Prospective evaluation of patient-reported quality-of-life outcomes following SBRT ± cetuximab for locally-recurrent, previously-irradiated head and neck cancer

Proton therapy re-irradiation outcomes and genomic landscape of patients with recurrent head and neck cancer

INTRODUCTION

Re-irradiation (re-RT) for recurrent head and neck cancer (rHNC) is challenging. We describe clinical outcomes and toxicity of proton therapy (PT) for recurrent HNC, and report genomic alterations associated with patterns of failure.

MATERIALS & METHODS

We performed a retrospective analysis of rHNC patients treated with PT. Outcomes were estimated using the Kaplan-Meier method. Univariate (UVA) and multivariate analyses (MVA) were performed to assess multiple patient factors. Next-generation sequencing and genomic analyses were performed on available samples.

RESULTS

Eighty-nine patients treated with PBS-PT for rHNC with a median follow-up of 12 mo (0-71 mo) were included. The 1- and 2-y local control (LC) rates were 80.8 % (95 % CI: 70.8-90.8) and 66.2 % (95 % CI: 50.7-81.7), and 1- and 2-y distant metastasis-free survival (DMFS) were 41.0 % (95 % CI: 30.0-52.0) and 26.3 % (95 % CI: 15.7-36.9). The median overall survival (OS) was 13 mo (95 % CI: 9.3-16.7). On UVA and MVA, smaller gross tumor volume (GTV) was associated with improved OS (HR 1.002, P = 0.004), DMFS (HR 1.002, P = 0.004), and PFS (HR 1.002, P = 0.014). There were 35 late Gr3 + toxicity events (30.3 %). Patients with higher candidate gene-specific mutation burden (genes with [OR] > 2, P < 0.05) had inferior PFS. TP53, NOTCH4, and ARID1B mutations were associated with inferior DMFS (OR > 2, P < 0.05).

CONCLUSIONS

PBS-PT is effective at achieving LC for rHNC with favorable toxicity. Distant metastases are common, and associated with TP53, NOTCH4, and ARID1B mutations. Inclusion of genomic alterations in the clinical decision process may be warranted.

Stereotactic ablative radiotherapy for treating primary head and neck cancer and locoregional recurrence: A comprehensive review of the literature

Introduction

Although stereotactic ablative radiotherapy (SABR) has advance to standard-of-care for many different indications like lung and liver malignancies, it still remains in its infancy for treating head and neck cancer. Nevertheless there is a growing body of experience and evidence, which is summarized in this review Methods A thorough search of the literature was performed and critically reviewed both for SABR as a primary treatment as well as for treating locoregionally recurrent disease in a pre-irradiated field.

Results

There exist only few prospective data published so far for treating head and neck cancer with SABR. In the primary situation especially implementing SABR as a boost after definitive radiotherapy or a single-modality for locally limited, small glottic cancer appear promising. On the other hand, SABR can be a useful modality for treating local recurrence in a pre-irradiated field. However, caution is needed in the case of proximity to a pre-irradiated carotid artery or other serial organs at risk. Usually only limited gross volumes are treated with 3-6 fractions every other day and a cumulative dose of 24-44 Gy in dedicated radiosurgery platforms or modern linacs with the possibility of online image-guidance and adequate immobilsation.

Conclusions

SABR is an innovative, effective and promising treatment modality for small targets, especially in near proximity to organs at risk or in a pre-irradiated region. Prospective trials are further needed for this technique to become standard-of care.

Advancements of radiotherapy for recurrent head and neck cancer in modern era

Head and neck cancer is a kind of cancer which can be eradicated from radical radiation therapy. However, with best efforts, nearly 40% patients will experience locoregional recurrence. Locoregional recurrence is the main cause of cancer-related death in head and neck cancers, so local treatments play a key role in improving progression free survival. In the last decades, radiation techniques have been tremendously developed, highly conformal radiation techniques such as intensity-modulated radiotherapy, stereotactic body radiation therapy, brachytherapy and proton or heavy ion radiation therapy have their unique radiobiological advances. Although reirradiation is widely used in clinical practice, but little is known when comparing the different techniques. In this review, we will provide a comprehensive overview of the role of reirradiation in recurrent head and neck cancers including radiation techniques, patient selection, overall clinical benefits, and toxicities.

