Concomitant Boost Research Articles

An Accelerated Radiotherapy Scheme Using a Concomitant Boost Technique for the Treatment of Unresectable Stage III Non-small Cell Lung Cancer

We designed a phase II trial for evaluation of the efficacy and tolerability of an accelerated concomitant boost radiotherapy scheme for the treatment of the patients with non-small cell lung cancer (NSCLC). Thirty patients with unresectable stage IIIA/IIIB NSCLC were prospectively enrolled in this protocol. All patients were scheduled to receive 15 fractions of conventional radiotherapy in doses of 1.8 Gy, to a total of 27 Gy. For the last 10 treatment days, an accelerated concomitant boost schedule was started that was composed of 1.8 Gy/fraction/day, 5 days/week to the large field and 1.8 Gy/fraction/day to the boost field 6 h apart, to a total dose of 63 Gy/35 fractions/5 weeks. Median follow-up time was 13 months (range, 5-50 months; 3-year overall, disease-free, loco-regional disease-free and metastasis-free survivals were 23%, 19%, 19% and 23%, respectively). The most common acute toxicity was esophagitis in 31% of patients with the Radiation Therapy Oncology Group and the European Organization for Research and Treatment of Cancer (RTOG/EORTC) criteria grade 1, and in 54% with grade 2. Radiation pneumonitis developed in 16% of patients with RTOG/EORTC grade 1. Three-year actuarial rate of late pulmonary and skin-subcutaneous toxicity were 12% and 16%, respectively. No late radiotherapy complications of spinal cord or esophagus were recorded. Overall survival, local control and freedom from local progression were comparable with the results reported with pure hyperfractionated radiotherapy. The overall rate of acute and late toxicity was acceptable.

Induction and Concurrent Chemotherapy with Concomitant Boost Radiotherapy in Non-Small Cell Lung Cancer

This study was designed to evaluate the tolerability and therapeutic activity of paclitaxel and carboplatin combination therapy followed by radical thoracic radiotherapy with a concomitant boost technique with concurrent weekly paclitaxel in good performance status of patients with stage IIIA and IIIB non-small cell lung cancer. Patients with newly diagnosed inoperable non-small cell lung cancer received paclitaxel (100 mg/m(2)) as a 1-h infusion on d 1,8,15,28,35, and 42. Carboplatin (area under the curve of 6) was given as a 30-min infusion on d 1 and 28. Radiotherapy commenced on d 49 and was delivered with accelerated fractionation with concomitant boost at 1.8 Gy/fraction/d, 5 d/week and 1.5 Gy/fraction/d to a boost field as a second daily treatment for the last 10 treatment days to 60 Gy/35 fractions/5 wk. During radiation treatment, paclitaxel (60 mg/m(2)) was given as a 1-h infusion once weekly for 5 wk. Twenty-four patients were enrolled in the study. Hematologic toxicities and alopecia were the major acute toxicities during induction chemotherapy; 8.7% of the patients experienced grade 3-4 neutropenia and alopecia. The main acute toxicity of concurrent chemoradiotherapy was esophagitis; grade 3 esophagitis was documented in 23.5% of the patients. No major late toxicity was seen. Overall response rate to the treatment was 65.2%. The median and 1-yr overall-survival rates were 24.9 mo and 63.8%, respectively. The median and 1-yr progression-free survival rates were 9.0 mo and 27.8%, respectively. The main acute toxicities were hematologic toxicity, esophagitis, and alopecia. The response rate and the survival rates achieved with this treatment regimen are particularly noteworthy, especially considering the advanced stage of the patients treated.

