Outcomes following reirradiation of patients with head and neck cancer

Retreatment of Recurrent or Second Primary Head and Neck Cancer After Prior Radiation: Executive Summary of the American Radium Society® (ARS) Appropriate Use Criteria (AUC): Expert Panel on Radiation Oncology - Head and Neck Cancer

BACKGROUND

Re-treatment of recurrent or second primary head and neck cancers occurring in a previously irradiated field is complex. Few guidelines exist to support practice.

METHODS

We performed an updated literature search of peer-reviewed journals in a systematic fashion. Search terms, key questions, and associated clinical case variants were formed by panel consensus. The literature search informed the committee during a blinded vote on the appropriateness of treatment options via the modified Delphi method.

RESULTS

The final number of citations retained for review was 274. These informed five key questions, which focused on patient selection, adjuvant re-irradiation, definitive re-irradiation, stereotactic body radiation (SBRT), and re-irradiation to treat non-squamous cancer. Results of the consensus voting are presented along with discussion of the most current evidence.

CONCLUSIONS

This provides updated evidence-based recommendations and guidelines for the re-treatment of recurrent or second primary cancer of the head and neck.

Radical external beam re-irradiation in the treatment of recurrent head and neck cancer: Critical review

Management of patients with recurrent head and neck cancer remains a challenge for the surgeon as well as the treating radiation oncologist. Even in the era of modern radiotherapy, the rate of severe toxicity remains high with unsatisfactory treatment results. Intensity-modulated radiation therapy (IMRT), stereotactic body radiation therapy (SBRT), and heavy-ion irradiation have all emerged as highly conformal and precise techniques that offer many radiobiological advantages in various clinical situations. Although re-irradiation is now widespread in clinical practice, little is known about the differences in treatment response and toxicity using diverse re-irradiation techniques. In this review, we provide a comprehensive overview of the role of radiation therapy in recurrent or second primary head and neck cancer including patient selection, therapeutic outcome, and risk using different re-irradiation techniques. Critical review of published evidence on IMRT, SBRT, and heavy-ion full-dose re-irradiation is presented including data on locoregional control, overall survival, and toxicity.

Long-term outcomes in patients with recurrent human papillomavirus-positive oropharyngeal cancer after upfront transoral robotic surgery

BACKGROUND

Clinical course following failure of human papillomavirus (HPV)-positive oropharyngeal cancers (HPV + OPC) is poorly understood. This study aims to characterize disease course following failure after transoral robotic surgery (TORS).

METHODS

We identified patients with HPV + OPC-treated upfront with TORS at our institution from 2007 to 2017. HPV status was confirmed with immunohistochemistry or HPV DNA polymerase chain reaction. Patient characteristics, treatment modalities, and post-recurrence outcomes were analyzed for the recurrent cohort.

RESULTS

Of the 317 HPV + OPC patients, 28 (8.8%) experienced recurrence, all of HPV 16/18 subtypes. Median post-recurrence survival was 19.8 months (range 2.3-195.8 months) in the 12 locoregional and 16 months (range 2.4-79.5 months) in the 14 distant failures. Sixteen are alive with a median of 39.8 months (range 5.5-209.4 months) after retreatment.

CONCLUSION

This is one of the largest series evaluating survival following TORS failure in HPV + OPC. Despite failure, long-term survival and durable remission are possible with single-modal or multiple-modal salvage treatment.

AHNS series: Do you know your guidelines? Guideline recommendations for recurrent and persistent head and neck cancer after primary treatment

Locoregional recurrent/persistent head and neck cancer following primary treatment is a significant challenge as it is usually difficult to treat and has worse outcomes compared to the primary setting. Surgical resection of a local or regional recurrence offers the best chance of cure when feasible. Local recurrence outcomes vary by subsite with laryngeal recurrences having the best prognoses and hypopharynx having the worst. Instances of persistent neck masses following primary nonsurgical treatment can be evaluated with positron emission tomography (PET) with CT (PET-CT) when there is no definitive diagnosis of a recurrence/persistence. Reirradiation with or without chemotherapy can be considered for primary treatment when surgery is not an option, for adjuvant treatment following salvage surgery, or for palliation. Immunotherapy represents a newer class of chemotherapeutic agents. Current guidelines recommend enrollment in clinical trials especially when surgery is not an option as outcomes remain universally poor in the recurrent/persistent setting.

