morbidity following surgery for head and neck cancer will be discussed. Morbidity will be set in the context of social concern, family, and psychosocial support for late surgical toxicities. Post-operative morbidity as part of the post-surgical admission will not be discussed e.g infection, reconstruction failure, fistula. The focus will be on patient derived outcomes based on patient self completed questionnaires. Morbidity after surgical treatment will be considered in terms of 'physical function' involving chewing, swallowing, speech, taste, saliva and appearance, 2) 'social-emotional function' involving anxiety, mood, pain, activity, recreation and shoulder function. Also 'morbidity' will be explained in terms of what the patients concerns are when attending follow-up review appointments as identified by the Patient Concerns Inventory (PCI). 1.Rogers SN, Lowe D, Yueh B, Weymuller EA. The Physical function and Social-Emotional function subscales of the University of Washington Quality of Life questionnaire (UW-QOL). Arch Otolaryngol Head Neck Surg.2010; 136: 352-357. 2.Rogers SN, El-Sheikha J, Lowe D. The development of a Patients Concerns Inventory (PCI) to help reveal patients concerns in the head and neck clinic.Ora1 Oncol. 2009; 45: 555-561.
'
34 speaker ACUTE AND LATE RADIATION-INDUCED SWALLOWING DYSFUNCTION IN HEAD AND NECK RADIOTHERAPY H. Langendijk'
' UNIVERSITY MEDICALCENTER GRONINGEN/ UNIVERSITY OF GRONIN-
GEN,
Groningen, Netherlands
Introduction: The last decade, major progress has been made in the treatment of head and neck squamous cell carcinoma (HNSCC). There is growing evidence that more aggressive treatment regimens, either the delivery of radiotherapy with concomitant chemotherapy or altered fractionation schedules, improve tumour control and survival. However, these new treatment regimens have come to the expense of increased morbidity, in particular, an increase in radiation-induced swallowing dysfunction (RISD). As health-related quality of life is particularly affected by RISD, prevention of this side effect may improve the therapeutic ratio of treatment for HNSCC. One of the ways to prevent RISD is to reduce the dose to the anatomical structures involved in
SATURDAY, FEBRUARY 26,201 1 swallowing, i.e. the swallowing organs at risk (SWOARs). Which anatomical structures should be spared?: Several authors investigated the relationship between the dose distributions in potential SWOARs and RISD. These studies retrieved different results, which may be due to a number of methodological problems, including the relatively small number of patients in most of these studies, differences in eligibility criteria among the different studies, differences in study design and endpoints chosen and differences in the definition and delineation of the SWAORs. To overcome these problems, we performed a prospective cohort study in two centres including 360 patients in which all possible relevant pre-treatment, treatment and outcome determinants were prospectively collected according to well defined guidelines. The primary endpoint was grade 2 2 RlSD at 6 months after completion of (chemo) radiation ((CH) RT) according to the RTOG late morbidity criteria (SWALMG). The prevalence of SWAL-M6 was 40%. The most important predictive factors were the mean dose to the superior pharyngeal constrictor muscle (PCM), the mean dose to the supraglottic area (SG) and the presence of swallowing problems at baseline. The predictive model consisting of these 3 variables had a good performance with an Area Under the Curve (AUC) of 0.79. This model also predicted acute RED and RlSD beyond 6 months. Different SWOARs were involved in the development of different aspects of swallowing problems. Problems with solid food are mainly determined by the mean dose in the PCM superior and inferior, problems with soft food by the dose in the middle PCM, age and tumour site, problems with swallowing liquids are mainly determined by the mean dose in the SG, while aspiration was associated with the mean dose in the SG and the esophageal inlet muscle (EIM). Can we prevent RlSD by swallowing sparing radiation techniques?: In order to see if RED can be prevented by swallowing sparing IMRT (SWIMRT), we performed an in-silico planning comparative study. In this study, we analysed if standard IMRT, aiming at sparing of the parotid glands, could be further developed into SWIMRT by sparing the dose in the aforementioned SWOARs, including the superior, middle and inferior PCM, the SG and the EIM. Based on the results of this in silico study, we expect that the incidence of SWAL-M6, problems with swallowing solid, soft and liquid food and aspiration can be relatively reduced by 29%, 13%. 15%, 23% and 16% respectively. It should be noted that the amount of reduction varies widely among individual patients. Clinical validation: Currently, we are carrying out a prospective cohort study in which patients are actually treated with SWIMRT to validate the assumptions from the prior studies. The first results of this study will be presented during the meeting. 35 speaker THE VIEW POINT OF THE ADVOCACY GROUP ON PATIENT MANAGEMENT M. Brooks Abstract not received.
Symposium 6: Metastatic / recurrent disease 36 speaker RE-IRRADIATION IN HEAD AND NECK CANCER E. Lartigau'
' CENTREOSCARLAMBRET,Lille, France
Recurrences are frequent in head and neck cancers and retreatment is a difficult issue. Today's reference treatments are surgery or brachytherapy but are rarely applicable (< 20 % of the patients). Chemotherapy and targeted treatments may be palliative but without real local control. Re-irradiation is an option which has been recently demonstrated to be improved by new technologies (IMRT, SBRT&). As example, treatments with stereotactic body radiotherapy can demonstrate good local control. In our department, 80 patients have been re-irradiated between June 2007 and October 2010. Total dose administered was 36 Gy in 6 fractions of 6 Gy to the 80.85% isodose line on 11 to 12 days. Local control rate > 70% at 18 months with very few toxicity. Preliminary results suggest that fractionated stereotactic radiotherapy is an effective salvage treatment for recurrent HNC in previously irradiated areas. This treatment is feasible and safe with acceptable acute toxicities. Longer follow-up is necessary to evaluate late toxicities, disease free survival and overall survival. Other data will be presented.