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Bussu F, Fionda B, Rigante M, Rizzo D, Loperfido A, Gallus R, De Luca LM, Corbisiero MF, Lancellotta V, Tondo A, D’Aviero A, Mattiucci GC, Kovacs G, Galli J, Tagliaferri L. Interventional radiotherapy (brachytherapy) for re-irradiation of recurrent head and neck malignancies: oncologic outcomes and morbidity. ACTA OTORHINOLARYNGOLOGICA ITALICA : ORGANO UFFICIALE DELLA SOCIETA ITALIANA DI OTORINOLARINGOLOGIA E CHIRURGIA CERVICO-FACCIALE 2024; 44:S28-S36. [PMID: 38745514 PMCID: PMC11098534 DOI: 10.14639/0392-100x-suppl.1-44-2024-n2824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/12/2024] [Indexed: 05/16/2024]
Abstract
Objective Management of recurrent head and neck cancer (HNC) is challenging. One option in previously irradiated patients is re-irradiation using interventional radiotherapy (IRT), the modern form of brachytherapy. Re-irradiation using IRT can be delivered as an exclusive strategy for salvage or through a postoperative or perioperative approach after salvage surgery. The aim of the present study is to analyse a bicentric Italian series focusing on the use of IRT as a re-irradiation modality and assess the resulting evidence concerning oncologic outcomes and morbidity. Methods This is a retrospective study performed in two referral centres in Italy: Policlinico Universitario Agostino Gemelli in Rome and Azienda Ospedaliera Universitaria in Sassari. All patients who had previously received a full course of external beam RT and have been re-irradiated using high-dose-rate IRT between December 2010 and June 2023 were included. Patients were retreated either by a combination of surgery and perioperative (either endocavitary or interstitial) IRT or by exclusive interstitial IRT. Results Thirty-four patients were included in the present series, 2 of whom underwent more than one IRT re-irradiation. Notably, no patient reported specific IRT-related toxicities. Median follow-up, excluding patients who died of HNC, was 24.5 months. Two-year local relapse-free survival was 26%, disease-specific survival 39.1%, and overall survival 36.6%. Conclusions The present series is the largest reported experience of re-irradiation by IRT for HNC in Italy. The very low rate of toxicity confirms IRT as the safest re-irradiation modality. It is noteworthy to underline that IRT is a multidisciplinary strategy based on the close cooperation between surgeons and radiation oncologists during every phase, from the recommendation of treatment and implantation in the operating theatre, to its prescription and dose painting.
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Affiliation(s)
- Francesco Bussu
- Divisione di Otorinolaringoiatria, Azienda Ospedaliera Universitaria, Sassari, Italy
- Dipartimento di Medicina, Chirurgia e Farmacia, Università di Sassari, Sassari, Italy
| | - Bruno Fionda
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Mario Rigante
- UOC Otorinolaringoiatria, Dipartimento di Scienze dell’Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Davide Rizzo
- Divisione di Otorinolaringoiatria, Azienda Ospedaliera Universitaria, Sassari, Italy
- Dipartimento di Medicina, Chirurgia e Farmacia, Università di Sassari, Sassari, Italy
| | - Antonella Loperfido
- UOC Otorinolaringoiatria, Dipartimento Testa, Collo e delle Neuroscienze, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | - Roberto Gallus
- Divisione di Otorinolaringoiatria, Mater Olbia Hospital, Olbia, Italy
| | - Laura Maria De Luca
- Divisione di Otorinolaringoiatria, Azienda Ospedaliera Universitaria, Sassari, Italy
| | - Michaele Francesco Corbisiero
- Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Valentina Lancellotta
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
| | - Andrea Tondo
- Divisione di Otorinolaringoiatria, Azienda Ospedaliera Universitaria, Sassari, Italy
| | - Andrea D’Aviero
- UO di Radioterapia Oncologica, Mater Olbia Hospital, Olbia, Italy
| | | | - Gyorgy Kovacs
- Università Cattolica del Sacro Cuore, Gemelli-INTERACTS, Rome, Italy
| | - Jacopo Galli
- UOC Otorinolaringoiatria, Dipartimento di Scienze dell’Invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Luca Tagliaferri
- UOC Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Rome, Italy
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Melo-Alvim C, Neves ME, Santos JL, Abrunhosa-Branquinho AN, Barroso T, Costa L, Ribeiro L. Radiotherapy, Chemotherapy and Immunotherapy-Current Practice and Future Perspectives for Recurrent/Metastatic Oral Cavity Squamous Cell Carcinoma. Diagnostics (Basel) 2022; 13:99. [PMID: 36611391 PMCID: PMC9818309 DOI: 10.3390/diagnostics13010099] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/23/2022] [Accepted: 12/25/2022] [Indexed: 01/01/2023] Open
Abstract
Oral squamous cell carcinoma is the most common malignant epithelial neoplasm affecting the oral cavity. While surgical resection is the cornerstone of a multimodal curative approach, some tumors are deemed recurrent or metastatic (R/M) and often not suitable for curative surgery. This mainly occurs due to the extent of lesions or when surgery is expected to result in poor functional outcomes. Amongst the main non-surgical therapeutic options for oral squamous cell carcinoma are radiotherapy, chemotherapy, molecular targeted agents, and immunotherapy. Depending on the disease setting, these therapeutic approaches can be used isolated or in combination, with distinct efficacy and side effects. All these factors must be considered for treatment decisions within a multidisciplinary approach. The present article reviews the evidence regarding the treatment of patients with R/M oral squamous cell carcinoma. The main goal is to provide an overview of available treatment options and address future therapeutic perspectives.
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Affiliation(s)
- Cecília Melo-Alvim
- Department of Medical Oncology, Centro Hospitalar Universitário Lisboa Norte, 1649-028 Lisboa, Portugal
| | - Maria Eduarda Neves
- Department of Radiotherapy, Centro Hospitalar Universitário Lisboa Norte, 1649-028 Lisboa, Portugal
| | - Jorge Leitão Santos
- Department of Radiotherapy, Centro Hospitalar Universitário Lisboa Norte, 1649-028 Lisboa, Portugal
| | | | - Tiago Barroso
- Department of Medical Oncology, Centro Hospitalar Universitário Lisboa Norte, 1649-028 Lisboa, Portugal
| | - Luís Costa
- Department of Medical Oncology, Centro Hospitalar Universitário Lisboa Norte, 1649-028 Lisboa, Portugal
- Luís Costa Lab, Instituto de Medicina Molecular–João Lobo Antunes, Faculdade de Medicina de Lisboa, 1649-028 Lisboa, Portugal
| | - Leonor Ribeiro
- Department of Medical Oncology, Centro Hospitalar Universitário Lisboa Norte, 1649-028 Lisboa, Portugal
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Bhattacharyya T, Koto M, Windisch P, Ikawa H, Hagiwara Y, Tsuji H, Adeberg S. Emerging Role of Carbon Ion Radiotherapy in Reirradiation of Recurrent Head and Neck Cancers: What Have We Achieved So Far? Front Oncol 2022; 12:888446. [PMID: 35677171 PMCID: PMC9167994 DOI: 10.3389/fonc.2022.888446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 04/13/2022] [Indexed: 11/13/2022] Open
Abstract
Administering reirradiation for the treatment of recurrent head and neck cancers is extremely challenging. These tumors are hypoxic and radioresistant and require escalated radiation doses for adequate control. The obstacle to delivering this escalated dose of radiation to the target is its proximity to critical organs at risk (OARs) and possible development of consequent severe late toxicities. With the emergence of highly sophisticated technologies, intensity-modulated radiotherapy (IMRT) and stereotactic body radiotherapy have shown promising outcomes. Proton beam radiotherapy has been used for locally recurrent head and neck cancers because of its excellent physical dose distribution, exploring sharp Bragg peak properties with negligible entrance and exit doses. To further improve these results, carbon ion radiotherapy (CIRT) has been explored in several countries across Europe and Asia because of its favorable physical properties with minimal entrance and exit doses, sharper lateral penumbra, and much higher and variable relative biological efficacy, which cannot be currently achieved with any other form of radiation. Few studies have described the role of CIRT in recurrent head and neck cancers. In this article, we have discussed the different aspects of carbon ions in reirradiation of recurrent head and neck cancers, including European and Asian experiences, different dose schedules, dose constraints of OARs, outcomes, and toxicities, and a brief comparison with proton beam radiotherapy and IMRT.
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Affiliation(s)
- Tapesh Bhattacharyya
- Department of Radiation Oncology, Tata Medical Centre, Kolkata, India
- QST Hospital, National Institutes for Quantum Science and Technology, Chiba, Japan
| | - Masashi Koto
- QST Hospital, National Institutes for Quantum Science and Technology, Chiba, Japan
| | - Paul Windisch
- Department of Radiation Oncology, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Hiroaki Ikawa
- QST Hospital, National Institutes for Quantum Science and Technology, Chiba, Japan
| | - Yasuhito Hagiwara
- Department of Radiation Oncology, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Hiroshi Tsuji
- QST Hospital, National Institutes for Quantum Science and Technology, Chiba, Japan
| | - Sebastian Adeberg
- National Center for Tumor Diseases (NCT), University Hospital Heidelberg (UKHD) and German Cancer Research Center (DKFZ), Heidelberg, Germany
- Department of Radiation Oncology, University Hospital Heidelberg (UKHD), Heidelberg, Germany
- Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), UKHD and DKFZ, Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany
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Quek LHH, Lim MY, Cheo T, Teo HL, Pua U. Percutaneous Management of Recurrent Head and Neck Cancer: Current Role and Evolving Principles in the Multidisciplinary Setting. Curr Oncol Rep 2021; 23:52. [PMID: 33754244 DOI: 10.1007/s11912-021-01045-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2021] [Indexed: 12/01/2022]
Abstract
PURPOSE OF REVIEW In this review, we will outline the role of percutaneous interventional radiological management of recurrent head and neck (H&N) cancer in the context of a multidisciplinary setting which consists of surgery, radiation therapy, as well as established and evolving systemic therapies that may impact current practice. RECENT FINDINGS Management of recurrent H&N cancer is complex, with attention to the preservation of function and minimal treatment-related morbidity. The favored treatment modalities in local recurrence previously treated with radiotherapy are surgical resection, and if unresectable, for chemotherapy as definitive treatment, or as a prelude to resection if there is good tumor response. Unfortunately, some of these patients are too frail for major surgery or to withstand the toxicity of chemotherapy. There is a gap for effective local therapy without the morbidity of surgery, toxicity of re-irradiation, and systemic side effects of chemotherapy. Percutaneous interventions have the potential to bridge that gap as well as provide palliative symptomatic treatment for patients that have exhausted all treatment options. In the multidisciplinary setting involving the treatment of complex recurrent H&N cancer, percutaneous management now plays a viable and effective role with a foothold in this team-based approach.