Recurrent/Metastatic Squamous Cell Carcinoma of the Head and Neck: A Big and Intriguing Challenge Which May Be Resolved by Integrated Treatments Combining Locoregional and Systemic Therapies

Squamous cell carcinoma of the head and neck (SCCHN) is a complex group of malignancies, posing several challenges to treating physicians. Most patients are diagnosed with a locally advanced disease and treated with strategies integrating surgery, chemotherapy, and radiotherapy. About 50% of these patients will experience a recurrence of disease. Recurrent/metastatic SCCHN have poor prognosis with a median survival of about 12 months despite treatments. In the last years, the strategy to manage recurrent/metastatic SCCHN has profoundly evolved. Salvage treatments (surgery or re-irradiation) are commonly employed in patients suffering from locoregional recurrences and their role has gained more and more importance in the last years. Re-irradiation, using some particularly fractionating schedules, has the dual task of reducing the tumor mass and eliciting an immune response against cancer (abscopal effect). In this review, we will analyze the main systemic and/or locoregional strategies aimed at facing the recurrent/metastatic disease, underlining the enormous importance of the multidisciplinary approach in these types of patients.

Fever range whole body hyperthermia for re-irradiation of head and neck squamous cell carcinomas: Final results of a prospective study

OBJECTIVES

Fever-range whole body hyperthermia (FRWBH) has been shown to improve tumor oxygenation in vivo. A prospective pilot study addressed the question if addition of FRWBH to re-irradiation is feasible in recurrent head and neck squamous cell carcinomas (HNSCC) with unfavorable prognostic features.

MATERIALS AND METHODS

The study completed accrual with the recruitment of ten patients between April 2018 and March 2020. Re-irradiation was administered using volumetric arc hyperfractionated radiotherapy with bi-daily 1.2 Gray (Gy) single fractions and a total dose of 66 Gy to all macroscopic tumor lesions. Concomitant chemotherapy consisted mostly of cisplatin (7 patients). FRWBH was scheduled weekly during re-irradiation. The study was registered in the clinicaltrials.gov database (NCT03547388).

RESULTS

Only five patients received all cycles of FRWBH. Poor patient compliance, active infections during treatment and study restrictions due to the Covid-19 pandemic were the main reasons for omitting FRWBH. No increase of acute toxicity was observed by FRWBH. Exploratory evaluation of outcome data suggests that FRWBH treatment according to protocol does not seem to have a detrimental effect on tumor control or survival and might even increase treatment efficacy.

CONCLUSION

FRWBH is difficult to apply concomitant to re-irradiation in HNSCC. No excess toxicity was observed in patients receiving FRWBH and exploratory analyses suggest potential anti-tumor activity and decreased patient-reported depression scores after FRWBH.

The value of moderate dose escalation for re-irradiation of recurrent or second primary head-and-neck cancer

Background

Treatment for local and locoregional recurrence or second head-and-neck (H&N) cancers after previous radiotherapy is challenging, and re-irradiation carries a significantly increased risk for radiotherapy-related normal tissue toxicities and treatment failure due to a radioresistant tumor phenotype. Here, we analyzed re-irradiation management and outcomes in patients with recurrent or second primary H&N carcinoma using state-of-the-art diagnostic procedures and radiotherapy techniques.

Methods

Between 2010 and 2019, 48 patients with recurrent or second primary H&N carcinoma received re-radiotherapy at the University of Freiburg Medical Center and were included in this study. Overall survival (OS) and progression-free survival (PFS) were calculated with the Kaplan-Meier method, and univariate Cox-regression analyses were performed to assess the effects of clinico-pathological factors on treatment outcomes. Acute and chronic treatment-related toxicities were quantified using the Common Terminology Criteria for Adverse Events (CTCAE v4.03).

Results

Thirty-one patients (64.6%) received definitive and 17 (35.4%) adjuvant radiotherapy. Simultaneous chemotherapy was administered in 28 patients (58.3%) with cetuximab as the most commonly used systemic agent (n = 17, 60.7%). After a median time of 17 months (range 4 months to 176 months) between first and second radiotherapy, patients were re-irradiated with a median of 58.4 Gy and a treatment completion rate of 87.5% (n = 42). Median OS was 25 months with a 1-year OS amounting to 62.4%, and median PFS was 9 months with a 1-year PFS of 37.6%. Univariate analyses demonstrated that both a lower rT-status and a radiotherapy boost were associated with improved OS (p < 0.05). There was a trend towards superior OS for patients who received > 50 Gy (p = 0.091) and who completed the prescribed radiotherapy (p = 0.055). Five patients (10.4%) suffered from at least one grade 3 toxicities, while 9 patients (27.3%) experienced chronic higher-grade toxicities (≥ grade 3) with one (3.0%) grade 4 carotid blowout and one (3.0%) grade 4 osteoradionecrosis.

Conclusion

Re-irradiation of recurrent or second primary H&N cancer with modern radiation techniques such as intensity-modulated radiotherapy resulted in promising survival rates with acceptable toxicities compared to historical cohorts. Increased re-irradiation doses, utilization of a radiotherapy boost and completion of the re-irradiation treatment were found to result in improved survival.

