Introduction
Methods
Results and discussion
Author and year of publication | Disease site | Study type, inclusion | Arms, design, endpoint, statistics | Patient number and characteristics | Median follow-up | Results and comments |
---|---|---|---|---|---|---|
Li et al. 2006 [9] | Nasopharynx cancer | Single centre dose escalation, China, 1999–2002 | 54 Gy followed by 16, 20 or 24 Gy in 4‑Gy fractions (3 fractions per week) 4 primary endpoints, power/assumed differences not reported | 36, interval ≥ 6 months, N0 M0 | 27 mo | In each arm 2–3 patients had received induction chemotherapy 3‑year recurrence-free survival was best in the 24-Gy boost group, p = 0.047 Similar OS, p = 0.6 Similar acute and late toxicity rates, but one fatal bleeding event in the 24-Gy boost group, which also had higher incidence of trismus, p = 0.08 |
Tian et al. 2014 [10] | Nasopharynx cancer | Single centre phase 2, China, 2003–2007 | IMRT 68 Gy in 34 fractions vs. 60 Gy in 27 fractions Overall survival, 80% power to detect 23% difference | 117, KPS ≥ 70, interval > 6 months | 25 mo | Longer OS in the 60-Gy arm, p = 0.06 Similar PFS Less mucosal necrosis in the 60-Gy arm, p = 0.02 |
Guan et al. 2016 [11] | Nasopharynx cancer | Single centre phase 2, China, 2002–2008 | IMRT 60 Gy in 27 fractions alone vs. same RT + concomitant weekly cisplatin Overall survival, 80% power to detect 30% difference | 69, KPS ≥ 70, interval > 6 months | 35 mo | Longer OS in the combined modality arm, p = 0.049 No significant increase in late toxicity, but more haematologic toxicity in the combined modality arm |
Liu et al. 2021 [19] | Nasopharynx cancer | Three centres, phase 3, China, 2011–2017 | Endoscopic nasopharyngectomy or IMRT 60–70 Gy (2–2.36 Gy per fraction, 5 fractions per week) Overall survival, 80% power and a two-sided 5% significance-level hazard ratio of 0.52 | 200, KPS ≥ 70, ≥ 12-month disease-free interval between the initial course of radiotherapy and recurrence, age 18–70 years | 56 mo | Improved 3‑year overall survival after surgery (86% versus 68% in the IMRT group, p = 0.0015) |
You et al. 2023 [20] | Nasopharynx cancer | Three centres phase 3, China, 2015–2019 | IMRT 60 Gy in 27 fractions vs. 65 Gy in 54 fractions (2 fractions per day) Overall survival and severe late complications, 80% power to detect 20% difference (survival) and 24% difference (toxicity grade 3 or more) | 144, KPS ≥ 70, interval > 12 months, age 18–65 years, no radiation-induced complications grade ≥ 3 | 45 mo | Reduced grade 3 or worse late radiation-induced toxicity in the hyperfractionation group (34% versus 57%, p = 0.02) Better 3‑year overall survival after hyperfractionation (75% versus 55%, p = 0.01) 49% of patients in the hyperfractionation group and 46% in the standard fractionation group had locoregional relapse significant differences favouring hyperfractionated radiotherapy in the general quality-of-life domains of global health status, role functioning, and social functioning, and in the symptom burden domains of pain, financial difficulties, and loss of appetite |
Janot et al. 2008 [12] | Head and neck squamous cell carcinoma | Multicentre phase 2, France/Belgium, 1999–2005 | 6 cycles of postoperative RT, each with 5 fractions of 2 Gy, with concomitant 5‑FU and hydroxyurea (9 day rest period between cycles) vs. observation DFS at 3 years, 80% power to detect 20% difference | 130, KPS ≥ 80, interval to salvage surgery ≥ 6 months, macroscopically complete resection, no severe sequelae after initial course | Not reported | Longer DFS in the RT arm, p = 0.006 Better locoregional control, p < 0.0001 3 treatment-related deaths within one month after RT and 2 at later time points More grade 3 or 4 late toxicity after RT, p = 0.06 Similar OS, p = 0.5 |
Tortochaux et al. 2011 [13] | Head and neck squamous cell carcinoma | Multicentre phase 3, France, 1999–2005 | 6 cycles of RT, each with 5 fractions of 2 Gy, with concomitant 5‑FU and hydroxyurea (9 day rest period between cycles) vs. weekly methotrexate Overall survival at 1 year, 80% power to detect 19% difference | 57 (premature closure, 160 required), KPS ≥ 70, unamenable to curative salvage therapy, interval ≥ 6 months, no severe sequelae after initial course | Complete, all patients died | Similar OS, p = 0.6 4 complete responses after radiochemotherapy vs. none after chemotherapy alone More toxicity after radiochemotherapy, including grade 5 events |
Rudžianskas et al. 2014 [14] | Head and neck squamous cell carcinoma | Single centre phase 2, Lithuania, 2008–2011 | EBRT 50 Gy in 25 fractions vs. HDR BT 30 Gy in 12 fractions Statistical hypothesis and primary endpoint not reported | 64, KPS ≥ 80, no grade 3 or 4 toxicity from initial course | Not reported | Significantly smaller PTV in BT arm despite randomization BT was associated with better LC, p < 0.001, OS, p = 0.002, and late toxicity, p = 0.001 |
