Selective use of postoperative neck radiotherapy in oral cavity and oropharynx cancer: a prospective clinical study

Abstract

BackgroundIn cervical postoperative radiotherapy, the target volume is usually the same as the extension of the previous dissection. We evaluated a protocol of selective irradiation according to the risk estimated for each dissected lymph node level.MethodsEighty patients with oral/oropharyngeal cancer were included in this prospective clinical study between 2005 and 2008. Patients underwent surgery of the primary tumor and cervical dissection, with identification of positive nodal levels, followed by selective postoperative radiotherapy. Three types of selective nodal clinical target volume (CTV) were defined: CTV0, CTV1, and CTV2, with a subclinical disease risk of <10%, 10-25%, and 25% and a prescribed radiation dose of <35 Gy, 50 Gy, and 66–70 Gy, respectively. The localization of node failure was categorized as field, marginal, or outside the irradiated field.ResultsA consistent pattern of cervical infiltration was observed in 97% of positive dissections. Lymph node failure occurred within a high-risk irradiated area (CTV1-CTV2) in 12 patients, marginal area (CTV1/CTVO) in 1 patient, and non-irradiated low-risk area (CTV0) in 2 patients. The volume of selective lymph node irradiation was below the standard radiation volume in 33 patients (mean of 118.6 cc per patient). This decrease in irradiated volume was associated with greater treatment compliance and reduced secondary toxicity. The three-year actuarial nodal control rate was 80%.ConclusionThis selective postoperative neck irradiation protocol was associated with a similar failure pattern to that observed after standard neck irradiation and achieved a significant reduction in target volume and secondary toxicity.

Patterns of recurrence after selective postoperative radiation therapy for patients with head and neck squamous cell carcinoma

“…Thus, different approaches should be made to improve the clinical results for patients with oral cavity or recurrent disease. In this study, the most frequent site of regional recurrence was the high-risk CTV (70 %), similar results showed with Carrillo et al [ 15 ]. Out of field regional recurrence was observed more frequently in ipsilateral neck than contralateral neck whereas only one patient developed contralateral-neck failure.…”

“…Later on, selective neck dissection (SND) was introduced which preserved one or more lymph node levels [ 10 ] and the development of common terminology of discriminating neck levels which was well-known as the classification of American Head and Neck Society (AHNS) followed [ 11 , 12 ]. However, the applicability of the concept of the selective nodal irradiation in postoperative setting is controversial [ 13 – 15 ]. Gregoire et al [ 13 ] and Chao et al [ 14 ] proposed the clinical target volume (CTV) guidelines for postoperative neck region, but the authors admitted the paucity of data on which one could create a specific guideline for postoperative CTV.…”

Современные Аспекты Лечения Плоскоклеточного Рака Головы И шеи

“…В исследовании Carrillo et al [24] по результатам регионарной лимфодиссекции были идентифицированы три клинических объема для регионарных ЛУ: CTV0, CTV1 и CTV2 с риском поражения <10%, 10-25% и 25% с предписанной дозой <35 Гр, 50 Гр и 66-70 Гр соответственно. Рецидивы в зоне высокого риска (CTV1 CTV2) диагностированы в 12 случаях, рецидивы в маргинальной зоне (CTV1/ CTVO) -в 1, вне зоны облучения -в 2 случаях.…”

“…Трехлетний регионарный контроль составил 80%. Результаты такого селективного послеоперационного облучения регионарных ЛУ оказались сопоставимы со стандартным объемом облучения при меньшем риске осложнений [24]. Эти данные свидетельствуют о том, что преимущества дифференцированного подведения различного уровня доз к клиническим объемам в зависимости от риска рецидива могут быть реализованы при точной идентификации этих объемов, что, в свою очередь, возможно при тесном взаимодействии специалистов на всех этапах лечения.…”

Response to “Evaluation of purely accelerated six fractions per week radiotherapy in postoperative oral cavity squamous cell carcinoma”—Does it require to irradiate neck in pN0 disease?

“…Although historically, the neck has been included in irradiating mid‐line OCSCC, there is growing evidence that postoperative radiotherapy (PORT) can be omitted safely in pN0 neck as the risk of occult metastases in surgically negative necks is low. Carrillo et al 4 reported that selected neck radiation postoperatively, in OCSCC and oropharyngeal primaries was safe and there were only 2.7% failures in unirradiated neck nodes. This resulted in an improved acute toxicity (16% Grade 3 OM and 14% grade 3 dysphagia).…”