Effect of CTV dose optimization in upper and middle neck on protecting the main midline structures in intensity-modulated radiotherapy for nasopharyngeal carcinoma
Xu Wenjing1, Chen Zhenzhang2, Wang Lijun2, Wen Jing2, Liu Degan1, Yu Jianhe1, Huang Shengfu2, He Xia2
1Department of Oncology, People′s Hospital of Xinghua, Xinghua 225700, China; 2Department of Radiotherapy, Jiangsu Cancer Hospital & Jiangsu Institute of Cancer Research & The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing 210009, China
Abstract:Objective To explore the significance of the clinical target volume (CTV) dose optimization in the upper and middle neck in protecting the laryngopharynx, anterior and posterior rings during intensity-modulated radiotherapy (IMRT) and multimodal imaging system for nasopharyngeal carcinoma. Methods Clinical data of 298 nasopharyngeal carcinoma patients admitted to Jiangsu Cancer Hospital from 2016 to 2018 were retrospectively analyzed. According to the following five strategies of CTV dose optimization in the upper and middle neck:group A, complete optimization of bilateral cervical lymph nodes (CLNs), that is, the CTV doses of bilateral CLNs were 50.4Gy;group B, complete optimization of unilateral CLNs, that is, the CTV dose of unilateral CLNs was 50.4Gy and the contralateral CLNs was 60Gy;group C, incomplete optimization of bilateral CLNs, that is, the CTV doses of bilateral CLNs were 50.4Gy, while the suspicious positive CLNs were selectively boosted to 60Gy;group D, incomplete optimization of unilateral CLNs, that is, the CTV dose of unilateral CLNs was 50.4Gy and the suspicious positive CLNs were selectively boosted to 60Gy, and the CTV dose of contralateral side was 60Gy;group E:no optimization, that is, the CTV doses of bilateral CLNs were 60Gy. Results Among 298 patients, 215 patients received dose optimization and 83 cases did not receive dose optimization. In the dose optimization schemes, 114 cases were assigned in group A, 36 cases in group B, 60 cases in group C and 5 cases in group D. The median (range) follow-up time was 28.5(6.0-46.3) months. The overall survival rate was 95.6%, the progression-free survival rate was 84.2% and the locoregional control rate of CLNs was 98.0%. Local relapse of CLNs occurred in six patients, including 1 case of retropharyngeal lymph node, 4 cases of Ⅱ area and 1 case of Ⅳ area. The P values of average dose of laryngopharynx in group A, group B, group C and group D compared with that in group E were<0.001, 0.016, 0.001 and 0.572, respectively. The P values of the average dose of the anterior ring in group A, group B, group C and group D compared with that in group E were<0.001, 0.011,<0.001 and 0.805, respectively. The P values of the average dose of the posterior ring in group A, group B, group C and group D compared with that in group E were<0.001, 0.004,<0.001 and 0.252, respectively. Conclusions Combined with the metastatic rules of CLNs and multimodal imaging system, it is safe to optimize the CTV dose of the upper and middle neck during IMRT in nasopharyngeal carcinoma patients, which can significantly reduce the doses of laryngopharynx, anterior and posterior rings, thereby providing evidence for reducing the CTV dose in the upper and middle neck.
Xu Wenjing,Chen Zhenzhang,Wang Lijun et al. Effect of CTV dose optimization in upper and middle neck on protecting the main midline structures in intensity-modulated radiotherapy for nasopharyngeal carcinoma[J]. Chinese Journal of Radiation Oncology, 2021, 30(5): 440-445.