Per-oral interstitial brachytherapy catheter insertion for boost in case of recurrent tonsillar carcinoma: dosimetry and clinical outcome

High-dose-rate interstitial brachytherapy (HDR-ISBT) is relatively rarely applied for the head and neck cancer. However, its dose distribution is more confined than intensity modulated radiation therapy (IMRT) and can deliver higher dose while sparing surrounding normal tissues. In this case report, the effectiveness of HDR-ISBT as a boost following IMRT for post-operative recurrent oropharyngeal cancer patient was indicated. A 73-year-old male who developed local recurrence after surgery for oropharyngeal squamous cell carcinoma. Salvage IMRT up to 70 Gy concurrent with weekly cetuximab was planned. However, CT taken at 60 Gy found a residual tumor, then, boost HDR-ISBT was proposed. 1 week after 60 Gy of IMRT, HDR-ISBT, 12 Gy in 2 fractions, was delivered under local anesthesia. MRI taken 2 months after HDR-ISBT showed no residual tumor. It was demonstrated that boost HDR-ISBT following IMRT for local recurrence of oropharyngeal cancer was performed safely and showed favorable efficacy.

Long-Term Patient-Reported Quality of Life After Stereotactic Body Radiation Therapy for Recurrent, Previously-Irradiated Head and Neck Cancer

Objectives: Long-term quality-of-life data following stereotactic body radiation therapy (SBRT) for recurrent head and neck cancer (rHNC) is underreported. We report patient-reported quality-of-life (PR-QOL) after at least 1 year post-treatment. Methods and Materials: A retrospective review was performed on 64 patients receiving SBRT for previously-irradiated rHNC. PR-QOL was prospectively evaluated using the University of Washington Quality of Life Questionnaire. The mixed effects proportional odds model was used to assess post-treatment overall PR-QOL changes, as well as the effects of late toxicities, tumor volume > 25 cc, local failure, nodal recurrence, distant failure, prior neck dissection, performance status other than ECOG 0 or Karnofsky 100, sex, age >65, squamous vs. non-squamous primary histology, and specific organ recurrence. Results: SBRT had no significant effect on overall PR-QOL at days 1-90 post-treatment (SBRT effect 0.035, p = 0.93) and days 91-365 (SBRT effect -0.30, p = 0.45). Beyond day 365, overall PR-QOL was significantly worse than baseline (SBRT effect -0.77, p =.03). Grade ≥3 late toxicities (p = 0.0072) and tumor volume > 25 cc (p = 0.032) predicted significantly worse overall PR-QOL. Oral cavity recurrence predicted significant decrements in chewing (p = 0.0006), swallowing (p = 0.0301), and taste PR-QOL (p = 0.02). Nasal recurrence predicted significant decrements in taste PR-QOL (p = 0.030). Grade ≥3 late dysphagia predicted significant decline in chewing (p = 0.039) and swallowing (p = 0.0004). Grade ≥3 late osteonecrosis predicted significant differences in pain PR-QOL (p = 0.0026). Conclusion: PR-QOL across several domains declines immediately after SBRT for previously-irradiated rHNC before returning to baseline levels at 1 year. Long-term PR-QOL declines thereafter. Patients with grade ≥3 late toxicities or tumor volume >25 cc report reduced long-term overall PR-QOL, likely representing late disease progression. Specific organ recurrence and grade ≥3 late toxicities predict decrements in specific PR-QOL domains.

Final results of a multi-institutional phase II trial of reirradiation with concurrent weekly cisplatin and cetuximab for recurrent or second primary squamous cell carcinoma of the head and neck

Background

The optimal regimen of chemotherapy and reirradiation (re-XRT) for recurrent head and neck squamous cell carcinoma (HNSCC) is controversial. We report the final outcomes of a multicenter phase II trial evaluating cetuximab and cisplatin-based chemotherapy concurrent with re-XRT for patients with recurrent HNSCC.

Materials and methods

Patients with unresectable recurrent disease or positive margins after salvage surgery arising within a previously irradiated field with KPS ≥ 70 were eligible for this trial. Cetuximab 400 mg/m2 was delivered as a loading dose in week 1 followed by weekly cetuximab 250 mg/m2 and cisplatin 30 mg/m2 concurrent with 6 weeks of intensity-modulated radiotherapy to a dose of 60-66 Gy in 30 daily fractions. Patients who previously received both concurrent cetuximab and cisplatin with radiation or who received radiotherapy less than 6 months prior were ineligible.

Results

From 2009 to 2013, 48 patients enrolled on this trial, 2 did not receive any protocol treatment. Of the remaining 46 patients, 34 were male and 12 female, with a median age of 62 years (range 36-85). Treatment was feasible and only 1 patient did not complete the treatment course. Common grade 3 or higher acute toxicities were lymphopenia (46%), pain (22%), dysphagia (13%), radiation dermatitis (13%), mucositis (11%) and anorexia (11%). There were no grade 5 acute toxicities. Eight grade 3 late toxicities were observed, four of which were swallowing related. With a median follow-up of 1.38 years, the 1-year overall survival (OS) was 60.4% and 1-year recurrence-free survival was 34.1%. On univariate analysis, OS was significantly improved with young age (P = 0.01). OS was not associated with radiation dose, surgery before re-XRT or interval from prior XRT.