A comparison of two scoring systems for late radiation toxicity in patients after radiotherapy for head and neck cancer

Summary Background The EORTC/RTOG late effects classification has been used for many years and covers nearly all organs and tissues, which may develop late radiation injuries. Dische developed a scoring system for radiation toxicity in which each clinical sign or symptom, that is characteristic for disturbance of function in an irradiated organ, is given scores for severity individually. EORTC and RTOG formed working groups to up-date their systems, for the recording of late injury to normal tissues, to be used in future clinical trials. The resulting system is called LENT-SOMA (1993). Aim In preparation for the introduction of the LENT-SOMA scale into clinical practice at the Centre of Oncology-Institute in Gliwice, we followed a sizeable cohort of patients using two scoring systems for the assessment of delayed radiation toxicity at each follow-up examination which took place every 6 months for up to 5 years after curative radiotherapy for head and neck cancer. Materials/Methods The analysed material comprised of 113 patients with oral cavity, pharyngeal or supraglottic cancer (T2-4N0-1) irradiated by conventional methods (18 patients), continuous accelerated irradiation (CAIR) (52 patients) or concomitant boost (CB) (43 patients). Total dose was in the range of 66–74 Gy. Delayed radiation toxicity was evaluated by two classification systems, those of Dische and LENT-SOMA, in the mucosal membranes, skin, larynx, salivary glands and spinal cord every 6 months after completion of radiotherapy treatment. The values in every scale were normalised (as a proportion of the maximum intensity for all symptoms) which permitted statistical comparison of the scales by use of the Wilcoxon test. Results Analysis of all materials indicated a difference in the intensity of late radiation toxicity as estimated by the Dische and LENT-SOMA scales. The intensity of delayed radiation toxicity in the normalised Dische scale, for mucosal membranes and for skin, had higher values than observed in the LENT-SOMA system for the majority of examined patients. In the case of the larynx and salivary glands, the opposite situation was noted. The extent of conformity between normalised scales was evaluated in the case of the spinal cord. Conclusions The scoring systems of Dische and LENT-SOMA can not be interchangeably used, in clinical practice, for the estimation of delayed radiation toxicity in tissues of the head and neck region. The sensitivity of the scoring systems is similar only for the evaluation of radiation reactions in spinal cord.

Accelerated Hyperfractionated Irradiation with Concomitant Boost for Stage II Laryngeal Cancer and Locally Advanced Head and Neck Cancer

ObjectiveThis study was conducted to evaluate the efficacy and feasibility of our accelerated hyperfractionation with concomitant boost for stage II laryngeal cancer and stages III–IVb locally advanced head and neck cancer.Patients and methodsFrom January 2000 to October 2001, eight patients with AJCC 1998 stage II laryngeal cancer and 11 patients with AJCC 1998 stages III–IVb locally advanced head and neck cancer underwent accelerated hyperfractionated radiation therapy. For the stage II laryngeal cancer, radiation was delivered at a 2.0 Gy fraction a day, 5 fractions per week for the first 3 weeks, then 2 fractions (1.8 and 1.2 Gy) a day, 5 times a week for 2.5 weeks, with total dose of 69 Gy. For stages III–IVb head and neck cancer, radiation was given at a 1.8 Gy fraction a day, 5 fractions per week for 6 weeks and a boost was added up to 70.5 Gy with 1.5 Gy as a second daily fraction during the last 2.2 weeks. Among the patients, 16 (84%) received concomitant chemotherapy, mainly with low-dose carboplatin. Acute toxicity based on RTOG criteria and tumor response at 1 month post-treatment were estimated as initial effects.ResultsThe overall response rate was 100% in patients with stage II laryngeal cancer and 91% in patients with stages III and IVb head and neck cancer. The incidence of grade 3 or worse acute effects was 47%. Eighteen patients (95%) completed radiation therapy without interruption related to acute side effects, while one had prolongation of the treatment for more than 1 week because of neutropenia.ConclusionsOur results demonstrated that accelerated hyperfractionation, mostly combined with concomitant chemotherapy, had a good overall response rate with acceptable toxicity in stage II laryngeal cancers and stages III–IVb head and neck tumors.

