AM ER IC AN JOURNAL OF OT OLARYNGOLOGY–H E A D A N D NE CK M E D IC IN E A ND S U RGE RY 3 6 (2 0 1 5) 1 17–1 2 1
Available online at www.sciencedirect.com
ScienceDirect www.elsevier.com/locate/amjoto
Original contributions
Chemoradiation in elderly patients with head and neck cancers: a single institution experience☆,☆☆ Tejinder Kataria, MD, DNB, Deepak Gupta, MD⁎, Shyam Singh Bisht, MD, Shikha Goyal, MD, DNB, Trinanjan Basu, MD, Anurita Srivastava, MD, DNB, Ashu Abhishek, MD, Govardhan HB, MD, DNB, Kuldeep Sharma, MD, DNB, Vikash Kumar, MD Division of Radiation Oncology, Medanta Cancer Institute, Medanta The Medicity, Gurgaon, Haryana, India
ARTI CLE I NFO
A BS TRACT
Article history:
Aims: To evaluate the efficacy and toxicity of concurrent chemoradiation in patients with
Received 19 June 2014
head and neck cancers aged 65 and older. Materials
and
methods:
Thirty-two
elderly
patients
were
treated
with
radical
chemoradiation. Twenty-six (81.3%) out of thirty-two patients had stage III–IV disease. Twenty-nine (90.6%) patients received concurrent weekly cisplatin or carboplatin, 3 (9.4%) patients received concurrent cetuximab or nimotuzumab. Total dose of radiotherapy ranged from 66 Gy to 70 Gy. Results: Twenty-nine patients (90.6%) completed at least 5 cycles of concurrent chemotherapy. Twenty-four (77.6%) patients achieved complete response. Fourteen (45.2%) patients experienced grade 3 mucositis. None of our patients developed grade 3 or above hematological toxicity. Loco-regional control and overall survival at 2 year were 71.6% and 88.9%, respectively. Conclusions: Chemoradiation in elderly patients with high precision radiotherapy is a feasible option. © 2015 Elsevier Inc. All rights reserved.
1.
Introduction
Head and neck cancers (HNC) constitute the fifth most common subsite of cancer worldwide, with an estimated annual global incidence of 533,100 cases [1]. Majority of HNC occur in the fifth and sixth decades of life but as many as 24%
patients are diagnosed in patients aged 70 years or older. Management of locoregionally advanced disease remains challenging, and an aggressive treatment approach is necessary to achieve cure [2]. MACH-NC meta-analysis showed an absolute survival benefit of 6.5% favoring concurrent chemoradiation [3]. Concurrent chemoradiotherapy is the standard
☆ Copyright transfer: “In consideration of the American Journal of Otolaryngology's reviewing and editing my submission, ‘(Chemoradiation in elderly patients with head and neck cancers: a single institution experience)’, the author(s) undersigned transfers, assigns and otherwise conveys all copyright ownership to Elsevier Inc. in the event that such work is published in the American Journal of Otolaryngology.” ☆☆ Key messages: Chemoradiation in elderly patients. ⁎ Corresponding author at: Division of Radiation Oncology, Medanta Cancer Institute, Medanta The Medicity, Gurgaon, Haryana, India, 122001. Tel.: + 91 8860261459. E-mail address: [email protected] (D. Gupta).
http://dx.doi.org/10.1016/j.amjoto.2014.07.015 0196-0709/© 2015 Elsevier Inc. All rights reserved.
118
AM ER IC AN JOURNAL OF OT OLA RYNGOLOGY–H E A D A N D NE CK M E D ICI N E AN D S U RGE RY 3 6 (2 0 1 5) 1 17 –1 2 1
of care in patients for organ preservation in stage III and IV oropharyngeal and laryngeal cancers, but the same has never been evaluated prospectively among elderly patients. This may drive elderly patients into receiving sub-optimal therapy on the pretext of their supposed lower ability to tolerate radical treatment. However, with technological advancement in the field of radiation oncology and the results of phase III PARSPORT trial emphasizing randomized evidence of reducing toxicities can actually increase the compliance of combined treatment [4]. On the assumption of higher age and related comorbidities, almost all the randomized data excluded elderly patients (patients > 65 years of age) from receiving chemoradiation. So, we conducted this study to evaluate radical chemoradiation among elderly patients to evaluate tolerance, toxicity and efficacy.
