Re-irradiation for recurrent and second primary cancers of the head and neck

Efficacy and safety of boron neutron capture therapy for Hypopharyngeal/Laryngeal cancer patients with previous head and neck irradiation

BACKGROUND AND PURPOSE

Patients with hypopharyngeal cancer (HPC)/laryngeal cancer (LCA) with a history of head and neck irradiation are often difficult to treat with conventional radiotherapy. This study aimed to clarify the efficacy and safety of boron neutron capture therapy (BNCT) for HPC/LCA.

MATERIALS AND METHODS

In this retrospective study, HPC/LCA with local lesions were analyzed, including both recurrent cases after treatment and second primary cases. The primary endpoints were tumor response and incidence of adverse events (AEs) after BNCT. The secondary endpoints were local control (LC), progression-free survival (PFS), and overall survival (OS). Evaluation of tumor response was terminated when any additional treatment was administered, and only survival data were collected.

RESULTS

The analysis included 25 and 11 cases of HPC and LCA, respectively. All had a history of head and neck irradiation, and median dose of prior radiotherapy was 70 Gy. The complete response (CR) rate was 72%, overall response rate was 84%, and the 1-year LC and PFS were 63.1% and 53.7%, respectively. The median survival time was 15.5 months, and the 2-year OS was 79.8%. Of the 27 patients with CR, 11 cases recurred at a median of 6.0 months. The acute G3 AEs were oral mucositis (6%), pharyngeal mucositis (3%), and soft tissue infection (3%). Acutely, there were no G4-5 AEs, except hyperamylasemia, and in the late phase, there were no G3 or higher AEs.

CONCLUSION

BNCT can be achieve good tumor response while preserving the larynx without severe AEs.

Reirradiation in head and neck squamous cell carcinoma; prognostic indicators, oncologic and functional outcomes

OBJECTIVES

Patients with recurrent squamous cell carcinoma of the head and neck (HNSCC) have a poor prognosis and limited therapeutic alternatives. While reirradiation is feasible, it is usually associated with high treatment toxicity and is not yet considered the standard of care. Based on current NCCN guidelines, in the context of very advanced head and neck cancer (recurrent and/or persistent disease), surgical intervention is explored initially with/without adjuvants while unresectable disease is approached with radiation and/or systemic therapies. Specific and reliable prognostic indicators for both -oncologic and functional outcomes- have yet to be defined for this population.

METHODS

Retrospective chart review of 54 patients treated with reirradiation at a tertiary academic institution between January of 1998 and January of 2024. Only patients with non-metastatic recurrent, and second primary HNSCC were included in the series. Demographics, staging, radiation dose and technique, additional therapy, histopathologic variables, EORTC toxicity, pre- and post-treatment PEG/tracheotomy dependency and oncologic outcomes were retrieved.

RESULTS

The study cohort consisted of 54 patients (37 males, 17 females) with HNSCC, averaging 62.7 years in age. Initial tumors were locally advanced in over 42 % of cases, with 58 % being node-negative. The head and cutaneous regions (24.5 %) and tongue (20.8 %) were the most common tumor sites. Primary surgical resection and adjuvant radiation were performed in 47.2 % of cases, and concurrent chemotherapy was used in 40.7 %. Reirradiation was mainly for local or regional recurrence (88.9 %), often following salvage surgery (68.5 %), with a mean dose of 5623 Gy over 52.5 fractions. Positive surgical margins were present in 29.4 % of cases, and extracapsular spread in 59.5 %. No significant differences were found between the salvage surgery and definitive reirradiation groups except for tumor site (P = 0.022). Median follow-up was 52.6 months, with 27 deaths reported. Lymphovascular invasion was significantly correlated with overall survival (P = 0.017), while initial tumor T-stage and neck disease involvement were linked to local-regional control (P = 0.030 and P = 0.033, respectively). Reirradiation increased tracheotomy and PEG-tube dependency by 20 % (P = 0.011) and 23 % (P = 0.003), respectively.