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Affiliation(s)
- Lawrence Han Hwee Quek
- Department of Diagnostic Radiology, Tan Tock Seng Hospital, Basement 1, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore. .,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.
| | - Ming Yann Lim
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.,Department of Otorhinolaryngology and Head and Neck Surgery, Tan Tock Seng Hospital, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Timothy Cheo
- Department of Radiation Oncology, Tan Tock Seng Hospital, Singapore, Singapore.,Department of Radiation Oncology, National University Health System, Singapore, Singapore
| | - Hui Lin Teo
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.,Department of Medical Oncology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Uei Pua
- Department of Diagnostic Radiology, Tan Tock Seng Hospital, Basement 1, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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Conventionally fractionated large volume head and neck re-irradiation using multileaf collimator-based robotic technique: A feasibility study. Clin Transl Radiat Oncol 2020; 24:102-110. [PMID: 32715109 PMCID: PMC7372092 DOI: 10.1016/j.ctro.2020.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 06/22/2020] [Accepted: 06/28/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose To report on the feasibility and performance of conventionally fractionated multileaf collimator (MLC)-based robotic stereotactic body re-irradiation of the head and neck region using MLC-based Cyberknife (CK) technology. Methods Patients treated for recurrent or second primary head and neck cancer (HNC) with curative proton therapy to a target volume > 30 cm3 between 2011 and 2015 were included. MLC-based CK plans were generated using the CK M6 InCise2 MLC system. Dose statistics from MLC-based CK plans were compared to proton beam therapy (PBT) plans according to the following metrics: target coverage, target homogeneity index, gradient index, Paddick conformity index (CI), prescription isodose volume (PIV), treatment time (tTime) for one fraction as well as doses to organs at risk (OAR). Wilcoxon signed-rank test was used to compare dose metrics. Results Eight patients were included; the tumor sites included: salivary glands, pharynx (oropharynx, hypopharynx and retropharynx) and sinonasal cavities. Five of 8 patients were treated with multifield optimisation intensity modulated proton therapy, 3 were treated with passive scattering proton therapy. Median dose was 67 Gy (range 60-70) in 32 fractions (range 30-35). The median high-dose planning target volume (PTV) was 45.4 cm3 (range 2.4 - 130.2 cm3) and the median elective PTV was 91.9 cm3 (range 61.2 - 269.7 cm3). Overall, the mean target coverage (mean 98.3% vs. 96.2% for CK vs. PBT, respectively), maximum dose to PTV (mean 111% vs. 111%, p = 0.2) and mean dose to PTV (mean 104% vs. 104%) were similar across modalities. Highly conformal plans were achieved with both modalities, but mean CI was better with PBT (0.5 vs. 0.6 for CK vs. PBT, p = 0.04). Homogeneity and gradient indexes were similar between the 2 modalities; mean tTime with PBT and CK was 17 vs. 18 min, respectively (p = 0.7). Case-based study revealed that CK and PBT plans allowed for excellent sparing of OAR, with some clinical scenarios associated with better performance of CK while others with better performance of PBT. Conclusion Our study has demonstrated the dosimetric performance of large volume head and neck re-irradiation using MLC-based CK in various clinical scenarios. While conformity was generally better achieved with PBT, MLC-based CK allowed for high dose gradient leading to rapid dose drop-off and sparing of OAR. Conventionally fractionated MLC-based CK could be a competitive alternative in large volume head and neck re-irradiation that deserves further investigation in the clinical setting.
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Schwartz DL, Hayes DN. The Evolving Role of Radiotherapy for Head and Neck Cancer. Hematol Oncol Clin North Am 2019; 34:91-108. [PMID: 31739954 DOI: 10.1016/j.hoc.2019.08.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The length and quality of head and neck cancer survivorship continues to meaningfully improve. Radiotherapy has been central to this process through advances in treatment delivery, fractionation schemas, radiosensitizing systemic therapy, and thoughtful interplay with technical surgical improvements. The future looks brighter still, with ongoing progress in targeted biologic therapy, immuno-oncology, and molecular-genetic tumor characterization for personalized treatment. Head and neck cancer, a disease once fraught with nihilism and failure, is evolving into a major success story of modern multidisciplinary cancer care.
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Affiliation(s)
- David L Schwartz
- Department of Radiation Oncology, UTHSC College of Medicine, 1265 Union Avenue, Memphis, TN 38104, USA; Department of Preventive Medicine, UTHSC College of Medicine, 1265 Union Avenue, Memphis, TN 38104, USA.
| | - D Neil Hayes
- Hematology/Oncology, Department of Medicine, UTHSC College of Medicine, 19 South Manassas Street, Cancer Research Building, 324, Memphis, TN 38103, USA; Department of Genetics/Genomics/Informatics, UTHSC College of Medicine, Memphis, TN, USA; Department of Preventive Medicine, UTHSC College of Medicine, Memphis, TN, USA; Department of Pathology, UTHSC College of Medicine, Memphis, TN, USA; Department of Computational Biology, St. Jude Children's Research Hospital, Memphis, TN, USA
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Chua GWY, Chua KLM. Which patients benefit most from stereotactic body radiotherapy or surgery in medically operable non-small cell lung cancer? An in-depth look at patient characteristics on both sides of the debate. Thorac Cancer 2019; 10:1857-1867. [PMID: 31389163 PMCID: PMC6775005 DOI: 10.1111/1759-7714.13160] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 07/18/2019] [Accepted: 07/20/2019] [Indexed: 12/25/2022] Open
Abstract
The role of stereotactic body radiotherapy (SBRT) in early stage medically operable non-small cell lung cancer is currently under debate. SBRT's advantage is its ability to provide high radiotherapy doses to a tumor in a short timeframe, without the risk of postoperative complications and mortality. Currently, in part due to limited prospective data comparing both treatments, international guidelines continue to recommend surgical resection as the gold standard for medically operable patients. However, not all patients possess uniform characteristics, and there is some evidence that certain subgroups of patients would benefit more from one form of treatment - SBRT or surgery - than the other. The aim of this review is to provide a brief summary of the evidence comparing SBRT to surgery, followed by a deeper discussion of the subgroups of patients who would benefit most from surgery: those with large tumors, centrally located tumors, increased risk of occult nodal metastases, increased risk of toxicity from radiotherapy and radioresistant histological tumor subtypes. Meanwhile, patients who could benefit most from SBRT might include elderly patients, those with reduced lung function or cardiac comorbidities, those with synchronous lung nodules, and those with specific tumor mutational status. We hope that this review will aid in the clinical decision-making process regarding patient selection for either treatment.
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Suárez C, Fernández-Alvarez V, Hamoir M, Mendenhall WM, Strojan P, Quer M, Silver CE, Rodrigo JP, Rinaldo A, Ferlito A. Carotid blowout syndrome: modern trends in management. Cancer Manag Res 2018; 10:5617-5628. [PMID: 30519108 PMCID: PMC6239123 DOI: 10.2147/cmar.s180164] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Carotid blowout syndrome (CBS) refers to rupture of the carotid artery and is an uncommon complication of head and neck cancer that can be rapidly fatal without prompt diagnosis and intervention. CBS develops when a damaged arterial wall cannot sustain its integrity against the patient’s blood pressure, mainly in patients who have undergone surgical procedures and radiotherapy due to cancer of the head and neck, or have been reirradiated for a recurrent or second primary tumor in the neck. Among patients irradiated prior to surgery, CBS is usually a result of wound breakdown, pharyngocutaneous fistula and infection. This complication has often been fatal in the past, but at the present time, early diagnosis and modern technology applied to its management have decreased morbidity and mortality rates. In addition to analysis of the causes and consequences of CBS, the purpose of this paper is to critically review methods for early diagnosis of this complication and establish individualized treatment based on endovascular procedures for each patient.
