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When should I add chemotherapy concurrently to radiation therapy in resected advanced head and neck squamous cell carcinoma (HNSCC)?

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Key concept

Disease recurrence is a major problem in resected advanced head and neck cancer. The addition of radiation treatment after surgical resection can reduce the risk of locoregional relapse. The addition of chemotherapy may further reduce that risk and improve outcomes in specific settings.

Clinical scenario

A 53-year-old man is post laryngectomy and left neck dissection for locally advanced laryngeal squamous cell carcinoma. His surgical pathology revealed positive margins, and 2 of 16 lymph nodes were positive for metastatic disease with presence of extracapsular extension (ECE). What adjuvant treatment should he receive?

Action items

Cisplatin is the drug of choice in the adjuvant setting. Cisplatin can be administered either weekly (40 mg/m2) or every 3 weeks (100 mg/m2), concurrently with adjuvant radiation. The role of cetuximab in the adjuvant setting remains investigational.

Chemotherapy strongly recommended

  • Positive surgical margin

  • ECE of nodal disease

Chemotherapy to be considered

  • Pathologic N2/N3 disease

  • Pathologic T3/T4 disease

  • Presence of perineural invasion

  • Presence of lympho-vascular invasion

Discussion

The RTOG95-01 trial, a randomized controlled study comparing adjuvant radiation to combined adjuvant cisplatin and radiation in patients with resected locally advanced HNSCC, revealed that in subgroups of patients with ECE or positive surgical margins, the locoregional failure rate (LRF) and disease-free survival at 10 years were significantly in favor of the chemoradiation arm. There were a trend toward improvement in overall survival (OS) in that study arm as well.1 Similarly, the EORTC-22931 study enrolled patients with resected HNSCC with high-risk features, including positive surgical margins, ECE, pathologic N2/N3 or T3/T4 stage, perineural involvement, and vascular tumor embolism. Concurrent high-dose cisplatin and radiation improved progression-free survival and OS and lowered LRF compared with adjuvant radiation only.2

Pearls

The addition of cisplatin concurrently with radiation improves clinical outcome in patients with high-risk features (and is strongly recommended in patients with ECE or positive margins), at the expense of increased toxicities.

References
  1. Cooper JS, Zhang Q, Pajak, TF, et al. Long-term follow-up of the RTOG 9501/intergroup phase III trial: postoperative concurrent radiation therapy and chemotherapy in high-risk squamous cell carcinoma of the head and neck. Int J Radiat Oncol Biol Phys 2012;84(5):1198-205.

  2. Bernier J, Domenge C, Ozsahin M, et al. Postoperative irradiation with or without concomitant chemotherapy for locally advanced head and neck cancer. N Engl J Med 2004;350(19):1945-52.

When should I recommend the placement of a feeding tube in a head and neck cancer (HNSCC) patient receiving radiation treatment?

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Key concept

Treatment with radiation with or without chemotherapy has improved the outcome of HNSCC patients. However, development of mucosal toxicities is common in these patients and often leads to weight loss. The question is whether a feeding tube ...

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