# Radiation Oncology/Head & Neck/Protons

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Proton Therapy in Head & Neck Cancers

## General

* Tsukuba; 2004 (1983-2000) PMID 14762662 -- "Proton therapy for head and neck malignancies at Tsukuba." (Tokuuye K, Strahlenther Onkol. 2004 Feb;180(2):96-101.)
** Retrospective. 33 patients with H&N malignancies, no surgery. Oral papillomatosis 12%, T1-2N0 21%, 67% locally advanced. Treated with protons +/- photons (depending on beam availability). Median dose 76 Gy, median proton dose 2.8 Gy/fraction.
** Outcome: 5-year LC 74%, 5-year OS 44%
** Toxicity: Grade 3+ acute 3%, late 18%
** Conclusion: High local control, with few toxicities compared with conventional RT. However, late toxicity if prior significant RT

## Specific Sites

* Nasopharynx
* Sinonasal tumors
* Adenoid cystic
* Oropharynx

## Treatment Planning

* Paul Scherrer Institute
** 2006 PMID 16916557 -- "Intensity modulated photon and proton therapy for the treatment of head and neck tumors." (Steneker M, Radiother Oncol. 2006 Aug;80(2):263-7. Epub 2006 Aug 17.)
*** Treatment planning. 5 patients, comparison of IMPT (3, 5, 9 fields and 2 spot sizes) and IMRT (5, 9 fields)
*** Outcome: Critical organs best spared using 3-field IMPT. Little advantage to more fields, but advantage to smaller spot size.
*** Conclusion: IMPT better ability to spare organs at risk than IMRT for the same dose homogeneity
** 2001 PMID 11730999 -- "A treatment planning comparison of 3D conformal therapy, intensity modulated photon therapy and proton therapy for treatment of advanced head and neck tumours." (Cozzi L, Radiother Oncol. 2001 Dec;61(3):287-97.)
*** Treatment planning. 5 patients, comparison of conventional photon/electron plan, 3D-CRT, IMRT, and proton therapy. PTV 54 Gy.
*** Outcome: PTV coverage for all techniques but conventional photon/electron plan; protons improved dose homogeneity. For spinal cord and parotid, proton best sparing; IMRT plans superior to 3D-CRT and conventional plans, but inferior to proton plans.
*** Conclusion: IMRT and protons have potential to reduce toxicity over conventional RT

## Review

* MAASTRO; 2010 PMID 20817407 -- "Systematic review and meta-analysis of radiotherapy in various head and neck cancers: Comparing photons, carbon-ions and protons." (Ramaekers BL, Cancer Treat Rev. 2010 Sep 1. [Epub ahead of print])
** Systematic review. 86 observational studies (74 photon, 5 carbon, 7 proton), 8 comparative in-silico studies
** Outcome: 5-year OS higher after carbon ion for mucusal melanoma compared to photons (44% vs 25%, SS). 5-year LC higher for carbon compared with IMRT for paranasal/sinonasal tumors (88% vs 66%, SS). No other significant comparisons
** Conclusion: Overall quality and quantity of data regarding carbon and proton therapy is poor
* Harvard; 2008 PMID 18493920 -- "Proton radiation therapy for head and neck cancer." (Chan AW, J Surg Oncol. 2008 Jun 15;97(8):697-700.)
* Review; 2006 PMID 16804876 -- "Particle beam radiotherapy for head and neck tumors: radiobiological basis and clinical experience." (Jereczek-Fossa, Head Neck. 2006 Aug;28(8):750-60.)

## Charged Particles

* Chiba
** 2008 PMID 18769999 -- "Comparative study of dose distribution between carbon ion radiotherapy and photon radiotherapy for head and neck tumor." (Amirul Islam, Radiat Med. 2008 Aug;26(7):415-21. Epub 2008 Sep 4.)
*** Treatment planning. 7 patients originally treated with carbon ion (sinonasal tumors). Carbon ion (CIRT) vs. 3D-CRT vs. IMRT.
*** Outcome: Mean conformity index 3D-CRT 1.46, IMRT 1.43, CIRT 1.22. Photon plans greater volumes of normal tissue at 10-95% isodose
*** Conclusion: Carbon ion has potential to improve target dose conformity, inhomogeneity and OAR sparing
** 2004 (1994-1997) PMID 15380567 -- "Dose escalation study of carbon ion radiotherapy for locally advanced head-and-neck cancer." (Mizoe JE, Int J Radiat Oncol Biol Phys. 2004 Oct 1;60(2):358-64.)
*** Phase I/II. 36 patients, locally advanced H&N. Group A: 18 fractions (48.6/18 GyE to 70.2/18 GyE). Group B: 16 fractions (52.8/16 to 64/16). Endpoint erythema and mucositis. Median F/U 7.5 years
*** Outcome: MTD 70.2/18 (1/2 patients Grade 3 acute toxicity) and 64/16 (2/3 patients Grade 3 acute toxicity). 5-year LC 75%, better with non-squamous tumors including adenoid cystic and melanoma
*** Conclusoin: Carbon ion will deliver high local control without unacceptable toxicity
* Lawrence Berkeley Laboratory
** 1994 (1977-1992) PMID 8040010 -- "Experience in charged particle irradiation of tumors of the skull base: 1977-1992." (Castro JR, Int J Radiat Oncol Biol Phys. 1994 Jul 1;29(4):647-55.)
*** Retrospective. 233 patients treated with charged particles. Tumors arising/extending to skull base. Arising: Chordoma 24%, chondrosarcoma 12%, meningioma 12%, other 9%; Extending: salivary glands 20%, nasopharynx 14%, paranasal sinuses 10%. Mean dose 65 GyE. Median F/U 4.2 years
*** Outcome: 5-year LC meningioma 85%, chondrosarcoma 78%, chordoma 63%
*** Conclusion: Charged particle therapy effective in controlling skull base lesions
** 1988 PMID 3350726 -- "Charged particle radiotherapy of selected tumors in the head and neck." (Castro JR, Int J Radiat Oncol Biol Phys. 1988 Apr;14(4):711-20.)
*** Retrospective. 98 patients, H&N. Mean F/U 3 years
*** Outcome: 2-year LC non-squamous 60%, squamous 35%