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

Abstract

Purpose: To 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.

Methods: Previously 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.

Results: At 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.

Conclusions: 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.

Keywords: Head-neck cancer; Outcomes; Radiotherapy; Subcutaneous fibrosis; Xerostomia.

Fig. 1

Kaplan-Meier estimates showing no significant difference between three-dimensional conformal radiotherapy (3D-CRT) versus intensity modulated radiation therapy (IMRT) for 10-year loco-regional control (a); progression-free survival (b), and overall survival (c) in patients with early to moderately advanced non-nasopharyngeal head and neck cancers

Fig. 2

Proportion of patients (error-bars represent 95% confidence intervals) with moderate to severe (≥grade 2) late xerostomia at specified time-points in three-dimensional conformal radiotherapy (3D-CRT) and intensity modulated radiation therapy (IMRT) arms. Note the statistically significant p-values favouring IMRT consistently. Lesser number of patients at risk in both arms on long-term follow-up (at 8–10 years) reduces statistical power but, clinically meaningful difference is sustained over time

Fig. 3

Proportion of patients (error-bars represent 95% confidence intervals) with moderate to severe (≥grade 2) subcutaneous fibrosis at specified time-points in three-dimensional conformal radiotherapy (3D-CRT) and intensity modulated radiation therapy (IMRT) arms. Note the statistically significant p-values favouring IMRT in the medium-term (1 and 3 years). Lesser number of patients at risk in both arms on long-term follow-up (between 5 and 10 years) reduces statistical power, but, clinically meaningful difference persists with time