ICHNO
The 3rd ICHNO, like the first and second occasions, took place in Barcelona, this year from 24 – 26 February 2011. A gentle sun provided a warm multi-disciplinary welcome away from rainy home and Gaudi rapidly became the hallmark of the meeting. The spread of participants was slightly skewed with 33% clinical oncologists, 12% head and neck surgeons, 46% radiation oncologists and 9% from other groups.
We started off with a keynote lecture by Kian Ang who gave an overview of randomised trials and the background for the chosen experimental arms. HPV positive patients do better (or more reliably: HPV negative, P16, do worse) and as in 2009 the question remains: can we decrease treatment and side effects for the prognostically more favorable group? An interesting observation was the continued anti-tumour effect of prolonged Cetuximab administration after chemoradiation.
Kaanders reported on the, overall negative, ARCON trial. In the case of hypoxia Arcon was effective. The Danish group proved the value of a sustained database on trials in head and neck cancer: not surprisingly, but clear from the data, co-morbidity is a determining prognostic factor for patients suffering from head and neck cancer, more so than in other tumour regions. Overall: the days that treatment selection was based upon classic TNM criteria are over. We need to do better than that. P16 positivity, less than 10 pack years…. Trials testing more specific tumour criteria with tailored treatment are ongoing.
In the afternoon proferred papers were presented. Dr. Takes demonstrated that microarray evaluation better predicts nodal metastasis than conventional investigations. Furthermore, the case was made for nimorazole in combination with radiotherapy especially in hypoxic tumours. Given the few side effects, why isn’t it used more widely? Dr. Nuyts reported on P16 and HPV-ve patients, they do as well as HPV+ve patients. The question that remains is: Is 80% good enough?
Friday stressed the multidisciplinary approach with technological advances on imaging, radiotherapy, nuclear imaging and robotic surgery. Exciting possibilities emerge for the tiny virtual surgeon. Operating from what would otherwise be impossible positions provides new possibilities with minimal side effects. Care should be taken to select patients without the need for adjuvant treatment.
Imaging gradually improves and diffusion MRI predicts response earlier than conventional MRI. Current PET imaging is 95% FDG based. This is likely to change; more tailored agents can better distinguish between tumour and inflammation.
In the afternoon the swallowing problem after radiotherapy was addressed. The main factors for late swallowing toxicity are chemotherapy with radiation and the dose to the upper pharyngeal constrictor. Langendijk demonstrated the need for standardisation in delineating the swallowing organs at risk. With different, published, guidelines the dose to the upper pharyngeal constrictor muscle varied from more than 60 to less than 40 Gy. However, a clear improvement in predicted normal tissue complications is possible with swallowing-sparing radiation techniques. Cleverly designed trials are needed to validate this assumption.
Mucositis in radiation remains a large concern. New drugs are being tested in phase II trials to accelerate regeneration of the mucosa. Given the high prevalence and impact on the quality of life this is an important field to watch.
After recurrent cancer, outcome is poor with radiation, surgery or chemotherapy. Surgical salvage treatment for recurrent cancer is possible but with a high complication rate of 72%. Good tumour control results were presented by C. Leemans. What is promising is that with proper selection “once irresectable: always unresectable” 49% disease free survival can be achieved, with 31% DFS after chemoradiation. With new stereotactic radiation treatments re-irradiation with hypofractionation seems possible but control rates remain poor. In the case of metastatic disease, polychemotherapy provides higher response rates but no improvement in survival. The addition of anti-EGFR to chemotherapy provides higher response rates especially in the presence of acneiform rash as a treatment side effect.
New targeted agents provide yet more possibilities in treating head and neck tumours. More and more treatment selection will be based upon molecular imaging and predictors for treatment specific outcome.
Dr Coen Rasch
NKI (The Netherlands Cancer Institute)
Amsterdam, The Netherlands