n3h0-30lh/90 $3.00 + .I0 (‘opynght ii; 1990 Pergamon Press plc

??Original Contribution

SINGLE FRACTION PER DAY VERSUS TWO FRACTIONS PER DAY VERSUS RADIOCHEMOTHERAPY IN THE TREATMENT OF HEAD AND NECK CANCER F. SANCHEZ, M.D., A. MILL& M.D., J. TORNER, M.D., F. BONET, M.D., N. ARTOLA, M.D., L. CARRE~O, M.D., L. M. MOYA, M.D., D. RIERA, M.D., S. RIPOL, M.D. AND L. CIRERA, M.D. Radiotherapyand OncologicalDepartment,I. Policlinico.21 Plat6nst., 08006, Barcelona.Spain From January 1978 to January 1988, 859 patients with T3-T4, NO-3, MO were randomly allocated to receive either: Group A-60Co 60,60 Gy in 30 fractions; Group B-60Co, 70.4 Gy in 64 fractions; Group C-60Co, 60 Gy in 30 fractions plus chemotherapy (5 Fu, 250 mg/m2/IV every 2 days). Chemotherapy and radiotherapy were combined simultaneously. The average age was 56 years; the male/female ratio was 802/57. Median performance status (ECOG scale) was 1 (range O-2). The TNM distribution as UICC criteria was T3 529 patients; T4 330 patients; No 217 patients; Nl 52 patients; N2 319 patients; and N3 271 patients. The primary sites were nasopharynx 92, oral cavity 252, hypopharynx 119, larynx 310, and others (sinuses and unknown primary) 86. Complete response was achieved in 188/277 patients in Group A (67.8%), 254/282 patients in Group B (90%), and 289/300 in Group C (96.3%). All patients were followed and statistical analysis shows a significant improvement in median duration of response, as well as survival for Groups B and C compared with Group A. No significant differences were seen between Group B and C. The acute toxicity was mucositis, skin toxicity, bone marrow depression. A mean temporary weight loss of 4.9 Kg was observed with a range of 2.3-10.5 Kg. Head and neck cancer, Locally advanced, Radiotherapy,

Hiperfragmentation,

INTRODUCTION

Radiochemotherapy.

ventional irradiation motherapy.

Cancer of the head and neck is perhaps the most frequent malignant tumor in the world. The majority of cases (7080%) are locally advanced at the time of diagnosis. This has a direct influence on the probability of disease-free survival at 5 years, which oscillates between 0 and 60% when treated by surgery and/or standard radiotherapy according to series. In fact, around 50% of all patients will continue with local relapse after initial response, and up to 30% will present with distance metastasis (2). The attempt to improve such poor results has motivated many researchers. The traditional strategy of radiotherapy has been modified. Hyperfragmentation, the use of radiopotentiators, etc. have produced notable improvements in responses. During the last decade, the use of cytostatics together with radiotherapy has supplied the best results. In principle, the use of medicaments in combination with radiotherapy is based, on one side, on their potential radiosensibilizing effect, and on the other, on their possible effectiveness for the destruction of hypothetical micrometastasic localizations. This report presents the results of a randomized study started in January 1978. comparing conventional radiotherapy with irradiation in hyperfragmentation and con-

together

METHODS

AND

with

simultaneous

che-

MATERIALS

Selection of patients: From January 1978 to January 1988, 892 patients were included in this study, with diagnosis of squamous cell carcinoma of the head and neck in locally advanced phase (MO). Among them, 859 patients were evaluable for the purpose ofthis study. In Table 1 general characteristics are shown. In Table 2 different tumoral sites are considered. For several reasons 33 patients were non-evaluable. In two instances this was because of death unrelated to treatment, in nine instances it was because of inadequate initial staging, and finally in the remaining 22 patients it was because they didn’t follow the therapeutic program in an adequate manner. All patients were staged by clinical exploration with endoscopy, CT scan of the primary area of tumoral seat and zones of lymphatic drainage, radiology of the thorax, bone scintigraphy, and hepatic ultrasound. Classification was based on criteria proposed by UICC (6). Table 3 shows the TNM distribution of patients. Only patients with appropriate performance status (ECOG) were included.

