|Year : 2021 | Volume
| Issue : 2 | Page : 98-101
Role of palliative chemoradiation in locally advanced head and neck cancer: A case series done in a tertiary care center in Uttar Pradesh
Gulafshan Jabi, Mohsin Khan, Pavan Deepak MandigalaVenkataRamana
Department of Radiotherapy and Clinical Oncology, JN Medical College, AMU, Aligarh, Uttar Pradesh, India
|Date of Submission||22-Mar-2022|
|Date of Acceptance||16-May-2022|
|Date of Web Publication||24-Aug-2022|
Department of Radiotherapy and Clinical Oncology, JN Medical College, AMU, Aligarh, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: Shorter palliative hypofractionated schedules when given concomitantly with chemotherapy, preferably cisplatin (radiosensitizer), enhance the response rate with acceptable toxicity, resulting in better compliance of the patients. Objectives: This case series retrospectively evaluated the role of concurrent chemotherapy, preferably cisplatin, with palliative radiation 30 Gy in 10 fractions in locally advanced head and neck cancers in terms of response rates, symptoms palliation, and acute toxicities. Materials and Methods: Twenty-six patients of histologically confirmed locally advanced head and neck cancers were selected and treated during the period January 2018 and December 2020. All patients (100%) completed the treatment with an average of two follow-ups. Results: The overall response rate of 73% was observed in patients treated, and interestingly, one patient had complete response. Moreover, 100% of the patients reported improvement in at least one symptom with severity reduction in pain. As defined by the Radiation Therapy Oncology Group (RTOG) criteria for toxicity assessment, Grade 2 mucositis in 61%, Grade 1 mucositis in 11%, Grade 1 skin reaction in 15% of the patients were observed. No grade III toxicity was reported. Conclusion: Concurrent chemotherapy acts as a radiosensitizer and provides a synergistic action when coupled with radiation resulting in more efficacious control of locoregional disease of locally advanced head and neck cancers with acceptable toxicities facilitating the compliance of patients.
Keywords: Cisplatin, locally advanced head and neck cancer, palliative RT
|How to cite this article:|
Jabi G, Khan M, MandigalaVenkataRamana PD. Role of palliative chemoradiation in locally advanced head and neck cancer: A case series done in a tertiary care center in Uttar Pradesh. Bengal J Cancer 2021;1:98-101
|How to cite this URL:|
Jabi G, Khan M, MandigalaVenkataRamana PD. Role of palliative chemoradiation in locally advanced head and neck cancer: A case series done in a tertiary care center in Uttar Pradesh. Bengal J Cancer [serial online] 2021 [cited 2023 Mar 25];1:98-101. Available from: http://www.bengaljcancer.org/text.asp?2021/1/2/98/354410
| Introduction|| |
In India, head and neck cancers pose a significant burden of all the cancers. Most often, patients present in advanced stage (66.6%) and often unamenable to curative treatment. Such patients are often distressed with advancement of disease and symptoms associated include pain, bleeding, swelling in neck, cough, and dysphagia. The main goal of treatment is to attain palliation, thereby improving quality of life with modest locoregional control.
Hypofractionated regimes (large dose per fraction) are ideal in advanced cases, because it kills tumor cells effectively before repopulation occurs and spares early responding tissues ensuring low toxicities for the duration of patients’ survival.
Although a number of studies have explored the benefit of concurrent chemoradiation vs. radiation alone in the management of head and neck squamous cell carcinoma (HNSCCs), its role in palliation is limited owing to the fear of toxicity, leading to detriment in quality of life. A higher biological effective dose and locoregional tumor control even with a complete response with concurrent chemoradiation is studied by a meta-analysis by Pignon et al.
Chemotherapy plays a synergistic role in the concurrent regime by inhibition of sublethal damage repair, sensitization of hypoxic cells, and cell synchronization. With concurrent chemoradiation, Carvalho et al. and Carrascosa et al. showed improvement in median survival and better tumor response rates with significantly higher palliation in advanced HNSCC.
Various hypofractionated trials using the Quad shot regimen and split course regimen showed benefit of concurrent chemoradiation and even the schedules were highly compliant with acceptable toxicities.