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Affiliation(s)
- Carlos Suárez
- Head & Neck Cancer Laboratory, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain, .,Head & Neck Cancer Laboratory, Instituto Universitario de Oncología del Principado de Asturias, CIBERONC, University of Oviedo, Oviedo, Spain,
| | | | - Marc Hamoir
- Department of Head and Neck Surgery, Head and Neck Oncology Program, King Albert II Cancer Institute, St Luc University Hospital, Brussels, Belgium
| | | | - Primoz Strojan
- Department of Radiation Oncology, Institute of Oncology, Ljubljana, Slovenia
| | - Miquel Quer
- Department of Otolaryngology, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Carl E Silver
- Department of Surgery, University of Arizona, Phoenix, AZ, USA
| | - Juan P Rodrigo
- Head & Neck Cancer Laboratory, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain, .,Head & Neck Cancer Laboratory, Instituto Universitario de Oncología del Principado de Asturias, CIBERONC, University of Oviedo, Oviedo, Spain, .,Department of Otolaryngology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | - Alfio Ferlito
- International Head and Neck Scientific Group Padua, Italy
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Ho JC, Phan J. Reirradiation of head and neck cancer using modern highly conformal techniques. Head Neck 2018; 40:2078-2093. [DOI: 10.1002/hed.25180] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Revised: 12/06/2017] [Accepted: 02/20/2018] [Indexed: 12/11/2022] Open
Affiliation(s)
- Jennifer C. Ho
- Department of Radiation Oncology; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Jack Phan
- Department of Radiation Oncology; The University of Texas MD Anderson Cancer Center; Houston Texas
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Rueda A, Giralt J, Mañós M, Lozano A, Sistiaga A, García-Miragall E, Cacicedo J, Esteban F, Scola B, Contreras J, Ruiz A, Carral A, Sanchez-Aniceto G, Pastor M, Herranz J, Bernal M, Mesía R. Multidisciplinary management of head and neck cancer: First expert consensus using Delphi methodology from the Spanish Society for Head and Neck Cancer (part 2). Oral Oncol 2017; 70:65-72. [DOI: 10.1016/j.oraloncology.2017.04.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 03/31/2017] [Accepted: 04/08/2017] [Indexed: 10/19/2022]
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Ahlawat P, Rawat S, Kakria A, Devnani B, Wahi IK, Simson DK. Reirradiation with IMRT for recurrent head and neck cancer: A single-institutional report on disease control, survival, and toxicity. Rep Pract Oncol Radiother 2017; 22:331-339. [PMID: 28663716 DOI: 10.1016/j.rpor.2017.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 03/05/2017] [Accepted: 05/13/2017] [Indexed: 01/13/2023] Open
Abstract
AIM To study and explores the feasibility and efficacy of re-irradiation (Re-RT) for locally recurrent head and neck cancer (HNC) and second primary (SP) malignancies. BACKGROUND The most common form of treatment failure after radiotherapy (RT) for HNC is loco-regional recurrence (LRR), and around 20-50% of patients develop LRR. Re-irradiation (Re-RT) has been the primary standard of care in the last decade for unresectable locally recurrent/SP HNC. MATERIALS AND METHODS It was a retrospective analysis in which we reviewed the medical records of 51 consecutive patients who had received Re-RT to the head and neck region at our institute between 2006 and 2015. RESULTS Forty-eight patients were included for assessment of acute and late toxicities, response evaluation at 3 months post Re-RT, and analyses of locoregional control (LRC) and overall survival (OS). The median LRC was 11.2 months, and at 2 and 5 years the LRC rates were 41% and 21.2%, respectively. A multivariate analysis revealed two factors: initial surgical resection performed prior to Re-RT, and achievement of CR at 3 months after completion of Re-RT to be significantly associated with a better median LRC. The median OS was 28.2 months, and at 1, 2, and 5 years, OS were 71.1%, 55.9% and 18%, respectively. A multivariate analysis revealed initial surgical resection performed prior to Re-RT, and achievement of CR at 3 months post completion of Re-RT being only two factors significantly associated with a better median OS. Acute toxicity reports showed that no patients developed grade 5 toxicity, and 2 patients developed grade 4 acute toxicities. CONCLUSION Re-RT for the treatment of recurrent/SP head and neck tumors is feasible and effective, with acceptable toxicity. However, appropriate patient selection criteria are highly important in determining survival and treatment outcomes.
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Affiliation(s)
- Parveen Ahlawat
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, New Delhi 110085, India
| | - Sheh Rawat
- Dharamshila Hospital and Research Centre, Vasundhara Enclave, New Delhi 110096, India
| | - Anjali Kakria
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, New Delhi 110085, India
| | - Bharti Devnani
- Department of Radiotherapy, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
| | - Inderjit Kaur Wahi
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, New Delhi 110085, India
| | - David K Simson
- Action Cancer Hospital, Paschim Vihar, New Delhi, 110063, India
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Facteurs pronostiques de la ré-irradiation des cancers des voies aérodigestives supérieures : revue de la littérature. Cancer Radiother 2017; 21:316-338. [DOI: 10.1016/j.canrad.2017.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 01/06/2017] [Accepted: 02/27/2017] [Indexed: 11/19/2022]
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13
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Kim YS. Reirradiation of head and neck cancer in the era of intensity-modulated radiotherapy: patient selection, practical aspects, and current evidence. Radiat Oncol J 2017; 35:1-15. [PMID: 28395502 PMCID: PMC5398346 DOI: 10.3857/roj.2017.00122] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 03/27/2017] [Accepted: 03/28/2017] [Indexed: 01/11/2023] Open
Abstract
Locoregional failure is the most frequent pattern of failure in locally advanced head and neck cancer patients and it leads to death in most of the patients. Second primary tumors occurring in the other head and neck region reach up to almost 40% of long-term survivors. Recommended and preferred retreatment option in operable patients is salvage surgical resection, reporting a 5-year overall survival of up to 40%. However, because of tumor location, extent, and underlying comorbidities, salvage surgery is often limited and compromised by incomplete resection. Reirradiation with or without combined chemotherapy is an appropriate option for unresectable recurrence. Reirradiation is carefully considered with a case-by-case basis. Reirradiation protocol enrollment is highly encouraged prior to committing patient to an aggressive therapy. Radiation doses greater than 60 Gy are usually recommended for successful salvage. Despite recent technical improvement in intensity-modulated radiotherapy (IMRT), the use of concurrent chemotherapy, and the emergence of molecularly targeted agents, careful patient selection remain as the most paramount factor in reirradiation. Tumors that recur or persist despite aggressive prior chemoradiation therapy imply the presence of chemoradio-resistant clonogens. Treatment protocols that combine novel targeted radiosensitizing agents with conformal high precision radiation are required to overcome the resistance while minimizing toxicity. Recent large number of data showed that IMRT may provide better locoregional control with acceptable acute or chronic morbidities. However, additional prospective studies are required before a definitive conclusion can be drawn on safety and effectiveness of IMRT.
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Affiliation(s)
- Yeon Sil Kim
- Department of Radiation Oncology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Nieder C, Langendijk JA, Guckenberger M, Grosu AL. Preserving the legacy of reirradiation: A narrative review of historical publications. Adv Radiat Oncol 2017; 2:176-182. [PMID: 28740929 PMCID: PMC5514242 DOI: 10.1016/j.adro.2017.02.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 02/16/2017] [Accepted: 02/21/2017] [Indexed: 12/09/2022] Open
Abstract
PURPOSE The purpose of this study is to illustrate the historical development of reirradiation during several decades of the 20th century, in particular between 1920 and 1960. METHODS AND MATERIALS We chose the format of a narrative review because the historical articles are heterogeneous. No systematic extraction of baseline data, treatment details, or follow-up care was possible in many cases. RESULTS Both hematological malignancies and solid tumors were treated with a second course of radiation therapy, and indications included local relapse, regional nodal recurrence, and second primary tumors developing in a previously treated region. The literature consists of retrospective single-institution analyses describing treatment approaches that included external beam radiation therapy, brachytherapy, or combinations thereof. Data on toxicities and survival were often provided. Breast cancer and gynecological, head and neck, brain, and skin tumors are among the entities included in this review. CONCLUSIONS The leading pioneers in the field are fully aware of many of the challenges we continue to debate today. These include the process of late tissue changes and development of personalized treatment approaches and better ways to select patients who are likely to benefit from a second course of radiation therapy.
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Affiliation(s)
- Carsten Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital Trust, Bodø, Norway.,Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
| | - Johannes A Langendijk
- Department of Radiation Oncology, University Medical Centre Groningen, Groningen, Netherlands
| | | | - Anca L Grosu
- Department of Radiation Oncology, University Hospital Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg, Freiburg, Germany
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Kaur P, Bansal N, Kumar JV, Khurana A, Chauhan A. A Retrospective Evaluation of Clinical Profile of Second Primary Head and Neck Cancer. J Clin Diagn Res 2016; 10:XC10-XC14. [PMID: 27891442 DOI: 10.7860/jcdr/2016/21069.8725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 07/18/2016] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Paramjeet Kaur
- Associate Professor, Department of Radiotherapy, Pt BDS PGIMS , Rohtak, Haryana, India
| | - Nupur Bansal
- Senior Resident, Department of Radiotherapy, Pt BDS PGIMS , Rohtak, Haryana, India
| | - J Vijaya Kumar
- Fellow in "Advanced Techniques in Radiotherapy" Health Care Global Enterprises Ltd. , Bangalore, India; HCG Bangalore Institute of Oncology, Bangalore, India
| | - Anil Khurana
- Medical Officer, Department of Radiotherapy, Pt BDS PGIMS , Rohtak, Haryana, India
| | - Ashok Chauhan
- Senior Professor, Department of Radiotherapy, Pt BDS PGIMS , Rohtak, Haryana, India
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Kovács G, Martinez-Monge R, Budrukkar A, Guinot JL, Johansson B, Strnad V, Skowronek J, Rovirosa A, Siebert FA. GEC-ESTRO ACROP recommendations for head & neck brachytherapy in squamous cell carcinomas: 1st update - Improvement by cross sectional imaging based treatment planning and stepping source technology. Radiother Oncol 2016; 122:248-254. [PMID: 27889184 DOI: 10.1016/j.radonc.2016.10.008] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 10/04/2016] [Accepted: 10/04/2016] [Indexed: 01/01/2023]
Abstract
The Head and Neck Working Group of the GEC-ESTRO (Groupe Européen de Curiethérapie - European Society for Therapeutic Radiology and Oncology) published in 2009 the consensus recommendations for low-dose rate, pulsed-dose rate and high-dose rate brachytherapy in head & neck cancers. The use of brachytherapy in combination with external beam radiotherapy and/or surgery was also covered as well as the use of brachytherapy in previously irradiated patients. Given the developments in the field, these recommendations needed to be updated to reflect up-to-date knowledge. The present update does not repeat basic knowledge which was published in the first recommendation but covers in a general part developments in (1) dose and fractionation, (2) aspects of treatment selection for brachytherapy alone versus combined BT+EBRT and (3) quality assurance issues. Detailed expert committee opinion intends to help the clinical practice in lip-, oral cavity-, oropharynx-, nasopharynx-, and superficial cancers. Different aspects of adjuvant treatment techniques and their results are discussed, as well the possibilities of salvage brachytherapy applications.