CONCLUSIONS

Reirradiation is a feasible therapeutic alternative in recurrent head and neck SCC. Oncologic outcomes observed in this series compare favorably to most published reports. Complete response and perineural invasion were independent prognostic factors for survival and locoregional control. While no mortality directly associated with treatment was observed in this series, reirradiation had a significant impact in functional outcomes in terms of increased risk of tracheotomy and peg tube dependency. Further studies are required to define the role of this treatment in head and neck cancer.

Posttreatment Surveillance Imaging After Radiation for Head and Neck Cancer

Importance

The role of surveillance imaging after treatment for head and neck cancer is controversial and evidence to support decision-making is limited.

Objective

To determine the use of surveillance imaging in asymptomatic patients with head and neck cancer in remission after completion of chemoradiation.

Design, Setting, and Participants

This was a retrospective, comparative effectiveness research review of adult patients who had achieved a complete metabolic response to initial treatment for head and neck cancer as defined by having an unequivocally negative positron emission tomography (PET) scan using the PET response criteria in solid tumors (PERCIST) scale within the first 6 months of completing therapy. The medical records of 501 consecutive patients who completed definitive radiation therapy (with or without chemotherapy) for newly diagnosed squamous cell carcinoma of the head and neck between January 2014 and June 2022 were reviewed.

Exposure

Surveillance imaging was defined as the acquisition of a PET with computed tomography (CT), magnetic resonance imaging (MRI), or CT of the head and neck region in the absence of any clinically suspicious symptoms and/or examination findings. For remaining patients, subsequent surveillance after the achievement of a complete metabolic response to initial therapy was performed on an observational basis in the setting of routine follow-up using history-taking and physical examination, including endoscopy. This expectant approach led to imaging only in the presence of clinically suspicious symptoms and/or physical examination findings.

Main Outcome and Measures

Local-regional control, overall survival, and progression-free survival based on assignment to either the surveillance imaging or expectant management cohort.

Results

This study included 340 patients (mean [SD] age, 59 [10] years; 201 males [59%]; 88 Latino patients [26%]; 145 White patients [43%]) who achieved a complete metabolic response during this period. There was no difference in 3-year local-regional control, overall survival, progression-free survival, or freedom from distant metastasis between patients treated with surveillance imaging vs those treated expectantly.

Conclusions and Relevance

In this comparative effectiveness research, imaging-based surveillance failed to improve outcomes compared with expectant management for patients who were seemingly in remission after completion of primary radiation therapy for head and neck cancer.

Dosimetric and clinical aspects of head and neck cancer reirradiation with intensity modulated radiotherapy techniques over the last decade

PURPOSE

Tumor recurrence in head and neck cancer (HNC) is very common, given that locoregional disease relapse occurs in up to 50% of patients. The clinical approach towards cancer recurrence is either by surgery and/or chemo-radiotherapy. Irrespective of the treatment, the management of HNC recurrence is highly challenging and often administered with palliative intent only. The aim of this work was to analyze clinical and dosimetric aspects, such as dose prescription, organ at risk sparing, overall survival and locoregional control of HNC after reirradiation with intensity modulated radiotherapy techniques based on studies published over the last decade, due to the wide clinical implementation of the intensity modulated radiotherapy and particularly of volumetric modulated arc therapy (VMAT) for this malignancy.

METHODS

A systematic search of the literature was conducted within Pub-med/Medline databases to find relevant studies. Of the 130 articles fulfilling the initial search criteria, 15 were selected for final analysis that encompassed all set requirements.

RESULTS

Clinical studies revealed the multitude of factors influencing treatment outcome, including anatomical location, histological tumor type, patient-related factors (smoking / comorbidities), cumulative dose and fractionation schedule, reirradiated volume and time between the irradiation of primary and recurrent tumor.