Tao et al. 2018 [21] | Head and neck squamous cell carcinoma | Multicentre phase 2, France, 2010–2014 | 60 Gy over 11 weeks with concomitant 5FU—hydroxyurea vs. 60 Gy (1.2 Gy twice daily) over 5 weeks with cetuximab Primary endpoint was treatment interruption > 15 days (acute toxicity) Simon’s two-stage design, with alpha = 10% and beta = 10%, 28 subjects were expected in each arm (stage 1 = 9 patients, stage 2 = 19 patients). After evaluation of the 9 first patients, if the number of patients which experienced toxicities was ≥ 3, the study had to be stopped. If this number was ≤ 2, 19 additional patients would be included in each arm | 60, PS 0‑1, > 6 months between initial RT and salvage surgery, sufficient healing for beginning reirradiation within 8 weeks of salvage surgery, age 18–75 years, without severe sequelae of initial RT | 36 mo | Similar rates of more than 15 days of treatment interruption due to toxicity (n = 1 and 0, respectively, p = 0.49) Toxicities and DFS were not different between both arms |
Chow et al. 2014 [15] | Bone metastases | International phase 3, 2004–2012 | 8 Gy single fraction vs. 20 Gy (5 or 8 fractions, depending on initial dose and body region) Pain response after 2 months, non-inferiority (difference < 10% with reference to the upper 95% CI of the 8‑Gy arm) | 850, minimum interval 4 weeks, no spinal cord compression, pathological fracture or impending fracture, pain score 2–10 | 12 mo | Intention-to-treat analysis confirmed non-inferiority Per protocol analysis did not confirm non-inferiority Significantly more toxicity after 20 Gy |
Wick et al. 2014 [16] | Glioblastoma | International phase 2, 2009–2011 | 36 Gy alone (2-Gy fractions) vs. 36 Gy + APG-101 weekly until progression PFS at 6 months, optimal two-stage design of Simon | 91, adult patients, 1st or 2nd progression, not resectable or residual tumor after resection, largest tumor diameter 1–4 cm, KPS ≥ 60, interval ≥ 8 months | 11.4 mo | PFS was significantly better in the combined modality arm |
Bergman et al. 2020 [22] | Glioblastoma and high-grade glioma (bevacizumab resistant) | Single centre, United States, 2012–2016 | BEV-based chemotherapy with irinotecan, etoposide, temozolomide, or carboplatin. Other arm: EBRT 8 Gy × 4 fractions within 2 weeks to the gross target volume and 6 Gy × 4 fractions to the clinical target volume (fluid-attenuated inversion recovery abnormality) plus BEV-based chemotherapy Primary endpoints: local tumor control at 2 months and PFS 80% power to detect 30% improvement by EBRT (sample size of 76 patients) | 35 (closed due to slow accrual), KPS ≥ 70 | Not reported | Patients treated with RT had significantly improved PFS (5.1 vs. 1.8 months, p < 0.001) and improved LC at 2 months (82% vs. 27%, p = 0.002) Overall median survival was 7.2 months with RT vs. 4.8 months with chemotherapy alone, p = 0.11 |
Voss et al. 2020 [23] | Glioblastoma or progression from lower grade glioma | Three centres, phase not stated, Germany, 2013–2017 | Dietary intervention over 9 days that consisted of 2 calorically restricted KD 3‑day intervals flanking 3 days of fasting plus reirradiation vs. reirradiation and calorically unrestricted diet Most patients had 5 or 10 fractions of reirradiation (5 × 4 Gy, 10 × 3.5 Gy) Increase of PFS at 6 months from 0% to 30% with a power of 80% | 50, KPS ≥ 60, interval at least 6 months | Not reported | No significant difference in PFS at 6 months: 20% vs. 16%, p = 0.7 Similar median OS: 331 days vs. 291 days |
Tsien et al. 2023 [24] | Glioblastoma | Multicentre phase 2, 2012–2016 | Bevacizumab alone vs. Bevacizumab plus reirradiation (10 fractions of 3.5 Gy) Overall survival, 80% power to detect a 31% reduction in the hazard ratio to 0.69 at the significance level of 0.1 | 170, KPS ≥ 60, interval at least 6 months, recurrent tumor ≤ 6 cm | 12.8 mo | No improvement in overall survival for BEV + RT, p = 0.46 (median 10.1 versus 9.7 months) Median PFS for BEV + RT was 7.1 versus 3.8 months for BEV, p = 0.05 |
Kouloulias et al. 2003 [17] | Skin metastases from breast cancer after mastectomy and RT | Single centre phase 2, Greece, 1998–1999 | PEGylated liposomal doxorubicin and 17 fractions of 1.8 Gy vs. same drug and 8 fractions of 3 Gy + one fraction of 4 Gy Disease-free interval to local relapse, power/assumed difference not reported | 30, KPS > 70, superficial tumours | Not reported | Similar efficacy and DFILR, p = 0.58 Less acute skin toxicity with 1.8-Gy fractions (all grade 1 or 2), p = 0.027 Less late skin toxicity with 1.8-Gy fractions (all grade 1 or 2), p < 0.001 |
Schouten et al. 2022 [25] | Locally recurrent breast cancer | Single centre phase 2, Netherlands, 2010–2019 | 32 Gy was given in 8 fractions of 4 Gy in 4 weeks, but after January 2015, the regimen was changed to 46 Gy in 23 fractions of 2 Gy, at five fractions per week Hyperthermia was added once a week after radiotherapy The combined arm was treated with four cycles of weekly cisplatin 40 mg/m2 90% power to detect an increase in the local control rate after 1 year from 54% in the standard treatment arm to 69% in the study arm with cisplatin | 49 (study closed due to slow accrual), PS 0–2, not suitable for resection | 7.1 and 12.6 mo, respectively | Similar complete response rates: 61% each Partial response rate was 30% in the standard arm and 33% in the combined arm, p = 0.79 One-year local progression-free interval was 81.5% in the standard arm and 88% in the combined arm, p = 0.95 Grade 3 or 4 acute toxicity 25% (standard) and 29% of patients (combined arm), p = 0.79 |