Presentedat the 17th InternationalCongressof Radiology,

Reprintrequeststo: F. Sanchiz,M.D. Accepted

Paris, July 1989. I347

for publication

21 June 1990

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Table 1. Patient characteristics Group

No. patients No evaluable Median age Age range Male/female ratio Performance status (ECOG) 0 1 2

A

B

C

Total

294 217 56.2 31-75 261/16

292 292 55.4 30-75 26 l/2 1

306 300 56.1 30-75 280120

892 852 56 30-75 802/57

131 138 31

391 389 79

141 114 22

134 122 26

Table 2. Sites of primary

December 1990, Volume 19, Number 6

Arm C: Cobaltherapy, 2 Gy per day, 60 Gy in 6 weeks, plus 5 FU at a dose of 250 mgs/m2/iv on alternate days, always applied immediate to irradiation. Evaluation of response: This was made at the conclusion of treatment, using the same diagnostic techniques used at the beginning. For the estimation of relapse-free interval and survival, only patients who presented complete response were considered (CR). This was defined as the total disappearance of all clinical evidence of the tumor. Statistic methodology: The relapse-free interval and actuarial survival were measured: the method of Kaplan and Meier was used for this (4). The curves were compared by log-rank test (5).

Group RESULTS

Nasopharynx Oral cavity Hypopharynx Larynx Other (sinuses,

unknown

primary)

Total

Table 3. Tumor(T)

Arm A B c

A

B

C

Total

29 91 37 99 21

28 84 36 104 30

35 77 46 107 35

92 252 119 310 86

277

282

300

859

and node (N) staging

3

4

0

1

2

3

176 174 179

101 108 121

68 70 79

16 17 19

101 104 114

92 91 88

Study Design: Patients were randomized among three different options (see Fig. 1): Arm A: Cobaltherapy, 2 Gy per day, 60 Gy in 6 weeks. Arm B: Cobaltherapy, 2.2 Gy per day in two fractions. with a minimum interval of 3 hr, and total dose of 70.4 Gy in 6.4 weeks.

THERAPY

DAILY DOSE

TOTAL TUMOR DOSE

2Gy

60 Gy

60

R A N D 0 M I z A T I 0 N

The study includes 859 patients: 277 were treated with radiotherapy of traditional fragmentation, 282 were treated with irradiation of hyperfragmentation, and 300 were treated with radiochemotherapy. The responses are substantially superior in the B and C groups (90% and 96.3%, respectively), to those seen in Group A (67.8%). Table 4 shows response according to site. In general. acute toxicity was moderate (Table 5). with the majority of undesirable effects being grouped in 1 and 2 degrees. The radiochemotherapy group shows a slightly greater toxicity, although not at significant levels. Late treatment sequelae include moderate xerostomia (42% of patients), bone necroses ( I 1% of patients), and skin elastoses ( 19% of patients). The average duration of response was 25.2 months for Group A, 5 1.1 months for Group B, and 60.2 months for Group C, with a significant difference favorable to Groups B and C when compared with Group A (Fig. 2). Average survival was 38.3 months for Group A, 84 months for Group B, and 85.1 months for the Group C; significant statistical values were again found to be favorable to the

CO

/ / /

/

/ --\

60 co

2,2 Gy (twice)

70.4 Gy

\ \ \ \

60 CO + 5Fu

2 GY 250 mgs/m2/iv/every

Fig. I. Study design.

60 Gy 2 days

I349

Head and neck cancer 0 F. SANCHEZP( al. Table 4. Responses

by sites Group B

A Nasopharynx Oral cavity Hypopharynx Larynx Others

20/29 49/91 23137 82/99 14/21

Total

(68%) (53%) (62%) (82%) (66%)

26/28 79/84 34/36 94/104 21/30

188/277 (67.8%)

c (92%) (94%) (94%) (90%) (70%‘)

34135 75177 42146 105/107 33135

254/282 (90%‘)

(97%) (97%,) (91%)) (97%)) (944’)

289/300 (96.3%)

Table 5. Acute toxicity Grade according Effect

Arm

Mucositis

Skin toxicity

Bone marrow

depression

-

c

-

A B

16 (6%) 17 (6%) -

c Mean temporary

weight loss 4.9 kg (range 2.3-10.5

DISCUSSION The object of this study was to determine whether irradiation with hyperfragmentation and/or radiotherapy together with chemotherapy. administered simultaneously, produced a better response than conventional

I 1

I 2

I 3

I

I

I

I

1

0

‘

7

Fig. 2. Progression-free

I .

period.

