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ICAR SINONASAL TUMORS

TABLE XXV.5 (Continued)

Clinical endpoints

Study

Year LOE Study design Study groups

Conclusion

Huang et al. 1673

1. No significant difference between ILNSI and ILNPI group in 3-year OS, RRFS, DFS, and DMFS 2. Ipsilateral lymph node recurrence rates are similar in ILNSI and ILNPI groups 1. 3-year OS 88% 2. 3-year PFS 71% 3. 15 (20%) developed grade 3 late toxicities 4. Grade 2 xerostomia 26%, 12%, and 9% at 1, 2, and 3 years, respectively

1. 3-year OS 2. RRFS, DFS,

2521 NPC patients in nine comparative studies (one RCT + eight retrospective cohort) ILNSI versus ILNPI IMRT in three studies, 2DRT in two studies, 2DRT or IMRT or 3DRT in four studies 75 NPC patients (Stage II-IV) treated with adaptive IMRT and concurrent chemotherapy

2018 2

Systemic

reviewand meta analysis

DMFS, and lymphnode recurrence

Nishimura et al. 1677

2020 3

Phase II single armstudy

1. 3-year OS 2. 3-year PFS

Abbreviations: CRT, concurrent chemoradiation; CTV, clinical target volume; DMFS, distant metastasis-free survival; Fr, fractions; IC, induction chemotherapy; ILNSI, ipsilateral lower neck sparing irradiation; ILPSI, ipsilateral lower neck prophylactic irradiation; LPFS, local progression-free survival; NPC, nasopharyngeal carcinoma; OS, overall survival; PFS, progression-free survival; PTV, planning target volume; RP, retropharyngeal; RPFS, regional progression-free survival; RRFS, regional recurrence-free survival; SEQ, sequential boost; SIB, simultaneous integrated boost; UICC, Union for International Cancer Control; UNI, upper neck irradiation; WNI, whole-neck irradiation.

have been included in the radiation field regardless of the nodal stage of the disease. This approach may contribute to increased soft tissue fibrosis of the neck and dyspha gia. Several retrospective nonrandomized cohort studies were performed to determine if the ipsilateral lower neck could be omitted in the radiation planning in patients with clinically node-negative NPC. A meta-analysis in 2018 showed that there was no difference in 3-year OS, regional relapse-free survival, and DMFS between ipsilateral lower neck sparing irradiation versus ipsilateral lower neck pro phylactic irradiation and it was found that both groups had similar nodal recurrence rate. However, the qual ity of the studies included were variable and there was a large heterogeneity in the treatment protocol between the included studies. 1673 Objective measurement of long term swallowing function and neck fibrosis is also missing in the studies. More recently, a large RCT showed that with careful patient selection using both MRI and PET/CT, reducing the field of radiation in the contralateral lower neck resulted in improved QOL but not inferior sur vival outcomes. 1674 Further clinical trials are in process to confirm these results.

Cost

IMRT significantly increases the time needed for radiotherapy planning and the direct cost of RT. However, reduction in late toxicities translates to long-term cost savings, which would be very hard to measure. Exact cost comparison analyses accounting for those would be very difficult to perform. Preponderance of benefits over harms.

Benefits–harm assessment

Value

Patients should be treated with IMRT whenever possible.

judgments

Policy level Strong recommendation. Intervention IMRT is the current standard of care for primary radiation treatment of NPC.

6 Elective radiation treatment of the N0 neck NPC has high propensity for bilateral cervical lymph node metastasis that can be clinically apparent or occult. Tra ditionally, bilateral upper and lower cervical lymphatics