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Affiliation(s)
- György Kovács
- Interdisciplinary Brachytherapy Unit, University of Lübeck/UKSH CL, Germany.
| | | | - Ashwini Budrukkar
- Department of Radiation Oncology, Tata Memorial Hospital, Mumbai, India
| | - Jose Luis Guinot
- Department of Radiation Oncology, Fundacion Institito Valenciano de Oncologia (IVO), Valencia, Spain
| | | | - Vratislav Strnad
- Department of Radiation Oncology, University Hospital of Erlangen, Germany
| | - Janusz Skowronek
- Department of Brachytherapy, Greater Poland Cancer Centre, Poznan, Poland; Department of Elektroradiology, Poznan University of Medical Sciences, Poland
| | - Angeles Rovirosa
- Department of Radiation Oncology, Hospital Clinic i Universitari, Barcelona, Spain
| | - Frank-André Siebert
- Department of Radiotherapy (Radiooncology), Christian-Albrechts-University/UKSH-CK, Kiel, Germany
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Geiger EJ, Basques BA, Chang CC, Son Y, Sasaki CT, McGregor A, Ariyan S, Narayan D. Pedicle versus free flap reconstruction in patients receiving intraoperative brachytherapy. J Plast Surg Hand Surg 2016; 50:227-32. [DOI: 10.3109/2000656x.2016.1152974] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Khan L, Tjong M, Raziee H, Lee J, Erler D, Chin L, Poon I. Role of stereotactic body radiotherapy for symptom control in head and neck cancer patients. Support Care Cancer 2014; 23:1099-103. [PMID: 25294656 DOI: 10.1007/s00520-014-2421-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 08/25/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE Our aim was to determine the efficacy and quality of life outcomes of head and neck (HN) stereotactic body radiotherapy (SBRT) in a palliative population with significant proportions of de novo HN tumors not amenable to surgery or protracted course of curative radiotherapy (RT). METHODS A retrospective review of a prospective database identified 21 patients with 24 sites that were treated. Patients were treated with intensity modulated RT (IMRT), usually 7-9 static fields with a 2-3-mm margin from gross tumor volume to planning target volume only with no microscopic margin added. Electronic patient records and treatment plans were reviewed. Basic demographic information was collected. The EORTC QLQ-H&N35 questionnaire was the tool used to collect QOL data both pre- and on-treatment fraction 5. Univariate analysis was performed for predictors of local control (LC) and prognostic factors for overall survival (OS). RESULTS A total of 21 patients had 24 sites that were treated. The median age was 87 (range 25-103) and median KPS was 70. The most common histology was squamous cell carcinoma (SCC) 19/24 (79 %), basal cell carcinoma (BCC) 3/24 (16 %), and melanoma (4 %). The median maximal diameter was 3.7 cm (range 1-10 cm). The most commonly treated site was lymph nodes in the neck 13/24 (54 %), skin 8/24 (33 %), 4/24 (16 %) other HN mucosal primary sites. Of the 24 lesions, 17 (71 %) were de novo, without prior treatment and 7/24 (29 %) were recurrent. The most commonly used dose/fraction (fx) was 40 Gy/5 (fx) (range 35/5fx-48/6fx). Of the 24 lesions, 6 (25 %) had complete response, 16/24 (67 %) had partial response, and 2/24 (8 %) had no response. Control was defined as no further progression after treatment. For the entire cohort, LC at 3, 6, and 9 months were 66, 50, and 33 %, respectively. In the de novo group, 2/16 (12.5 %) had local failures with the LC rate of 94, 94, and 87 % at 3 months, 6 months, and 1 year, respectively. In the recurrent group, 4/8 (50 %) had failure with LC rates of 87. 5, 62.5, and 50 % at 3 months, 6 months, and 1 year, respectively. Of the 21 patients, 10 died during follow up, with the OS rate at 3 months, 6 months, and 1 year of 90, 70, and 60 %, respectively. Being defined "de novo" showed a trend toward statistical significance p = 0.046 for local failure. Overall survival did not show significant difference between de novo and recurrent with a p value of 0.267. No significant prognostic variables for OS were found. Pre-treatment QOL scores for the entire cohort were 53/130 versus 38/130 (lower scores indicating better QOL) scores with a trend toward statistical significance p = 0.05. CONCLUSIONS SBRT is efficacious with improved quality of life within this elderly frail population in the treatment of de novo and recurrent tumors of the head and neck with promising quality of life scores.
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Affiliation(s)
- Luluel Khan
- Odette Cancer Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
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20
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Strnad V, Lotter M, Kreppner S, Fietkau R. Re-irradiation with interstitial pulsed-dose-rate brachytherapy for unresectable recurrent head and neck carcinoma. Brachytherapy 2014; 13:187-95. [DOI: 10.1016/j.brachy.2013.10.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 08/26/2013] [Accepted: 10/16/2013] [Indexed: 01/07/2023]
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Strojan P, Corry J, Eisbruch A, Vermorken JB, Mendenhall WM, Lee AWM, Haigentz M, Beitler JJ, de Bree R, Takes RP, Paleri V, Kelly CG, Genden EM, Bradford CR, Harrison LB, Rinaldo A, Ferlito A. Recurrent and second primary squamous cell carcinoma of the head and neck: when and how to reirradiate. Head Neck 2014; 37:134-50. [PMID: 24481720 DOI: 10.1002/hed.23542] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 07/22/2013] [Accepted: 10/30/2013] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Primož Strojan
- Department of Radiation Oncology, Institute of Oncology, Ljubljana, Slovenia
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Chin D, Boyle GM, Porceddu S, Theile DR, Parsons PG, Coman WB. Head and neck cancer: past, present and future. Expert Rev Anticancer Ther 2014; 6:1111-8. [PMID: 16831082 DOI: 10.1586/14737140.6.7.1111] [Citation(s) in RCA: 170] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Head and neck cancer consists of a diverse group of cancers that ranges from cutaneous, lip, salivary glands, sinuses, oral cavity, pharynx and larynx. Each group dictates different management. In this review, the primary focus is on head and neck squamous cell carcinoma (HNSCC) arising from the mucosal lining of the oral cavity and pharynx, excluding nasopharyngeal cancer. Presently, HNSCC is the sixth most prevalent neoplasm in the world, with approximately 900,000 cases diagnosed worldwide. Prognosis has improved little in the past 30 years. In those who have survived, pain, disfigurement and physical disability from treatment have had an enormous psychosocial impact on their lives. Management of these patients remains a challenge, especially in developing countries where this disease is most common. Of all human cancers, HNSCC is the most distressing since the head and neck is the site of the most complex functional anatomy in the human body. Its areas of responsibility include breathing, the CNS, vision, hearing, balance, olfaction, taste, swallowing, voice, endocrine and cosmesis. Cancers that occur in this area impact on these important human functions. Consequently, in treating cancers of the head and neck, the effects of the treatment on the functional outcome of the patient need the most serious consideration. In assessing the success of HNSCC treatment, consideration of both the survival and functional deficits that the patient may suffer as a consequence of their treatment are of paramount importance. For this reason, the modern-day management of head and neck patients should be carried out in a multidisciplinary head and neck clinic.
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Affiliation(s)
- David Chin
- Department of Plastic Surgery and Head & Neck Unit, Princess Alexandra Hospital, Brisbane 4102, Queensland, Australia.
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Jeong S, Yoo EJ, Kim JY, Han CW, Kim KJ, Kay CS. Re-irradiation of unresectable recurrent head and neck cancer: using Helical Tomotherapy as image-guided intensity-modulated radiotherapy. Radiat Oncol J 2013; 31:206-15. [PMID: 24501708 PMCID: PMC3912234 DOI: 10.3857/roj.2013.31.4.206] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 10/15/2013] [Accepted: 10/24/2013] [Indexed: 11/15/2022] Open
Abstract
Purpose Re-irradiation (re-RT) is considered a treatment option for inoperable locoregionally recurrent head and neck cancer (HNC) after prior radiotherapy. We evaluated the efficacy and safety of re-RT using Helical Tomotherapy as image-guided intensity-modulated radiotherapy in recurrent HNC. Materials and Methods Patients diagnosed with recurrent HNC and received re-RT were retrospectively reviewed. Primary endpoint was overall survival (OS) and secondary endpoints were locoregional control and toxicities. Results The median follow-up period of total 9 patients was 18.7 months (range, 4.1 to 76 months) and that of 3 alive patients was 49 months (range, 47 to 76 months). Median dose of first radiotherapy and re-RT was 64.8 and 47.5 Gy10. Median cumulative dose of the two courses of radiotherapy was 116.3 Gy10 (range, 91.8 to 128.9 Gy10) while the median interval between the two courses of radiation was 25 months (range, 4 to 137 months). The response rate after re-RT of the evaluated 8 patients was 75% (complete response, 4; partial response, 2). Median locoregional relapse-free survival after re-RT was 11.9 months (range, 3.4 to 75.1 months) and 5 patients eventually presented with treatment failure (in-field failure, 2; in- and out-field failure, 2; out-field failure, 1). Median OS of the 8 patients was 20.3 months (range, 4.1 to 75.1 months). One- and two-year OS rates were 62.5% and 50%, respectively. Grade 3 leucopenia developed in one patient as acute toxicity, and grade 2 osteonecrosis and trismus as chronic toxicity in another patient. Conclusion Re-RT using Helical Tomotherapy for previously irradiated patients with unresectable locoregionally recurrent HNC may be a feasible treatment option with long-term survival and acceptable toxicities.
