Prediction of Distant Metastasis in Head Neck Cancer Patients: Implications for Induction Chemotherapy and Pre-treatment Staging?

Abstract

Background and Purpose: Intensity modulated radiation therapy (IMRT) combined treatment approaches, surgical and radiodiagnostic advances, respectively, lead to improved local-regional control in head neck cancer (HNC). With increasing local-regional control, distant metastases (DM) become more meaningful. In some trials without concomitant chemotherapy, induction chemotherapy (IC) resulted in an absolute reduction of DM by ~10-15%. In order to define a more efficient selection of patients at risk for DM with respect to IC and M-staging, we analysed our patients treated by contemporary standards. Patients and Methods: Between 1/2002 to 12/2007, 409 HNC patients were treated with IMRT; 303/409 (74%) underwent definitive, 106 (26%) postoperative IMRT. The mean/median follow-up was 23/20 months (3-72). 70% tolerated 4-7, 9% 1-3 cycles of simultaneous cisplatin. Treatment followed a prospectively designed protocol. In a previous study with 172 HNC IMRT patients, gross tumor volume (GTV) was found the strongest predictor for local-regional control. In the current study, this criterion has been prospectively tested for DM. Numbers needed to treat were calculated for IC. Results: DM developed in 28/399 (7%) patients; 10 presented initially with DM (total 38/409). In 13/28 (46%), DM remained the only manifestation of disease. GTV was the strongest predictor for DM (p < 0.0001) of all tested. Only 4% of patients with GTV < 70 cc developed DM, vs. 25% (18/73) with > 70 cc; only 6 of them (6/73, 8%) developed isolated DM. Conclusion: GTV was the most significant predictor for DM, that could guide selective pre-treatment M-staging. The subgroup with isolated DM in the high risk group, that could benefit from IC, is small. (Table 1). Die Therapie folgte einem prospektiv festgelegten Protokoll. In einer früheren Studie mit 172 KHTPatienten mit definitiver IMRT wurde das "gross tumor volume" (GTV) als signifikantester Prädiktor für die Lokoregionalkontrolle nachgewiesen. In der hier präsentierten Studie wurde dasselbe volumetrische Staging-System getestet hinsichtlich dessen prä-diktiven Wert für DM, um eine allfällige IC wie auch die initiale Metastasensuche selektiver auf ein Hochrisikopatientensegment beschränken zu können. Ergebnisse: DM fanden sich bei 38/409 Patienten bzw. bei 28/399 mit initialem M0-Status (7%) (Abbildung 1, Tabelle 2); 10 Patienten hatten initial bereits DM. Bei nur 13/28 (46%) blieben DM die einzige Krankheitsmanifestation. Das GTV erwies sich als signifikantester aller getesteter Metastasenprädiktoren (p < 0,0001, Abbildung 2, Tabelle 3); nur 4% der Patienten mit einem GTV < 70 cc entwickelten DM, vs. 25% (18/73) mit GTV > 70 cc, von diesen nur 6 mit isolierter DM (6/73, 8%). IntroductionClinical implementation of intensity modulated radiation therapy (IMRT), together with combined treatment approaches in definitive and postoperative treatment settings, surgical and radio-diagnostic advances, respectively, lead to an encouraging improvement of the loco-regional control in head and neck cancer (HNC)...

Adjuvant Low Single Dose Cisplatin-based Concurrent Radiochemotherapy of Oral Cavity and Oropharynx Carcinoma

“…These results are in agreement with data from Carvalho et al [4]. In addition, Studer et al [21] have also shown that a gross tumor volume > 70 ml in combination with locoregionally advanced stages (≥ T3 N1-3) are risk predictors for distant metastases (DM) in H&N cancer patients [18]. There is no doubt that the risk of capsular rupture of neck nodes is related to the higher N2b,c/3 categories of the TNM classification [7].…”

Cystatin C – A Fast and Reliable Biomarker for Glomerular Filtration Rate in Head and Neck Cancer Patients

“…The urinary clearance of exogenous substances, such as (51)Cr-EDTA and inulin, are accepted as gold standards for GFR assessment. However, because of costs and inconvenience, plasma creatinine, creatinine clearance (ECC), and creatinine-based estimation formulas are most commonly used to measure renal function [7,8,13,14,30,31].…”

Radiochemotherapy Including Cisplatin Alone versus Cisplatin + 5-Fluorouracil for Locally Advanced Unresectable Stage IV Squamous Cell Carcinoma of the Head and Neck

“…RT alone, which had been the standard treatment for patients with unresectable tumors for many years, resulted in survival rates of < 25% and 2-year locoregional control (LC) rates of < 20% [1,2,17,23]. Several approaches have been tried in order to improve the prognosis of these patients [6,11,21,24]. Treatment outcome may be improved by adding concurrent chemotherapy [1,2,8,10].…”