Conclusions

Concurrent cisplatin and cetuximab with re-XRT is feasible and offers good treatment outcomes for patients with high-risk features. Younger patients had significantly improved OS.

ClinicalTrials.Gov Identifier

NCT00833261.

Salvage Stereotactic Body Radiation Therapy for Locally Recurrent Previously Irradiated Head and Neck Squamous Cell Carcinoma: An Analysis from the RSSearch® Registry

Objectives

To report on overall survival (OS), local control (LC), dose-outcome relationships, and related toxicities following stereotactic body radiation therapy (SBRT) for locally recurrent, previously irradiated squamous cell carcinoma of the head and neck (rSCCHN).

Methods

We queried the prospectively-maintained RSSearch® Registry for patients with rSCCHN treated with five-fraction SBRT from January 2008 to November 2016. Patients with non-squamous cell histology, missing registry data regarding prior irradiation, those treated with less than five fractions of SBRT, and those treated with SBRT in primary or boost settings were excluded. LC and OS were estimated using the Kaplan-Meier method with comparisons between groups completed using log-rank t-tests and multivariable Cox regression. Logistic regression analyses were used to examine factors predictive of toxicity.

Results

Forty-five rSCCHN patients treated with SBRT delivered in five fractions at 12 radiotherapy centers were identified. Prescription doses ≥ 40 Gy were associated with higher one-year rates of OS, LC, and a higher likelihood of experiencing toxicities. Acute and late toxicity rates were low (22.2% and 15.6%, respectively) and were all Grade 1-2 with only one late Grade 3 esophagitis.

Conclusion

Salvage SBRT for rSCCHN resulted in outcomes comparable to prior single-institutional reports in a multi-institutional cohort across clinical settings with low toxicity, thus supporting more widespread adoption of SBRT with recommended doses ≥ 40 Gy.

A Multi-institutional Comparison of SBRT and IMRT for Definitive Reirradiation of Recurrent or Second Primary Head and Neck Cancer

PURPOSE

Two modern methods of reirradiation, intensity modulated radiation therapy (IMRT) and stereotactic body radiation therapy (SBRT), are established for patients with recurrent or second primary squamous cell carcinoma of the head and neck (rSCCHN). We performed a retrospective multi-institutional analysis to compare methods.

METHODS AND MATERIALS

Data from patients with unresectable rSCCHN previously irradiated to ≥40 Gy who underwent reirradiation with IMRT or SBRT were collected from 8 institutions. First, the prognostic value of our IMRT-based recursive partitioning analysis (RPA) separating those patients with unresectable tumors with an intertreatment interval >2 years or those with ≤2 years and without feeding tube or tracheostomy dependence (class II) from other patients with unresected tumors (class III) was investigated among SBRT patients. Overall survival (OS) and locoregional failure were then compared between IMRT and SBRT by use of 2 methods to control for baseline differences: Cox regression weighted by the inverse probability of treatment and subset analysis by RPA classification.

RESULTS

The study included 414 patients with unresectable rSCCHN: 217 with IMRT and 197 with SBRT. The unadjusted 2-year OS rate was 35.4% for IMRT and 16.3% for SBRT (P<.01). Among SBRT patients, RPA classification retained an independent association with OS. On Cox regression weighted by the inverse probability of treatment, no significant differences in OS or locoregional failure between IMRT and SBRT were demonstrated. Analysis by RPA class showed similar OS between IMRT and SBRT for class III patients. In all class II patients, IMRT was associated with improved OS (P<.001). Further subset analysis demonstrated comparable OS when ≥35 Gy was delivered with SBRT to small tumor volumes. Acute grade ≥4 toxicity was greater in the IMRT group than in the SBRT group (5.1% vs 0.5%, P<.01), with no significant difference in late toxicity.

CONCLUSIONS

Reirradiation both with SBRT and with IMRT appear relatively safe with favorable toxicity compared with historical studies. Outcomes vary by RPA class, which informs clinical trial design. Survival is poor in class III patients, and alternative strategies are needed.

Stereotactic Body Radiotherapy Treatment for Recurrent, Previously Irradiated Head and Neck Cancer

Purpose:

Locally recurrent, previously irradiated primary head and neck tumors have historically been associated with poor outcomes. Stereotactic body radiation therapy has emerged as a feasible and promising treatment option for tumor recurrence, particularly in nonsurgical candidates. This study aimed to assess the associated outcomes of stereotactic body radiation therapy used in this setting.

