Postoperative radiotherapy in pediatric versus adult head and neck malignancies: A two-center analysis of survival outcomes and age-specific late effects.
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BACKGROUND: Head and neck malignancies represent <10% of pediatric cancers, but require intensive multimodal treatment including postoperative radiotherapy (RT), posing unique risks for lifelong late effects impacting quality of life. OBJECTIVES: To evaluate survival outcomes, toxicity profiles, and recurrence patterns in pediatric versus adult head and neck cancer patients receiving postoperative RT, and characterize age-specific late effects. METHODS: This retrospective cohort study analyzed 519 patients from two Indian tertiary centers (2010-2023): 27 pediatric (<18 years), 88 young adults (18-39 years), and 404 older adults (≥40 years) receiving surgery followed by adjuvant RT ± chemotherapy. Endpoints included disease-free survival (DFS), overall survival (OS), toxicity, and recurrence patterns, analyzed using Kaplan-Meier estimates, Cox regression, and competing risk analysis. RESULTS: Despite predominantly advanced-stage disease (74%-81% Stage III-IV), survival outcomes were comparable. Two-year DFS rates were 62% (pediatric), 64% (young adults), and 61% (older adults, P = 0.88); 2-year OS rates were 68%, 70%, and 67% ( P = 0.85). Kaplan-Meier curves showed overlapping trajectories without age-based separation. Age was not an independent prognostic factor (HR 1.02, P = 0.93), while advanced stage, positive margins, and extracapsular extension significantly predicted outcomes. Acute toxicity rates were similar (grade 2-3 mucositis: 74%-80%, P = 0.65). However, chronic effects affected 70.4% of pediatric survivors versus 42.0-48.5% of adults ( P = 0.02), including facial growth disturbances (33.3% vs. 2.0-8.0%), dental abnormalities (48.1% vs. 11.1-15.9%), endocrinopathies (44.4% vs. 14.8-15.1%), and neurocognitive impairment (29.6% vs. 3.2%-6.8%, all P < 0.001). CONCLUSION: Postoperative RT achieves comparable disease control, but disproportionate chronic late effects in > 70% of pediatric survivors necessitate age-adapted treatment strategies and survivorship care.