Radiol med
DOI 10.1007/s11547-013-0359-7
RADIOTHERAPY
Conventional 2D (2DRT) and 3D conformal radiotherapy
(3DCRT) versus intensity-modulated radiotherapy (IMRT)
for nasopharyngeal cancer treatment
Francesco Moretto • Monica Rampino • Fernando Munoz • Maria Grazia Ruo Redda •
Alessia Reali • Vittoria Balcet • Serena Badellino • Cristina Piva • Marina Schena •
Mario Airoldi • Oliviero Ostellino • Giancarlo Pecorari • Riccardo Ragona • Umberto Ricardi
Received: 4 March 2013 / Accepted: 13 May 2013
Ó Italian Society of Medical Radiology 2014
Abstract
Purpose Nasopharyngeal carcinoma represents a distinct
entity as compared to other head and neck tumours. Radio-
chemotherapy is the treatment of first choice in non-met-
astatic disease. Intensity-modulated radiation therapy
(IMRT) allows the sparing of parotid glands, improving the
toxicity profile. The aim of this study was to compare the
results obtained with IMRT with those obtained with
conventional 2D (2DRT) and 3D conformal radiation
therapy (3DCRT) in terms of tumour control, survival,
acute and late toxicity.
Materials and methods We reviewed the clinical records
of 52 patients with histologically proven carcinoma of the
nasopharynx (stage I–IVB according to the 2002 American
Joint Committee on Cancer staging system) treated with
curative intent between January 2003 and August 2011: 26
patients were treated with 2D or 3D technique (arm A) and
26 with IMRT technique (arm B) with simultaneous inte-
grated boost. Fifty patients (96 %) received chemotherapy.
F. Moretto (&)
S. Badellino
C. Piva
R. Ragona

U. Ricardi
Dipartimento di Oncologia, Radioterapia U, Università di
Torino, Turin, Italy
e-mail: moretto.francesco@hotmail.it
M. Rampino
F. Munoz
Radioterapia U, Azienda Ospedaliero-Universitaria Città della
Salute e della Scienza di Torino, Turin, Italy
M. G. Ruo Redda
Dipartimento di Oncologia, Radioterapia, Università di Torino,
Azienda Ospedaliero-Universitaria San Luigi Gonzaga,
Orbassano, Turin, Italy
A. Reali
Radioterapia, Azienda Ospedaliero-Universitaria San Luigi
Gonzaga, Orbassano, Turin, Italy
Local control (LC), locoregional control (LRC), disease-
free survival (DFS), overall survival (OS), acute and late
toxicity were retrospectively evaluated.
Results After a median follow-up of 37.6 months
(69 months in arm A and 23 months in arm B), 69 % of
patients were alive and disease-free, 10 % were alive with
disease and 21 % died of disease, with an OS of 81 % at
2 years and 79 % at 5 years, a LC rate of 88 % at 2 years
and 78 % at 5 years, a LRC rate of 80 % at 2 years and
73 % at 5 years and a DFS of 74 % at 2 years and 65 % at
5 years, with no statistically significant differences
between IMRT and 2DRT/3DCRT. In multivariate ana-
lysis, the TNM stage and the volume treated at high dose
correlated with DFS. No factor was found to be related to
OS. Chronic toxicity was not statistically different in the
two study groups and in particular CG2 xerostomia rates
were 67 and 41 % in arm A and B, respectively (p = 0.10).
Conclusions The findings of this study confirm that
IMRT associated with chemotherapy, even with
V. Balcet
Radioterapia, Azienda Ospedaliera Sant’Anna, Como, Italy
M. Schena
Oncologia Medica 1, Azienda Ospedaliero-Universitaria Città
della Salute e della Scienza di Torino, Turin, Italy
M. Airoldi
O. Ostellino
Oncologia Medica 2, Azienda Ospedaliero-Universitaria Città
della Salute e della Scienza di Torino, Turin, Italy
G. Pecorari
Dipartimento di Scienze Chirurgiche, Otorinolaringoiatria 1-U,
Università di Torino, Turin, Italy
123

moderately hypofractionated regimens, allows good dis-
ease control with better results in terms of late xerostomia,
although without statistically significant differences com-
pared to 2DRT and 3DCRT. The hypothesis of an impact
of IMRT on survival has yet to be confirmed.
Keywords Nasopharyngeal cancer
Radiotherapy