Methods:

Retrospective analysis of a prospectively collected database of 25 patients treated with CyberKnife for unresectable, recurrent head and neck cancer in a previously irradiated field. The primary end points evaluated were rates of survival, tumor control, and treatment-related toxicities.

Results:

Median survival of the study population was 7.5 months (range, 1.5-47.0 months). Median survival of the 20 (80%) patients who were treated with curative purpose was 8.3 months. One-year overall survival rate for the entire population was 32%. The respective 1-year and 2-year survival rates for the curative subcohort were 40% and 20%, respectively. Local and locoregional failure occurred in 8 (32%) and 7 (28%) patients, respectively. Low severe acute (4%) and late (6%) treatment-related toxicity rates were observed. No grade 4 or 5 toxicities were observed.

Conclusion:

Stereotactic body radiation therapy is a viable treatment option for patients with unresectable, recurrent head and neck cancer. Significant tumor control rates are achievable with minimal severe toxicity. Although perhaps associated with patient selection and a heterogeneous sample, overall survival of stereotactic body radiation therapy outcomes appears unfavorable.

Stereotactic Body Radiation Therapy for Recurrent Head and Neck Cancer

Stereotactic body radiation therapy (SBRT) offers a promising opportunity for cure and/or palliation to patients with recurrent head and neck cancer whose comorbidities, performance status, and history of prior treatment may preclude many other salvage options. Stereotactic body radiation therapy appears to have a favorable response and toxicity profile compared with other nonoperative salvage options for recurrent head and neck cancer. However, the risk of severe toxicity remains, with carotid blowout syndrome a unique concern, although the incidence of this complication may be minimized with alternating-day fractionation. The short overall treatment time and low rates of acute toxicity make SBRT an optimal vehicle to integrate with novel systemic therapies, and several phase II studies have used concurrent cetuximab as a radiosensitizer with SBRT with promising results. Ongoing studies aim to evaluate the potential synergistic effect of SBRT with immune checkpoint inhibitors in recurrent head and neck cancer.

Reirradiation of head and neck cancer in the era of intensity-modulated radiotherapy: patient selection, practical aspects, and current evidence

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.

Advanced Squamous Cell Carcinoma of the Head and Neck: The Current Role of Cetuximab

We review clinical trials of squamous cell carcinoma of the head and neck (SCCHN) to address the current and potential uses of cetuximab (CTX). PubMed was reviewed to identify papers published between 2010 and 2016. The search terms used were "cetuximab" and "head and neck cancer." A total of 634 articles were identified. Phase II or III studies with CTX in patients with advanced SCCHN without treatment or with recurrent/metastatic tumors were selected. Forty-six registries were obtained. Information was critically reviewed and relevant information presented. As definitive treatment of advanced squamous cells carcinomas and as palliative treatment of recurrent/metastatic disease, CTX alone or associated with chemotherapy and/or radiotherapy is an alternative to chemoradiotherapy because of its distinct and favorable toxicity profile.

Locoregional Recurrent or Second Primary Head and Neck Cancer: Management Strategies and Challenges

Treatment of patients with locoregional recurrent or second primary head and neck squamous cell cancer (HNSCC) has been guided by well-reasoned principles and informed by carefully tested chemotherapy and radiation regimens. However, clinical decision making for this population is complicated by many factors. Although surgery is generally considered the treatment of choice for patients with HNSCC with recurrent disease or new second primary disease in a previously irradiated field, operability of cases is not always straightforward. Postoperative treatment is frequently warranted but carries significant risk. In addition, the rapid rise in the incidence of HPV-associated HNSCC raises the question of whether established treatment paradigms should be re-examined in this population of patients with a much better prognosis than the non-HPV population. Furthermore, new radiation techniques and new systemic agents show early promising results in recent clinical studies, suggesting potential for practice-changing effects in the future management of this disease. This article examines each of the treatment modalities used in the care of patients with HNSCC with recurrent or new second primary disease and provides a perspective to aid clinicians in the management of this disease.

Proton Radiation Therapy for Local Control in a Case of Osteosarcoma of the Neck

A 33-year-old man with symptomatic, unresectable osteosarcoma of the neck experienced disease progression despite treatment with multiple systemic agents. Given the tumor location, adjacent to the spinal cord and encasing the brachial plexus, proton beam therapy was recommended instead of conventional photon radiation therapy. The treatment was delivered in 3 weekly 10 cobalt-gray equivalents fractions, and there was minimal associated toxicity. There has been significant improvement in the patient's presenting symptoms as well as radiologically stable disease at 1 year. A photon intensity-modulated radiation therapy plan was created retrospectively for dosimetric comparison and demonstrated noninferiority, thereby highlighting the need for judicious use of proton therapy in certain cases.

