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Postoperative Radiation for Oral Cavity Squamous Cell Carcinoma: The EP. John M. Holland, MD OHSU Radiation Oncology March 19, 2008. The Difference?. EP. Album. Postoperative Radiation for Oral Cavity Squamous Cell Carcinoma. Oral Cavity Cancer is a Surgical Disease

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Postoperative radiation for oral cavity squamous cell carcinoma the ep

Postoperative Radiation for Oral Cavity Squamous Cell Carcinoma: The EP

John M. Holland, MD

OHSU Radiation Oncology

March 19, 2008


The difference

The Difference?

EP

Album


Postoperative radiation for oral cavity squamous cell carcinoma

Postoperative Radiation for Oral Cavity Squamous Cell Carcinoma

Oral Cavity Cancer is a Surgical Disease

Use Radiation Postoperatively for Appropriate Patients


Radiation alone for early stage oral cavity cancer

Radiation Alone for Early Stage Oral Cavity Cancer

RT can be used as primary therapy for small (T1, T2) tumors of the oral cavity.

Oral tongue

Floor of Mouth

Lip

Best results are with a combination of external beam radiation and brachytherapy


Radiation alone for early stage oral cavity cancer1

Radiation Alone for Early Stage Oral Cavity Cancer

Difficult getting enough dose to primary with brachytherapy while still delivering

adequate dose to the regional nodes IJROBP 1990; 18:1287-92.

Brachytherapy complications: soft tissue necrosis, osteonecrosis


Postoperative radiation for oral cavity squamous cell cancer

Postoperative Radiation for Oral Cavity Squamous Cell Cancer

Who needs postop RT?

Definite Indications:

1) Positive Margins

2) Multiple Nodes

3) Extracapsular Extension


Postoperative radiation for oral cavity squamous cell cancer1

Postoperative Radiation for Oral Cavity Squamous Cell Cancer

Who needs postop RT?

Less certain indications:

1) Lymphovascular space invasion

2) Perineural spread

3) Single encapsulated node +

4) Thick tumors (Tumors 3-9 mm: 44% node+, 7% local recurrence; >9 mm: 53% subclinical node+, 24% local recurrence Head Neck 2002: 24:513-20)

5) Surgeon Vibe


Postoperative radiation for oral cavity squamous cell cancer2

Postoperative Radiation for Oral Cavity Squamous Cell Cancer

  • Why give radiation after surgery?

  • RTOG 73-03: locally advanced H&N cancers: supraglottic larynx, hypopharynx, oral cavity and oropharynx

  • Preop (50 Gy) vs Postop (60 Gy)

  • Oral Cavity/oropharynx also had definitive RT arm (65-70 Gy) followed by surgery if residual cancer

  • Head Neck Surg 1987;10:19-30


Postoperative radiation for oral cavity squamous cell cancer3

Postoperative Radiation for Oral Cavity Squamous Cell Cancer

RTOG 73-03

277 patients

Ten year follow-up

Improved locoregional control in postoperative RT arm (65%) vs. preop RT (48%, p=0.04)

Trend toward improved survival: 38% vs 33%, p=0.10)

Surgical and radiation therapy complications “similar”. IJROBP 1991;20:21-8.


Postoperative radiation for oral cavity cancer radiation dose

Postoperative Radiation for Oral Cavity Cancer: Radiation Dose

RTOG 7303 established 60 Gy as postop RT dose

MD Anderson performed prospective randomized trial evaluating RT dose for 240 patients with resected stage III/IV cancers of oral cavity, oropharynx, hypopharynx, larynx

180 cGy fractions

Dose ranged from 52.2 Gy to 68.4 Gy

IJROBP 1993; 26:3-11.


Postoperative radiation for oral cavity cancer radiation dose1

Postoperative Radiation for Oral Cavity Cancer: Radiation Dose

  • Patients receiving <54 Gy had significantly higher failure rate.

  • No dose response beyond 57.6 Gy except for patients with extracapsularnodal spread.

  • +ECE needed at least 63 Gy

  • “Clusters” of two or more of the following also predicted increased risk of failure and need for 63 Gy: oral cavity primary, positive/close margins, nerve invasion, >2 positive nodes, largest node >3 cm, treatment delay >6weeks, Zubrod performance status>2

  • Moderate to severe complications seen in 7.1%; more if RT dose >63 Gy

  • Dose escalation above 63 Gy “does not appear to improve the therapeutic ratio”.


Postoperative radiation for oral cavity cancer rt chemotherapy

Postoperative Radiation for Oral Cavity Cancer: RT + Chemotherapy

Two large randomized trials evaluating RT with or without cisplatin chemotherapy in high-risk resected head and neck squamous cell cancers.

EORTC

RTOG

NEJM 2004; 350:1945-1952

NEJM 2004: 350:1937-1944

High risk features: >2 + nodes, +ECE, + margins (EORTC also included perineural spread and vascular tumor embolism)


Postoperative radiation for oral cavity cancer rt chemotherapy1

Postoperative Radiation for Oral Cavity Cancer: RT + Chemotherapy

Radiation dose: 60 Gy RTOG; 66 Gy EORTC

Cisplatin 100 mg/m2 days 1, 22, 43 both

334 EORTC + 459 RTOG patients (793 total)

26-27% oral cavity primaries

In combined analysis, only patients with +ECE and/or + margins benefited from addition of cisplatin Head Neck 2005; 27: 843-850


Postoperative radiation for oral cavity cancer rt chemotherapy2

Postoperative Radiation for Oral Cavity Cancer: RT + Chemotherapy


Postoperative radiation for oral cavity cancer rt chemotherapy3

Postoperative Radiation for Oral Cavity Cancer: RT + Chemotherapy


Postoperative radiation for oral cavity cancer rt chemotherapy4

Postoperative Radiation for Oral Cavity Cancer: RT + Chemotherapy

What’s Next?

RTOG 0234 evaluated postop chemoRT (cisplatin or docetaxel) + EGFR inhibitor cetuximab (Erbitux)

This phase II study completed but results are pending


Get to work

Get to Work!!

Three-Way Tie for Last


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