CONCLUSIONS

Since the literature reports no specific data related to the type of intensity modulation used in reirradiation or any correlation with treatment outcome, IMRT and VMAT might offer comparable result after HNC reirradiation. Patient selection is potentially the main factor leading to an efficient outcome.

Re-irradiation for head and neck cancer: outcome and toxicity analysis using a prospective single institution database

Purpose

Re-irradiation (re-RT) in head and neck cancer is challenging. This study prospectively explored the feasibility of re-RT in patients with loco-regionally recurrent or second primary head and neck cancer (LRR/SP HNC).

Methods

From 2004 to 2021, 61 LRR/SP HNC patients were treated with re-RT, defined as having a second course of RT with curative intent resulting in a cumulative dose of ≥100 Gy in an overlapping volume. Postoperative or definitive dynamic intensity-modulated and/or volumetric modulated re-RT was administered using twice daily hyperfractionation to 60 Gy combined with cisplatin or carboplatin/5-fluorouracil. Overall survival (OS), progression-free survival (PFS), locoregional control (LRC) and distant metastasis control (DMC) were analyzed and prognostic factors evaluated. Toxicity was prospectively recorded and graded.

Results

The median follow-up was 9.8 months. In 41 patients (67.1%), complete administration of the intended treatment was not feasible. In 9 patients (15%) re-RT was interrupted prematurely and in other 9, the complete re-RT dose was lower than 60 Gy, and 37 patients (61%) could not receive or complete chemotherapy. Two-year OS, PFS and LRC rates were 19%, 18% and 30%, respectively. 20 patients (33%) received the complete intended treatment, and 1- and 2-year OS rates were 70% and 47%, respectively. Charlson comorbidity index was an important predictor for treatment completion. Multivariate analysis revealed recurrent N stage 0-1, age, chemotherapy administration and re-RT dose of 60 Gy as prognostic factors for clinical outcomes. No grade 5 re-RT-related toxicity was observed. The most common new grade ≥3 acute toxicities were dysphagia (52%) and mucositis (46%). Late toxicity included grade ≥3 dysphagia in 5% and osteoradionecrosis in 10% of evaluable patients, respectively. 6 patients (10%) were alive after 9 years without progression and no late toxicity grade ≥3, except for 2 patients presenting with osteoradionecrosis.

Conclusion

Hyperfractionated re-RT with 60 Gy combined with platinum-based chemotherapy was a curative treatment option with acceptable toxicity in LRR/SP patients. Patients with higher comorbidity had a higher probability of failing to receive and complete the intended therapy. Consequently, they derived unsatisfactory benefits from re-RT, highlighting the importance of patient selection.

Tolerance limit of external beam radiotherapy combined with low-dose rate brachytherapy in normal rabbit tissue

BACKGROUND

Dosage-optimized multimodal radiotherapies that are safe for head and neck cancer patients are desirable. In this study, we investigated tissue tolerance to varying doses of external beam radiotherapy (EBRT) combined with low-dose rate brachytherapy in the neck of a rabbit model.

METHODS

Twenty rabbits were used in the four test groups (five each) with iodine-125 seeds implanted in the neck treated with EBRT in four doses at 50, 40, 30 and 20 Gy each. Twelve rabbits for three control groups (four each). Three months after implantation, all rabbits were euthanized, and target tissues were collected. Analyses included seed implantation assessment, histopathological evaluation, immunohistochemistry staining, terminal deoxynucleotidyl transferase dUTP nick end labeling assay, electron microscopy and statistics with the SPSS software.

RESULTS

Five rabbits died in the four test groups, and three rabbits died in the three control groups (one per group), which showed no significant difference by survival analysis. The calculated minimum peripheral dose was 17.6 Gy, the maximum dose near the seed was 1812.5 Gy, the D90 was 34.5 Gy and the mean dose was 124.5 Gy. In all groups that received radiation, apoptosis occurred primarily in the esophageal mucosa and corresponded to the dose of radiation; a higher dose caused a greater apoptosis, with significant difference between groups (P < 0.05). Electron microscopy of carotid arteries revealed that endothelial cells were swollen and some were shed from basement membrane, but no other noticeable tissue damages.