Organ preservation for patients treated with induction chemotherapy (IC) followed by radiation therapy (RT) or chemoradiation (CRT) for advanced stage squamous cell carcinoma of the larynx (SCCL)

5600 Background: We reviewed the charts of patients with laryngeal cancer treated with IC and definitive RT or CRT to determine the rates of overall organ preservation and function. Methods: Between September 1995 and December 2001, 29 patients with stage III (45%) and IV (55%) SCCL, were treated with IC and definitive RT or CRT on one of seven consecutive trials. The median age at diagnosis was 54 years (range 38–74). 55% had clinically node-positive disease. 55% and 45% had T3 and T4 tumors, respectively. All received 3 cycles of IC with a platinum-based regimen. QD RT was given to 48%, BID RT to 45%, and concomitant boost (CB) RT to 7%. CRT was given with carboplatin (28%) or docetaxel (28%). Those treated with BID RT did not receive CRT. Results: Median follow-up is 52 months (range 17–85). Overall survival is 66%. Relapse occurred in12 (41%) patients, and 6 underwent salvage laryngectomy (5 Stage III, 1 Stage IV). Of the entire cohort, 59% (17/29) are alive at last follow-up with an anatomically intact larynx, and 48% (14/29) are alive with a functional larynx. Detailed information on g-tube placement/removal was available for 23 patients. Median time with G-tube was 12 months (range, 1–50 months), and 15/23 (65%) had g-tube for 6 months or longer. 23 of all 29 patients (79%) retained an anatomically intact larynx, but 30% (7/23) did not resume their pre-treatment swallowing mechanics and airway protection. Overall rate of functional organ preservation, regardless of survival was, 55% (16/29). The 7/29 patients (26%) who retained a non-functional larynx required permanent g-tube or were unable to return to pretreatment oral intake capability. Nine of 13 with T4 SCCL (69%) compared to 7 of 16 (44%) T3 SCCL retained a functional larynx. Conclusions: The rate of larynx preservation is high, but toxicity remains significant with combined modality therapy. Advanced stage was not an indicator of poor outcome. Half of all patients were alive, able to retain their larynx, and return to pretreatment function. Author Disclosure Employment or Leadership Consultant or Advisory Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Aventis Aventis

Organ preservation for patients treated with induction chemotherapy (IC) followed by radiation therapy (RT) or chemoradiation (CRT) for advanced stage squamous cell carcinoma of the larynx (SCCL)

5600 Background: We reviewed the charts of patients with laryngeal cancer treated with IC and definitive RT or CRT to determine the rates of overall organ preservation and function. Methods: Between September 1995 and December 2001, 29 patients with stage III (45%) and IV (55%) SCCL, were treated with IC and definitive RT or CRT on one of seven consecutive trials. The median age at diagnosis was 54 years (range 38–74). 55% had clinically node-positive disease. 55% and 45% had T3 and T4 tumors, respectively. All received 3 cycles of IC with a platinum-based regimen. QD RT was given to 48%, BID RT to 45%, and concomitant boost (CB) RT to 7%. CRT was given with carboplatin (28%) or docetaxel (28%). Those treated with BID RT did not receive CRT. Results: Median follow-up is 52 months (range 17–85). Overall survival is 66%. Relapse occurred in12 (41%) patients, and 6 underwent salvage laryngectomy (5 Stage III, 1 Stage IV). Of the entire cohort, 59% (17/29) are alive at last follow-up with an anatomically inta...

29. Accelerated Fractionated Radiation by Concomitant Boost (Afx-Cb) with Concurrent Cis-Platinum (CDDP) for Advanced Naso-pharyngeal Carcinoma

PROCEEDINGS: Program from the Annual Meeting of the American Radium Society: PAPERS: Monday, April 28, 2003: 10: 45 – 11: 35 AM: HEAD AND NECK PAPERS

Concomitant boost of stratified target area with gamma knife radiosurgery: a treatment planning study.