Treatment techniques
Introduction
Nasopharyngeal carcinoma (NPC) is a pathological,
epidemiological and clinical entity distinct from other
head and neck cancers. It is rare in the United States and
other Western countries, but common in Southern China,
Southeast Asia, the Middle East and North Africa [1, 2].
In these countries, most patients have differentiated
nonkeratinizing or undifferentiated carcinoma (WHO
types 2 or 3), while keratinizing squamous cell carci-
noma or WHO type 1 is rare, but more common in
Western countries [3, 4]. Many patients present with
locally advanced disease.
The standard of care for locally advanced NPC is a
combination of radiotherapy (RT) and chemotherapy [2].
The overall survival (OS) rate at 5 years ranges from 32 to
52 % in large series of patients with locally advanced disease
treated with RT alone [2]. Many trials and meta-analysis
proved an overall and event-free survival (EFS) benefit with
concurrent chemotherapy [3, 5–9]. The recommended RT
dose is in the range of 65–75 Gy over 6–7 weeks. No sig-
nificant reduction in the risk of locoregional recurrence and/
or distant metastases, and no improvement of OS were
shown for adjuvant chemotherapy after chemo-radiation.
The addition of neoadjuvant chemotherapy to radiation
significantly reduced the risk of locoregional recurrence and
distant metastases, but without a significant improvement in
OS [10].
NPC has a relatively good prognosis also in locally
advanced cases: the disease is often chemo- and radio-
sensitive and patients are usually younger and less exposed
to tobacco and alcohol than the majority of head and neck
cancer patients.
Conformal radiotherapy (3DCRT) was considered the
standard technique when intensity-modulated radiation
therapy (IMRT) emerged as a technique able to better
conform the dose around target volumes and to better spare
organs at risk. Because of a steep dose gradient and a high
conformity index, the risk of target missing with IMRT is
higher than with conformal technique, as the integral dose.
Xerostomia is a common and disturbing late effect of
conventional RT. Several authors demonstrated the supe-
riority of IMRT over 2DRT or 3DCRT in parotid gland
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Radiol med
sparing and two randomised controlled trials have proved a
better salivary toxicity profile [11, 12].
Since 2006, at the Radiation Oncology Department of
the University of Turin, patients affected by nasopharyn-
geal cancer were treated with IMRT, with or without
chemotherapy. The aim of the present study was to retro-
spectively review clinical outcomes (efficacy and toxicity)
of this subgroup of patients and to compare these results
with a previous series of patients treated in the same
institution with 2DRT and 3DCRT.
Materials and methods
Patients
All patients affected by histologically proven, stage I–IVB
(according to the 2002 American Joint Committee on
Cancer staging system) nasopharyngeal carcinoma treated
with curative intent between January 2003 and August
2011 at our institution were included, with a minimum
follow-up time of 6 months. Patients with a previous his-
tory of cancers other than non-melanomatous skin carci-
noma or in situ cervical carcinoma were excluded.
Fifty-seven patients met the inclusion criteria: 30 patients
underwent 2DRT or 3DRT (arm A) and 27 IMRT (arm B).
Five patients (four from arm A and one from arm B) were
excluded from the analysis because of a history of malig-
nancies. The median age was 53 years old (range 29–77).
All patients were evaluated at diagnosis with a complete
physical examination, fiber-optic nasopharyngoscopy,
magnetic resonance imaging (MRI) or computed tomog-
raphy (CT) of the head and neck with contrast medium,
chest CT or radiography, abdominal CT or sonography, a
bone scan or a [18F]-fluoro-2-deoxy-D-glucose positron
emission tomography-CT scan (18F-FDG PET-CT) and a
complete blood count with a biochemical profile. After
diagnosis and staging, all patients were evaluated for
therapy by a multidisciplinary team consisting of a sur-
geon, a radiation oncologist and a medical oncologist. All
patients were referred for dental examination and dietary
counselling before radiation therapy. Patients’ character-
istics are summarised in Table 1.
Radiation therapy
All patients were immobilised with a thermoplastic mask.
In the 2DRT group, to define treatment fields, facial–
cervical radiograms were taken using a conventional X-ray
simulator. Nasopharynx, metastatic lymph nodes and
adjacent tissues were treated with 70.2 Gy and the unin-
volved neck with 59.4–64.8 Gy (1.8 Gy daily fractions, 5
fractions per week) using a shrinking lateral opposed field
Radiol med