I 9

187 201 164 244 259 262 I85 191 143

(67%,) (71%) (55%) (88%) (918) (87%) (67%) (68%‘) (47%)

2 76 70 105 33 22 34 76 74 I46

3

4

(27%‘) (25%) (35%‘) (12%‘) (8%)

14 (6%) I I (4%) 31 (10%)

-

](I%)

-

(1 I%‘,

4 (3%))

(27%‘) (26%‘) (48%)

-

I I (5%)

kg.).

two latter groups (Fig. 3). (Table 6 shows the recurrence pattern. Table 7 summarizes causes of death.)

I

I

0

A B c A B

to the WHO criteria

irradiation and to determine if both therapeutic modalities influenced the duration of response and survival. The results provided by conventional irradiation are similar to those obtained by other researchers (3). However. the other two branches induced a greater number of positive responses, reflected in the relapse-free interval and the average survival of both groups. The statistical analysis shows a 17% probability of disease-free survival at IO years, with regards to 37% of Group

1 to-

Fig. 3. Overall survival.

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Table 6. Patterns of recurrence Group A

B

C

Local Regional Metastasis

55 106 21

35 119 7

66 119 I5

Total

188

161

200

Table 7. Causes of death Group

C Progressive disease Hemorrhage Infection Other

129 29 26 4

118 16 29 6

108 29 31 II

B and 3 1% of Group C. Likewise, the probability of survival is 17% for Group A, in the same period, with regards to 40% of Group B and 42% of Group C.

December 1990. Volume 19. Number 6

Another concern which must be addressed is whether the toxicity produced was higher. The toxicity patterns observed were similar in the three groups. However, a fairly major incidence of grade 3 toxicities was noted in patients receiving radiochemotherapy. The strategy of radiochemotherapy combinations may be done in three ways (1): chemotherapy prior to irradiation, simultaneous radiotherapy and chemotherapy, and radiotherapy with intercalation of chemotherapy. Considering the advantages and disadvantages of the three strategies, we prefer simultaneous administration. Among the positive aspects of simultaneous administrations, we note the radiosensibilizing function of the cytostatic drugs, and perhaps tumoral reduction induced by medication will increase the proliferative level, thus making the cells more sensitive to the effect of cytostatics. The problems signified by the increase of toxicity can itself be notably attenuated with the use of non-myelotoxic drugs which can be administered at lower doses than those used in noncombined drug therapy since they produce the desired effect in lower doses. Finally, to increase the relapse-free interval after initial response, the same drugs that had shown their effectiveness in the initial treatment should be used, now with adjuvant character.

REFERENCES Choksi, A. J.; Dimery, I. W.; Kramer, A.; Hong, W. K. Strategy of combining chemotherapy and radiotherapy in advanced head and neck cancer. In: Jacquillat, C., Weil, H., Khayat, D., eds. Neo-adjuvant chemotherapy. London: John Libbey Eurotext; 1988:287-294. Honk, W. K.; Bromer, R. Chemotherapy in head and neck cancer. N. Eng. J. Med. 308(2):75-79; 1983. Jesse, R. H.; Fletcher, G. H.; Lindberg, R. D.; et al. Cancer of the head and neck. In: Clark, R. L., Howe, C. D.. eds. Cancer patient care at M. D. Anderson Hospital and Tumor

Institute. Chicago: Yearbook Medical Pub. Inc.; 1976:89I24 Kaplan. E. L.: Meier, P. Nonparametric estimation from incomplete observations. J. Am. Stat. Assoc. 53:457-474; 1958. Peto, R.; Pike. M. Conservation of the approximation e (O/ E) 2/E in the log-rank test for survival data on tumor incidence data. Biometrics 29:579-585; 1973. UICC. TNM classification of malignant tumors. Geneve: UICC, 1978.