[1] Ho FC, Tham IW, Earnest A, et al. Patterns of regional lymph node metastasis of nasopharyngeal carcinoma:a meta-analysis of clinical evidence[J]. BMC Cancer, 2012, 12:98. DOI:10.1186/1471-2407-12-98. [2] Lee NY, Zhang Q, Pfister DG, et al. Addition of bevacizumab to standard chemoradiation for locoregionally advanced nasopharyngeal carcinoma (RTOG 0615):a phase 2 multi-institutional trial[J]. Lancet Oncol, 2012, 13(2):172-180. DOI:10.1016/S1470-2045(11)70303-5. [3] 黄素宁,潘林江,王仁生,等. 鼻咽癌颈部可疑阳性淋巴结60Gy放疗剂量的疗效观察[J]. 临床医学工程, 2013, 20(10):1192-1193,1196. DOI:10.3969/j.issn.1674-4659.2013.10.1192. Huang SN, Pan LJ, Wang RS, et al. Efficacy of 60Gy radiotherapy dose in the treatment of suspicious positive cervical lymph nodes of nasopharyngeal carcinoma[J]. Clin Med Engin, 2013, 20(10):1192-1193,1196. DOI:10.3969/j.issn.1674-4659.2013.10.1192. [4] Shen T, Tang LQ, Luo DH, et al. Different prognostic values of plasma Epstein-Barr virus DNA and maximal standardized uptake value of 18F-FDG PET/CT for nasopharyngeal carcinoma patients with recurrence[J]. PLoS One, 2015, 10(4):e0122756. DOI:10.1371/journal.pone.0122756. [5] 中国鼻咽癌临床分期工作委员会.2010鼻咽癌调强放疗靶区及剂量设计指引专家共识[J]. 中华放射肿瘤学杂志, 2011, 20(4):267-269. DOI:10.3760/cma.j.issn.1004-4221.2011.04.001. Chinese Nasopharyngeal Carcinoma Clinical Staging Committee. 2010 expert consensus on target area and dose design guidelines for nasopharyngeal carcinoma[J]. Chin J Radiat Oncol, 2011, 20(4):267-269. DOI:10.3760/cma.j.issn.1004-4221.2011.04.001. [6] 徐林,周冠群,胡江,等. 鼻咽癌调强放疗中对危及器官勾画及计划优化改进的剂量学探讨[J]. 中山大学学报(医学科学版),2015, 36(5):745-752. DOI:1672-3554(2015)05-0745-08. Xu L, Zhou GQ, Hu J, et al. Dosimetry study to improve the method of organs at risk (OAR) delineations and planning optimization in intensity modulated radiation therapy for nasopharyngeal carcinoma[J]. J SUN Yat-sen Univ (Med Sci), 2015, 36(5):745-752. DOI:1672-3554(2015)05-0745-08. [7] Colevas AD, Yom SS, Pfister DG, et al. NCCN guidelines insights:head and neck cancers, version 1.2018[J]. J Natl Compr Canc Netw, 2018, 16(5):479-490. DOI:10.6004/jnccn.2018.0026. [8] 朱苏雨,胡炳强. 鼻咽癌调强放疗靶区描绘和设定及剂量分配的现状[J]. 中国肿瘤临床,2008, 35(3):173-177. Zhu SY, Hu BQ. Current status of delineation and determination of the targets and their dose prescription scheme in intensity modulated radiotherapy for nasopharyngeal cancer[J]. Chin J Clin Oncol, 2008, 35(3):173-177. [9] August M, Dodson TB, Nastri A, et al. Nasopharyngeal carcinoma:clinical assessment and review of 176 cases[J]. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 2001, 91(2):205-214. DOI:10.1067/moe.2001.110698. [10] 孙颖,马骏,卢泰祥,等. 512例鼻咽癌颈淋巴结转移规律的研究[J]. 癌症,2004, 23(11s):1523-1527. DOI:1000-467X (2004)11s-1524-05. Sun Y, Ma J, Lu TX, et al. Regulation for distribution of metastatic cervical lymph nodes of 512 cases of nasopharyngeal carcinoma[J]. Chin J Cancer, 2004, 23(11s):1523-1527. DOI:1000-467X (2004)11s-1524-05. [11] Lin SJ, Pan JJ, Han L, et al. Nasopharyngeal carcinoma treated with reduced-volume intensity-modulated radiation therapy:report on the 3-year outcome of a prospective series[J]. Int J Radiat Oncol Biol Phys, 2009, 75(4):1071-1078. DOI:10.1016/j.ijrobp.2008.12.015. [12] 王丽君,黄生富,蒋明华,等. 鼻咽癌调强放疗临床靶区中 ⅡB区的优化对腮腺剂量的影响研究[J]. 