Conventional Gamma Knife Stereotactic Radiosurgery (GKSRS) has been focused on delivering a single peripheral dose to the gross target volume based on the anatomic information derived from the magnetic resonance or computed tomography (CT) studies. In this study, we developed a treatment planning approach that allows a boost dose to be delivered concomitantly to the desired subtarget area while maintaining the peripheral isodose coverage of the target volume. The subtarget area is defined as the high-risk or the tumor burden areas based on the functional imaging information such as the magnetic resonance spectroscopy (MRS) studies or the physician's clinical diagnosis. Treatment plan comparisons were carried out between the concomitant boost plans and the conventional treatment plans using dose volume histogram (DVH), tissue volume ratio (TVR), and the maximum dose to the peripheral dose ratio (MD/PD) analysis. Using the concomitant boost approach, more conformal and higher dose was delivered to the desired subtarget area while maintaining the peripheral isodose coverage of the gross target volume (GTV). Additionally, the dose to the normal brain tissue was found to be equivalent between the concomitant boost plans and the conventional plans. As a result, we conclude that concomitant boost of a stratified target area is feasible for GKSRS.

A Novel Concomitant Boost Regimen for Head and Neck Cancers Employing an Incomplete Repair Model

Ahn, Eugene MD; Lee, Steve MD; Kim, Bryan MD; Withers, H. Rodney MBBS, DSc; Juillard, Guy F. MD Author Information

Treatment, patient and tumor characteristics impact quality of life (QOL) in patients with locally advanced head and neck cancer: Report of the radiation therapy oncology group (RTOG) trial 90-03

Purpose: To determine factors that effect QOL in patients with locally advanced squamous cell cancer of the head and neck randomized to standard fractionation radiotherapy (SFX), hyperfractionation (HFX), Accelerated Fractionation with Split (AFX-S) and Accelerated Fractionation with Concomitant Boost (AFX-C). Materials and Methods: RTOG 90-03 used the Head and Neck Performance Status Scale (HNPSS) and the Functional Assessment of Cancer Therapy (FACT-H&N), version 2 to assess QOL. The HNPSS has three components Normalcy of Diet, Eating in Public, and Understandability of Speech. The FACT-H&N has two components: a global QOL questionnaire (FACT-G) consisting of 4 domains; Physical Well Being (PWB), Social Well Being (SWB), Emotional Well Being (EWB), Functional Well Being (FWB), and an additional H&N specific questionnaire (AC). Between 3/92 and 8/97, 1113 pts. were randomized; 718 completed a pretreatment FACT-H&N. Pts. completed the HNPSS & FACT-H&N; pretreatment, 4 weeks post-RT, every 3 months for 1year. Results: Prior to the start of radiotherapy (RT) 48% of pts had normal diets, 64% had normal public eating, and 77% had normal speech. Age (<60 vs. > 60), KPS, tumor site (oral cavity vs. other), T-stage (T3+T4 vs. T1+T2+TX), N-stage (N0 vs. other), Race (Non-White vs. White), and marital status (single vs. married), FACT-G, PWB, EWB, FWB, AC, use of oral nutrient supplements, feeding tube, and parenteral nutrition predicted for pretreatment diet, public eating, and speech. During the acute toxicity phase diet, eating, and speech were related to the intensity of RT (HFX or AFX-C), marital status (single), tumor site (oral cavity), use of oral nutrient supplements, and feeding tube. At one-year oral cavity tumors, AFX-C, oral nutrient supplements, feeding tube, and single patients had worse diet, eating, and speech. Conclusion: Pretreatment patient and tumor characteristics impact on QOL prior to the initiation of therapy. Intensification of radiotherapy, marital status, tumor site, and nutritional support all effect QOL during the first year post therapy. These data suggest that interventions prior to the start of therapy may improve QOL in long-term survivors.