As there is no compelling evidence for framing a standard regimen in this setting, we have retrospectively reviewed patients’ records and hereby share our experience of concurrent chemoradiation in palliation of locally advanced HNSCCs by analyzing three parameters, i.e., response rates, improvement in symptoms, and toxicity.
| Case Series|| |
Materials and methods
From patients’ case records, we have retrospectively reviewed the data of 26 patients who were biopsy proven with advanced unresectable HNSCCs treated during the period January 2018 and December 2020. Patients’ disease status was assessed on clinico-radiological examination pre- and post-treatment. Inclusion criteria included histopathological evidence of HNSCCs with extensive disease rendering it inoperable or patients denying surgery. Exclusion criteria included patients’ denial, history of any prior treatment for malignancy, history of metastatic disease at presentation, or second primary tumor. Patients were treated with palliative regimen of 30 Gy in 10 fractions and weekly administration of concurrent cisplatin 35 mg/m2. The biological equivalent dose of the total dose is 39 Gy. Irradiation was done 1 h after chemotherapy administration. Orfit thermoplastic casts were used for immobilization. All the patients were treated in supine position with retracted shoulders. Radiotherapy was delivered by the bilateral parallel-opposed fields technique on a telecobalt machine. After 6 months of treatment completion, the tumor response was assessed on the basis of Recist v1.0 criteria, RTOG acute toxicity criteria, and pain assessment visual analog scale (VAS).
| Results|| |
In the current series as shown in [Table 1], patients’ baseline characteristics correspond to 24 male and 2 female patients with a median age of 56 years and median Karnofsky Performance Status Scale of 60. All patients were of stage IV disease, with IVa in 4 patients and IVb in 22 patients. On TNM Staging, T4a had 12 patients, T4b 14, N2b 3, N2c 5, N3a 9, and N3b with 8 patients (as per AJCC 8th ed.). All had squamous cell histology. The primary tumor originated maximally from the oral cavity (54%), followed by oropharynx (35%). The commonest subsite of origin is buccal mucosa (38%), followed by the base of the tongue (23%).
The most common complaint being pain and generalized weakness present in all patients. According to the VAS pain scale,[Table 2] depicts those 12 patients who had severe pain, 11 who had moderate intensity, and 3 who had mild intensity of pain. Six patients complained of bleeding from the local site. Twelve patients had discharge from the local site. Ten patients had dysphagia. Five patients complained of dyspnea and three patients with complaint of cough.
|Table 2: Results of treatment with response, toxicity, and symptoms relief pre- and post-treatment|
Click here to view
All patients (26) completed treatment with good tolerability. No deaths reported due to treatment, and patients were compliant to the schedule. Tumor response was assessed using RECIST v1.0 criteria, with the help of clinicoradiological examination and 90° endoscopy. On post-treatment evaluation as depicted in [Table 2], an overall response rate (ORR) of 73% (CR+PR) was observed. CR corresponds to complete response of disease both at primary and at nodal sites. PR corresponds to more than 30% decrease in the size of the disease. Majority of the patients had partial response (22); complete response was found in one patient and 6 had stable disease. Mean reduction between pre- and post-treatment in primary disease was 42.6% and in nodal mass was 48.6%, respectively.
On completion of treatment, [Table 2] shows that a significant relief of pain (reduction in intensity) was observed in all patients. Mild intensity pain was found in nine and moderate intensity pain in five patients. There was complete resolution of symptoms such as bleeding and dyspnea. Four patients had persistent dysphagia and one patient had cough.
As defined by the RTOG criteria for toxicity assessment mentioned in [Table 2], Grade 2 mucositis (11.5%), Grade 1 mucositis (73%), Grade 2 skin reaction (3.8%), and Grade 1 skin reaction (19%) were observed. No grade III toxicity was reported.
| Discussion|| |
In India, the majority of cases of head and neck cancers present with locally advanced disease. In such patients, palliation of symptoms remains a big concern and a prime focus of treatment with modest tumor control.
In the past years, several studies have combined chemotherapy with radiation and yielded mixed results in terms of response rate and survival. Conflicting outcomes were reported in view of the toxicity, especially late effects make it difficult to deliver a standard regimen.
In RT-only studies such as Corry et al., an ORR of 53%, with 43% at the primary site and 50% at the nodal site, was observed. Mohanti et al. reported an ORR of 37% in patients receiving short-course RT alone.
However, with addition of chemotherapy, Monnier et al. (IHF2SQ regimen) reported an ORR of 52.6%. Kumar et al. (phase II trial) compared the efficacy of short-course hypofractionated RT alone 20 Gy in 5 fractions (Arm A) with concurrent cisplatin CRT (6 mg/m2/day) (Arm B). ORRs were higher in the CRT arm (50% vs. 27.2%).
Our data showed even higher ORRs with locoregional control of the disease, i.e., 73%. These results can be attributed to higher radiation and use of cisplatin as chemotherapy.