肿瘤学杂志,2014, 20(10):812-818. DOI:10.11735/j.issn.1671-170X.2014.10. B007. Wang LJ, Huang SF, Jiang MH, et al. The effect of optimizing clinical target volume in ⅡB region on parotid gland dose in nasopharyngeal carcinoma treated with intensity modulated radiotherapy[J]. J Chin Oncol, 2014, 20(10):812-818. DOI:10.11735/j.issn.1671-170X.2014.10. B007. [13] 陈薇,王丽君,王飞江,等. 鼻咽癌调强放疗临床靶区中Ⅳ区优化对甲状腺剂量的影响[J]. 临床肿瘤学杂志,2015, 20(11):1023-1027. DOI:1009-0460(2015)11-1023-05. Chen W, Wang LJ, Wang FJ, et al. Effect of optimizing clinical target volume in neck node level Ⅳ on thyroid dose in nasopharyngeal carcinoma[J]. Chin Clin Oncol, 2015, 20(11):1023-1027. DOI:1009-0460(2015)11-1023-05. [14] 周益琴,王丽君,黄生富,等. 鼻咽癌调强放疗对患者颌下腺保护的临床研究[J]. 肿瘤学杂志,2014, 20(12):1012-1017. DOI:10.11735/j.issn.1671-170X.2014.12. B009. Zhou YQ, Wang LJ, Huang SF, et al. Clinical study on submandibular gland sparing in intensity modulated radiotherapy for nasopharyngeal carcinoma[J]. J Chin Oncol, 2014, 20(12):1012-1017. DOI:10.11735/j.issn.1671-170X.2014.12. B009. [15] 陈薇,王丽君,王飞江,等. 单侧颈淋巴结转移鼻咽癌患者IMRT对侧颈部临床靶区优化的可行性[J]. 江苏医药,2015, 41(24):2981-2984. DOI:0253-3685(2015)24-2981-04. Chen W, Wang LJ, Wang FJ, et al. Feasibility of optimizing clinical target volume on contralateral neck by IMRT in nasopharyngeal carcinoma patients with unilateral cervical lymph node metastasis[J]. Jiangsu Med J, 2015, 41(24):2981-2984. DOI:0253-3685(2015)24-2981-04. [16] 刘菊英,陈薇,王丽君,等. 鼻咽癌调强放疗优化颈部靶区对甲状腺功能保护的临床研究[J]. 中国肿瘤,2015, 24(12):1031-1037. DOI:10.11735/j.issn.1004-0242.2015.12. A016. Liu JY, Chen W, Wang LJ, et al. The study of intensity modulated radiation therapy (IMRT) for nasopharyngeal carcinoma in optimizing cervical clinical target volume on the protection of thyroid function[J]. Chin Cancer, 2015, 24(12):1031-1037. DOI:10.11735/j.issn.1004-0242.2015.12. A016. [17] 问静,王丽君,张兰芳,等. 鼻咽癌N1患者对侧下颈调强靶区优化的临床研究[J]. 肿瘤学杂志,2019, 25(2):102-106. DOI:10.11735/j.issn.1671-170X.2019.02. B006. Wen J, Wang LJ, Zhang LF, et al. Clinical study of contralateral lower neck intensity-modulated radiotherapy target volumn optimization in patients with N1-staged nasopharyngeal carcinoma[J]. J Chin Oncol, 2019, 25(2):102-106. DOI:10.11735/j.issn.1671-170X.2019.02. B006. [18] Vainshtein JM, Griffith KA, Feng FY, et al. Patient-reported voice and speech outcomes after whole-neck intensity modulated radiation therapy and chemotherapy for oropharyngeal cancer:prospective longitudinal study[J]. Int J Radiat Oncol Biol Phys, 2014, 89(5):973-980. DOI:10.1016/j.ijrobp.2014.03.013. [19] Rancati T, Fiorino C, Sanguineti G. NTCP modeling of subacute/late laryngeal edema scored by fiberoptic examination[J]. Int J Radiat Oncol Biol Phys, 2009, 75(3):915-923. DOI:10.1016/j.ijrobp.2009.04.087. [20] Levendag PC, Teguh DN, Voet P, et al. Dysphagia disorders in patients with cancer of the oropharynx are significantly affected by the radiation therapy dose to the superior and middle constrictor muscle:a dose-effect relationship[J]. Radiother Oncol, 2007, 85(1):64-73. DOI:10.1016/j.radonc.2007.07.009. [21] Lee AW, Ng WT, Pan JJ, et al. International guideline on dose prioritization and acceptance criteria in radiation therapy planning for nasopharyngeal carcinoma[J]. Int J Radiat Oncol Biol Phys, 2019, 105(3):567-580. DOI:10.1016/j.ijrobp.2019.06.2540.