Treatment of regionally-advanced head and neck squamous cell carcinoma (HNSCC) requires a multidisciplinary approach with a combination of surgery, radiotherapy (RT) and chemotherapy. Due to these aggressive combined modalities, patients undergoing treatment and many survivors develop toxicities which impact quality of life (QoL) and sometimes lead to mortality. Lymph node metastases of HNSCC are frequent and considered one of the most important prognostic factors, resulting in decreased survival by 50%. More than three decades, the optimal management strategy of node positive HNSCC was a key subject of debate. In summary, the current literature provides us two important findings: First, with the contemporary imaging and treatment modalities, there is no role of a planned neck dissection (ND) added to (chemo)radiotherapy ((C)RT) in terms of oncological outcome and survival. Second, with modern RT techniques, a tailored treatment followed after an up-front neck dissection (UFND) allows a significant reduction of treatment volumes and de-escalation of the dose to the neck, leading to reduction of treatment related toxicities. In this study strategies with and without up-front neck dissection prior to chemo-radiotherapy will be compared.
The main objective of this project is to test the hypothesis that the addition of UFND prior to (C)RT results in a significant reduction of treatment toxicities and improvement of QoL in regionally advanced (cN2-3) HNSCC through dose de-escalation and volume reduction of RT. The primary endpoint of this trial is to evaluate the toxicity from the beginning of radiotherapy until 90 days after the end of the treatment. The incidence of acute and subacute toxicities higher than grade ≥3 (CTCAE v.4, except for Xerostomia, for which RTOG/EORTC scale will be used) will be compared between study arms. Secondary endpoints include the survival endpoints for both treatment modalities; i.e. loco-regional control, progression-free and overall survival. Assessment of QoL (EORTC QLQ-C30 + H\&N43), late toxicity, surgical complications, cost-effectiveness and the need of feeding-tube will be a part of the final analysis of this trial. Trial design: randomized multi-center open-label comparative one-staged phase III trial with a superiority design and the primary endpoint of highest grade radiation toxicity during and until 90 days after the completion of the treatment. Interventions in both arms of the trial are considered as standard treatments. No experimental diagnostic tools will be used during the trial. In addition to the randomized arms, two identical observational arms will be opened for the patients who are diagnosed before the activation of the randomized arms, and subsequently for those who refuse to be randomized. Their aim is to prospectively acquire high quality data for patients who refuse randomization. The observational and randomized cohorts will be analyzed separately for the pre-defined endpoints. For the calculation of the sample size, grade ≥3 acute radiation toxicity in the CRT alone (Arm A) was assumed as 70% based on literature. For the primary endpoint, a follow-up period of 90 days after the last day of (C)RT is needed after the accrual of the last patient. However, 2 years of follow-up after (C)RT is needed for the secondary endpoints (exception: oncological outcome and survival will be calculated from the day of randomization in order to avoid immortal time bias). On this basis, sample size was calculated based on the Pearson chi-squared test and performed in Stata. Assuming a toxicity fraction of 70% for any grade 3 or higher toxicity in Arm A, a relative risk of 0.5 (35% in Arm B), a two-sided alpha of 0.05, a power of 80%, a drop-out rate of 5%, and an allocation ratio of 1 we calculated an overall sample size of 65. Expected accrual time is 3 years.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
NONE
Enrollment
65
70 Gy in 35 fractions to the macroscopic disease 50 Gy in 25 fractions (if sequential boost) or 56 Gy in 35 fractions (if simultaneous integrated boost) to the elective volumes 66 Gy in 35 fractions to the post-operative region with lymphatic extracapsular extension (Arm B only)
100 mg/m2 every three weeks during radiotherapy In Arm B, chemotherapy can be omitted in case of a cT1-2 primary and a surgical downstaged pN0-1 neck without lymphatic extracapsular extension.
Early salvage neck dissection in case of residual lymph node disease will be performed based on the response evaluation by MRI and PET/CT performed 3 and 4 months after the end of (chemo)radiotherapy, respectively (and additional diagnostic modalities if clinically indicated by the physician) and not more than 3 weeks after this post-radiotherapy evaluation. In Arm A, a successful early salvage neck dissection without the operation of the primary tumor in case of less than clinical complete response (cCR) will be considered a component of the multimodality treatment and not as a failure.
Inselspital Bern
Bern, Switzerland
University Hospital of Geneva
Geneva, Switzerland
Number of patients with acute & subacute toxicity based on CTCAE scoring system v4.03
Time frame: from the beginning of radiotherapy until 90 days after the end of the treatment
Number of patients with late Toxicity based on CTCAE scoring system v4.03
Time frame: beginning from 91 days after the end of radiotherapy until the end of the 2 years follow up
Change from baseline quality of life(QoL)using EORTC QLQ-C30 v3&EORTC QLQ-H&N43 modules(Health related QoL specific for Head&Neck ca.)scores at end of RT, 3,12&24 months after RT.Swallowing (H&N43:4-item scale)3 months after RT is the primary QoL domain
EORTC QLQ-C30 and H\&N43 will be used
Time frame: up to 24-28 months depending on the treatment duration.
Loco-regional control
Time frame: 2 years from the randomization
Progression-free survival
Time frame: 2 years from the randomization
Overall survival
Time frame: 2 years from the randomization
Distant metastasis-free survival
Time frame: 2 years from the randomization
Disease-specific survival
Time frame: 2 years from the randomization
QoL comparison between the patients who accepted to be randomized (into rA and rB) and not (into oA and oB: in other words, patients who chose their own treatment strategy)
Time frame: Baseline QoL and until the end of 2 years follow-up
Surgical complication rates
Time frame: 2 years from the randomization
Rate of Isolated nodal control
The absence of metastatic lymph node metastases in the neck without any synchronous or preceding local recurrence or distant metastases
Time frame: 2 years from the randomization
Radiation dose and volumes
The dose-volume histograms of all organs-at-risk (defined per protocol) will be compared between patients with and without up-front neck dissection. The doses will be reported in Gy and the volumes in cc.
Time frame: until the end of radiotherapy, expected to be on average 7 weeks
Comparison of applied RT plan and the virtual RT plan done on the pre-UFND diagnostic CT images
The dose-volume histograms of all organs-at-risk (defined per protocol) will be compared between the plans generated based on the pre- and post-UFND CT-scans of patients allocated the UFND arm. The doses will be reported in Gy and the volumes in cc.
Time frame: until the end of radiotherapy, expected to be on average 7 weeks
Comparison between clinical and pathological stages of patients allocated to the UFND arm. according to the AJCC/UICC TNM staging system (7th edition).
Time frame: until the generation of the definitive pathology report after the up-front neck dissection, expected to be within 3 weeks after patients' study enrollment
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