CONCLUSIONS

Limited EBRT at maximal dose (50 Gy) combined with the brachytherapy interstitially applied to the neck was tolerated well in the rabbit model.

Dose-escalated re-irradiation improves outcome in locally recurrent head and neck cancer - Results of a large multicenter analysis

To determine efficacy and prognostic parameters of definitive re-irradiation of locoregionally recurrent squamous cell carcinoma of the head and neck (HNSCC).

MATERIALS AND METHODS

Patients with locoregionally recurrent or second primary HNSCC undergoing re-irradiation with modern radiotherapy technique were eligible for this multicentric retrospective analysis. Main endpoints were overall survival (OS), progression-free survival (PFS) and locoregional control (LC). Univariate analyses were performed using the Kaplan Meier Method (log-rank). For multivariable analysis, Cox regression was used.

RESULTS

A total of 253 patients treated between 2009 and 2020 at 16 university hospitals in Germany were included. The median follow up was 27.4 months (range 0.5-130). The median OS and PFS were 13.2 (CI: 10.7 - 15.7) months and 7.9 (CI: 6.7 - 9.1) months, respectively, corresponding to two-year OS and PFS rates of 29 % and 19 %. Rates of locoregional progression and "in-field-failure" were 62 % and 51 % after two years. Multivariable Cox regression analysis identified good ECOG performance status and high radiation dose as independent prognostic parameters for OS. Doses above 50 Gy (EQD2) achieved longer median OS of 17.8 months (vs 11.7 months, p < 0.01) and longer PFS of 9.6 months (vs 6.8 months, p < 0.01). In addition, there was a trend for worse survival in patients with tracheostomy (multivariable, p = 0.061). Concomitant systemic therapy did not significantly impact PFS or OS.

CONCLUSION

Re-irradiation of locally recurrent or second primary HNSCC is efficient, especially if doses above 50 Gy (EQD2) are delivered. ECOG performance score was the strongest prognostic parameter for OS and PFS.

Current radiotherapy for recurrent head and neck cancer in the modern era: a state-of-the-art review

BACKGROUND

In the management of head and neck cancer (HNC) patients, local recurrence is a common cause of treatment failure. Only a few patients with recurrent HNC (rHNC) are eligible for salvage surgery and the majority of patients receive systemic therapy and radiotherapy. In recent years, with the development of irradiation technology, radiotherapy for rHNC patients has markedly attracted clinicians' attention and its therapeutic effects on patients with end-stage cancer are worthy of investigation as well.

METHODS

Several studies have investigated the role of radiotherapy in the treatment of rHNC patients. We reviewed retrospective reports and prospective trials published in recent decades that concentrated on the management of rHNC.

RESULTS

A growing body of evidence supported the application of irradiation to rHNC patients. According to the results of this review, current radiotherapy could achieve a better efficacy with a lower incidence of toxicity.

CONCLUSION

Radiotherapy is a promising treatment for rHNC patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Re-irradiation for recurrent or second primary head and neck cancer

Purpose

To investigate the efficacy and safety of intensity-modulated radiotherapy (IMRT)-based re-irradiation (reRT) for recurrent or second primary head and neck cancer (HNC).

Materials and Methods

Patients who underwent IMRT-based reRT for recurrent or second primary HNC between 2007 and 2019 at two institutions were included. Medical records and dosimetric data were retrospectively reviewed. Overall survival (OS), progression-free survival (PFS), severe late toxicities, and clinicopathological prognostic factors were analyzed.