Table 1 Patients’ characteristics Table 2 Chemotherapy timing in the two arms

Total ARM A ARM B Total Arm A Arm B

No. patients 52 26 26 Chemotherapy 50 25 25

Median age (range) 53 (29–77) 55.5 (29–77) 50 (29–72) Induction only 2 2 0
Gender (M/F) 41/11 21/5 20/6 Induction ? concurrent 31 12 19
Histology (WHO) Concurrent only 9 6 3
I 3 3 0 Concurrent ? adjuvant 8 5 3
II 4 1 3 No chemotherapy 2 1 1
III 45 22 23
T
T1 7 3 4 unique anterior field for inferior neck and supraclavicular
T2 25 11 14 fossa) and six with a whole-field technique, to treat the
T3 12 6 6 entire volume with a single plan.
T4 8 6 2 In the IMRT group a planning CT without contrast
N enhancement was performed. GTV was defined according
N0 9 4 5 to the extent of the tumour as evaluated by clinical
N1 13 6 7 examination, contrast-enhanced CT and/or MRI and/or CT-
N2 20 12 8 PET. CTV1 was generated after a 5–10 mm expansion of
N3 10 4 6 the GTV; CTV2 included all lymph node levels at risk of
Stage I–II 14 6 8 subclinical disease (levels Ib–II–III–IV-upper part of V
Stage III–IV 38 20 18 level). The PTVs were obtained with an isotropic expan-
sion of 5 mm of the respective CTVs. The PTVs in naso-
pharynx and upper neck were treated using 7–9 coplanar
technique, with exclusion of the spinal cord after beams; a variety of fractionations was used, for example
39.6–43.2 Gy. The lower neck was treated with 50–54 Gy 69.44 Gy in 32 fractions, 69.96 Gy in 33 fractions or
through a single anterior field with midline shielding. 70 Gy in 35 fractions were prescribed to the PTV1 and
Megavoltage photons (6 MV) were used to treat the pri- 51.2 Gy in 32 fractions, 54.25 Gy in 35 fractions or
mary tumour and neck lymph nodes, with high-energy 59.4 Gy in 33 fractions to the node-negative regions
electron boost (10–20 Gy) for posterior neck lymph nodes. (PTV2). Eventually 60.8 Gy in 32 fractions, 63 Gy in 35
In the 3DCRT group, a planning CT without contrast fractions or 57.6 Gy in 32 fractions were delivered to high
enhancement was performed. Radiation fields were chosen risk negative lymph node echelons. The dose to the lower
according to the extent of the tumour as evaluated by neck and supraclavicular fossae was 50 Gy in 25 fractions
clinical examination, contrast-enhanced CT and/or MRI in the split-field technique. IMRT plans were delivered
and/or CT-PET. The Gross Tumour Volume (GTV) with a 6 MV Linac (Elekta Precise or Elekta Synergy,
included the primary tumour and abnormal lymph nodes. Stockholm, Sweden).
Clinical Target Volume 1 (CTV 1) included the naso- An optimal sparing of at least one parotid gland was
pharynx, bilateral upper cervical lymph nodes (levels Ib– attempted, especially the contralateral one with respect to
II–III, upper part of level V) and retropharyngeal lymph- the tumour or metastatic lymph nodes. Mean doses to the
atics; CTV2 included low cervical and supraclavicular ipsilateral and contralateral parotid gland were 55.9,
nodes. CTV 3 resembled CTV1 with exclusion of the 32.8 Gy and 53.2, 31.8 Gy in arm A and arm B, respec-
spinal cord and the CTV 4 encompassed a 0.5 to 1-cm tively. Twelve patients in the arm A and 11 patients in arm
margin around GTV. CTVs were expanded by a 5-mm B had bilateral neck involvement.
margin to form their corresponding Planning Target Vol-
umes (PTVs) to compensate for set-up variability. Doses to Chemotherapy
PTV1, PTV2, PTV3 and PTV4 were 39.6–43.2, 50–54,
45–64.8 and 70.2 Gy, respectively, in conventional frac- All patients but two (with T1N0M0 and T2bN0M0 disease,
tionation, using a shrinking field technique for PTV1, respectively) were treated with chemotherapy; 33 patients
PTV3 and PTV4 and an anterior unique field for PTV2. 2D (63.5 %) underwent induction chemotherapy plus concur-
and 3D plans were delivered with a 6 MV Linac (Elekta rent chemotherapy in 31 patients (Table 2). For 30 patients
SL-75, Stockholm, Sweden). a cisplatin-based chemotherapy was scheduled at the dose
Twenty-six patients were treated with IMRT. Twenty of of 100 mg/m2 every 21 days, and 14 patients were treated
them were treated with a split-field technique (with a with weekly doses (30 mg/m2).