2.
Subjects and methods
Patients with histologically proven HNC, aged more than 65 years, Karnofsky performance status (KPS) >70, who were treated with concurrent chemoradiation (CRT) at our center between April 2010 and October 2012, were included in this study. All patients gave informed consent for administering concurrent chemotherapy with radiation therapy. Baseline laboratory requirements for eligibility included a WBC count greater than 3000 cell/μL, an absolute neutrophil count greater than 1500 cell/μL, platelet count >100,000 platelets/μL and serum creatinine 10% weight loss.
2.1.
Radiation therapy
Patients were immobilized in a commercially available custom-molded thermoplastic mask with fixation of head and shoulders. RT planning CECT was acquired with 3 mm slice thickness and zero interslice gap from the vertex to fourth thoracic vertebra with a flat table top configured to linear accelerator table top. The gross tumor volume (GTV) was defined as gross disease determined from CT, clinical information, endoscopic findings and PET-CECT/MRI, when available. Clinical target volumes (CTV1) were defined as the GTV plus areas containing potential microscopic disease, delineated by the treating physician. The GTV–CTV1 expansion was typically 1.5–2 cm, with a minimum of 5 mm except in areas with natural barriers to spread. CTV2 included neck node levels clinically uninvolved but at low risk of dissemination. Planning target volume (PTV1 around CTV1 and PTV2 around CTV2) generation was as per institutional protocol of 5 mm around CTV in all dimensions. Dose was prescribed at 2 Gy per fraction, 66–70 Gy to PTV1 and 54 Gy to PTV2. All relevant organs at risk were assigned dose constraints. Spinal cord and brain stem: maximum dose (Dmax) < 45 Gy, mean dose (Dmean)
Available online at www.sciencedirect.com
ScienceDirect www.elsevier.com/locate/amjoto
Original contributions
Chemoradiation in elderly patients with head and neck cancers: a single institution experience☆,☆☆ Tejinder Kataria, MD, DNB, Deepak Gupta, MD⁎, Shyam Singh Bisht, MD, Shikha Goyal, MD, DNB, Trinanjan Basu, MD, Anurita Srivastava, MD, DNB, Ashu Abhishek, MD, Govardhan HB, MD, DNB, Kuldeep Sharma, MD, DNB, Vikash Kumar, MD Division of Radiation Oncology, Medanta Cancer Institute, Medanta The Medicity, Gurgaon, Haryana, India
ARTI CLE I NFO
A BS TRACT
Article history:
Aims: To evaluate the efficacy and toxicity of concurrent chemoradiation in patients with
Received 19 June 2014
head and neck cancers aged 65 and older. Materials
and
methods:
Thirty-two
elderly
patients
were
treated
with
radical
chemoradiation. Twenty-six (81.3%) out of thirty-two patients had stage III–IV disease. Twenty-nine (90.6%) patients received concurrent weekly cisplatin or carboplatin, 3 (9.4%) patients received concurrent cetuximab or nimotuzumab. Total dose of radiotherapy ranged from 66 Gy to 70 Gy. Results: Twenty-nine patients (90.6%) completed at least 5 cycles of concurrent chemotherapy. Twenty-four (77.6%) patients achieved complete response. Fourteen (45.2%) patients experienced grade 3 mucositis. None of our patients developed grade 3 or above hematological toxicity. Loco-regional control and overall survival at 2 year were 71.6% and 88.9%, respectively. Conclusions: Chemoradiation in elderly patients with high precision radiotherapy is a feasible option. © 2015 Elsevier Inc. All rights reserved.
1.
