Radiation Therapy in Head and Neck Cancer

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • A randomized study by the radiation therapy oncology group (RTOG) 90–03:
    • Evaluated the use of low-LET radiation alone
      with four fractionation schemes for the treatment of squamous cell carcinoma of the head and neck
    • Patients included in this trial underwent radiation therapy as a single modality, without the use of chemotherapy
    • The sites included the oral cavity, oropharynx, hypopharynx, and supraglottic larynx
    • The stages were limited to III and IV (with no distant metastases):
      • However, the base of the tongue and the hypopharynx subsites included stage II patients as well
    • The four arms were as follows:
      • Conventional fractionation:
        • The conventional fractionation schedule that entails use of 180 to 200 cGy per fraction
        • One fraction per day, 5 days per week for 6 to 7 weeks for a total dosage of 6500 to 7000 cGy has evolved empirically over many years
      • Hyperfractionation:
        • Hyperfractionation is preferred for slowly proliferating tumors
        • Hyperfractionation improves the therapeutic ratio primarily through:
          • Redistribution of tumor cells into more radiosensitive phases as a result of multiple fractions
          • Differential sparing of late-responding normal tissues because of a decrease in the size of the dose per fraction
        • Hyperfractionation:
          • Smaller fraction size (115 to 120 cGy) compared with conventional fractionation (180 to 200 cGy)
          • BID to TID fractionation
          • Larger total dosage (7440 to 8460 cGy) than conventional fractionation (7000 cGy)
          • Similar overall treatment duration as
            conventional fractionation
      • Accelerated fractionation with split:
        • Accelerated fractionation is the strategy of choice for rapidly proliferative tumors
        • Accelerated fractionation is based on the concept that the shortened overall treatment time would reduce the opportunity for accelerated repopulation effectively
        • Accelerated fractionation:
          • Similar fraction size as conventional fractionation (180 to 200 cGy)
          • BID to TID fractionation
          • Similar total dosage as conventional
            fractionation
          • Shortened overall treatment
            duration compared with conventional fractionation
      • Accelerated fractionation with a concomitant boost
  • The RTOG 90-03:
    • Had a significantly improved 2-year locoregional control and disease-free survival rate with:
      • Accelerated fractionation with a concomitant boost compared with conventional fractionation and accelerated fractionation with a split
    • Patients treated with hyperfractionation also had a trend toward improved results:
      • However, a phase III Groupe Oncologie Radiotherapie Tete et Cou cooperative trial did not show a benefit when altered fractionation was combined with chemotherapy
      • In fact, patients treated with accelerated fractionation with concurrent chemotherapy experienced more toxicities than did patients treated with conventional fractionation with concurrent chemotherapy
  • The RTOG 99-14 trial:
    • Asked the same question about whether chemotherapy given concurrently with concomitant boost radiation can further improve on locoregional control
    • Because of the encouraging preliminary results, RTOG 01-29 was conducted to answer the question of whether altered fractionation should be used in the setting of chemotherapy
    • The results of this two-arm prospective randomized trial of more than 700 patients was was reported:
      • Showing that when chemotherapy is given concurrently with radiation:
        • There is no added benefit of using altered fractionation compared with standard once-daily radiation
      • Furthermore, the long-term grade 3 to 4 late toxic effects of chemotherapy from RTOG 99-14 with concomitant boost radiation was extremely high at 42%
      • Gastrostomy tube dependence rates anytime during follow-up, at 1 year, and at 2 years were 83%, 41%, and 17%, respectively
      • However, it should be mentioned that these patients were treated with older, conventional nonconformal radiation techniques, such as Cobalt 60
      • Since the introduction of IMRT, which allows for significant reduction in radiation dose to normal tissues, treatment-associated toxicities have improved
  • Three randomized studies comparing conventional radiation technique versus IMRT for head and neck cancer:
    • Have indeed shown that there are lower late complications with IMRT
    • Furthermore, there is no evidence that IMRT causes compromise in locoregional control
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Published by Rodrigo Arrangoiz MS, MD, FACS, FSSO

My name is Rodrigo Arrangoiz I am a breast surgeon/ thyroid surgeon / parathyroid surgeon / head and neck surgeon / surgical oncologist that works at Center for Advanced Surgical Oncology in Miami, Florida. I was trained as a surgeon at Michigan State University from (2005 to 2010) where I was a chief resident in 2010. My surgical oncology and head and neck training was performed at the Fox Chase Cancer Center in Philadelphia from 2010 to 2012. At the same time I underwent a masters in science (Clinical research for health professionals) at the University of Drexel. Through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center I performed a two year head and neck surgery and oncology / endocrine fellowship that ended in 2016. Mi nombre es Rodrigo Arrangoiz, soy cirujano oncólogo / cirujano de tumores de cabeza y cuello / cirujano endocrino que trabaja Center for Advanced Surgical Oncology en Miami, Florida. Fui entrenado como cirujano en Michigan State University (2005 a 2010 ) donde fui jefe de residentes en 2010. Mi formación en oncología quirúrgica y e n tumores de cabeza y cuello se realizó en el Fox Chase Cancer Center en Filadelfia de 2010 a 2012. Al mismo tiempo, me sometí a una maestría en ciencias (investigación clínica para profesionales de la salud) en la Universidad de Drexel. A través de la Federación Internacional de Sociedades de Cabeza y Cuello / Memorial Sloan Kettering Cancer Center realicé una sub especialidad en cirugía de cabeza y cuello / cirugia endocrina de dos años que terminó en 2016.

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