Neoplasms

Mouth and Tooth Diseases

Ear, Nose, and Throat Diseases

All Conditions

Rare Diseases

Nasopharyngeal Carcinoma

Carcinoma

Neoplasms, Glandular and Epithelial

Neoplasms by Histologic Type

Nasopharyngeal Neoplasms

Pharyngeal Neoplasms

Otorhinolaryngologic Neoplasms

Head and Neck Neoplasms

Nasopharyngeal Diseases

Pharyngeal Diseases

Stomatognathic Diseases

Otorhinolaryngologic Diseases

Whole neck irradiation is given in the involved neck. Elective neck irradiation of Level II,III and Va lymph node area is given in the uninvolved neck, and Level IV and Vb lymph node area were not irradiated in the uninvolved neck.

Whole neck irradiation is given regardless of the involved or uninvolved neck.

Elective neck irradiation

Whole neck irradiation

Linglong Tang, M.D.,PhD

Currently, most protocols of nasopharyngeal carcinoma (NPC) of various research bodies such as the Radiation Therapy Oncology Group require routine elective irradiation to the retropharyngeal area and to levels II-V lymph nodal areas regardless of the status of nodal metastasis. Previous studies had confirmed that the pattern of cervical lymph node (LN) metastasis in NPC followed an orderly manner. Retropharyngeal LNs were the most commonly involved, followed by upper neck levels II, III, or VA nodes, and finally to the lower neck nodes including level IV and VB nodes; and the incidence of LN skip metastasis is rare, ranging from 0.5% to 7.9%. It was rare for NPC patients without neck LN metastases to experience neck failure after elective irradiation to levels II, III and VA. It was also confirmed that with unilateral LN metastases of higher-level LNs usually spread down ipsilateral LNs. Thus, the investigators conduct the non-inferior randomized trial to determine the value of elective neck irradiation in NPC patients with unilateral or bilateral uninvolved neck.

Individualized Elective Neck Irradiation Based on MRI in NPC Patients

The Multicenter Randomized Phase 3 Trial of Individualized Elective Neck Irradiation Based on MRI in Patients With Nasopharyngeal Carcinoma

The regional relapse-free survival rate will be estimated using Kaplan-Meier method for each arm from the date of randomization to the date of nodal relapse or death from any cause, whichever occurred first. Their differences will be compared between treatment arms using the log-rank test.

Acute and late toxicity will be documented according to RTOG/EORTC System and the CTCAE(Common Terminology Criteria for Adverse Events). Toxicity will be summarized using descriptive statistics.

The overall survival rate will be estimated using Kaplan-Meier method for each arm from the date of randomization to death from any cause. Their differences will be compared between treatment arms using the log-rank test.

The local relapse-free survival rate will be estimated using Kaplan-Meier method for each arm from the date of randomization to documented local relapse or death from any cause. Their differences will be compared between treatment arms using the log-rank test.

The distant metastasis-free survival rate will be estimated using Kaplan-Meier method for each arm from the date of randomization to documented distant metastasis or death from any cause. Their differences will be compared between treatment arms using the log-rank test.

European Organization for Research and Treatment of Cancer Quality-of-Life Core 30 items (QLQ-C30) version 1.0 questionnaires will be used to assess quality-of-life. All items pointing to this domain are averaged and then transformed to a scale of 0-100 according to the EORTC scoring manual. Higher scores on global health status suggest better health.

European Organization for Research and Treatment of Cancer Quality-of-Life Core 30 items (QLQ-C30) version 1.0 questionnaires will be used to assess quality-of-life. All items pointing to this domain are averaged and then transformed to a scale of 0-100 according to the EORTC scoring manual. Higher scores on the functioning scales suggest better function.

European Organization for Research and Treatment of Cancer Quality-of-Life Core 30 items (QLQ-C30) version 1.0 questionnaires will be used to assess quality-of-life. All items pointing to this domain are averaged and then transformed to a scale of 0-100 according to the EORTC scoring manual. Higher scores on the symptom scales indicate more severe symptoms.

European Organization for Research and Treatment of Cancer Quality-of-Life Head and Neck 35 items (QLQ-H\&N35) version 1.0 questionnaires will be used to assess quality-of-life. All items pointing to this domain are averaged and then transformed to a scale of 0-100 according to the EORTC scoring manual. Higher scores on the symptom scales indicate more severe symptoms.