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Affiliation(s)
- Songmi Jeong
- Department of Radiation Oncology, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Eun Jung Yoo
- Department of Radiation Oncology, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Ji Yoon Kim
- Department of Radiation Oncology, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Chi Wha Han
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Ki Jun Kim
- Department of Diagnostic Radiology, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Chul Seung Kay
- Department of Radiation Oncology, The Catholic University of Korea College of Medicine, Seoul, Korea
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The role of re-irradiation of secondary and recurrent head and neck carcinomas. Is it a potentially curative treatment? A practical approach. Cancer Treat Rev 2013; 40:178-89. [PMID: 23993769 DOI: 10.1016/j.ctrv.2013.08.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Revised: 05/18/2013] [Accepted: 08/01/2013] [Indexed: 11/22/2022]
Abstract
Despite aggressive efforts to cure head and neck cancer patients, including altered fractionation and the addition of chemotherapy to radiation, locoregional recurrence remains a serious issue to face in clinical practice. Indeed, recurrent and second primary tumors occurring in previously irradiated area are common clinical challenge. Whenever possible, patients are advised to undergo salvage surgery. Nevertheless, few patients are suitable candidates for curative resection. In such cases, chemotherapy alone has traditionally been considered, with a poor response rate. It has been questioned whether re-irradiation toxicity outweighs the potential benefits, considering that the median survival of re-irradiated patients marginally exceeds the benefits observed with chemotherapy alone. However, full-dose re-irradiation is a viable treatment option, offering long-term survival for selected patients. Moreover, several prognostic factors should be considered for patients undergoing re-irradiation, such as basic patient characteristics, performance status, the location and extension of recurrent disease, patient co-morbidities, current speech and swallowing function, the interval from the initial radiation therapy to recurrence, previously received doses by critical structures and prior treatment toxicity. Nevertheless, several questions remain unanswered. The purpose of this review is to evaluate the major issues in the field of re-irradiation regarding the current evidence. Therefore, the major selection criteria and new treatment strategies are discussed to define the ideal candidates to undergo re-irradiation and describe a practical approach to these patients. Given the limited evidence in this field, the optimal treatment of recurrent and second primary cancers remains to be defined. Future prospective study of this approach is warranted.
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Zhu L, Jiang Y, Wang J, Ran W, Yuan H, Liu C, Qu A, Yang R. An investigation of 125I seed permanent implantation for recurrent carcinoma in the head and neck after surgery and external beam radiotherapy. World J Surg Oncol 2013; 11:60. [PMID: 23496973 PMCID: PMC3607919 DOI: 10.1186/1477-7819-11-60] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Accepted: 02/07/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A preliminary assessment was conducted of the feasibility, efficacy, and morbidity of 125I seed implantation for recurrent head and neck carcinoma after surgery and external beam radiotherapy. METHODS Nineteen patients with recurrent head and neck carcinomas underwent 125I seed implantation under ultrasound or computed tomography guidance. The actuarial D90 of 125I seed implantation ranged from 90 to 160 Gy (median, 131 Gy). The follow-up period ranged from 3 to 44 months (median, 11 months). RESULTS The median local control was 24 months (95% confidence interval, 10.2 to 37.8). The one- year, two-year and three-year local controls were 73.3%, 27.5% and 27.5%, respectively, whereas the one-year, two-year and three-year survival rates were 53.0%, 18.2% and 18.2%, respectively, and the median survival was 13 months (95% confidence interval, 6.6 to 19.4). A total of 26.3% of patients (5/19) died of local recurrence and 21.1% of patients (4/19) died of metastases. One suffered from a grade 1 skin reaction. CONCLUSIONS 125I seed implantation is feasible and safe as a salvage treatment for patients with recurrent head and neck cancers. The high local control results and low morbidity merits further investigation.
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Affiliation(s)
- Lihong Zhu
- Department of Radiation Oncology, Peking University 3rd Hospital, No, 49 Huayuan North road, Haidian district, Beijing, 100191, People's Republic of China
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Target delineation in stereotactic body radiation therapy for recurrent head and neck cancer: a retrospective analysis of the impact of margins and automated PET-CT segmentation. Radiother Oncol 2013; 106:90-5. [PMID: 23333021 DOI: 10.1016/j.radonc.2012.11.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Revised: 11/08/2012] [Accepted: 11/20/2012] [Indexed: 11/21/2022]
Abstract
BACKGROUND Few guidelines exist on stereotactic body radiation therapy (SBRT) treatment planning for recurrent head and neck cancer. We assessed the impact of retrospectively adding margins/automated PET volumes to the gross tumor volume (GTV) in patients with post-SBRT recurrences. MATERIALS AND METHODS We reviewed 89 patients with recurrent head and neck cancer treated with SBRT using no margin around the GTV. GTVs were recontoured with 1-5mm margins. PET-CT planned GTVs were also recontoured by adding PET-standardized uptake value (SUV)(3.5), SUV(4.5), SUV(40% max), and signal/background ratio (SBR) to the original GTV. We deformably registered recontoured GTVs to post-SBRT scans and assessed fraction of recurrence volume (RV) falling within the GTV, the "RV-GTV overlap." RESULTS With non-PET-CT planning, median RV-GTV overlap increased from 11.7% to 48.2% using 5mm margins, and median GTV size increased by 41.8 cc (156%). With PET-CT planning, RV-GTV overlap increased from 45% to 93.6% using 5mm margins, and GTV size increased by 34.8 cc (140%). Adding SUV(3.5) and SBR increased RV-GTV overlap from 45% to 73.3% and 73.6%, with GTV size increases of 0.8 (3%) and 3.1 cc (11%), respectively. CONCLUSIONS Recontouring increased recurrence coverage and also GTV size. Margins up to 5mm may reduce failures but could possibly increase toxicities. Automated PET contours may reduce near-miss failures with smaller increases in GTV size.
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Lim CM, Clump DA, Heron DE, Ferris RL. Stereotactic Body Radiotherapy (SBRT) for primary and recurrent head and neck tumors. Oral Oncol 2013; 49:401-6. [PMID: 23332685 DOI: 10.1016/j.oraloncology.2012.12.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Revised: 12/18/2012] [Accepted: 12/19/2012] [Indexed: 11/30/2022]
Abstract
Stereotactic Body Radiotherapy (SBRT) is increasingly used to treat a variety of head and neck tumors as a result of its highly conformal dose distributions and stereotactic spatial accuracy in delivery. Our experience and other previous reports have shown that SBRT is technically feasible, well-tolerated and compares favorably to other alternatives of salvage therapy in the management of patients with recurrent and/or previously irradiated head and neck cancers. Furthermore, it has the advantage of a shorter treatment schedule, greater compliance, and safe delivery in the outpatient setting. This affords an opportunity to introduce SBRT as a definitive treatment in select patients. This review presents an overview of the use of SBRT for managing head and neck tumors by highlighting the existing indications and the expanding role of SBRT in managing these patients.
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Affiliation(s)
- Chwee Ming Lim
- Department of Otolaryngology, University of Pittsburgh Medical Center, PA, USA
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Mantel F, Flentje M, Guckenberger M. Stereotactic body radiation therapy in the re-irradiation situation--a review. Radiat Oncol 2013; 8:7. [PMID: 23289496 PMCID: PMC3552718 DOI: 10.1186/1748-717x-8-7] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Accepted: 12/27/2012] [Indexed: 11/10/2022] Open
Abstract
Although locoregional relapse is frequent after definitive radiotherapy (RT) or multimodal treatments, re-irradiation is only performed in few patients even in palliative settings like e.g. vertebral metastasis. This is most due to concern about potentially severe complications, especially when large volumes are exposed to re-irradiation. With technological advancements in treatment planning the interest in re-irradiation as a local treatment approach has been reinforced. Recently, several studies reported re-irradiation for spinal metastases using SBRT with promising local and symptom control rates and simultaneously low rates of toxicity. These early data consistently indicate that SBRT is a safe and effective treatment modality in this clinical situation, where other treatment alternatives are rare. Similarly, good results have been shown for SBRT in the re-irradiation of head and neck tumors. Despite severe late adverse effects were reported in several studies, especially after single fraction doses >10 Gy, they appear less frequently compared to conventional radiotherapy. Few studies with small patient numbers have been published on SBRT re-irradiation for non-small cell lung cancer (NSCLC). Overall survival (OS) is limited by systemic progression and seems to depend particularly on patient selection. SBRT re-irradiation after primary SBRT should not be practiced in centrally located tumors due to high risk of severe toxicity. Only limited data is available for SBRT re-irradiation of pelvic tumors: feasibility and acceptable toxicity has been described, suggesting SBRT as a complementary treatment modality for local symptom control.
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Affiliation(s)
- Frederick Mantel
- Department of Radiation Oncology, University of Wuerzburg, Wuerzburg, Germany.
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Seiwert TY, Darga T, Haraf D, Blair EA, Stenson K, Cohen EEW, Salama JK, Villaflor V, Witt ME, Lingen MW, Weichselbaum RR, Vokes EE. A phase I dose escalation study of Ad GV.EGR.TNF.11D (TNFerade™ Biologic) with concurrent chemoradiotherapy in patients with recurrent head and neck cancer undergoing reirradiation. Ann Oncol 2012; 24:769-76. [PMID: 23104721 DOI: 10.1093/annonc/mds523] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND AdGV.EGR.TNF.11D (TNFerade™ Biologic) is a replication-deficient adenoviral vector expressing human tumor necrosis factor alpha (TNF-α) under the control of the chemoradiation-inducible EGR-1 promoter. TNF-α has been shown to function as a radiation sensitizer. We conducted a phase I dose escalation study to determine the maximum tolerated dose (MTD) and dose-limiting toxicity (DLT) of TNFerade™ Biologic, when added to chemoradiotherapy in poor prognosis patients with recurrent, previously irradiated head and neck cancer (HNC). METHODS TNFerade™ Biologic was injected intratumorally on day 1 of each 14-day cycle and dose-escalated in log increments from 4 × 10(9) to 4 × 10(11) PU. Daily radiation, infusional 5-fluorouracil (5-FU), and hydroxyurea were given on days 1-5 for seven cycles (FHX). Tumor biopsies were obtained before, during, and after treatment. RESULTS Fourteen patients were treated. DLT was reached at a dose level of 3 (4 × 10(11) PU) with three thrombotic events. The response rate was 83.3%. The median survival was 9.6 months. One patient (7.1%) remained alive 3 years after treatment. Biopsies were obtained in 90% of patients. Nearly all tumors expressed adenovirus receptors, TNF-α, and TNF-α receptors. Adenoviral DNA was detected in three biopsies from one patient. CONCLUSIONS TNFerade™ Biologic can be safely integrated with FHX chemoradiotherapy at an MTD of 4 × 10(10) PU. Monitoring for thrombotic events is indicated.
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Affiliation(s)
- T Y Seiwert
- Departments of Medicine, The University of Chicago, Chicago, IL 60615, USA.
