Medical Archive

삼성의 dose schedule

De-escalation

• RTOG 0129
• ECOG 3311
• DART trial
• RTOG 0022

Hypofractionation

UKHAN1 (Tobias, Lanc Onc, 2010 / Sanghera, IJROBP, 2007)

55/20 to primary, 45/20 for ENI

Oncologic outcome

• 2y LC ~75%, drops to 64% for T3-4

Toxicity

Mucosal toxicity peaks at 5w

IAEA-HYPNO (Bentzen, LBA02 ASTRO 2023, phase III)

Introduction

• 66/33 (DAHANCA) vs 44-55/20
• 792 pts with OP(51%) HPX (14%) LX (25%) OC (9%)

Oncologic outcome

• 3y OS ~55%, 3y PFS 45%, 3y LRC 51%

Toxicity

3y late G3+ AE ~20% → 19%

CompARE (NCT04116047, phase III)

70/35/CDDP vs 64/25/CDDP vs Surgery

695 pts with IR and HR OPC

240403 250307 pf. 우홍균

Definition

• >2.0Gy/Fx ← according to FARO survey of hypofractionation in HNSCC in 2023
• ≥3.0Gy/Fx ← for pf. Wu

2025 INNOCENCE-ASIA survey

5R = 4R + inherent radiosensitivity

Parameters for radiotherapy

1. Total dose
2. Dose per fraction
3. Overall treatment time
   Deceleration: repopulation이 문제가 될 것.
   Acceleration: ※ small cell lung cancer 는 bid로 하는게 좋다고 한다.
   • Reimbursement 문제로 사용하지 않게 됨.
   • CCRT의 효과가 입증되면서 altered fractionation 안하게 됨.
4. Time interval between fractions
   → 4시간 이내가 되면 toxicity 커진다. 최소 6시간 이상은 띄우도록.
5. Target volume
   • 5+5mm rule을 꼭 지켜야 할까 → 이혜인 선생님 논문에 따르면 +5mm만 해도 괜찮더라.
   • Vocal cord
     • 2D bilateral field – C5 근처 5x5cm2 field.
       maximal dose는 가운데가 아니고 바깥쪽 skin에 많이 들어가게 되어 hot spot이 carotid에 있었다.
     • Single vocal cord irradiation (Al-Mamgani A et al., IJROBP, 2015)

GOAT experiment

48Gy in 4Gy dd → erythema 34%, fibrosis 67%
52Gy in 2.4Gy dd → erythema 30%, fibrosis 5%

Various schemes

Conventional (SNUH)

• in all SIB tech. total 30fx for definitive, 28fx for postop adj., once daily, 5f/week

Review by Piras A et al.

HNSCC palliation 하는 경우 보통 3Gy x10, 4Gy x5, 8Gy x1을 많이 한다.

Vocal cord

2Gy vs 2.25Gy

⭐️NCD analysis) Yamazaki et al., IJROBP, 2006

<2.5Gy vs 2.5Gy

Lim Y et al., Cancer Res Treat, 2015 (SNUH)

<2.5Gy vs 2.5Gy
2.5Gy가 survival이 더 좋더라.

⛔ SNUH phase I trial (pf. Wu, 유도솔 선생님)

Dose limiting toxicity in 5Gy per fx arm
59.5Gy/3.5Gy (17fx) can be safely delievered

5Gy per fx arm → 2 G3 chronic laryngegal inflammation

• Prev. prospective trial
  • CTV1 = GTV+3mm margin
  • CTV2 = remaining larynx (thyrodid notch – cricoid cartilage)
• Changes from 2018
  • Posterior commissure was excluded from CTV
    -> posterior commissure was treated in 9 (25.7%) patients)
• PTV = CTV+3mm
  • CTV to PTV expansion to the posterior direction was reduced when CTV was close to hypopharynx
• 59.5Gy/17Fx to PTV1, 47.6Gy/17Fx to PTV2
• 35 pts recruited -> 7 from prev. prospective trial in 2015
• MFU 16.23 mo
• No LRR, DM, death reported
• 1 Gr.3 acute mucositis

supraglottic ca.는 기본적으로 ENI를 해야 하나, 고령에 일부 환자에 있어서 hypofractionation 진행 중.

Treatment outcomes

• Hypofx with 3.5Gy/f is effective

Considerations

• 2.25Gy seems safe. In early cancer, 2.5Gy or even higher dd is feasible.

작년 ASTRO 발표 – Perillo A et al. Radiation Oncol, 2021

SABR at IRCSS Regina Elena National Cancer Center Institute, Italy

현재의 방침
PTV margin을 계속 줄여 나가는 것. 지금도 palliation 에서는 CTV=PTV 를 사용.
Bulky한 경우는 (특히 ACC) GTV-1.0cm에 2.5-3Gy 를 주는 것도 생각해 볼 수 있을 것.

UKHAN1 (Tobias, Lanc Onc, 2010 / Sanghera, IJROBP, 2007)

55/20 to primary, 45/20 for ENI

Oncologic outcome

• 2y LC ~75%, drops to 64% for T3-4

Toxicity

Mucosal toxicity peaks at 5w

IAEA-HYPNO (Bentzen, LBA02 ASTRO 2023, phase III)

Introduction

• 66/33 (DAHANCA) vs 44-55/20
• 792 pts with OP(51%) HPX (14%) LX (25%) OC (9%)

Oncologic outcome

• 3y OS ~55%, 3y PFS 45%, 3y LRC 51%

Toxicity

3y late G3+ AE ~20% → 19%

CompARE (NCT04116047, phase III)

70/35/CDDP vs 64/25/CDDP vs Surgery

695 pts with IR and HR OPC

SABR

Study at italy

36 Gy/3 Fx