First People's Hospital of Foshan

Guilin Medical College

Sun Yat-sen University

associated professor

Respiratory Tract (Lung and Bronchial) Diseases

Carcinoma, Squamous Cell

Laryngeal Diseases

Squamous Cell Carcinoma of Head and Neck

Neoplasms, Squamous Cell

* Sentinel lymph node biopsy
* Radiotherapy (IMRT/VMAT with SIB) to the primary tumor with selective elective neck irradiation guided by histopathologic status of the sentinel lymph node(s)

- Radiotherapy (IMRT/VMAT with SIB) to the primary tumor with standard bilateral elective neck irradiation

Patients will undergo sentinel lymph node biopsy. Based on the histopathologic status of the sentinel lymph node(s), selective elective neck irradiation is performed with standard radiation treatment of the primary tumor.

There are 3 possible treatment scenarios.

1. Bilateral elective neck irradiation is indicated when sentinel lymph nodes at both sides of the neck contain metastases or when sentinel lymph node detection fails.
2. Unilateral elective neck irradiation is indicated when sentinel lymph node(s) at one side of the neck contain metastases.
3. Full omission of elective neck irradiation is indicated when all sentinel lymph nodes are free of metastases.

Sentinel lymph node biopsy guided selective elective neck irradiation

Patients randomized to the control arm will receive the standard of care, according to (inter)national clinical practice guidelines. This will consist of (chemo)radiotherapy to the primary tumor with standard elective neck irradiation in all patients. No sentinel lymph node biopsy will be performed.

Standard elective neck irradiation

Dr. S. van den Bosch, MD, PhD

Prof. Dr. J.H.A.M. Kaanders, MD, PhD

Dr. A. Al-Mamgani, MD, PhD

Dr. W.H. Schreuder, MD, PhD

Dr. T.W.H. van Zon-Meijer, MD, PhD

Dr. B.E.C. Plaat, MD, PhD

Drs. M.A. de Jong, MD

Prof. dr. J.C. Jansen, MD, PhD

Dr. S. van Weert, MD, PhD

Dr. F.J.P. Hoebers, MD, PhD

Prof. Dr. J.H.A.M. Kaanders

Prof. dr. R.P. Takes, MD, PhD

Dr. J.B.W. Elbers, MD, PhD

Dr. J.A. Hardillo, MD, PhD

Dr. M. de Ridder, MD, PhD

Prof. dr. R. de Bree, MD, PhD

Rationale \| Squamous cell carcinoma of the upper aerodigestive tract comes with a substantial risk for cervical lymph node metastases. Elective neck irradiation is performed in patients receiving (chemo)radiotherapy aiming to eradicate nodal metastases that are under the diagnostic detection level. Most toxicity and permanent long-term radiation side effects are caused by elective neck irradiation. In particular xerostomia and dysphagia are notoriously known to negatively and permanently affect quality of life. Sentinel lymph node biopsy has emerged as a staging procedure that can reliably detect microscopic metastases by histopathological examination of sentinel lymph nodes and the pathologic status of the sentinel lymph node accurately reflects the status of the remaining nodal basin. A recent meta-analysis demonstrated an excellent diagnostic test accuracy of sentinel lymph node biopsy in patients with cancer of the oropharynx, larynx and hypopharynx (sensitivity 0.93 and negative predictive value 0.97). It is conceivable that personalized elective neck irradiation can be performed guided by the results of sentinel lymph node biopsy. With this approach it is expected that elective neck irradiation can be omitted in the majority of patients with a clinically negative neck because occult nodal metastases are present approximately in 3 out of 10. This will enable better sparing of normal tissues from radiation and consequentially result in less permanent long-term radiation side effects with better quality of life after treatment.

Objective \| To compare safety and efficacy of treatment with sentinel lymph node biopsy guided elective neck irradiation versus standard elective neck irradiation in patients receiving definitive (chemo)radiotherapy for squamous cell carcinoma of the oropharynx, larynx or hypopharynx.