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Table 3 Chemotherapy regimens in the two treatment arms toxicity. OS, DFS, LC and LRC were estimated using the
Timing of Drugs No. No.
Kaplan–Meier method and the differences according to
chemotherapy patients patients treatment were analysed using the log-rank test. The fol-
(arm A) (arm B) low-up time was counted from the date of completion of
radiation therapy.
Neoadjuvant Cisplatin ? 5FU 6 3
Univariate and multivariate analyses were performed for
Cisplatin ? paclitaxel/ 5 2
docetaxel evaluation of the prognostic factors and factors correlated
Cisplatin ? 5-FU ? paclitaxel 3 8 to late toxicity. A level of p B 0.05 was assumed as sta-
Cisplatin ? epirubicin 5 tistically significant. STATA Statistical Package version
Paclitaxel ? bleomycin 1
11.0 (StataCorp LP, Texas, USA) was used for statistical
Concurrent Cisplatin (100 mg/m2) 14 16
computations.
Cisplatin (30 mg/m2) 7 8
Cisplatin ? 5-FU 1 0
Results
Carboplatin 1 0
Paclitaxel 0 1
After a median follow-up of 37.6 months, 69 months in
Adjuvant Cisplatin ? 5-FU 5 3
arm A (range 7–108) and 23 months in arm B (range
8–74), 36 patients (69 %) were alive and without evidence
In arm A, 14 patients were treated with induction che- of disease, 5 (10 %) were alive with disease, 11 (21 %)
motherapy (median, two cycles) and 23 patients received died from disease. OS was 81 % at 2 years and 79 % at
concurrent chemotherapy, followed by adjuvant chemo- 5 years in the entire cohort of patients. Two- and five-year
therapy in five patients. Tolerance to concurrent chemo- LC rates were 88 and 78 %; 2- and 5-year LRC rates were
therapy was quite good: nine of 14 patients completed the 80 and 73 %; and 2- and 5-year DFS rates were 74 and
three planned cycles of high-dose cisplatin and four of 65 %, respectively.
seven patients completed at least five cycles of weekly dose In arm A, five patients had persistent disease after RT: a
cisplatin. In five patients, amifostine was used before every nasopharyngeal mass in one case, lymph node metastases in
RT session. two cases and disease in both locations in other two cases:
In arm B, 19 patients were treated with induction che- three patients with residual nodal disease also developed
motherapy (median, two cycles) followed by concurrent distant metastases. During follow-up, other five patients
treatment, with good compliance: 13 of 16 patients com- relapsed, two locally (one of whom then developed distant
pleted three cycles of high-dose cisplatin and seven of eight metastases), one in the neck, one in both the nasopharynx and
patients finished at least five cycles with weekly dose cis- neck and another one with bone metastases, respectively.
platin. Three patients were given additional adjuvant che- Two patients with persistent lymph node metastases under-
motherapy (Table 3). went salvage surgery, but only one was still alive when the
study was concluded. One patient underwent photodynamic
Follow-up therapy for a local recurrence, and then a neck dissection was
performed for a regional recurrence, without evidence of
Patients underwent weekly examinations during treatment. disease at the last follow-up.
The first follow-up evaluation occurred at 2 months and
then every 3–6 months during the first 2 years, every
6 months during years 3–5 and then annually with clinical
examination and contrast-enhanced CT or MRI, chest
radiograms every year and thyroid function tests every
year. Acute and late toxicity was scored according to
CTCAE v3.0 (Common Terminology Criteria for Adverse
Events) and RTOG/EORTC (Radiation Therapy Oncology
Group/European Organisation for Research and Treatment
of Cancer), respectively.