Results

A total of 42 patients were analyzed. With a median follow-up of 15.1 months (range, 3.7 to 85.8 months), the median OS was 28.9 months with a 2-year OS rate of 54.6%. The median PFS and 2-year PFS rates were 10.0 months and 30.9%, respectively. Multivariate analysis showed that good performance (Eastern Cooperative Oncology Group [ECOG] 0 or 1), a longer time interval (≥24 months) between radiotherapy courses, and higher reRT dose (>60 Gy) were significantly favorable factors for OS (all p < 0.05). Higher reRT dose and salvage surgery were significantly associated with improved PFS (all p < 0.05). Regarding the Multi‐Institution Reirradiation (MIRI) Collaborative RPA classification, the 2-year OS rates of each class were 87.5% in class I, 51.8% in class II, and 0% in class III (p = 0.008). Grade ≥3 late toxicity was reported in 10 (23.8%) patients. There was no significant factor associated with increased late toxicities.

Conclusion

IMRT-based reRT should be considered as a treatment option for patients with recurrent or second primary HNC. Further trials are needed to establish a subset of patients who may benefit from reRT without severe late toxicity.

Intensity-Modulated Radiotherapy-Based Reirradiation for Head and Neck Cancer: A Multi-institutional Study by Korean Radiation Oncology Group (KROG 1707)

Purpose

The benefits of reirradiation for head and neck cancer (HNC) have not been determined. This study evaluated the efficacy of reirradiation using intensity-modulated radiotherapy (IMRT) for recurrent or second primary HNC (RSPHNC) and identified subgroups for whom reirradiation for RSPHNC is beneficial.

Materials and Methods

A total of 118 patients from seven Korean institutions with RSPHNC who underwent IMRT-based reirradiation between 2006 and 2015 were evaluated through retrospective review of medical records. We assessed overall survival (OS) and local control (LC) within the radiotherapy (RT) field following IMRT-based reirradiation. Additionally, the OS curve according to the recursive partitioning analysis (RPA) suggested by the Multi-Institution Reirradiation (MIRI) Collaborative was determined.

Results

At a median follow-up period of 18.5 months, OS at 2 years was 43.1%. In multivariate analysis, primary subsite, recurrent tumor size, interval between RT courses, and salvage surgery were associated with OS. With regard to the MIRI RPA model, the class I subgroup had a significantly higher OS than class II or III subgroups. LC at 2 years was 53.5%. Multivariate analyses revealed that both intervals between RT courses and salvage surgery were prognostic factors affecting LC. Grade 3 or more toxicity and grade 5 toxicity rates were 8.5% and 0.8%, respectively.

Conclusion

IMRT-based reirradiation was an effective therapeutic option for patients with RSPHNC, especially those with resectable tumors and a long interval between RT courses. Further, our patients' population validated the MIRI RPA classification by showing the difference of OS according to MIRI RPA class.

Reirradiation with intensity-modulated radiation therapy for recurrent or secondary head and neck cancer: Meta-analysis and systematic review

BACKGROUND

To summarize outcomes of reirradiation with intensity-modulated radiotherapy (IMRT) for recurrent or secondary head and neck cancer (HNC).

METHODS

Primary endpoints were 2-year local control (LC) and overall survival (OS). Studies involving only recurrent nasopharyngeal patients with cancer were excluded.

RESULTS

A total of 17 studies involving 1635 patients were included. Fourteen (82%) of those were retrospective, and 15 (88%) were from single institution. Reirradiation with IMRT produced pooled 2-year LC and OS rates of 52% (95% confidence interval [CI], 46%-57%) and 46% (95% CI, 41%-50%), respectively. In subgroup analyses, the rate of salvage surgery (<42% vs ≥42%) influenced the pooled 2-year LC rate (45.9% vs 58.5%, P = .011). The pooled rates of late grade ≥ 3 and grade 5 toxicities were 26% (95% CI, 20%-32%) and 3.1% (95% CI, 2%-5%), respectively.