Design \| This is a multicenter, randomized controlled trial. In total 242 patients will be randomized in ratio 1:1 to the control arm with standard bilateral elective neck irradiation or to the interventional arm with sentinel lymph node biopsy guided personalized elective neck irradiation. During a 2 year follow-up, data on toxicity, quality of life and oncologic outcomes will be collected. If this trial demonstrates that the interventional treatment is non-inferior to the standard treatment in terms of regional recurrence and is superior in terms of xerostomia-related quality of life, this will become the new standard of care.

Population \| Patients to be treated with definitive (chemo)radiotherapy for stage cT1-4N0M0 squamous cell carcinoma of the oropharynx, larynx or hypopharynx for whom bilateral elective neck irradiation is indicated. Excluded are patients with recurrent disease or patients who received previous oncologic surgery or radiotherapy to the neck.

Intervention \| Patients randomized to the intervention arm will undergo sentinel lymph node biopsy. Based on the histopathologic status of the sentinel lymph node(s), patients will receive no elective neck irradiation (if all sentinel lymph nodes are negative), unilateral only (if a sentinel lymph node is positive at one side of the neck) or bilateral (if sentinel lymph nodes are positive at both sides of the neck). For patients randomized to the control arm sentinel lymph node biopsy will not be performed and all will receive standard bilateral elective neck irradiation.

Primary endpoints \| The primary safety endpoint is the number of patients with recurrence in regional lymph nodes (in the absence of synchronous recurrence of the primary tumor or second primary tumor) within 2 years after treatment. The primary efficacy endpoint is patient reported xerostomia-related quality of life measured by the xerostomia symptom scale of the EORTC QLQ-H\&N35 at 6 months after treatment.

Other endpoints \| Acute and late radiation toxicity, quality of life after treatment with focus on xerostomia and dysphagia, local and regional control rates, disease specific and overall survival, and cost-effectiveness.

Burden associated with participation \| Patients randomized to the intervention arm will undergo sentinel lymph node biopsy (flexible endoscopic tracer injection under topical anesthesia in the outpatient clinic, SPECT/CT-scan and surgical removal of identified sentinel lymph nodes under general anesthesia). These procedures will not be performed in patients in the control arm. For patients randomized to the intervention arm there is a potential increased risk for regional recurrence because elective neck irradiation is omitted based on the histopathologic status of the sentinel lymph node(s). However this risk is expected to be very small (3.1% versus 2.0% in the control arm). Because regional recurrences can be cured in 70-90% of the patients with salvage neck dissection, the effect on overall survival is expected to be negligible. Independent of randomization, participants will undergo non-invasive procedures to objectify radiation sequelae and will be asked to complete quality of life questionnaires.

Benefit associated with participation \| With sentinel lymph node biopsy, it is expected that futile elective neck irradiation can be omitted to one or both sides of the neck in 9 out of 10 patients. This will enable better sparing of normal tissues from radiation and it is expected that this will result in a major decrease of permanent long-term radiation side effects (such as xerostomia and dysphagia) with better quality of life after treatment compared to standard elective neck irradiation.

Personalized Elective Neck Irradiation Guided by Sentinel Lymph Node Biopsy in Larynx and Pharynx Cancer. The PRIMO Study.

Personalized Elective Neck Irradiation Guided by Sentinel Lymph Node Biopsy in Patients With Squamous Cell Carcinoma of the Oropharynx, Larynx or Hypopharynx With a Clinically Negative Neck: (Chemo)Radiotherapy to the PRIMary Tumor Only. The PRIMO Study.

Only regional recurrences in the absence of synchronous local recurrence or second primary tumors are considered as events

Study title	NCT ID	Conditions	Interventions	Eligibility	Organization	Link
Individualized Elective Neck Irradiation Based on MRI in NPC Patients	NCT02642107	Nasopharyngeal ...	Elective neck i... Whole neck irra...	18 Years - 65 Years	Sun Yat-sen University
Personalized Elective Neck Irradiation Guided by Sentinel Lymph Node Biopsy in Larynx and Pharynx Cancer. The PRIMO Study.	NCT05333523	Laryngeal Squam... Hypopharynx Squ... Oropharyngeal S...	Sentinel lymph ... Standard electi...	18 Years -	Radboud University Medical Center

Spots Global Cancer Trial Database for elective neck irradiation