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Wang K, Heron DE, Flickinger JC, Rwigema JCM, Ferris RL, Kubicek GJ, Ohr JP, Quinn AE, Ozhasoglu C, Branstetter BF. A retrospective, deformable registration analysis of the impact of PET-CT planning on patterns of failure in stereotactic body radiation therapy for recurrent head and neck cancer. HEAD & NECK ONCOLOGY 2012; 4:12. [PMID: 22515371 PMCID: PMC3414786 DOI: 10.1186/1758-3284-4-12] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Accepted: 04/19/2012] [Indexed: 11/10/2022]
Abstract
BACKGROUND Stereotactic body radiation therapy (SBRT) has seen increasing use as a salvage strategy for selected patients with recurrent, previously-irradiated squamous cell carcinoma of the head and neck (rSCCHN). PET-CT may be advantageous for tumor delineation and evaluation of treatment failures in SBRT. We analyzed the patterns of failure following SBRT for rSCCHN and assessed the impact of PET-CT treatment planning on these patterns of failure. METHODS We retrospectively reviewed 96 patients with rSCCHN treated with SBRT. Seven patients (7%) were treated after surgical resection of rSCCHN and 89 patients (93%) were treated definitively. PET-CT treatment planning was used for 45 patients whereas non-PET-CT planning was used for 51 patients. Categories of failure were assigned by comparing recurrences on post-treatment scans to the planning target volume (PTV) from planning scans using the deformable registration function of VelocityAI™. Failures were defined: In-field (>75% inside PTV), Overlap (20-75% inside PTV), Marginal (<20% inside PTV but closest edge within 1cm of PTV), or Regional/Distant (more than 1cm from PTV). RESULTS Median follow-up was 7.4 months (range, 2.6-52 months). Of 96 patients, 47 (49%) developed post-SBRT failure. Failure distribution was: In-field-12.3%, Overlap-24.6%, Marginal-36.8%, Regional/Distant-26.3%. There was a significant improvement in overall failure-free survival (log rank p = 0.037) and combined Overlap/Marginal failure-free survival (log rank p = 0.037) for those receiving PET-CT planning vs. non-PET-CT planning in the overall cohort (n = 96). Analysis of the definitive SBRT subgroup (n = 89) increased the significance of these findings (overall failure: p = 0.008, Overlap/Marginal failure: p = 0.009). There were no significant differences in age, gender, time from prior radiation, dose, use of cetuximab with SBRT, tumor differentiation, and tumor volume between the PET-CT and non-PET-CT groups. CONCLUSIONS Most failures after SBRT treatment for rSCCHN were near misses, i.e. Overlap/Marginal failures (61.4%), suggesting an opportunity to improve outcomes with more sensitive imaging. PET-CT treatment planning showed the lowest rate of overall and near miss failures and is beneficial for SBRT treatment planning.
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Affiliation(s)
- Kyle Wang
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA
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Jiang P, Jiang Y, Wang JJ, Meng N, Ran W, Qu A, Yang R. Percutaneous Ultrasonography-Guided Permanent Iodine-125 Implantation as Salvage Therapy for Recurrent Head and Neck Carcimonas. Cancer Biother Radiopharm 2011; 26:753-7. [PMID: 22133099 DOI: 10.1089/cbr.2010.0844] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ping Jiang
- Department of Radiation Oncology, Peking University 3rd Hospital, Beijing, P.R. China
| | - Yuliang Jiang
- Department of Radiation Oncology, Peking University 3rd Hospital, Beijing, P.R. China
| | - Jun-jie Wang
- Department of Radiation Oncology, Peking University 3rd Hospital, Beijing, P.R. China
| | - Na Meng
- Department of Radiation Oncology, Peking University 3rd Hospital, Beijing, P.R. China
| | - Weiqiang Ran
- Department of Ultrasound, Peking University 3rd Hospital, Beijing, P.R. China
| | - Ang Qu
- Department of Radiation Oncology, Peking University 3rd Hospital, Beijing, P.R. China
| | - Ruijie Yang
- Department of Radiation Oncology, Peking University 3rd Hospital, Beijing, P.R. China
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Villaflor V, Haraf D, Salama J, Kocherginsky M, Langerman A, Gomez-Abuin G, Beniwal P, Blair E, Stenson K, Portugal L, Seiwert T, Williams R, Dekker A, Witt M, Vokes E, Cohen E. Phase II trial of pemetrexed-based induction chemotherapy followed by concomitant chemoradiotherapy in previously irradiated patients with squamous cell carcinoma of the head and neck. Ann Oncol 2011; 22:2501-2507. [DOI: 10.1093/annonc/mdq785] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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Second course of radiation for new primary head-and-neck cancer: population-based study of survival. Am J Clin Oncol 2011; 34:367-71. [PMID: 20859195 DOI: 10.1097/coc.0b013e3181e84b7a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To analyze patient and tumor characteristics, and survival of patients who received 2 courses of radiotherapy for different primary head and neck cancers (HNCs). METHODS A total of 234 patients who underwent 2 courses of radiotherapy for different primary, localized, or regional HNCs registered in the population-based Surveillance, Epidemiology, and End Results database were identified. RESULTS The latency between first and second irradiated HNCs ranged from 0.3 to 28.8 years (median, 6.3 years). Only 22% of first irradiated HNCs were node positive, and only 22% of second irradiated HNCs were node positive. After the diagnosis of the second irradiated HNC, the 1-, 2-, and 5-year overall survivals were 68%, 40%, and 17%, respectively. The variables of gender, race, latency, and stage of second cancer did not significantly impact survival. At the time of diagnosis of second irradiated HNC, younger age (P = 0.026), later year of diagnosis (P = 0.005), and cancer-directed surgery (P = 0.032) were favorable predictors of improved survival. With Cox regression analyses, younger age (P = 0.060) and cancer-directed surgery for the second irradiated HNC (HR = 0.75, 95% CI: 0.55-1.01, P = 0.062) were borderline significantly favorable risk factors, whereas year of diagnosis (P = 0.13) was not. CONCLUSIONS From a population-based analysis, patients undergoing a second course of radiation for HNC appear to benefit from cancer-directed surgery, although this did not reach statistical significance with Cox regression analyses. The improved outcome after resection is perhaps attributable to a therapeutic benefit from surgery and/or more indolent disease among those amenable to resection.
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The impact of tumor volume and radiotherapy dose on outcome in previously irradiated recurrent squamous cell carcinoma of the head and neck treated with stereotactic body radiation therapy. Am J Clin Oncol 2011; 34:372-9. [PMID: 20859194 DOI: 10.1097/coc.0b013e3181e84dc0] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To assess the effect of stereotactic body radiotherapy (SBRT) dose and tumor volume on outcomes in patients with recurrent, previously irradiated squamous cell carcinoma of the head and neck. MATERIALS AND METHODS A total of 96 patients with recurrent, previously irradiated squamous cell carcinoma of the head and neck were treated with SBRT using Cyberknife and Trilogy-intensity-modulated radiosurgery. Kaplan-Meier survival analyses were used to estimate locoregional control (LRC) and overall survival rates. Response was evaluated using positron emission tomography/computed tomography or computed tomography and detailed physical examination. RESULTS The median follow-up for all patients was 14 months (2-39 months). The median dose of prior radiation was 68.4 Gy (32-170 Gy). Patients were divided into 4 SBRT dose groups: I (15-28 Gy/n = 29), II (30-36 Gy/n = 22), III (40 Gy/n = 18), and IV (44-50 Gy/n = 27). The median gross tumor volume (GTV) was 24.3(3) cm (2.5-162 cm). For GTV ≤25 cm(3) (n = 50), complete response rates were 27.8%/30%/45.5%/45.5%, and for GTV >25 cm(3) (n = 46), complete response rates were 20%/25%/42.8%/50% for SBRT groups I-IV, respectively. The 1-/2-/3-year LRC rates for doses 40 to 50 Gy were 69.4%/57.8%/41.1%, respectively, whereas for 15 to 36 Gy, they were 51.9%/31.7%/15.9%, respectively (P = 0.02). The overall 1- and 2-year overall survival rates were 58.9% and 28.4%, respectively. Treatment was well tolerated with no grade 4/5 toxicities. CONCLUSIONS Dose escalation up to 50 Gy in 5 fractions is feasible with SBRT for recurrent head and neck squamous cell carcinoma. Higher SBRT doses were associated with significantly higher LRC rates. Large tumor volume required higher SBRT doses to achieve optimal response rates compared with smaller tumor volume.
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Yamazaki H, Kodani N, Ogita M, Sato K, Himei K. Reirradiation of head and neck cancer focusing on hypofractionated stereotactic body radiation therapy. Radiat Oncol 2011; 6:98. [PMID: 21854640 PMCID: PMC3179722 DOI: 10.1186/1748-717x-6-98] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2011] [Accepted: 08/21/2011] [Indexed: 11/10/2022] Open
Abstract
Reirradiation is a feasible option for patients who do not otherwise have treatment options available. Depending on the location and extent of the tumor, reirradiation may be accomplished with external beam radiotherapy, brachytherapy, radiosurgery, or intensity modulated radiation therapy (IMRT). Although there has been limited experience with hypofractionated stereotactic radiotherapy (hSRT), it may have the potential for curative or palliative treatment due to its advanced precision technology, particularly for limited small lesion. On the other hand, severe late adverse reactions are anticipated with reirradiation than with initial radiation therapy. The risk of severe late complications has been reported to be 20- 40% and is related to prior radiotherapy dose, primary site, retreatment radiotherapy dose, treatment volume, and technique. Early researchers have observed lethal bleeding in such patients up to a rate of 14%. Recently, similar rate of 10-15% was observed for fatal bleeding with use of modern hSRT like in case of carotid blowout syndrome. To determine the feasibility and efficacy of reirradiation using modern technology, we reviewed the pertinent literature. The potentially lethal side effects should be kept in mind when reirradiation by hSRT is considered for treatment, and efforts should be made to minimize the risk in any future investigations.
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Affiliation(s)
- Hideya Yamazaki
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, Japan.