Corry et al. used the RT-alone Quad regimen and showed palliation of pain and dysphagia in 56% and 33%, respectively. In Mohanti et al., 505 patients of Stage IV HNSCC were treated with 20 Gy over 1 week and reported improved relief of symptoms (50% or more). The concurrent CRT arm in Kumar et al. showed relative improvement in quality of life for most parameters. Consistent with the above findings, our study reported more than 50% symptomatic relief when compared with baseline, signifying improvement in quality of life addressing the need of palliation.
Although there was an increase in acute toxicities in our records, the regimen was very well tolerated adhering the patient’s compliance. It is noteworthy that our patients did not have higher grades of toxicity, i.e., 3 and 4. Corry et al. reported no severe grade toxicities. In Kumar et al., Grade 3 and 4 dysphagia was seen more commonly in the chemo-RT arm than in the RT-alone arm (68% vs 7.6%).
| Conclusion|| |
Shorter palliative schedules of radiation when coupled with chemotherapy can be considered in an attempt to improve the outcomes of radiotherapy in terms of reasonably high ORRs and better palliation of symptoms with acceptable toxicity.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mathur P, Sathishkumar K, Chaturvedi M, Das P, Sudarshan KL, Santhappan S, et al
; ICMR-NCDIR-NCRP Investigator Group. Cancer Statistics, 2020: Report from National Cancer Registry Programme, India. JCO Glob Oncol 2020;6:1063-75.
Carrascosa LA, Yashar CM, Paris KJ, Larocca RV, Faught SR, Spanos WJ Palliation of pelvic and head and neck cancer with paclitaxel and a novel radiotherapy regimen. J Palliat Med 2007;10:877-81.
Al-Mamgani A, Tans L, Van Rooij PH, Noever I, Baatenburg de Jong RJ, Levendag PC Hypofractionated radiotherapy denoted as the “christie scheme”: An effective means of palliating patients with head and neck cancers not suitable for curative treatment. Acta Oncol 2009;48:562-70.
Pignon JP, le Maître A, Maillard E, Bourhis J; MACH-NC Collaborative Group. Meta-analysis of chemotherapy in head and neck cancer (MACH-NC): An update on 93 randomised trials and 17,346 patients. Radiother Oncol 2009;92:4-14.
Minatel E, Gigante M, Franchin G, Gobitti C, Mascarin M, Bujor L, et al
. Combined radiotherapy and bleomycin in patients with inoperable head and neck cancer with unfavourable prognostic factors and severe symptoms. Oral Oncol 1998;34:119-22.
Carvalho AL, Salvajoli JV, Kowalski LP A comparison of radiotherapy or radiochemotherapy with symptomatic treatment alone in patients with advanced head and neck carcinomas. Eur Arch Otorhinolaryngol 2000;257:164-7.
Gamez ME, Agarwal M, Hu KS, Lukens JN, Harrison LB Hypofractionated palliative radiotherapy with concurrent radiosensitizing chemotherapy for advanced head and neck cancer using the “QUAD-SHOT regimen”. Anticancer Res 2017;37:685-91.
Therasse P, Arbuck SG, Eisenhauer EA, Wanders J, Kaplan RS, Rubinstein L, et al
. New guidelines to evaluate the response to treatment in solid tumors. European Organization for Research and Treatment of Cancer, National Cancer Institute of the United States, National Cancer Institute of Canada. J Natl Cancer Inst 2000;92:205-16.
Cox JD, Stetz J, Pajak TF Toxicity criteria of the Radiation Therapy Oncology Group (RTOG) and the European Organization for Research and Treatment of Cancer (EORTC). Int J Radiat Oncol Biol Phys 1995;31:1341-6.
Haefeli M, Elfering A Pain assessment. Eur Spine J 2006;15 (Suppl. 1):S17-24.
Corry J, Peters LJ, Costa ID, Milner AD, Fawns H, Rischin D, et al
. The “QUAD SHOT”—A phase II study of palliative radiotherapy for incurable head and neck cancer. Radiother Oncol 2005;77:137-42.
Mohanti BK, Umapathy H, Bahadur S, Thakar A, Pathy S Short course palliative radiotherapy of 20 Gy in 5 fractions for advanced and incurable head and neck cancer: AIIMS study. Radiother Oncol 2004;71:275-80.
Monnier L, Touboul E, Durdux C, Lang P, St Guily JL, Huguet F Hypofractionated palliative radiotherapy for advanced head and neck cancer: The IHF2SQ regimen. Head Neck 2013;35:1683-8.
Kumar A, Sharma A, Mohanti BK, Thakar A, Shukla NK, Thulkar SP, et al
. A phase 2 randomized study to compare short course palliative radiotherapy with short course concurrent palliative chemotherapy plus radiotherapy in advanced and unresectable head and neck cancer. Radiother Oncol 2015;117:145-51.
[Table 1], [Table 2]