Statistics

The endpoints were OS, disease-free survival (DFS), local

control (LC), locoregional control (LRC), acute and late Fig. 1 Overall survival in the two treatment arms

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Fig. 2 Local control in the two treatment arms
Fig. 3 Locoregional control in the two treatment arms
Fig. 4 Disease-free survival in the two treatment arms
In arm B, two patients had persistent local disease after
treatment and both died of disease. During follow-up, one
patient had a local relapse and three developed distant
metastases.
No significant difference was found in the LC, LRC,
DFS and OS rates for patients treated with IMRT versus
2DRT/3DCRT (Figs. 1, 2, 3, 4).
On multivariate analysis, age, gender, histology, T
stage, N stage, TNM stage, RT technique, biological
equivalent dose (BED), high-dose PTV volume, fraction-
ation schedule, overall radiation treatment time (OTT),
timing of chemotherapy and comorbidities were evaluated
and none was correlated with OS, but TNM stage I–II
(p = 0.021) and high-dose PTV volume C275 ml
(p = 0.014) were statistically correlated to better DFS.
There were no treatment-related deaths and no grade 4
acute toxicity. Rates of acute skin toxicity CG3 were 8 %
in arm A and 15 % in arm B (p = 0.38), mucositis CG3
was 23 and 31 % in arm A and arm B (p = 0.43) and
dysphagia CG3 was 19 and 31 % in arm A and arm B,
respectively (p = 0.13). Parenteral nutrition was necessary
in one patient in arm A and in two patients in arm B and
enteral feeding tube in two patients in arm A and in three
patients in arm B. The median treatment interruption was
2 days in arm A and arm B (range 0–12 days, the same in
the two groups), with a median RT overall treatment time
(OTT) of 63.5 days in arm A (range 46–84) and 47.5 days
in arm B (range 42–64), because a programmed electron
boost was administered to 23 patients after treatment with
photons in arm A.
Late toxicity data were unknown for three patients (two
in arm A and one in arm B). No patient experienced grade
4 late toxicity. At 5 years of follow-up xerostomia CG2
was 67 and 41 % for arm A and B, respectively (p = 0.10),
chronic dysphagia CG2 was 17 and 12 % (p = 0.81),
hearing loss CG2 was 29 and 35 % (p = 0.22) and dys-
geusia CG2 was 4 and 11 % (p = 0.54), respectively, for
arm A and B.
Possible correlations between late toxicity and variables
such as age, gender, stage of disease, high-dose PTV vol-
umes, total radiation dose and fractionation, RT technique,
timing of chemotherapy, amifostine use and severe acute
toxicity were assessed. A trend between hearing loss and
dose per fraction C2 Gy was detected (p = 0.08).
Discussion
During the last 15 years, the use of chemotherapy, espe-
cially in concurrent schedule, improved disease control and
survival of locally advanced head and neck cancer patients.
Concurrent chemo-RT became a standard treatment option
in nasopharyngeal carcinoma patients, except in infrequent
cases with early disease. Furthermore IMRT was shown to
be superior in terms of better target coverage and better
sparing of organs at risk [11, 12].
In our study, the median age (53 years old) and the
male/female ratio (3.7/1) were the same as in most clinical
trials [7, 8, 11–15]. The proportion between early and
123