[Radiotherapy and targeted therapy/immunotherapy]

Thanks to recent advances achieved in oncologic systemic and local ablative treatment, the treatments become more and more efficient in term of local control and overall survival. Thus, the targeted therapies, immunotherapy or stereotactic radiotherapy have modified the management of patients, especially in case of oligometastatic disease. Many questions are raised by these innovations, particularly the diagnosis and management of new side effects or that of the combination of these different treatments, depending on the type of primary tumor. Fundamental data are available, while clinical data are still limited. Ongoing trials should help to clarify the clinical management protocols. This manuscript is a review of the combination of radiotherapy and targeted therapy/immunotherapy.

Reirradiation of Recurrent and Second Primary Head and Neck Cancer With Proton Therapy

PURPOSE

To report the clinical outcomes of head and neck reirradiation with proton therapy.

METHODS AND MATERIALS

From 2004 to 2014, 61 patients received curative-intent proton reirradiation, primarily for disease involving skull base structures, at a median of 23 months from the most recent previous course of radiation. Most had squamous cell (52.5%) or adenoid cystic (16.4%) carcinoma. Salvage surgery before reirradiation was undertaken in 47.5%. Gross residual disease was present in 70.5%. For patients with microscopic residual disease, the median dose of reirradiation was 66 Gy (relative biological effectiveness), and for gross disease was 70.2 Gy (relative biological effectiveness). Concurrent chemotherapy was given in 27.9%.

RESULTS

The median follow-up time was 15.2 months and was 28.7 months for patients remaining alive. The 2-year overall survival estimate was 32.7%, and the median overall survival was 16.5 months. The 2-year cumulative incidence of local failure with death as a competing risk was 19.7%; regional nodal failure, 3.3%; and distant metastases, 38.3%. On multivariable analysis, Karnofsky performance status ≤70%, the presence of a gastrostomy tube before reirradiation, and an increasing number of previous courses of radiation therapy were associated with a greater hazard ratio for death. A cutaneous primary tumor, gross residual disease, increasing gross tumor volume, and a lower radiation dose were associated with a greater hazard ratio for local failure. Grade ≥3 toxicities were seen in 14.7% acutely and 24.6% in the late setting, including 3 treatment-related deaths.

CONCLUSIONS

Reirradiation with proton therapy, with or without chemotherapy, provided reasonable locoregional disease control, toxicity profiles, and survival outcomes for an advanced-stage and heavily pretreated population. Additional data are needed to identify which patients are most likely to benefit from aggressive efforts to achieve local disease control and to evaluate the potential benefit of proton therapy relative to other modalities of reirradiation.

A prospective phase 2 trial of reirradiation with stereotactic body radiation therapy plus cetuximab in patients with previously irradiated recurrent squamous cell carcinoma of the head and neck

PURPOSE

Salvage options for unresectable locally recurrent, previously irradiated squamous cell carcinoma of the head and neck (rSCCHN) are limited. Although the addition of reirradiation may improve outcomes compared to chemotherapy alone, significant toxicities limit salvage reirradiation strategies, leading to suboptimal outcomes. We therefore designed a phase 2 protocol to evaluate the efficacy of stereotactic body radiation therapy (SBRT) plus cetuximab for rSCCHN.

METHODS AND MATERIALS

From July 2007 to March 2013, 50 patients >18 years of age with inoperable locoregionally confined rSCCHN within a previously irradiated field receiving ≥60 Gy, with a Zubrod performance status of 0 to 2, and normal hepatic and renal function were enrolled. Patients received concurrent cetuximab (400 mg/m(2) on day -7 and then 250 mg/m(2) on days 0 and +8) plus SBRT (40-44 Gy in 5 fractions on alternating days over 1-2 weeks). Primary endpoints were 1-year locoregional progression-free survival and National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0 graded toxicity.

RESULTS

Median follow-up for surviving patients was 18 months (range: 10-70). The 1-year local PFS rate was 60% (95% confidence interval [CI]: 44%-75%), locoregional PFS was 37% (95% CI: 23%-53%), distant PFS was 71% (95% CI: 54%-85%), and PFS was 33% (95% CI: 20%-49%). The median overall survival was 10 months (95% CI: 7-16), with a 1-year overall survival of 40% (95% CI: 26%-54%). At last follow-up, 69% died of disease, 4% died with disease, 15% died without progression, 10% were alive without progression, and 2% were alive with progression. Acute and late grade 3 toxicity was observed in 6% of patients respectively.

CONCLUSIONS

SBRT with concurrent cetuximab appears to be a safe salvage treatment for rSCCHN of short overall treatment time.

The humanistic burden of head and neck cancer: a systematic literature review

BACKGROUND

Head and neck cancer (HNC) and its treatment can affect communication, nutrition, and physical appearance, and the global impact of this disease on patients' quality of life may be substantial.

