Download Postoperative Radiation for Oral Cavity Squamous Cell Carcinoma

Postoperative Radiation for Oral
Cavity Squamous Cell Carcinoma:
The EP
The Difference?
Album
EP
Postoperative Radiation for Oral Cavity
Squamous Cell Carcinoma
• Oral Cavity Cancer is a Surgical Disease
• Use Radiation Postoperatively for
Appropriate Patients
• RT can be used as primary therapy for
small (T1, T2) tumors of the oral cavity.
• Oral tongue
• Floor of Mouth
• Lip
• Best results are with a combination of
external beam radiation and
brachytherapy
Difficult getting enough dose to primary with brachytherapy while still delivering
adequate dose to the regional nodes IJROBP 1990; 18:1287-92.
Brachytherapy complications: soft tissue necrosis, osteonecrosis
Postoperative Radiation for Oral Cavity
Squamous Cell Cancer
•
•
•
•
•
Who needs postop RT?
Definite Indications:
1) Positive Margins
2) Multiple Nodes
3) Extracapsular Extension
Postoperative Radiation for Oral Cavity
Squamous Cell Cancer
•
•
•
•
•
•
Who needs postop RT?
Less certain indications:
1) Lymphovascular space invasion
2) Perineural spread
3) Single encapsulated node +
4) Thick tumors (Tumors 3-9 mm: 44% node+, 7% local
recurrence; >9 mm: 53% subclinical node+, 24% local recurrence Head Neck
2002: 24:513-20)
• 5) Surgeon Vibe
Postoperative Radiation for Oral Cavity
Squamous Cell Cancer
• Why give radiation after surgery?
• RTOG 73-03: locally advanced H&N cancers:
supraglottic larynx, hypopharynx, oral cavity and
oropharynx
• Preop (50 Gy) vs Postop (60 Gy)
• Oral Cavity/oropharynx also had definitive RT
arm (65-70 Gy) followed by surgery if residual
cancer
•
Head Neck Surg 1987;10:19-30
Postoperative Radiation for Oral Cavity
Squamous Cell Cancer
•
•
•
•
RTOG 73-03
277 patients
Ten year follow-up
Improved locoregional control in postoperative
RT arm (65%) vs. preop RT (48%, p=0.04)
• Trend toward improved survival: 38% vs 33%,
p=0.10)
• Surgical and radiation therapy complications
“similar”. IJROBP 1991;20:21-8.
Postoperative Radiation for Oral Cavity
Cancer: Radiation Dose
• RTOG 7303 established 60 Gy as postop RT
dose
• MD Anderson performed prospective
randomized trial evaluating RT dose for 240
patients with resected stage III/IV cancers of oral
cavity, oropharynx, hypopharynx, larynx
• 180 cGy fractions
• Dose ranged from 52.2 Gy to 68.4 Gy
•
IJROBP 1993; 26:3-11.
Postoperative Radiation for Oral Cavity
Cancer: Radiation Dose
• Patients receiving <54 Gy had significantly higher failure rate.
• No dose response beyond 57.6 Gy except for patients with
extracapsular nodal spread.
• +ECE needed at least 63 Gy
• “Clusters” of two or more of the following also predicted increased
risk of failure and need for 63 Gy: oral cavity primary, positive/close
margins, nerve invasion, >2 positive nodes, largest node >3 cm,
treatment delay >6weeks, Zubrod performance status>2
• Moderate to severe complications seen in 7.1%; more if RT dose
>63 Gy
• Dose escalation above 63 Gy “does not appear to improve the
therapeutic ratio”.
Postoperative Radiation for Oral Cavity
Cancer: RT + Chemotherapy
• Two large randomized trials evaluating RT with
or without cisplatin chemotherapy in high-risk
resected head and neck squamous cell cancers.
• EORTC
• RTOG
•
•
NEJM 2004; 350:1945-1952
NEJM 2004: 350:1937-1944
• High risk features: >2 + nodes, +ECE, + margins
(EORTC also included perineural spread and
vascular tumor embolism)
Postoperative Radiation for Oral Cavity
Cancer: RT + Chemotherapy
•
•
•
•
Radiation dose: 60 Gy RTOG; 66 Gy EORTC
Cisplatin 100 mg/m2 days 1, 22, 43 both
334 EORTC + 459 RTOG patients (793 total)
26-27% oral cavity primaries
• In combined analysis, only patients with +ECE
and/or + margins benefited from addition of
cisplatin Head Neck 2005; 27: 843-850
Postoperative Radiation for Oral Cavity
Cancer: RT + Chemotherapy
Postoperative Radiation for Oral Cavity
Cancer: RT + Chemotherapy
Postoperative Radiation for Oral Cavity
Cancer: RT + Chemotherapy
• What’s Next?
• RTOG 0234 evaluated postop chemoRT
(cisplatin or docetaxel) + EGFR inhibitor
cetuximab (Erbitux)
• This phase II study completed but results
are pending
Get to Work!!
Three-Way Tie for Last