Sequential therapy with induction chemotherapy followed by concurrent chemoradiation in locally advanced squamous cell carcinomas of the head and neck: A single arm prospective study

AIMS & OBJECTIVES: To assess the immediate loco regional response rates and to assess the toxicity profile of sequential therapy with three cycles of induction PFT followed by Concurrent Chemo Radiation with weekly Cisplatin in Locally Advanced Head and Neck Cancers. MATERIALS AND METHODOLOGY: 30 consecutive patients with locally advanced head and neck cancers attending the OPD at our institute were included in the study. All patients were treated with 3 cycles of Induction chemotherapy with PFT regimen (Paclitaxel 175mg/m2 Day1, Cisplatin 100 mg/m² split to (Day 1-3), 5-FU 750 mg/m² Day 1 to 3) every 21 days. The patients were then taken up for concurrent chemo radiation (66 Gy RT along with weekly Cisplatin 40mg/sq.m.). The immediate loco regional response rates were assessed by clinical and radiological imaging. The toxicity profile of the treatment was assessed with RTOG acute morbidity scoring criteria and CTCAE Version 4. RESULTS: 30 patients (3 female) were recruited for the study. Among them 3 were laryngeal cancer patients and the hypo pharyngeal, oropharyngeal and the oral cavity cancers were 9 each. 63% of them had complete response and 30% had partial response. The sub-sites of hypopharynx and the oropharynx had the best outcomes from this treatment protocol. 2 patients did not complete the planned treatment.11 patients had grade 3 leukopenia and 2 patients had grade 4/febrile neutropenia. There were no grade 3 thrombocytopenia in the study group. CONCLUSIONS: Sequential therapy with three cycles of induction PFT followed by concurrent chemo radiation is a feasible alternative for moderately advanced and very advanced head and neck cancer. Patient selection and supportive care during treatment are very important for successful outcome

Second-look PET-CT following an initial incomplete PET-CT response to (chemo)radiotherapy for head and neck squamous cell carcinoma

OBJECTIVES: The limited positive predictive value of an incomplete response on PET-CT following (chemo)radiotherapy for head and neck squamous cell carcinoma (HNSCC) means that the optimal management strategy remains uncertain. The aim of the study is to assess the utility of a 'second-look' interval PET-CT. METHODS: Patients with HNSCC who were treated with (chemo)radiotherapy between 2008 and 2017 and underwent (i) baseline and (ii) response assessment PET-CT and (iii) second-look PET-CT following incomplete (positive or equivocal scan) response were included. Endpoints were conversion rate to complete response (CR) and test characteristics of the second-look PET-CT. RESULTS: Five hundred sixty-two patients with HNSCC underwent response assessment PET-CT at a median of 17 weeks post-radiotherapy. Following an incomplete response on PET-CT, 40 patients underwent a second-look PET-CT at a median of 13 weeks (range 6-25) from the first response PET-CT. Thirty-four out of 40 (85%) patients had oropharyngeal carcinoma. Twenty-four out of 40 (60%) second-look PET-CT scans converted to a complete locoregional response. The primary tumour conversion rate was 15/27 (56%) and the lymph node conversion rate was 14/19 (74%). The sensitivity, specificity, positive predictive value and negative predictive value (NPV) of the second-look PET-CT were 75%, 75%, 25% and 96% for the primary tumour and 100%, 92%, 40% and 100% for lymph nodes. There were no cases of progression following conversion to CR in the primary site or lymph nodes. CONCLUSIONS: The majority of patients who undergo a second-look PET-CT convert to a CR. The NPV of a second-look PET-CT is high, suggesting the potential to avoid surgical intervention. KEY POINTS: • PET-CT is a useful tool for response assessment following (chemo)radiotherapy for head and neck squamous cell carcinoma. • An incomplete response on PET-CT has a limited positive predictive value and optimal management is uncertain. • These data show that with a 'second-look' interval PET-CT, the majority of patients convert to a complete metabolic response. When there is doubt about clinical and radiological response, a 'second-look' PET-CT can be used to spare patients unnecessary surgical intervention

ICON-P – A double-blind evaluation of quality improvements with individualized CONstraints from low-cost knowledge-based radiation therapy planning in prostate cancer

Purpose: /Objective(S)A low-cost, prior knowledge-based individualized dose-constraint generator for organs-at-risk has been developed for prostate cancer radiation therapy (RT) planning. In this study, we aimed to evaluate the feasibility and improvements in organs-at-risk (OAR) doses in prostate cancer RT planning using this tool served on a web application. Materials And Methods: A set of previously treated prostate cancer cases planned and treated with generic constraints were replanned using individualized dose constraints derived from a library of cases with similar volumes of target, OAR, and overlap regions and served on the web-based application. The goal was to assess the reduction in mean dose, specified dose volumes (V59Gy, V56Gy, V53Gy, V47Gy, and V40Gy), and generalized equivalent uniform dose (gEUD) to the rectum and bladder. Planners and assessors were blinded to the initial achieved doses and penalties. Sample size estimation was based on improvement in V53Gy for the rectum and bladder with a paired evaluation. Results: Twenty-four patients were replanned. All the plans had a PTV D95 of at least 97% of the prescribed dose. The individualized OAR constraints could be met for 87.5% of patients for all dose levels. The mean dose, V59Gy, V53Gy, and V47Gy for the bladder was reduced by 7.5 Gy, 1.12%, 5.51%, and 10.53% respectively. Similarly for the rectum, the mean dose, V59Gy, V53Gy, V47Gy and was reduced by 5.5 Gy, 4.34%, 6.97%, and 11.61% respectively. All dose reductions were statistically significant. The gEUD of the bladder was reduced by 2.47 Gy (p < 0.001) and the rectum by 3.21 Gy (p < 0.001). Conclusion: Treatment planning based on individualized dose constraints served on a web application is feasible and leads to improvement at clinically important dose volumes in prostate cancer RT planning. This application can be served publicly for improvements in RT plan quality