locally advanced disease (73 % of stage III–IVB) is similar
to other data published in the literature [16–20].
Total radiation dose, as well as fractionation and OTT,
are decisive for local and regional tumour control. In our
practice, a conventional fractionation schedule was used
for almost all patients treated with 2DRT and 3DCRT,
resulting in a median OTT of 63.5 days; on the other hand
a slightly hypofractionated accelerated schedule was cho-
sen in most IMRT cases (median OTT 47.5 days). In our
study, there was no statistically significant difference
between standard and hypofractionated regimen, in terms
of OS, LC, acute and late toxicity.
In our retrospective study, there was no significant dif-
ference in OS between 2DRT/3DCRT and IMRT tech-
niques, although a marginal survival benefit could be
expected with IMRT because of the better dose distribution
and the acceleration of radiation treatment. Unfortunately,
our sample size was too small and follow-up time was quite
short in arm B to demonstrate any survival advantage.
IMRT use did not correlate with a significant difference
in LC, but a weak trend for better LRC was found. On the
contrary, DFS, which takes into account distant failures
too, was very similar in the two groups. Some data in
favour of a better LC with IMRT have been reported in the
literature [20].
In our study, almost all patients were treated with che-
motherapy. Concurrent chemotherapy was always pre-
ferred and neoadjuvant or adjuvant chemotherapy was
eventually evaluated. Trials and meta-analyses demon-
strated no clear advantage in using chemotherapy after
completion of radiation and the compliance was often poor
[5, 6]. In the treatment of nasopharyngeal cancer, the most
recommended neoadjuvant therapy was a combination of
two [14, 21] or three [22–24] cycles of cisplatin and 5-FU,
but in the literature associations of cisplatin with epirubicin
[23, 25, 26], bleomycin [27] or taxanes [28, 29] are
described. TPF chemotherapy (cisplatin-paclitaxel-5-FU),
which correlated with a survival benefit in two trials on
squamous head and neck tumours [30, 31], is being tested
in ongoing international nasopharyngeal cancer trials
[GORTEC-NPC2006, NCT00828386; NCT01245959]. In
our study, 82 % of patients underwent induction chemo-
therapy, almost always two cycles, with a certain variety of
schedules and doses (Table 3). Actually some reports
suggested a benefit in distant disease control [9, 10], but
with potentially higher toxicity and difficulty in completing
an adequate concomitant phase.
In the present study, 92 % of patients were treated with
concurrent chemotherapy. Compliance was good with
high-dose cisplatin: 74 % of patients in arm A and 94 % in
arm B completed at least two cycles. With weekly dose
cisplatin 57 % of patients in arm A and 88 % in arm B
completed five cycles or more. In our practice, there is a
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Radiol med
large use of weekly dose cisplatin, due to its low toxicity,
but there are some controversies about this schedule [3, 13,
15].
Globally, in our study, it was not possible to show any
relationship between chemotherapy timing and patients’
outcome, but the biases were numerous: the use of several
different drugs and schedules, the absence of a control
group, the lack of formal restaging after induction, the low
number of events and the inadequate number of cycles
given after radiation therapy.
In historical reports, the 5-year survival rate was
40–50 % with a LC of 60–70 % before 1990 [32, 33]. In
the 90s, improvements in imaging and the use of conformal
RT combined with chemotherapy resulted in 5-year sur-
vival rates of 75 % and LC rates of 85 % [34]. After that,
