Technological innovations in head and neck radiotherapy: What does the future hold?

Radiotherapy in head and neck oncology is advancing thanks to technologies that improve treatment precision, adaptation, and tolerance. The most promising approaches are discussed in this narrative review. The use of automatic segmentation through artificial intelligence (deep learning) now allows rapid delineation of organs at risk, thus reducing contouring time and the risk of errors. Several tools are already routinely used and are evaluated for replanning process. Imaging, acquired before each session, ensures precise patient repositioning. The benefit of using systematic image-guidance to adapt the radiotherapy plan according to anatomical changes remains to be confirmed. The combination of magnetic resonance imaging (MRI) with a linear accelerator ([MRI]-guided linear accelerator), offers a precise and promising option for adaptative radiotherapy at each session. Personalized radiotherapy is being considered for patients with human papillomavirus-related oropharyngeal cancers, which have a better prognosis, through de-escalation strategies aimed at reducing toxicity and preserving quality of life. This includes the possible reduction of prophylactic volumes and doses, as well as dose modulation based on tumor hypoxia detected by functional positron-emission tomography imaging. These approaches are promising but require validation in randomized trials. Intensity-modulated proton therapy improves dose distribution thanks to the Bragg peak, limiting irradiation of healthy tissues. A recent randomized study highlighted better tolerance compared to intensity-modulated proton therapy, without loss of efficacy in oropharyngeal cancer. However, access remains limited in France. Flash radiotherapy, still experimental, delivers ultrarapid doses with reduced toxicity in preclinical studies, pending clinical confirmation. Finally, telemonitoring optimizes the management of side effects and quality of life, with particular interest in clinical trial settings.