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Choe KS, Haraf DJ, Solanki A, Cohen EEW, Seiwert TY, Stenson KM, Blair EA, Portugal L, Villaflor VM, Witt ME, Vokes EE, Salama JK. Prior chemoradiotherapy adversely impacts outcomes of recurrent and second primary head and neck cancer treated with concurrent chemotherapy and reirradiation. Cancer 2011; 117:4671-8. [DOI: 10.1002/cncr.26084] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Revised: 01/28/2011] [Accepted: 02/01/2011] [Indexed: 01/10/2023]
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McDonald MW, Moore MG, Johnstone PAS. Risk of carotid blowout after reirradiation of the head and neck: a systematic review. Int J Radiat Oncol Biol Phys 2011; 82:1083-9. [PMID: 21549520 DOI: 10.1016/j.ijrobp.2010.08.029] [Citation(s) in RCA: 142] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Revised: 08/16/2010] [Accepted: 08/17/2010] [Indexed: 11/30/2022]
Abstract
PURPOSE Carotid blowout (CB) is a rare but frequently fatal complication of head-and-neck (H&N) cancer or its treatment. We sought to determine the reported rate of CB in patients receiving salvage reirradiation for H&N cancer. METHODS AND MATERIALS A literature search identified 27 published articles on H&N reirradiation involving 1554 patients, and a pooled analysis was performed to determine the rate of CB. Treatment parameters, including prior radiation dose, interval from prior radiation, dose and fractionation of reirradiation, use of salvage surgery, and chemotherapy, were abstracted and summarized. The cumulative risk of CB was compared between groups using Fisher's exact test. RESULTS Among 1554 patients receiving salvage H&N reirradiation, there were 41 reported CBs, for a rate of 2.6%; 76% were fatal. In patients treated in a continuous course with 1.8-2-Gy daily fractions or 1.2-Gy twice-daily fractions, 36% of whom received concurrent chemotherapy, the rate of CB was 1.3%, compared with 4.5% in patients treated with 1.5 Gy twice daily in alternating weeks or with delayed accelerated hyperfractionation, all of whom received concurrent chemotherapy (p = 0.002). There was no statistically significant difference in the rate of CB between patients treated with or without concurrent chemotherapy, or between patients treated with or without salvage surgery before reirradiation. CONCLUSION Carotid blowout is an infrequent but serious complication of salvage reirradiation for H&N cancer. The rate of CB was lower among patients treated with conventional or hyperfractionated schedules compared with regimens of accelerated hyperfractionation, though heterogeneous patient populations and treatment parameters preclude definite conclusions. Given the high mortality rate of CB, discussion of the risk of CB is an important component of informed consent for salvage reirradiation.
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Affiliation(s)
- Mark W McDonald
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN 46202-5289, USA.
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McDonald MW, Lawson J, Garg MK, Quon H, Ridge JA, Saba N, Salama JK, Smith RV, Yeung AR, Yom SS, Beitler JJ. ACR appropriateness criteria retreatment of recurrent head and neck cancer after prior definitive radiation expert panel on radiation oncology-head and neck cancer. Int J Radiat Oncol Biol Phys 2011; 80:1292-8. [PMID: 21530100 DOI: 10.1016/j.ijrobp.2011.02.014] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Accepted: 02/09/2011] [Indexed: 02/08/2023]
Abstract
Recurrent and second primary head-and-neck squamous cell carcinomas arising within or in close proximity to previously irradiated fields are a common clinical challenge. Whereas surgical salvage therapy is recommended for resectable disease, randomized data support the role of postoperative reirradiation in high-risk patients. Definitive reirradiation is an established approach for patients with recurrent disease who are medically or technically inoperable or decline radical surgery. The American College of Radiology Expert Panel on Head and Neck Cancer reviewed the relevant literature addressing re-treatment after prior definitive radiation and developed appropriateness criteria for representative clinical scenarios. Examples of unresectable recurrent disease and microscopic residual disease after salvage surgery were addressed. The panel evaluated the appropriateness of reirradiation, the integration of concurrent chemotherapy, radiation technique, treatment volume, dose, and fractionation. The panel emphasized the importance of patient selection and recommended evaluation and treatment at tertiary-care centers with a head-and-neck oncology team equipped with the resources and experience to manage the complexities and toxicities of re-treatment.
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MESH Headings
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Cancer Care Facilities/standards
- Carcinoma/drug therapy
- Carcinoma/radiotherapy
- Carcinoma/surgery
- Carcinoma, Squamous Cell
- Female
- Head and Neck Neoplasms/drug therapy
- Head and Neck Neoplasms/radiotherapy
- Head and Neck Neoplasms/surgery
- Humans
- Male
- Nasopharyngeal Neoplasms/radiotherapy
- Nasopharyngeal Neoplasms/surgery
- Neoplasm Recurrence, Local/drug therapy
- Neoplasm Recurrence, Local/radiotherapy
- Neoplasm Recurrence, Local/surgery
- Neoplasm, Residual
- Neoplasms, Second Primary/drug therapy
- Neoplasms, Second Primary/radiotherapy
- Neoplasms, Second Primary/surgery
- Neoplasms, Squamous Cell/drug therapy
- Neoplasms, Squamous Cell/radiotherapy
- Neoplasms, Squamous Cell/surgery
- Organs at Risk/radiation effects
- Patient Selection
- Radiation Oncology/standards
- Radiation Tolerance
- Retreatment/standards
- Salvage Therapy/methods
- Squamous Cell Carcinoma of Head and Neck
- United States
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Affiliation(s)
- Mark W McDonald
- Indiana University School of Medicine, Indianapolis, Indiana.
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Platteaux N, Dirix P, Vanstraelen B, Nuyts S. Outcome after re-irradiation of head and neck cancer patients. Strahlenther Onkol 2010; 187:23-31. [PMID: 21234530 DOI: 10.1007/s00066-010-2139-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2010] [Accepted: 08/26/2010] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Nele Platteaux
- Department of Radiation Oncology, Leuvens Kankerinstituut, University Hospitals Leuven, Campus Gasthuisberg, Leuven, Belgium.
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Comet B, Lartigau E. Réirradiation des carcinomes de la tête et du cou. Cancer Radiother 2010; 14:416-20. [DOI: 10.1016/j.canrad.2010.06.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2010] [Accepted: 06/08/2010] [Indexed: 11/16/2022]
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Jiang YL, Meng N, Wang JJ, Jiang P, Yuan HSH, Liu C, Qu A, Yang RJ. CT-guided iodine-125 seed permanent implantation for recurrent head and neck cancers. Radiat Oncol 2010; 5:68. [PMID: 20673340 PMCID: PMC2919543 DOI: 10.1186/1748-717x-5-68] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2010] [Accepted: 07/30/2010] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND To investigate the feasibility, and safety of 125I seed permanent implantation for recurrent head and neck carcinoma under CT-guidance. RESULTS A retrospective study on 14 patients with recurrent head and neck cancers undergone 125I seed implantation with different seed activities. The post-plan showed that the actuarial D90 of 125I seeds ranged from 90 to 218 Gy (median, 157.5 Gy). The follow-up was 3 to 60 months (median, 13 months). The median local control was 18 months (95% CI, 6.1-29.9 months), and the 1-, 2-, 3-, and 5- year local controls were 52%, 39%, 39%, and 39%, respectively. The 1-, 2-, 3-, and 5- survival rates were 65%, 39%, 39% and 39%, respectively, with a median survival time of 20 months (95% CI, 8.7-31.3 months). Of all patients, 28.6% (4/14) died of local recurrence, 7.1% (1/14) died of metastases, one patient died of hepatocirrhosis, and 8 patients are still alive to the date of data analysis. CONCLUSION CT-guided 125I seed implantation is feasible and safe as a salvage or palliative treatment for patients with recurrent head and neck cancers.
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Affiliation(s)
- Yu L Jiang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing 100191, PR China
| | - Na Meng
- Department of Radiation Oncology, Peking University Third Hospital, Beijing 100191, PR China
| | - Jun J Wang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing 100191, PR China
| | - Ping Jiang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing 100191, PR China
| | - Hui SH Yuan
- Department of Radiology, Peking University Third Hospital, Beijing, 100191, PR China
| | - Chen Liu
- Department of Radiology, Peking University Third Hospital, Beijing, 100191, PR China
| | - Ang Qu
- Department of Radiation Oncology, Peking University Third Hospital, Beijing 100191, PR China
| | - Rui J Yang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing 100191, PR China
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Fractionated stereotactic body radiation therapy in the treatment of previously-irradiated recurrent head and neck carcinoma: updated report of the University of Pittsburgh experience. Am J Clin Oncol 2010; 33:286-93. [PMID: 19875950 DOI: 10.1097/coc.0b013e3181aacba5] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of this study was to assess the safety and outcome of stereotactic body radiotherapy (SBRT) in patients with recurrent previously irradiated squamous cell carcinoma of the head and neck (rSCCHN). METHODS We reviewed our experience with 85 patients who received SBRT for rSCCHN between January 2003 and May 2008. The mean dose of SBRT was 35 Gy (range: 15-44 Gy). The following end points were evaluated: tumor response, time-to-progression, acute and late toxicities, local control (LC) rates and impact of tumor dose and tumor size on LC, and overall survival. RESULTS The median follow-up of all patients was 6 months (range: 1.3-39 months). For those patients who were alive at last follow-up (40%) the median follow-up was 17.6 months. The mean total dose of prior radiation to the primary site was 74 Gy (range: 32-170 Gy). Those patients who received SBRT <35 Gy had significantly lower LC than those with > or =35 Gy at 6 months the median follow-up time (P = 0.014). Tumor responses were 34% complete response, 34% partial response, 20% stable disease, and 12% progressive disease. Among those with an initial tumor response followed by progression (58 patients), there was a median interval of 5.5 months for time-to-progression. The 1-year and 2-year LC and overall survival rates for all patients were 51.2% and 30.7%, and 48.5% and 16.1%, respectively. Overall, the median survival for all patients was 11.5 months (range: 3-51). Treatment was well-tolerated with no grade 4 or 5 treatment-related toxicities. CONCLUSIONS SBRT is feasible and safe with minimal toxicities for treatment of rSCCHN patients with prior radiation therapy deemed to be poor candidates for re-irradiation by conventional means.