CONCLUSIONS

Reirradiation with IMRT was an effective modality compared to historical outcomes in the pre-IMRT era.

Boron neutron capture therapy for locally recurrent head and neck squamous cell carcinoma: An analysis of dose response and survival

BACKGROUND AND PURPOSE

Head and neck squamous cell carcinoma (HNSCC) that recurs locally is a therapeutic challenge. We investigated the efficacy of boron neutron capture therapy (BNCT) in the treatment of such patients and the factors associated with treatment response and survival.

METHODS AND MATERIALS

Seventy-nine patients with inoperable, locally recurred HNSCC were treated with l-boronophenylalanine-mediated BNCT in Espoo, Finland, between February, 2003 and January, 2012. Prior treatments consisted of surgery and conventionally fractionated radiotherapy to a median cumulative dose of 66 Gy (interquartile range [IQR], 59-70 Gy) administered with or without concomitant chemotherapy. Tumor response was assessed using the RECISTv.1.0 criteria.

RESULTS

Forty patients received BNCT once (on 1 day), and 39 twice. The median time between the 2 treatments was 6 weeks. Forty-seven (68%; 95% confidence interval [CI], 57-79%) of the 69 evaluable patients responded; 25 (36%) had a complete response, 22 (32%) a partial response, 17 (25%) a stable disease lasting for a median of 4.2 months, and 5 (7%) progressed. The patients treated with BNCT twice responded more often than those treated once. The median follow-up time after BNCT was 7.8 years. The 2-year locoregional progression-free survival rate was 38% and the overall survival rate 21%. A high minimum tumor dose and a small volume were independently associated with long survival in a multivariable analysis.

CONCLUSIONS

Most patients responded to BNCT. A high minimum tumor dose from BNCT was predictive for response and survival.

Volume, Dose, and Fractionation Considerations for IMRT-based Reirradiation in Head and Neck Cancer: A Multi-institution Analysis

PURPOSE

Limited data exist to guide the treatment technique for reirradiation of recurrent or second primary squamous carcinoma of the head and neck. We performed a multi-institution retrospective cohort study to investigate the effect of the elective treatment volume, dose, and fractionation on outcomes and toxicity.

METHODS AND MATERIALS

Patients with recurrent or second primary squamous carcinoma originating in a previously irradiated field (≥40 Gy) who had undergone reirradiation with intensity modulated radiation therapy (IMRT); (≥40 Gy re-IMRT) were included. The effect of elective nodal treatment, dose, and fractionation on overall survival (OS), locoregional control, and acute and late toxicity were assessed. The Kaplan-Meier and Gray's competing risks methods were used for actuarial endpoints.

RESULTS

From 8 institutions, 505 patients were included in the present updated analysis. The elective neck was not treated in 56.4% of patients. The median dose of re-IMRT was 60 Gy (range 39.6-79.2). Hyperfractionation was used in 20.2%. Systemic therapy was integrated for 77.4% of patients. Elective nodal radiation therapy did not appear to decrease the risk of locoregional failure (LRF) or improve the OS rate. Doses of ≥66 Gy were associated with improvements in both LRF and OS in the definitive re-IMRT setting. However, dose did not obviously affect LRF or OS in the postoperative re-IMRT setting. Hyperfractionation was not associated with improved LRF or OS. The rate of acute grade ≥3 toxicity was 22.1% overall. On multivariable logistic regression, elective neck irradiation was associated with increased acute toxicity in the postoperative setting. The rate of overall late grade ≥3 toxicity was 16.7%, with patients treated postoperatively with hyperfractionation experiencing the highest rates.

CONCLUSIONS

Doses of ≥66 Gy might be associated with improved outcomes in high-performance patients undergoing definitive re-IMRT. Postoperatively, doses of 50 to 66 Gy appear adequate after removal of gross disease. Hyperfractionation and elective neck irradiation were not associated with an obvious benefit and might increase toxicity.