Radiation Therapy for the Head and Neck Patient: Advances, Challenges, and Perspectives

Part of the Cancer Treatment and Research book series (CTAR, volume 174)


Radiation therapy for head and neck malignancies has made remarkable advances in treatment technology, resulting in improved clinical and functional outcomes. It is necessary for the radiation oncologist to have a complex understanding of the patient’s tumor and its relationship to the surrounding normal anatomy, in order to safely limit dose to normal tissues. Complications following radiation can be managed with timely intervention, usually on an outpatient basis. This chapter will discuss the technological advances in the field, the impact of human papillomavirus (HPV)-mediated disease on radiation treatment, efforts to limit dose to critical salivary and swallowing structures, and management of certain radiation-related toxicities.


Radiation IMRT Side effects HPV Protons 


  1. 1.
    Boero IJ, Paravati AJ, Xu B et al (2016) Importance of radiation oncologist experience among patients with head-and-neck cancer treated with intensity-modulated radiation therapy. J Clin Oncol 34:684–690CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    David JM, Ho AS, Luu M et al (2017) Treatment at high-volume facilities and academic centers is independently associated with improved survival in patients with locally advanced head and neck cancer. CancerGoogle Scholar
  3. 3.
    Peters LJ, O’Sullivan B, Giralt J et al (2010) Critical impact of radiotherapy protocol compliance and quality in the treatment of advanced head and neck cancer: results from TROG 02.02. J Clin Oncol 28:2996–3001CrossRefPubMedGoogle Scholar
  4. 4.
    Wuthrick EJ, Zhang Q, Machtay M et al (2015) Institutional clinical trial accrual volume and survival of patients with head and neck cancer. J Clin Oncol 33:156–164CrossRefPubMedGoogle Scholar
  5. 5.
    Lambrecht M, Nevens D, Nuyts S (2013) Intensity-modulated radiotherapy vs. parotid-sparing 3D conformal radiotherapy. Effect on outcome and toxicity in locally advanced head and neck cancer. Strahlenther Onkol 189:223–229CrossRefPubMedGoogle Scholar
  6. 6.
    Lee N, Xia P, Quivey JM et al (2002) Intensity-modulated radiotherapy in the treatment of nasopharyngeal carcinoma: an update of the UCSF experience. Int J Radiat Oncol Biol Phys 53:12–22CrossRefPubMedGoogle Scholar
  7. 7.
    Takiar V, Ma D, Garden AS et al (2016) Disease control and toxicity outcomes for T4 carcinoma of the nasopharynx treated with intensity-modulated radiotherapy. Head Neck 38(Suppl 1):E925–E933CrossRefPubMedGoogle Scholar
  8. 8.
    Kam MK, Teo PM, Chau RM et al (2004) Treatment of nasopharyngeal carcinoma with intensity-modulated radiotherapy: the Hong Kong experience. Int J Radiat Oncol Biol Phys 60:1440–1450CrossRefPubMedGoogle Scholar
  9. 9.
    Gupta T, Agarwal J, Jain S et al (2012) Three-dimensional conformal radiotherapy (3D-CRT) versus intensity modulated radiation therapy (IMRT) in squamous cell carcinoma of the head and neck: a randomized controlled trial. Radiother Oncol 104:343–348CrossRefPubMedGoogle Scholar
  10. 10.
    Rathod S, Gupta T, Ghosh-Laskar S et al (2013) Quality-of-life (QOL) outcomes in patients with head and neck squamous cell carcinoma (HNSCC) treated with intensity-modulated radiation therapy (IMRT) compared to three-dimensional conformal radiotherapy (3D-CRT): evidence from a prospective randomized study. Oral Oncol 49:634–642CrossRefPubMedGoogle Scholar
  11. 11.
    Yao M, Zhang Q, Woods CR et al (2016) Intensity modulated radiation therapy versus 3-dimensional conformal radiation therapy in head and neck squamous cell carcinoma: a pooled analysis of NRG oncology/RTOG 0129 and 0522. Int J Radiat Oncol Biol Phys 96:S116–S117CrossRefGoogle Scholar
  12. 12.
    Pfister DG, Ang KK, Brizel DM et al (2013) Head and neck cancers, version 2.2013. Featured updates to the NCCN guidelines. J Natl Compr Canc Netw 11:917–923CrossRefPubMedGoogle Scholar
  13. 13.
    Ang KK, Trotti A, Brown BW et al (2001) Randomized trial addressing risk features and time factors of surgery plus radiotherapy in advanced head-and-neck cancer. Int J Radiat Oncol Biol Phys 51:571–578CrossRefPubMedGoogle Scholar