Potential for low-value palliative care of patients with recurrent head and neck cancer

Curative treatment for patients with advanced head and neck cancer can be associated with many side-effects, and many patients suffer from persistent treatment-related side-effects. Patients with recurrent cancer bear the burden of these effects along with additional symptoms attributed to the recurrent tumour. To better understand the benefits and burden of palliative treatments for patients with recurrent head and neck cancer, we reviewed the evidence on commonly used palliative treatments and their effect on quality of life. When used for palliative care purposes, chemotherapy and radiotherapy have limited effectiveness in improving quality of life. Moreover, if these treatments are not congruent with a patient's end-of-life goals, they could constitute low-value care. We recommend that patients with advanced and recurrent cancer should be offered early, comprehensive palliative and supportive services to maximise benefit. The principles of beneficence and respect for patients in the context of shared decision making must prevail if the trust of this vulnerable patient population is to be honoured.

A Retrospective Evaluation of Clinical Profile of Second Primary Head and Neck Cancer

INTRODUCTION

Incidence of Second Primary Malignancy (SPM) after successful treatment of primary is increasing and may cause the problem for optimal treatment.

AIM

This study was conducted retrospectively to analyse incidence, disease free survival between malignancies, pattern of treatment and outcome.

MATERIALS AND METHODS

Sixteen out of 22 patients of previously treated cases of head and neck cancer those develop SPM of head and neck region managed over a period of January 2012 to December 2015 in Department of Radiotherapy-II, Pt. BD Sharma PGIMS, Rohtak were analyzed retrospectively. Sixteen patients with unresectable disease were given reirradiation with external beam radiotherapy.

RESULTS

Median age of presentation of first malignancy was 27 years (Ranged 26 -65 years), whereas median age was 60 years for second malignancy (range 45-71 years). All patients were smokers during first malignancy; 87.5% (14/16) had historyof smoking during second malignancy. Oropharynx (50%) was most common site of presentation of primary tumor whereas oral cavity was most common site of presentation in second primary tumor.

CONCLUSION

Incidence of Second primary head and neck tumor after successful treatment for primary Head and neck cancer are increasing due to newer treatment strategies, longer survival and follow up. Reirradiation, surgery and or chemotherapy are treatment modalities. However second primary tumor of this region are associated with poor prognosis.

A retrospective study of head and neck re-irradiation for patients with recurrent or second primary head and neck cancer: the McGill University experience

Background

We report our experience with patients who received re-irradiation to the head and neck area for locoregional recurrences (LRR) or second primaries (SP) in a previously irradiated field.

Methods

We reviewed 27 consecutive patients with a diagnosis of LRR or SP head and neck carcinoma treated with a second course of radiotherapy between April 2004 and July 2012. The main outcome measures were local control, overall survival, and complications. The results are expressed as actuarial values using the Kaplan–Meier estimates.

Results

The median follow-up time was 24.7 months (range: 11 days–79.3 months). There were 23 males and four females with a median age of 61 years (range: 40–87 years). The actuarial overall survival rates at 1, 2, and 5 years were 77, 59, and 57 %, respectively. The actuarial local control rate was 80, 52, and 52 % at 1, 2, and 5 years, respectively. Three patients developed systemic metastases. The rate of grade 3 toxicity was 26 %, and that of grade 4 toxicity was 3 %. There were two treatment-related deaths (grade 5 toxicity).

Conclusions

Continuous course re-irradiation in patients with LRR or SP head and neck cancer is feasible with acceptable toxicity. With current encouraging rates of local control and overall survival, this option should be discussed with patients who have few alternative therapeutic options.

Re-irradiation of adenoid cystic carcinoma: analysis and evaluation of outcome in 52 consecutive patients treated with raster-scanned carbon ion therapy

BACKGROUND

Treatment of local relapse in adenoid cystic carcinoma (ACC) following prior radiation remains a challenge: without the possibility of surgical salvage patients face the choice between palliative chemotherapy and re-irradiation. Chemotherapy yields response rates around 30% and application of tumouricidal doses is difficult due to proximity of critical structures. Carbon ion therapy (C12) is a promising method to minimize side-effects and maximize re-treatment dose in this indication. We describe our initial results for re-irradiation in heavily pre-treated ACC patients.

METHODS

Patients treated with carbon ion therapy between 04/2010 and 05/2013 (N=52pts, median age: 54 a) were retrospectively evaluated regarding toxicity (NCI CTC v.4), tumour response (RECIST) and control rates. 48pts (92.3%) received carbon ions only, 4pts received IMRT plus C12.