OBJECTIVE

The aim of this systematic literature review was to describe the impact of HNC and its treatment on the physical, emotional, and social well-being of patients over time, by examining longitudinal studies of patient-reported outcomes (PRO) evaluating these domains.

METHODS

Databases (MEDLINE and Embase) were searched to identify studies published in English between January 2004 and January 2014 analyzing the humanistic aspects of HNC in adult patients. Additional relevant publications were identified through manual searches of abstracts from recent conference proceedings.

RESULTS

Of 1,566 studies initially identified, 130 met the inclusion criteria and were evaluated in the assessment. Investigations using a variety of PRO instruments in heterogeneous patient populations consistently reported that PRO scores decrease significantly from diagnosis through the treatment period, but generally recover to baseline in the first year post-treatment. This trend was observed for many functional domains, although some side effects, such as xerostomia, persisted well beyond 1 year. In addition, considerable evidence exists that baseline PRO scores can predict clinical endpoints such as overall and progression-free survival.

CONCLUSIONS

Many aspects of HNC, both disease and treatment specific, profoundly affect patients' quality of life. Improved knowledge of these effects on PRO may allow for more informed treatment decisions and can help physicians to better prepare patients for changes they may experience during therapy. Furthermore, the predictive value of baseline PRO data may enable healthcare providers to identify at-risk patients in need of more intensive intervention.

Laryngeal cancer

PURPOSE OF REVIEW

Treatment of laryngeal carcinoma continues to evolve, and whereas there was a transition from total laryngectomy to chemoradiation in response to the Veterans Affairs study and Radiation Therapy Oncology Group (RTOG) 91-11, recent data suggest the role of partial laryngectomy must be revisited.

RECENT FINDINGS

Recent data have shown that laryngeal preservation does not equate with laryngeal function. Data are accumulating in support of operative management of advanced laryngeal carcinoma away from chemoradiation for select patients. In particular, supracricoid laryngectomy may be a viable option for intermediate and selected advanced laryngeal carcinoma while maintaining laryngeal function.

SUMMARY

The evolution of treatment for advanced laryngeal carcinoma is focusing treatment on maintaining locoregional control while also maintaining a functional larynx.

Role of stereotactic body radiotherapy for symptom control in head and neck cancer patients

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.

FDG volumetric parameters and survival outcomes after definitive chemoradiotherapy in patients with recurrent head and neck squamous cell carcinoma

OBJECTIVE

The purpose of this study was to establish the predictive value of (18)F-FDG parameters for overall survival in biopsy-proven recurrent head and neck squamous cell cancer (HNSCC) patients after definitive chemoradiotherapy.

MATERIALS AND METHODS

We conducted a retrospective study including 34 patients with HNSCC who had biopsy-proven recurrence between April 2004 and March 2012 and underwent FDG PET/CT at our institution at the time of recurrence. Maximum standardized uptake value (SUVmax), peak SUV (SUVpeak), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) were measured. The primary outcome measure was overall survival. ROC analysis, univariate and multivariate Cox regression models, and Kaplan-Meir survival curves were performed.

RESULTS

In univariate analyses, human papillomavirus (HPV) status (p = 0.04), primary site recurrence of MTV (p = 0.03), metastasis of MTV (p = 0.02), metastasis of TLG (p = 0.02), total MTV (p = 0.002), and total TLG (p = 0.04) were significantly associated with overall survival outcome. Total MTV remained as significant independent prognostic factor when adjusted for all other covariates except for primary site recurrence SUVmax and SUVpeak and lymph node SUVmax and SUVpeak. There was a significant difference in time to survival between patients with total MTV above and below the 50th percentile (Mantel-Cox log-rank test, p = 0.05 and Gehan-Breslow-Wilcoxon test, p = 0.03) and the optimum threshold of 16.8 mL (Mantel-Cox log-rank test, p = 0.01 and Gehan-Breslow-Wilcoxon test, p = 0.01; hazard ratio [HR], 0.25).

CONCLUSION

FDG PET/CT-based total MTV and clinical HPV status may be significant prognostic markers for overall survival of patients with recurrent HNSCC after definitive chemoradiotherapy.

Stereotactic body radiotherapy for recurrent oropharyngeal cancer - influence of HPV status and smoking history

PURPOSE

HPV status and smoking history stratifies patients into 3 distinct risk groups for survival following definitive chemoradiotherapy. Local-regional recurrences are common patterns of failure across all 3 risk-groups. SBRT±cetuximab has emerged as a promising salvage strategy for unresectable locally-recurrent, previously-irradiated head-and-neck cancer (rHNC) relative to conventional re-irradiation±chemotherapy. However the influence of HPV and smoking remains unknown in the setting of re-irradiation.