Fast Neutron Radiotherapy: The University of Washington Experience and Potential Use of Concomitant Boost with Boron Neutron Capture

Well defined, randomised clinical trials have demonstrated significant advantages for fast neutron radiotherapy over photon radiotherapy in locally advanced prostate cancer (10-year survival 46% vs 29%), salivary gland tumours (10-year local/regional control 56% vs 17%), and inoperable squamous cell carcinoma of the lung (2-year survival 16% vs 3%). Fast neutron treatment of high grade brain tumours (astrocytomas/resulted in tumour sterilisation, but also caused significant brain injury. This effect was important, however, in that conventional radiation therapy, and other conventional treatments, have not demonstrated sterilisation of high grade astrocytomas at any dose. The treatment of cancer utilising 10 B and its neutron capture reaction (boron neutron capture therapy, or BNCT) may have potential to be effective in brain tumours and melanoma. Recent studies at the University of Washington have demonstrated that fast neutron radiotherapy cell kill can be significantly enhanced by the boron capture reaction utilising the thermal component of our fast neutron beam. This enhancement can increase cell kill between 10 and 100 fold. The implications for concomitant BNCT/fast neutron therapy with new 10 B carriers will be discussed with emphasis on high grade brain tumours.

A Feasibility Study of Concomitant Boost Radiotherapy for Patients with Cancer of the Supraglottic Larynx

Between February 1988 and December 1989, 65 patients with supraglottic cancer completed a course of concomitant boost radiotherapy. Cases with N3 disease, a Karnovsky performance score less than 70, age above 70 years, or a second primary cancer were not eligible for the study. Distribution of the patients was: Stage T1-T2 30%, T3-T4 70%, N0 68%, N+ 32%. The total dose ranged from 60 Gy to 76 Gy (median 66 Gy); overall treatment time ranged from 36 to 56 days with a median of 42 days. The daily dose during the first 4 weeks was 1.8 Gy, and during the last 2 weeks it was 1.6 Gy b.i.d. with a 4- or (after September 1988) 6-h interval. The clinical impression was that the early mucosal reactions were acceptable but more severe than after conventional treatment, with confluent membranous mucosal reaction being observed in 54% of the patients. Also, this reaction was significantly more frequent in patients treated with a 4-h interval (68%) than with a 6-h interval (41%) between the daily fractions. To relieve severe dysphagia, narcotics were required in 22% of the patients. The follow-up time ranged from 22 to 50 months, median 34 months. Treatment-requiring late complications were observed in 8 patients, and the 3-year actuarial risk was 17% with 95% confidence limits (6%, 27%). Two of these patients had severe complications: one of them required a temporary tracheostomy due to arytenoid edema and the other developed a laryngo-cutaneous fistula which healed after pharmacological treatment. Actuarial 3-year local-regional control was 59% (46%, 71%) and 3-year actuarial crude survival 55% (42%, 67%). There was no significant difference in the incidence of late complications or tumor control between the two groups of patients treated with a 4- or 6-h interval between the daily fractions. This study shows that the concomitant boost regimen tried here is feasible, but also stresses that the interval between dose fractions should be 6 h or more.

Influence of the Timing of a Concomitant Boost During Fractionated Irradiation of Rat Rhabdomyosarcoma R1H

Rhabdomyosarcomas R1H of the rat (WAG/Rij) were treated using fractionation schedules including a boost. The total dose was 60 Gy. Overall treatment time was 6 weeks. Four different boost schedules were applied: a single dose boost (12.15 Gy) at the last day of treatment, a single dose boost (12.15 Gy) at the first day of treatment, a schedule including the boost in 7 fractions during the first week, and a schedule including the boost in 10 fractions during the first week of treatment. A standard schedule with 30 fractions of 2 Gy without a boost was used for comparison. Initially accelerated schedules, i.e. those with a boost at start of treatment, revealed higher effect on tumour parenchyma as monitored by local control rate and net growth delay. This could be due to a decrease of radio-sensitivity, that is, an increase of the hypoxic fraction of clonogenic tumour cells during fractionated irradiation.