RESULTS

4pts were treated following R1-resection, 43pts for inoperable local relapse. Most common tumour sites were paranasal sinus (36.5%), parotid (19.2%), and base of skull (17.3%). Pts received a median dose of 51GyE C12/63Gy BED and cumulative dose of 128Gy BED [67-182Gy] after a median RT-interval of 61months. Median target volume was 93ml [9-618ml]. No higher-grade (>°II) acute reactions were observed, 7pts showed blood-brain-barrier changes (°I/II: 8pts; °III: 2pts), 1 pt corneal ulceration, xerophthalmia 7pts, °IV bleeding 1 pt, tissue necrosis 2pts, otherwise no significant late reactions. Objective response rate (CR/PR) was 56.6%. With a median follow-up of 14months [1-39months] local control and distant control at 1a are 70.3% and 72.6% respectively. Of the 18pts with local relapse, 13pts have recurred in-field, 1 pt at the field edge, 3pts out of field, and one in the dose gradient.

CONCLUSION

Despite high applied doses, C12 re-irradiation shows moderate side-effects, response rates even in these heavily pre-treated patients are encouraging and present a good alternative to palliative chemotherapy. Though most local recurrences occur within the high-dose area, further dose escalation should be viewed with caution.

Re-irradiation in head and neck cancers: an Indian tertiary cancer centre experience

Objective:

To explore the treatment outcomes of patients treated with re-irradiation for recurrent or second primary head and neck cancer.

Method:

An analysis was performed of 79 head and neck cancer patients who underwent re-irradiation for second primaries or recurrent disease from January 1999 to December 2011.

Results:

Median time from previous radiation to re-irradiation for second primary or recurrence was 53.6 months (range, 2.7–454.7 months). Median age at diagnosis of first primary was 54 years. Median re-irradiation dose was 45 Gy (range, 45–60 Gy). Acute grade 3 or worse toxicity was seen in 30 per cent of patients. Median progression-free survival for recurrent disease was 15.0 months (95 per cent confidence interval, 8.33–21.66). The following factors had a statistically significant, positive impact on progression-free survival: patient age of less than 50 years (median progression-free survival was 29.43, vs 13.9 months for those aged 50 years or older; p = 0.004) and disease-free interval of 2 years or more (median progression-free survival was 51.66, vs 13.9 months for those with less than 2 years disease-free interval).

Conclusion:

Re-irradiation of second primaries or recurrences of head and neck cancers with moderate radiation doses yields acceptable progression-free survival and morbidity rates.

Recurrent and second primary squamous cell carcinoma of the head and neck: when and how to reirradiate

BACKGROUND

Local and/or regional recurrence and metachronous primary tumor arising in a previously irradiated area are rather frequent events in patients with head and neck squamous cell carcinoma (HNSCC). Re-treatment is associated with an increased risk of serious toxicity and impaired quality of life (QOL) with an uncertain survival advantage.

METHODS

We analyzed the literature on the efficacy and toxicity of photon/electron-based external beam reirradiation for previously irradiated patients with HNSCC of non-nasopharyngeal origin. Studies were grouped according to the radiotherapy technique used for reirradiation. Patient selection criteria, target volume identification method, tumor dose, fractionation schedule, systemic therapy administration, and toxicities were reviewed.

RESULTS

In addition to disease-related factors, current comorbidities and preexisting organ dysfunction must be considered when selecting patients for reirradiation. As morbidity from re-treatment may be considerable and differ depending on which mode of re-treatment is used, it is important to give patients information on potential morbidity outcomes so that an informed choice can be made within a shared decision-making context. With improved dose distribution and adequate imaging support, including positron emission tomography-CT, modern radiotherapy techniques may improve local control and reduce toxicity of reirradiation. A reirradiation dose of ≥60 Gy and a volume encompassing the gross tumor with up to a 5-mm margin are recommended. Concomitant administration of systemic therapeutics and reirradiation is likely to be of similar benefit as observed in large randomized studies of upfront therapy.

