How Does Intensity-Modulated Radiotherapy Versus Conventional Two-Dimensional Radiotherapy Influence the Treatment Results in Nasopharyngeal Carcinoma Patients?

doi:10.1016/j.ijrobp.2010.03.024

International Journal of Radiation OncologyBiologyPhysics

Volume 80, Issue 3, 1 July 2011, Pages 661-668

https://doi.org/10.1016/j.ijrobp.2010.03.024 Get rights and content

Purpose

To compare the results of intensity-modulated radiotherapy (IMRT) with those of two-dimensional conventional radiotherapy (2D-CRT) in the treatment of patients with nasopharyngeal carcinoma (NPC).

Methods and Materials

A retrospective review of data from 1,276 patients with biopsy-proven, nonmetastatic NPC was performed. All patients had undergone magnetic resonance imaging and were staged according to the sixth edition of the American Joint Committee on Cancer staging criteria. Radiotherapy was the primary treatment for all patients.

Results

Of the 1,276 patients, 512 were treated with IMRT and 764 with 2D-CRT. The 5-year actuarial local relapse-free survival (LRFS), the nodal relapse-free survival (NRFS), the distant metastasis-free survival (DMFS), and the disease-free survival (DFS) rates were 92.7%, 97.0%, 84.0%, and 75.9%, respectively, for the IMRT group, and 86.8%, 95.5%, 82.6%, and 71.4%, respectively, for the 2D-CRT group. In stage T1 patients, improvement of LRFS in the IMRT group was even significantly higher than in the 2D-CRT group (100% vs. 94.4%; p = 0.016). A trend of improvement of DFS was observed in the IMRT group compared with the 2D-CRT group but without reaching statistical significance. NRFS and DMFS rates were similar in the two groups.

Conclusions

A greater improvement of treatment results with IMRT than with 2D-CRT was demonstrated primarily by achieving a higher local tumor control rate in NPC patients, especially in the early T stage patients. The goal of better control of both local failure in advanced, nonmetastatic NPC patients and of distant failure should be addressed in future studies.

Introduction

Nasopharyngeal carcinoma (NPC) is a radiosensitive disease, and radiotherapy remains the mainstay of treatment for nondisseminated disease. Up until the early 1990s, conventional two-dimensional radiotherapy (2D-CRT) was used to deliver a “tumoricidal” dose (66–70 Gy; 2 Gy per fraction; 6.6–7 weeks) via laterally opposed fields. However, treatment with 2D-CRT transitioned to three-dimensional conformal radiotherapy (3D-CRT), and in particular to intensity-modulated radiotherapy (IMRT), representing a major step forward in the treatment of NPC(1).

Contrary to the local control rates of only 64% to 95% for stage T1/T2 and 44% to 68% for T3/T4 tumors described in the 1992 American Joint Committee on Cancer (AJCC) manual, Lee et al. (2) reported excellent outcomes for 4-year local relapse-free survival (LRFS) rates and local-regional progression–free rates of 97% and 98%, respectively, for NPC patients treated with IMRT. Kam et al. (1) subsequently presented 3-year LRFS and nodal relapse-free survival NRFS rates of 92% and 98%, respectively. Other studies have also reported beneficial IMRT results for the treatment of NPC 3, 4. However, it was not clear whether the improvements associated with IMRT were due to IMRT alone or to the contribution of many factors. For example, the historical results used as a baseline represented only the treatment outcomes reported from the 1970s through the early 1990s, which represent a time when NPC patients were staged mainly by physical examination, skull X-ray, and computed tomography (CT). However, in IMRT studies, patient diagnosis was based on magnetic resonance imaging (MRI), which has emerged as an advantage of the modern era (5). Also, the staging systems used in historical studies were not the same as those used in IMRT studies, thus affecting the ability to directly compare treatment results among these studies. In addition, most NPC patients in historical studies were treated with radiotherapy alone, whereas advanced-disease patients in IMRT studies received cisplatin-based chemotherapy in combination with radiotherapy, which is superior to radiotherapy alone (6).

To our knowledge, no comparison studies of the effects of IMRT versus 2D-CRT on the outcomes of NPC exist; neither do studies to investigate whether early T stage patients receive a greater therapeutic benefit from IMRT than advanced-disease patients. Therefore, we conducted a retrospective study to directly compare IMRT versus 2D-CRT results in patients treated in the same time period.

Section snippets

Patient characteristics

A total of 1,276 patients with newly diagnosed, biopsy-proven, nonmetastatic NPC presented at our center between January 2003 and December 2006 were included in this study. The male/female ratio was 3:1 (959 men and 317 women), and the median age was 45 years (range, 11–78 years). Histological examination showed that 98.8% of the patients had World Health Organization (WHO) type II or III disease, 0.6% had WHO type I disease, and 0.6% of patients had adenocarcinoma.

Clinical staging

All patients underwent a

Patient characteristics

There were no significant differences in the host factors, histological categories, tumor factors, and chemotherapy between the IMRT and 2D-CRT groups (Table 1). However, significantly more patients with stage T3 to T4 disease in the 2D-CRT group than in the IMRT group had received additional boost treatments (22.9% vs. 1.5%, p < 0.001) (Table 1).

Overall pattern of failure

Overall, 313 (24.5%) patients failed at one or more sites. Distant metastasis as the only site of failure (13.4%) was the most common incidence,

Discussion

Nowadays, the number of head-and-neck cancer patients receiving IMRT, which is considered a safe and effective treatment for NPC 1, 2, 4, has been increasing. In the current study, the treatment results of NPC patients treated with IMRT were compared with results for those treated with 2D-CRT. NPC in both groups was staged with the same investigation methods, classified by the current staging system, and treated with current standard systemic treatments.

Conclusions

Improvement of treatment results with IMRT versus 2D-CRT was demonstrated primarily by achieving higher local tumor control rate in NPC patients, especially in the early T stage patients. However, further improvement of the local control of stage T3/4 patients might be achieved by escalating the physical radiation dose, altering fractionation, and combining IMRT with other effective therapies. Distant control of NPC remains insufficient with this treatment modality. Additional randomized trials

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: Shu-Zhen Lai and Wen-Fei Li contributed equally to this work.

: This work was supported by grants from the Science Foundation of Key Hospital Clinical Program of Ministry of Health, P.R. China (no. 2007-353), the Hi-Tech Research and Development Program of China (no. 2006AA02AA404), the International Cooperation Foundation of Guangdong Science and Technology Department of China (no. 2008B050100039), and the Specialized Research Fund for the Doctoral Program of Higher Education of China (no. 20090171110077).

: Conflicts of interest: none.

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Clinical InvestigationHow Does Intensity-Modulated Radiotherapy Versus Conventional Two-Dimensional Radiotherapy Influence the Treatment Results in Nasopharyngeal Carcinoma Patients?

Purpose

Methods and Materials

Results

Conclusions

Introduction

Section snippets

Patient characteristics

Clinical staging

Patient characteristics

Overall pattern of failure

Discussion

Conclusions

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Am J Surg

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Clinical Investigation
How Does Intensity-Modulated Radiotherapy Versus Conventional Two-Dimensional Radiotherapy Influence the Treatment Results in Nasopharyngeal Carcinoma Patients?