  14. 14.
    Lyhne NM, Primdahl H, Kristensen CA et al (2015) The DAHANCA 6 randomized trial: effect of 6 vs. 5 weekly fractions of radiotherapy in patients with glottic squamous cell carcinoma. Radiother Oncol 117:91–98CrossRefPubMedGoogle Scholar
  15. 15.
    Fu KK, Pajak TF, Trotti A et al (2000) A radiation therapy oncology group (RTOG) phase III randomized study to compare hyperfractionation and two variants of accelerated fractionation to standard fractionation radiotherapy for head and neck squamous cell carcinomas: first report of RTOG 9003. Int J Radiat Oncol Biol Phys 48:7–16CrossRefPubMedGoogle Scholar
  16. 16.
    Bourhis J, Overgaard J, Audry H et al (2006) Hyperfractionated or accelerated radiotherapy in head and neck cancer: a meta-analysis. Lancet 368:843–854CrossRefPubMedGoogle Scholar
  17. 17.
    Nguyen-Tan PF, Zhang Q, Ang KK et al (2014) Randomized phase III trial to test accelerated versus standard fractionation in combination with concurrent cisplatin for head and neck carcinomas in the radiation therapy oncology group 0129 trial: long-term report of efficacy and toxicity. J Clin Oncol 32:3858–3866CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Chen AM, Farwell DG, Luu Q et al (2011) Evaluation of the planning target volume in the treatment of head and neck cancer with intensity-modulated radiotherapy: what is the appropriate expansion margin in the setting of daily image guidance? Int J Radiat Oncol Biol Phys 81:943–949CrossRefPubMedGoogle Scholar
  19. 19.
    Chen AM, Yu Y, Daly ME et al (2014) Long-term experience with reduced planning target volume margins and intensity-modulated radiotherapy with daily image-guidance for head and neck cancer. Head Neck 36:1766–1772CrossRefPubMedGoogle Scholar
  20. 20.
    Hsieh CH, Kuo YS, Liao LJ et al (2011) Image-guided intensity modulated radiotherapy with helical tomotherapy for postoperative treatment of high-risk oral cavity cancer. BMC Cancer 11:37CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Cooper JS, Pajak TF, Forastiere AA et al (2004) Postoperative concurrent radiotherapy and chemotherapy for high-risk squamous-cell carcinoma of the head and neck. N Engl J Med 350:1937–1944CrossRefPubMedGoogle Scholar
  22. 22.
    Huang EY, Leung SW, Wang CJ et al (2000) Oral glutamine to alleviate radiation-induced oral mucositis: a pilot randomized trial. Int J Radiat Oncol Biol Phys 46:535–539CrossRefPubMedGoogle Scholar
  23. 23.
    Eisbruch A, Ten Haken RK, Kim HM et al (1999) Dose, volume, and function relationships in parotid salivary glands following conformal and intensity-modulated irradiation of head and neck cancer. Int J Radiat Oncol Biol Phys 45:577–587CrossRefPubMedGoogle Scholar
  24. 24.
    Weinstein GS, O’Malley BW Jr, Cohen MA et al (2010) Transoral robotic surgery for advanced oropharyngeal carcinoma. Arch Otolaryngol Head Neck Surg 136:1079–1085CrossRefPubMedGoogle Scholar
  25. 25.
    Kim JH, Jenrow KA, Brown SL (2014) Mechanisms of radiation-induced normal tissue toxicity and implications for future clinical trials. Radiat Oncol J 32:103–115CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Lee YH, Kim YS, Chung MJ et al (2016) Soft tissue necrosis in head and neck cancer patients after transoral robotic surgery or wide excision with primary closure followed by radiation therapy. Medicine (Baltimore) 95:e2852CrossRefGoogle Scholar
  27. 27.
    Lukens JN, Lin A, Gamerman V et al (2014) Late consequential surgical bed soft tissue necrosis in advanced oropharyngeal squamous cell carcinomas treated with transoral robotic surgery and postoperative radiation therapy. Int J Radiat Oncol Biol Phys 89:981–988CrossRefPubMedGoogle Scholar
  28. 28.
    Stone HB, Coleman CN, Anscher MS et al (2003) Effects of radiation on normal tissue: consequences and mechanisms. Lancet Oncol 4:529–536CrossRefPubMedGoogle Scholar
  29. 29.
    Rosenthal DI, Chambers MS, Fuller CD et al (2008) Beam path toxicities to non-target structures during intensity-modulated radiation therapy for head and neck cancer. Int J Radiat Oncol Biol Phys 72:747–755CrossRefPubMedGoogle Scholar
