Maximizing Local Control And Organ Preservation In Advanced Squamous Cell Head And Neck Cancer (SCHNC) With Hyperfractionated Radiation (HRT) And Concurrent Chemotherapy
Diana Stripp, MD
University of Pennsylvania Cancer
Last Modified: May 13, 2001
Presenter: David J. Adelstein
Affiliation: Cleveland Clinic Foundation, Cleveland, OH.
- 5Fu and cDDP are the best studied and most effective drugs for head and neck cancer.
- Both agents are radiosensitizers.
- Altered fractionation regimen is more effective than conventional therapy.
Materials and Methods:
- 44 patients (pts) with stage III-IV squamous carcinoma of the head and neck were treated on a Cleveland Clinic Foundation clinical trial since January 1996, with HRT (72Gy @ 120cGy b.i.d.) and 2 courses of concurrent chemotherapy using 5-fluorouracil, 1,000 mg/m2/day and cisplatin 20 mg/m2/day; both given as 96 hour continuous intravenous infusions during weeks 1 and 4 of the HRT.
- Primary site resection was reserved for residual or recurrent primary site disease after chemoradiotherapy (CRT).
- Neck dissection was considered for N2 or greater disease, irrespective of clinical response, and for residual or recurrent neck disease after CRT.
- The median age was 56 (range 42-71) years. All but 3 had stage IV disease
- Toxicity included Grade 3-4 mucositis in 98% of pts, dysphagia in 89%, skin reaction in 86% and nausea/vomiting in 7%. Neutropenia occurred in 31 pts (70%).
- Forty-two of the 43 evaluable pts achieved a complete primary site response after CRT. The 1 pt with partial response underwent salvage surgery sucessfully.
- Twenty-one pts underwent neck dissection; 13 (62%) were pathologically negative.
- Distant metastases developed in 8 pts.
- With a median follow-up of 30 months, the 2-year overall survival is 81%, and 61% for 3 yr. survival, disease-specific survival 83%, and freedom from recurrence 78%.
- At 2 years, local control with salvage surgery, if necessary, is 97%, local control without the need for salvage surgery (i.e. organ preservation) is 90% and distant disease control is 81%.
- This CRT schedule produces considerable but manageable toxicity.
- Survival, local control and organ preservation are excellent in this poor prognosis patient cohort.
- Distant metastases are now the most common cause of treatment failure.
- This agressive combined modality treatment regimen produces good local control and better than expected survival in this group of patients with an extremely poor prognosis. However, toxicity is significant and patients must be selected who can tolerate this agressive management.