an increasing number of publications reported even better
results with the use of IMRT, despite the shorter follow-up
time: LC up to 90 % and similar survival rates at 3 years
[18–20, 35–38]. Taking into account the different follow-
up time, the results obtained in our institution compare
quite well with those previously reported, particularly with
studies using neoadjuvant [27, 29] or concurrent and
adjuvant chemotherapy [5–8].
The outcome of our patients treated with IMRT is
similar to that reported in randomised and retrospective
trials, suggesting the appropriateness of our practice in
terms of radiation doses, target volume definition and
chemotherapy. In comparison, a study with 86 patients
(26 % treated with IMRT) published by Palazzi et al. [16]
showed a LC, a LRC and an OS of 96, 93 and 90 %,
respectively. Patients were staged III–IV in 75 % of cases;
70 % of patients were treated with induction plus concur-
rent chemotherapy and 20 % with concurrent chemother-
apy only.
No analysed factor was related to OS or tumour control,
but stage and volumes of PTV treated with high dose were
related to DFS. In particular, the relationship between
higher PTV volumes and a better DFS appears paradoxical.
Some elements could make this finding a little more sen-
sible: first, GTVs, PTVs and disease stage are linked in a
nonlinear way; second, PTV delineation is also related to
the treatment technique; third, there was an imbalance
between treatment arms: patients treated with IMRT also
had larger planning treatment volumes and higher pre-
scription doses.
The acute toxicity rate in our sample is similar to that of
clinical trials and retrospective surveys [4, 11, 12, 16, 18,
19], even if a underestimation is quite likely because of the
retrospective collection of data.
Two randomised controlled trials [11, 12] demonstrated
the benefit of parotid-sparing IMRT in late xerostomia and
stimulated salivary flow. With regard to late xerostomia,
while in the absence of a significant advantage with IMRT,
Radiol med
our data are similar to those of other studies except for the
timing: typically, patients treated with parotid-sparing
IMRT experience a recovery; on the contrary late xero-
stomia after conventional RT is irreversible. In our cases,
while in arm B, xerostomia had some stabilisation after
little more than 1 year of follow-up, the toxicity rate
increased with time in arm A, with an advantage that
became more evident over time.
Our dosimetric data compared favourably with published
studies: if in our series the mean dose to the spared parotid
was about 32 Gy, in the randomised study by Pow et al. [11]
comparing 2DRT and IMRT mean dose to the contralateral
parotid was 41.3 Gy (33.1–51.8), while in another random-
ised trial, Kam et al. [12] reported a median dose of 32.2 Gy
to the parotids. In the MSKCC study [20] the mean dose to
the parotid glands in 42 patients was 35.2 Gy.
Conclusions
Our study confirms that IMRT in association with che-
motherapy achieves satisfactory disease control rates and
has a good toxicity profile. The parotid gland sparing
IMRT technique led to excellent results in terms of late
xerostomia, although it was not possible to demonstrate a
statistically significant difference as compared to conven-
tional and conformal RT. Finally, IMRT did not show any
survival advantage.
Conflict of interest Francesco Moretto, Monica Rampino, Fernando
Munoz, Maria Grazia Ruo Redda, Alessia Reali, Vittoria Balcet, Se-
rena Badellino, Cristina Piva, Marina Schena, Mario Airoldi, Oliviero
Ostellino, Giancarlo Pecorari, Riccardo Ragona, Umberto Ricardi
declare that they have no conflict of interest related to the publication
of this article.
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