  30. 30.
    Reuther T, Schuster T, Mende U et al (2003) Osteoradionecrosis of the jaws as a side effect of radiotherapy of head and neck tumour patients—a report of a thirty year retrospective review. Int J Oral Maxillofac Surg 32:289–295CrossRefPubMedGoogle Scholar
  31. 31.
    De Felice F, Musio D, Tombolini V (2015) Osteoradionecrosis: an old toxicity in the IMRT era? Oral Oncol 51:e60–e61CrossRefPubMedGoogle Scholar
  32. 32.
    Eisbruch A, Harris J, Garden AS et al (2010) Multi-institutional trial of accelerated hypofractionated intensity-modulated radiation therapy for early-stage oropharyngeal cancer (RTOG 00-22). Int J Radiat Oncol Biol Phys 76:1333–1338CrossRefPubMedGoogle Scholar
  33. 33.
    Chen JA, Wang CC, Wong YK et al (2016) Osteoradionecrosis of mandible bone in patients with oral cancer—associated factors and treatment outcomes. Head Neck 38:762–768CrossRefPubMedGoogle Scholar
  34. 34.
    McKenzie MR, Wong FL, Epstein JB et al (1993) Hyperbaric oxygen and postradiation osteonecrosis of the mandible. Eur J Cancer B Oral Oncol 29B:201–207CrossRefPubMedGoogle Scholar
  35. 35.
    Ang KK, Harris J, Wheeler R et al (2010) Human papillomavirus and survival of patients with oropharyngeal cancer. N Engl J Med 363:24–35CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Marur S, Li S, Cmelak AJ et al (2016) E1308: Phase II trial of induction chemotherapy followed by reduced-dose radiation and weekly cetuximab in patients with HPV-associated resectable squamous cell carcinoma of the oropharynx-ECOG-ACRIN cancer research group. J Clin Oncol (JCO2016683300)Google Scholar
  37. 37.
    Chera BS, Amdur RJ, Tepper J et al (2015) Phase 2 trial of de-intensified chemoradiation therapy for favorable-risk Human Papillomavirus-associated oropharyngeal squamous cell carcinoma. Int J Radiat Oncol Biol Phys 93:976–985CrossRefPubMedGoogle Scholar
  38. 38.
    Chen AM, Felix C, Wang PC et al (2017) Reduced-dose radiotherapy for human papillomavirus-associated squamous-cell carcinoma of the oropharynx: a single-arm, phase 2 study. Lancet Oncol 18:803–811CrossRefPubMedGoogle Scholar
  39. 39.
    Leeman JE, Romesser PB, Zhou Y et al (2017) Proton therapy for head and neck cancer: expanding the therapeutic window. Lancet Oncol 18:e254–e265CrossRefPubMedGoogle Scholar
  40. 40.
    Blanchard P, Garden AS, Gunn GB et al (2016) Intensity-modulated proton beam therapy (IMPT) versus intensity-modulated photon therapy (IMRT) for patients with oropharynx cancer—A case matched analysis. Radiother Oncol 120:48–55CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    McDonald MW, Liu Y, Moore MG et al (2016) Acute toxicity in comprehensive head and neck radiation for nasopharynx and paranasal sinus cancers: cohort comparison of 3D conformal proton therapy and intensity modulated radiation therapy. Radiat Oncol 11:32CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Romesser PB, Cahlon O, Scher E et al (2016) Proton beam radiation therapy results in significantly reduced toxicity compared with intensity-modulated radiation therapy for head and neck tumors that require ipsilateral radiation. Radiother Oncol 118:286–292CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Sio TT, Lin HK, Shi Q et al (2016) Intensity modulated proton therapy versus intensity modulated photon radiation therapy for oropharyngeal cancer: first comparative results of patient-reported outcomes. Int J Radiat Oncol Biol Phys 95:1107–1114CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Patel SH, Wang Z, Wong WW et al (2014) Charged particle therapy versus photon therapy for paranasal sinus and nasal cavity malignant diseases: a systematic review and meta-analysis. Lancet Oncol 15:1027–1038CrossRefPubMedGoogle Scholar
  45. 45.
    Leeman JE, Romesser PB, Zhou Y et al (2017) Proton therapy for head and neck cancer: expanding the therapeutic window. Lancet Oncol 18(5):e254–e265Google Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  1. 1.Department of Radiation OncologyCity of Hope Medical CenterDuarteUSA
  2. 2.Department of Radiation OncologyCedars Sinai Medical CenterLos AngelesUSA

Personalised recommendations