CONCLUSION

Reirradiation, administered either with or without concurrent systemic therapy, is feasible and tolerable in properly selected patients with recurrent or a new primary tumor in a previously irradiated area of the head and neck, offering a meaningful survival (in the range of 10% to 30% at 2 years). Whenever feasible, salvage surgery is the method of choice for curative intent; patients at high-risk for local recurrence should be advised that postoperative reirradiation is expected to increase locoregional control at the expense of higher toxicity and without survival advantage compared to salvage surgery without reirradiation. © 2014 Wiley Periodicals, Inc. Head Neck 37: 134-150, 2015.

Outcome after re-irradiation of head and neck cancer patients

PURPOSE

To retrospectively report the outcome of head and neck cancer patients following re-irradiation.

PATIENTS AND METHODS

A total of 51 patients with recurrent or second primary head and neck cancer received re-irradiation at Leuven University Hospital. Survival and locoregional control were calculated. Doses to organs at risk were retrieved from dose-volume histograms. Radiation-related toxicities were reported.

RESULTS

The 2-year actuarial overall survival rate was 30%. On univariate analysis, surgery before re-irradiation and high radiation dose were associated with superior survival. Grade 3 acute and grade 3 or more late toxicity occurred in respectively 29.4% and 35.3% of the patients.

CONCLUSION

Re-irradiation in head and neck cancer patients is feasible with acceptable late toxicity, although the survival remains poor.

Brachytherapy for tongue cancer in the very elderly is an alternative to external beam radiation

BACKGROUND

The result of curative treatment for very elderly patients with tongue carcinoma has not been reported to date. We retrospectively reviewed the results of brachytherapy in 125 the patients aged over 75 years.

METHODS

The results of brachytherapy in 125 patients, 75 years old or older, with Stage I or II squamous cell carcinoma of the oral tongue were reviewed. The 125 cases consisted of 31 Stage I and 94 Stage II cases; 67 patients were under 80 years old and 58 were over 80 years old. All patients were treated using low-dose-rate brachytherapy ((198)Au/(222)Rn: 59 cases; (192)Ir: 38 cases; (226)Ra/(137)Cs: 28 cases).

RESULTS

None of the patients stopped treatment during the course of brachytherapy. The 3 year and 5 year control rates of the primary lesions were both 86%. Post-brachytherapy neck node metastasis was diagnosed in 43 cases and radical neck dissection was performed for 24 cases (21 of the 24 cases were under 80 years old). As a result, the 7 year disease-specific survival (DSS) rate for patients aged under 80 years old was 70% and 41% for those over 80 years old (p = 0.03).

CONCLUSION

The brachytherapy for elderly patients with tongue cancer was safe, and the control of the primary lesion was almost the same as in younger patients. However, modalities available to treat neck node metastasis are limited. More conservative surgical approaches combined with post-operative irradiation may be advocated for neck node metastasis for elderly patients with tongue cancer.

The pattern of failure after reirradiation of recurrent squamous cell head and neck cancer: implications for defining the targets

PURPOSE

Reirradiation (re-RT) of recurrent head and neck cancer (HNC) may achieve long-term disease control in some patients, at the expense of high rates of late sequelae. Limiting the re-RT targets to the recurrent gross tumor volume (rGTV) would reduce the volumes of reirradiated tissues; however, its effect on tumor recurrence pattern is unknown.

METHODS AND MATERIALS

This is a retrospective review of 66 patients who underwent curative-intent re-RT for nonresectable recurrent or second primary mucosal squamous cell HNC. Treatment was delivered with three-dimensional conformal (3D) RT or intensity-modulated RT (IMRT). The targets in all patients consisted of the rGTVs with tight (0.5-cm) margins, with no intent to treat prophylactically lymph nodes or subclinical disease in the vicinity of the rGTVs. The sites of locoregional failures (LRFs) were determined using imaging at the time of failure and were compared with the rGTVs.

RESULTS

Median re-RT dose was 68 Gy. Forty-seven patients (71%) received concomitant chemotherapy, and 31 (47%) received hyperfractionated, accelerated RT. At a median follow-up of 42 months, 16 (23%) were alive and disease-free. Fifty patients (77%) had a third recurrence or persistent disease, including 47 LRFs. All LRFs occurred within the rGTVs except for two (4%) (95% confidence interval, 0-11%). Nineteen patients (29%) had Grade > or = 3 late complications, mostly dysphagia (12 patients).

CONCLUSIONS

Almost all LRFs occurred within the reirradiated rGTVs despite avoiding prophylactic RT of tissue at risk of subclinical disease. These results support confining the re-RT targets to the rGTVs to reduce reirradiated tissue volumes.