Letter to Editor
Dear Editor
I congratulate Chaturvedi et al. [1] on their valuable study, which aimed to compare the efficacy and toxicity profiles of weekly (n = 26) versus three-weekly (n = 25) cisplatin regimens in the context of definitive concurrent chemoradiotherapy (CCRT) for locally advanced head and neck cancers (LAHNC). All patients received 70 Gy, 63 Gy, and 56 Gy to the high-, intermediate-, and low-risk planning target volumes using intensity-modulated radiotherapy (IMRT). While statistically indistinguishable, survival results were generally better with three-weekly than weekly cisplatin-based CCRT. Acute toxicities were more frequent in the three-weekly than the weekly cisplatin arm, but these were generally manageable grade 1 or 2 toxicities. Late toxicity rates were not statistically different between the two treatment groups, with xerostomia and dysphagia being the most frequent toxicities. This pilot study presents valuable insights into the management of patients with LAHNC; however, I have reservations regarding certain toxicities that the authors did not address, particularly from the perspective of an oral and maxillofacial surgeon.
Although the incidence of late toxicities associated with radiotherapy (RT) or CCRT has significantly decreased due to the increased utilization of advanced IMRT, it is not feasible to eliminate them. This is particularly true for tumors where organs at risk are close to the radiation portal, such as oral cavity (OCC) and oropharyngeal cancers (OPC) [2]. Studies utilizing IMRT have indicated that the rates of periodontitis, tooth loss, and osteoradionecrosis (ORN) in LAHNC patients can reach as high as 61.5% [3], 67% [4], and 9.2% [5], respectively. Therefore, it is unexpected that in a study involving 38 out of 51 patients (74.5%) diagnosed with OCC and OPC, no toxicities such as periodontitis, dental caries, tooth loss, or ORN were observed. This finding is particularly surprising given that these patients were subjected to 70 Gy of RT and concurrent chemotherapy. Confirming this assertion, despite using cutting-edge proton therapy, Singh and colleagues recently reported a 10.6% rate of ORN in a study incorporating 122 HNC patients [6]. Given that the teeth, jaws, and periodontal tissues may have received critical doses exceeding 50 Gy, which are necessary for the development of periodontal, dental, and mandibular late toxicities in a significant number of patients treated with a prescription dose of 70 Gy, as noted in the study by Chaturvedi and colleagues, it would be beneficial to report the prevalence of these toxicities for a more comprehensive overview of the therapies administered [1, 7]. Moreover, these particular late toxicities can significantly impact various aspects of quality of life [8] and worsen disease prognosis for many LAHNC patients who have undergone IMRT [9], with or without CCRT. Therefore, sharing this information could be instrumental in encouraging the multidisciplinary team to monitor high-risk patients closely and promptly initiate preventive or treatment strategies against these disabling late-onset toxicities.
Declarations
Compliance with Ethical Standards
None to declare.
Research Involving Human Participants and/or Animals
None.
Informed Consent
NA.
Conflicts of Interest
None to declare.
Footnotes
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References
- 1.Chaturvedi A, Sehrawat A, Mopidevi TR et al (2024) Comparison of the Effect of Weekly Cisplatin Versus Three Weekly Cisplatin in Concurrent Chemoradiotherapy of Head and Neck Cancer: a pilot study. Indian J Otolaryngol Head Neck Surg. 10.1007/s12070-024-05190-w39558982 [Google Scholar]
- 2.van der Veen J, Nuyts S (2017) Can intensity-modulated-Radiotherapy reduce toxicity in Head and Neck squamous cell carcinoma? Cancers (Basel) 9(10):135. 10.3390/cancers9100135 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Ammajan RR, Joseph R, Rajeev R, Choudhary K, Vidhyadharan K (2013) Assessment of periodontal changes in patients undergoing radiotherapy for head and neck malignancy: a hospital-based study. J Cancer Res Ther 9(4):630–637. 10.4103/0973-1482.126461 [DOI] [PubMed] [Google Scholar]
- 4.Somay E, Topkan E, Bascil S, Ozturk D, Senyurek S, Durankus NK et al (2024) Topkan’s CARWL index efficiently predicts the radiation-induced tooth loss rates in radically treated locally advanced nasopharyngeal cancer patients. Technol Cancer Res Treat 23. 10.1177/15330338241292234 [DOI] [PMC free article] [PubMed]
- 5.Kilic Durankus N, Somay E, Bascil S, Senyurek S, Ozturk D, Selek U, Topkan E (2024 Sep) Predicting osteoradionecrosis risk in patients with locoregionally advanced nasopharyngeal carcinoma undergoing concurrent chemoradiotherapy: the value of the CARWL index. Biomol Biomed 22. 10.17305/bb.2024.11155 [DOI] [PMC free article] [PubMed]
- 6.Singh A, Kitpanit S, Neal B, Yorke E, White C, Yom SK et al (2023) Osteoradionecrosis of the jaw following proton radiation therapy for patients with head and neck cancer. JAMA Otolaryngol Head Neck Surg 149(2):151–159. 10.1001/jamaoto.2022.4165 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Gomes-Silva W, Morais-Faria K, Rivera C et al (2021) Impact of radiation on tooth loss in patients with head and neck cancer: a retrospective dosimetric-based study. Oral Surg Oral Med Oral Pathol Oral Radiol 132(4):409–417. 10.1016/j.oooo.2021.06.021 [DOI] [PubMed] [Google Scholar]
- 8.Somay E, Yilmaz B, Topkan E, Kucuk A, Pehlivan B, Selek U (2022) Assessment of the impact of osteoradionecrosis on quality-of-life measures in patients with head and neck cancer. Exon Publications.: 41–56 [PubMed]
- 9.Topkan E, Kucuk A, Somay E, Yilmaz B, Pehlivan B, Selek U (2023) Review of osteoradionecrosis of the Jaw: Radiotherapy modality, technique, and dose as risk factors. J Clin Med 12(8):3025. 10.3390/jcm12083025 [DOI] [PMC free article] [PubMed] [Google Scholar]