Clinical and translational radiation oncology · 2026
De-escalation of elective radiotherapy guided by FDG-PET lowers modeled late swallowing-related toxicity in head and neck cancer.
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Stritzke Florian, Dvornikovich Katharina, Lau Hin, Tessonnier Thomas, Schröter Philipp, Neugebauer David, Netzer Nils, Bauer Lukas, Thölken Rubens, Winter Erik, Harrabi Semi, Mairani Andrea, Haberkorn Uwe, Debus Jürgen, Held Thomas
Аннотация
PURPOSE: Whether FDG-PET-guided de-escalation of elective target volumes in radiotherapy of the head and neck reduces late toxicity remains uncertain. Therefore, we compared predicted toxicity of two de-escalation strategies-reduced elective nodal irradiation (RNI) and involved node irradiation (INI)-with standard elective nodal irradiation (ENI).
MATERIALS AND METHODS: In a within-patient plan comparison (n = 26), we generated RNI and INI plans using the same FDG-PET informed high-/intermediate-risk targets as ENI. RNI limited elective volumes to within 2 cm cranio-caudal from gross disease; INI omitted elective treatment. Proton plans were created in representative oropharyngeal cases. Co-primary outcomes were six-month normal-tissue complication probabilities (NTCPs) for dysphagia, feeding-tube dependence, and xerostomia.
RESULTS: Median total planning target volume decreased from 540 cm3 (ENI) to 418 cm3 (RNI) and 173 cm3 (INI). RNI and INI reduced modeled dysphagia risk by 5.9 percentage points (pp) (95% CI 2.3 to 9.6 pp; padj = 0.005) and 11.0 pp (6.9 to 15.2 pp; padj < 0.001), feeding-tube dependence by 2.8 pp (1.2 to 4.5 pp; padj = 0.005) and 4.2 pp (2.5 to 6.0 pp; padj < 0.001), and xerostomia by 2.8 pp (0.0 to 5.7 pp; padj = 0.054) and 8.8 pp (5.5 to 12.2 pp; padj < 0.001), respectively. Predicted benefits were greatest in hypopharyngeal and laryngeal cancers. In selected cases, de-escalated proton therapy further reduced organ-at-risk dose.
CONCLUSIONS: FDG-PET-guided volumetric de-escalation was associated with lower modeled late swallowing-related toxicity. These findings support the rationale for ongoing and future trials investigating volumetric de-escalation strategies.
MATERIALS AND METHODS: In a within-patient plan comparison (n = 26), we generated RNI and INI plans using the same FDG-PET informed high-/intermediate-risk targets as ENI. RNI limited elective volumes to within 2 cm cranio-caudal from gross disease; INI omitted elective treatment. Proton plans were created in representative oropharyngeal cases. Co-primary outcomes were six-month normal-tissue complication probabilities (NTCPs) for dysphagia, feeding-tube dependence, and xerostomia.
RESULTS: Median total planning target volume decreased from 540 cm3 (ENI) to 418 cm3 (RNI) and 173 cm3 (INI). RNI and INI reduced modeled dysphagia risk by 5.9 percentage points (pp) (95% CI 2.3 to 9.6 pp; padj = 0.005) and 11.0 pp (6.9 to 15.2 pp; padj < 0.001), feeding-tube dependence by 2.8 pp (1.2 to 4.5 pp; padj = 0.005) and 4.2 pp (2.5 to 6.0 pp; padj < 0.001), and xerostomia by 2.8 pp (0.0 to 5.7 pp; padj = 0.054) and 8.8 pp (5.5 to 12.2 pp; padj < 0.001), respectively. Predicted benefits were greatest in hypopharyngeal and laryngeal cancers. In selected cases, de-escalated proton therapy further reduced organ-at-risk dose.
CONCLUSIONS: FDG-PET-guided volumetric de-escalation was associated with lower modeled late swallowing-related toxicity. These findings support the rationale for ongoing and future trials investigating volumetric de-escalation strategies.