Introduction
Head and neck cancers (HNC) constitute the fifth most common subsite of cancer worldwide, with an estimated annual global incidence of 533,100 cases [1]. Majority of HNC occur in the fifth and sixth decades of life but as many as 24%
patients are diagnosed in patients aged 70 years or older. Management of locoregionally advanced disease remains challenging, and an aggressive treatment approach is necessary to achieve cure [2]. MACH-NC meta-analysis showed an absolute survival benefit of 6.5% favoring concurrent chemoradiation [3]. Concurrent chemoradiotherapy is the standard
☆ Copyright transfer: “In consideration of the American Journal of Otolaryngology's reviewing and editing my submission, ‘(Chemoradiation in elderly patients with head and neck cancers: a single institution experience)’, the author(s) undersigned transfers, assigns and otherwise conveys all copyright ownership to Elsevier Inc. in the event that such work is published in the American Journal of Otolaryngology.” ☆☆ Key messages: Chemoradiation in elderly patients. ⁎ Corresponding author at: Division of Radiation Oncology, Medanta Cancer Institute, Medanta The Medicity, Gurgaon, Haryana, India, 122001. Tel.: + 91 8860261459. E-mail address: [email protected] (D. Gupta).
http://dx.doi.org/10.1016/j.amjoto.2014.07.015 0196-0709/© 2015 Elsevier Inc. All rights reserved.
118
AM ER IC AN JOURNAL OF OT OLA RYNGOLOGY–H E A D A N D NE CK M E D ICI N E AN D S U RGE RY 3 6 (2 0 1 5) 1 17 –1 2 1
of care in patients for organ preservation in stage III and IV oropharyngeal and laryngeal cancers, but the same has never been evaluated prospectively among elderly patients. This may drive elderly patients into receiving sub-optimal therapy on the pretext of their supposed lower ability to tolerate radical treatment. However, with technological advancement in the field of radiation oncology and the results of phase III PARSPORT trial emphasizing randomized evidence of reducing toxicities can actually increase the compliance of combined treatment [4]. On the assumption of higher age and related comorbidities, almost all the randomized data excluded elderly patients (patients > 65 years of age) from receiving chemoradiation. So, we conducted this study to evaluate radical chemoradiation among elderly patients to evaluate tolerance, toxicity and efficacy.
2.
Subjects and methods
Patients with histologically proven HNC, aged more than 65 years, Karnofsky performance status (KPS) >70, who were treated with concurrent chemoradiation (CRT) at our center between April 2010 and October 2012, were included in this study. All patients gave informed consent for administering concurrent chemotherapy with radiation therapy. Baseline laboratory requirements for eligibility included a WBC count greater than 3000 cell/μL, an absolute neutrophil count greater than 1500 cell/μL, platelet count >100,000 platelets/μL and serum creatinine 10% weight loss.
2.1.
Radiation therapy
Patients were immobilized in a commercially available custom-molded thermoplastic mask with fixation of head and shoulders. RT planning CECT was acquired with 3 mm slice thickness and zero interslice gap from the vertex to fourth thoracic vertebra with a flat table top configured to linear accelerator table top. The gross tumor volume (GTV) was defined as gross disease determined from CT, clinical information, endoscopic findings and PET-CECT/MRI, when available. Clinical target volumes (CTV1) were defined as the GTV plus areas containing potential microscopic disease, delineated by the treating physician. The GTV–CTV1 expansion was typically 1.5–2 cm, with a minimum of 5 mm except in areas with natural barriers to spread. CTV2 included neck node levels clinically uninvolved but at low risk of dissemination. Planning target volume (PTV1 around CTV1 and PTV2 around CTV2) generation was as per institutional protocol of 5 mm around CTV in all dimensions. Dose was prescribed at 2 Gy per fraction, 66–70 Gy to PTV1 and 54 Gy to PTV2. All relevant organs at risk were assigned dose constraints. Spinal cord and brain stem: maximum dose (Dmax) < 45 Gy, mean dose (Dmean)
