Intensity-modulated radiation therapy versus three-dimensional conformal radiotherapy in head and neck squamous cell carcinoma: long-term and mature outcomes of a prospective randomized trial

Tejpal Gupta,Naveen Mummudi,Reena Phurailatpam,Sarbani Ghosh-Laskar,Monali Swain,Kumar Prabhash,Ashwini Budrukkar,Shwetabh Sinha,Jai Prakash Agarwal

doi:10.1186/s13014-020-01666-5

Abstract

PurposeTo compare long-term disease-related outcomes and late radiation morbidity between intensity-modulated radiation therapy (IMRT) and three-dimensional conformal radiotherapy (3D-CRT) in head and neck squamous cell carcinoma (HNSCC) in the setting of a prospective randomized controlled trial.MethodsPreviously untreated patients with early to moderately advanced non-metastatic squamous carcinoma of the oropharynx, larynx, or hypopharynx (T1-T3, N0-N2b, M0) planned for comprehensive irradiation of primary site and bilateral neck nodes were randomly assigned to either IMRT or 3D-CRT after written informed consent. Patients were treated with 6MV photons to a total dose of 70Gy/35 fractions over 7 weeks (3D-CRT) or 66Gy/30 fractions over 6 weeks (IMRT). A sample size of 60 patients was estimated to demonstrate 35% absolute difference in the incidence of ≥grade 2 acute xerostomia between the two arms. All time-to-event outcomes were calculated from date of randomization until the defined event using the Kaplan-Meier method.ResultsAt a median follow-up of 140 months for surviving patients, 10-year Kaplan-Meier estimates of loco-regional control (LRC); progression-free survival (PFS); and overall survival (OS) with 95% confidence interval (95%CI) were 73.6% (95%CI: 61.2–86%); 45.2% (95%CI: 32–58.4%); and 50.3% (95%CI: 37.1–63.5%) respectively. There were no significant differences in 10-year disease-related outcomes between 3D-CRT and IMRT for LRC [79.2% (95%CI: 62.2–96.2%) vs 68.7% (95%CI: 51.1–86.3%), p = 0.39]; PFS [41.3% (95%CI: 22.3–60.3%) vs 48.6% (95%CI: 30.6–66.6%), p = 0.59]; or OS [44.9% (95%CI: 25.7–64.1%) vs 55.0% (95%CI: 37–73%), p = 0.49]. Significantly lesser proportion of patients in the IMRT arm experienced ≥grade 2 late xerostomia and subcutaneous fibrosis at all time-points. However, at longer follow-up, fewer patients remained evaluable for late radiation toxicity reducing statistical power and precision.ConclusionsIMRT provides a clinically meaningful and sustained reduction in the incidence of moderate to severe xerostomia and subcutaneous fibrosis compared to 3D-CRT without compromising disease-related outcomes in long-term survivors of non-nasopharyngeal HNSCC.

Highlights

The contemporary standard of care in non-surgical, curative-intent management of head and neck squamous cell carcinoma (HNSCC) is definitive radiotherapy (RT) with or without concurrent chemotherapy [1, 2]
There were no significant differences in 10-year disease-related outcomes between Three dimensional Conformal Radiotherapy (3D-CRT) and intensity-modulated radiation therapy (IMRT) for locoregional control (LRC) [79.2% (95%CI: 62.2– 96.2%) vs 68.7% (95%CI: 51.1–86.3%), p = 0.39]; progression-free survival (PFS) [41.3% (95%CI: 22.3–60.3%) vs 48.6% (95%CI: 30.6–66.6%), p = 0.59]; or overall survival (OS) [44.9% (95%CI: 25.7–64.1%) vs 55.0% (95%CI: 37–73%), p = 0.49]
IMRT provides a clinically meaningful and sustained reduction in the incidence of moderate to severe xerostomia and subcutaneous fibrosis compared to 3D-CRT without compromising disease-related outcomes in long-term survivors of non-nasopharyngeal HNSCC

Summary

Introduction

The contemporary standard of care in non-surgical, curative-intent management of head and neck squamous cell carcinoma (HNSCC) is definitive radiotherapy (RT) with or without concurrent chemotherapy [1, 2]. HNSCC had been treated with conventional RT techniques which generally comprised of simple field arrangements, typically parallel-opposed portals with or without matching low anterior neck field or anterolateral wedge pair based on two-dimensional (2D) fluoroscopic imaging with no major emphasis on shielding of normal tissues. Such conventional techniques led to considerable morbidity [3] such as dryness of mouth, sticky saliva, swallowing dysfunction, and subcutaneous fibrosis with resultant negative impact upon healthrelated quality-of-life (QOL) in long-term survivors [4, 5]. We report and compare the long-term diseaserelated outcomes and late toxicity of the index trial at an extended and mature follow-up (> 10 years)

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Results

Discussion

Conclusion