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Fractionated stereotactic radiosurgery for reirradiation of head-and-neck cancer. Int J Radiat Oncol Biol Phys 2010; 77:1411-9. [PMID: 20056341 DOI: 10.1016/j.ijrobp.2009.06.070] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2009] [Revised: 06/15/2009] [Accepted: 06/18/2009] [Indexed: 11/23/2022]
Abstract
PURPOSE Stereotactic radiosurgery (SRS) is an appealing treatment option after previous radiotherapy because of its precision, conformality, and reduced treatment duration. We report our experience with reirradiation using fractionated SRS for head-and-neck cancer. METHODS AND MATERIALS From 2002 to 2008, 65 patients received SRS to the oropharynx (n = 13), hypopharynx (n = 8), nasopharynx (n = 7), paranasal sinus (n = 7), neck (n = 7), and other sites (n = 23). Thirty-eight patients were treated definitively and 27 patients with metastatic disease and/or untreated local disease were treated palliatively. Nine patients underwent complete macroscopic resection before SRS. Thirty-three patients received concurrent chemoradiation. The median initial radiation dose was 67 Gy, and the median reirradiation SRS dose was 30 Gy (21-35 Gy) in 2-5 fractions. RESULTS Median follow-up for surviving patients was 16 months. Fifty-six patients were evaluable for response: 30 (54%) had complete, 15 (27%) had partial, and 11 (20%) had no response. Median overall survival (OS) for all patients was 12 months. For definitively treated patients, the 2-year OS and locoregional control (LRC) rates were 41% and 30%, respectively. Multivariate analysis demonstrated that higher total dose, surgical resection, and nasopharynx site were significantly associated with improved LRC; surgical resection and nonsquamous histology were associated with improved OS. Seven patients (11%) experienced severe reirradiation-related toxicity, including one treatment-attributed death. CONCLUSION SRS reirradiation for head-and-neck cancer is feasible. This study demonstrates encouraging response rates with acceptable toxicity. Fractionated SRS reirradiation with concurrent chemotherapy in select patients warrants further study.
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Truong MT, Grillone G, Tschoe C, Chin L, Kachnic LA, Jalisi S. Emerging applications of stereotactic radiotherapy in head and neck cancer. Neurosurg Focus 2009; 27:E11. [DOI: 10.3171/2009.9.focus09199] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Advances in the management of locally advanced head and neck cancer (HNC) have been focused on treatment intensification, including concomitant chemoradiotherapy, biological agents, and combining surgery with chemoradiotherapy. Despite these improvements, locoregional recurrence still constitutes the main pattern of treatment failure. As improvements in radiotherapy delivery and image-guided therapy have come to fruition, the principles of stereotactic radiosurgery are now being applied to extracranial sites, leading to stereotactic body radiotherapy. This article focuses on the emerging evidence for the use of stereotactic body radiotherapy for treatment of HNC as a boost after conventional external-beam radiotherapy, and also as reirradiation in recurrent or second primary HNC.
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Affiliation(s)
| | | | - Christine Tschoe
- 3Neurosurgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Lawrence Chin
- 3Neurosurgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | | | - Scharukh Jalisi
- 2Otolaryngology, and
- 3Neurosurgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
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Heron DE. Stereotactic body radiation therapy for recurrent head & neck cancers: rethinking nonoperative salvage strategies. Future Oncol 2009; 5:1321-5. [DOI: 10.2217/fon.09.107] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Affiliation(s)
- Dwight E Heron
- Associate Professor & Vice Chairman Director of Radiation Services, Department of Radiation Oncology, University of Pittsburgh Cancer Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA 15232, USA
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Watkins JM, Shirai KS, Wahlquist AE, Stuart RK, Chaudhary UB, Garrett-Mayer E, Day TA, Gillespie MB, Sharma AK. Toxicity and survival outcomes of hyperfractionated split-course reirradiation and daily concurrent chemotherapy in locoregionally recurrent, previously irradiated head and neck cancers. Head Neck 2009; 31:493-502. [PMID: 19156831 DOI: 10.1002/hed.20986] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND : Reirradiation of locoregionally recurrent, previously irradiated head/neck cancer may be considered in situations of unresectability, medical inoperability, or adverse pathologic features found at salvage resection. METHODS : Retrospective cohort analysis of toxicity and survival outcomes in locoregionally recurrent, previously irradiated patients with head/neck cancer treated with hyperfractionated split-course radiotherapy and concurrent chemotherapy. RESULTS : Between March 1998 and September 2006, 39 patients initiated reirradiation at median of 2.3 years (range, 0.5-19) following prior radiotherapy. At median survivor follow-up of 24.5 months (range, 3-63.9), 10 patients are alive without evidence of disease. Median survival is 19.0 months, with estimated 1-, 2-, and 3-year overall survivals of 60.1%, 45.1%, and 22.7%, respectively. Locoregional failure was the predominant site of postreirradiation recurrence. Male sex, total radiotherapy dose, cycles of chemotherapy completed, and clinical response were associated with improved overall survival. CONCLUSIONS : Reirradiation can offer long-term survival for patients with recurrent, previously irradiated head/neck cancers.
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Affiliation(s)
- John M Watkins
- Department of Radiation Oncology, Medical University of South Carolina, Charleston, South Carolina, USA.
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Langer CJ, Duffy K, Horwitz EM, Litwin S, Rosvold E, Schol J, Keenan E, Nicolaou N, Friedman CD, Ridge JA. Phase I Trial of Concurrent Hyperfractionated Split Course Radiotherapy (HFx RT), Cisplatin (cDDP), and Paclitaxel in Patients with Recurrent, Previously Irradiated, or Treatment-Naïve Locally Advanced Upper Aerodigestive Malignancy. Cancer Invest 2009; 24:164-73. [PMID: 16537186 DOI: 10.1080/07357900500524421] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE Phase I study to determine the maximally tolerated dose (MTD) of cisplatin (cDDP), paclitaxel (P), and concurrent split course hyperfractionated (BID) RT in advanced squamous cell carcinoma of the head and neck (SCCHN) and other upper aerodigestive tumors. MATERIALS AND METHODS Eligibility stipulated ECOG performance status 0-2 and either Tx-naïve, locally advanced, or locally recurrent, previously radiated, surgically unresectable upper aerodigestive cancer. Metastases were permitted if disease was predominantly locoregional. RT-naïve patients received 150 cGy bid x 5 d Q 2 wks x 4. Previously radiated patients received 150 cGy bid x 5, wk 1; then 120 cGy bid x 5 Q 2 wk x 3 (later increased to 150 cGy BID for the entire treatment). Treatment fields included recurrent tumor only with 2 cm margins. Whenever possible, conventional and 3-D conformal techniques were used. Elective nodal radiation was not administered. Starting doses of cDDP and P were 12 mg/m2/d x 5 and 15 mg/m2/d x 5, respectively, Q 2 wk x 4, each given on RT days only. At dose level 2, cDDP was increased to 15 mg/m2/d x 5. At dose level 3, P was increased to 20 mg/m2/d x 5. Granulocyte colony stimulating factor (G-CSF) days 6-12 (off treatment week) was added if cumulative neutropenia precipitated treatment delays. RESULTS Thirty-one patients (21 men, 10 women) were treated. Eight had received prior chemotherapy, 27 prior RT. At dose level three, regular treatment delays of >or=1 week due to slow neutrophil recovery occurred. Addition of G-CSF (dose level 3b) reduced treatment delays from 100 percent to 28 percent and decreased the incidence of Grade >or=2 neutropenia and mucositis. Six of 7 patients at this dose level completed all 4 cycles of treatment and all received full dose RT (60 Gy). No other dose-limiting toxicities occurred. Of 22 assessable patients with locally recurrent SCCHN, 12 (55 percent) responded. Median time to progression in this group was 6 months, with median and one-year survival of 9.5 mos and 41 percent, respectively. CONCLUSION Concurrent daily cisplatin/paclitaxel and split course hyperfractionated RT (60 Gy) is feasible in previously radiated patients. G-CSF, administered between each cycle, reduces the incidence of treatment delays. Activity is promising and toxicity acceptable.
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Affiliation(s)
- Corey J Langer
- Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania 19111, USA.
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Heron DE, Ferris RL, Karamouzis M, Andrade RS, Deeb EL, Burton S, Gooding WE, Branstetter BF, Mountz JM, Johnson JT, Argiris A, Grandis JR, Lai SY. Stereotactic body radiotherapy for recurrent squamous cell carcinoma of the head and neck: results of a phase I dose-escalation trial. Int J Radiat Oncol Biol Phys 2009; 75:1493-500. [PMID: 19464819 DOI: 10.1016/j.ijrobp.2008.12.075] [Citation(s) in RCA: 140] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2008] [Revised: 12/09/2008] [Accepted: 12/24/2008] [Indexed: 11/28/2022]
Abstract
PURPOSE To evaluate the safety and efficacy of stereotactic body radiotherapy (SBRT) in previously irradiated patients with squamous cell carcinoma of the head and neck (SCCHN). PATIENTS AND METHODS In this Phase I dose-escalation clinical trial, 25 patients were treated in five dose tiers up to 44 Gy, administered in 5 fractions over a 2-week course. Response was assessed according to the Response Evaluation Criteria in Solid Tumors and [(18)F]-fluorodeoxyglucose standardized uptake value change on positron emission tomography-computed tomography (PET-CT). RESULTS No Grade 3/4 or dose-limiting toxicities occurred. Four patients had Grade 1/2 acute toxicities. Four objective responses were observed, for a response rate of 17% (95% confidence interval 2%-33%). The maximum duration of response was 4 months. Twelve patients had stable disease. Median time to disease progression was 4 months, and median overall survival was 6 months. Self-reported quality of life was not significantly affected by treatment. Fluorodeoxyglucose PET was a more sensitive early-measure response to treatment than CT volume changes. CONCLUSION Reirradiation up to 44 Gy using SBRT is well tolerated in the acute setting and warrants further evaluation in combination with conventional and targeted therapies.
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Affiliation(s)
- Dwight E Heron
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, PA 15232, USA.
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