METHODS/MATERIALS

Patients (n=30) with rHNC of the oropharynx salvaged with SBRT±cetuximab from August 2002 through August 2013 were retrospectively reviewed; HPV status was determined based on p16 staining of primary pathology.

RESULTS

At a median follow-up of 10months for surviving patients, the mean overall survival for all patients was 12.6 months. HPV positivity was a significant predictor of overall survival (13.6 vs. 6.88 months, p=0.024), while smoking status did not significantly impact overall survival (p=0.707).

CONCLUSION

HPV status remains a significant predictor of overall survival in the re-irradiation setting with HPV positive rHNC demonstrating superior overall survival following salvage SBRT±cetuximab.

[Intensity-modulated radiation therapy and stereotactic body radiation therapy for head and neck tumors: evidence-based medicine]

Over the last decade, there have been many technical advances in radiation therapy, such as the spread of intensity-modulated conformal radiotherapy, and the rise of stereotactic body radiation therapy. By allowing better dose-to-target conformation and thus better organs at risk-sparing, these techniques seem very promising, particularly in the field of head and neck tumors. The present work aims at analyzing the level of evidence and recommendation supporting the use of high-technology radiotherapy in head and neck neoplasms, by reviewing the available literature.

Stereotactic body radiotherapy as primary treatment for elderly patients with medically inoperable head and neck cancer

PURPOSE

With a growing elderly population, elderly patients with head and neck cancers represent an increasing challenge with limited prospective data to guide management. The complex interplay between advanced age, associated co-morbidities, and conventional local therapies, such as surgery and external beam radiotherapy ± chemotherapy, can significantly impact elderly patients' quality of life (QoL). Stereotactic body radiotherapy (SBRT) is a well-established curative strategy for medical-inoperable early-stage lung cancers even in elderly populations; however, there is limited data examining SBRT as primary therapy in head and neck cancer.

MATERIAL/METHODS

Twelve patients with medically inoperable head and neck cancer treated with SBRT ± cetuximab from 2002 to 2013 were retrospectively reviewed. SBRT consisted of primarily 44 Gy in five fractions delivered on alternating days over 1-2 weeks. Concurrent cetuximab was administered at a dose of 400 mg/m(2) on day -7 followed by 250 mg/m(2) on day 0 and +7 in n = 3 (25%). Patient-reported quality of life (PRQoL) was prospectively recorded using the previously validated University of Washington quality of life revised (UW-QoL-R).

RESULTS

Median clinical follow-up was 6 months (range: 0.5-29 months). The 1-year actuarial local progression-free survival, distant progression-free survival, progression-free survival, and overall survival for definitively treated patients were 69, 100, 69, and 64%, respectively. One patient (8%) experienced acute grade 3 dysphagia and one patient (8%) experienced late grade 3 mucositis; there were no grade 4-5 toxicities. Prospective collection of PRQoL as assessed by UW-QoL-R was preserved across domains.

CONCLUSION

Stereotactic body radiotherapy shows encouraging survival and relatively low toxicity in elderly patients with unresectable head and neck cancer, which may provide an aggressive potentially curative local therapy while maintaining QoL.

[Combination of stereotactic irradiation and chemotherapy or targeted therapies: state of the art and preliminary recommendations]

The clinical management of systemic treatments and irradiation has long been studied for conventional irradiation. Yet, many associations are of difficult management and some drugs are contra-indicated in the concomitant setting owing to excessive toxicities. Sequential regimens using a therapeutic window of variable duration (based on drug half-life and tissue wash out) between each modality may be preferred for easier logistics and to avoid toxicities. The use of intra- and extracranial stereotactic ablative radiation therapy (hypofractionated) is expanding rapidly. Yet, little is known regarding associations between stereotactic ablative radiation therapy and systemic treatments. The short stereotactic ablative radiation therapy course in one day to two weeks offers a theoretical advantage compared to longer conventional irradiation with respect to shorter discontinuation of therapy. This may be of particular interest in situations where cancer is addicted to systemic treatment. While it is believed that stereotactic ablative radiation therapy might be safer because of limited irradiation volumes and steep gradients sparing most organs at risk, it should be noted that irradiation of normal tissues cannot be considered null; that stereotactic ablative radiation therapy has vascular effects in addition to other cell death radiation-induced mechanisms and cancer progression with discontinuation of systemic treatment is often reversible. To date, based on several phase II studies, combined stereotactic ablative radiation therapy and cetuximab can be recommended in head and neck tumours. Other stereotactic ablative radiation therapy-based combinations require prospective phase I-II studies and sufficient therapeutic window (in the order of at least 5 half-lives) between the systemic and local modalities must be left in routine practice.

High-dose reirradiation with intensity-modulated radiotherapy for recurrent head-and-neck cancer: disease control, survival and toxicity

PURPOSE

To evaluate disease control, survival and severe late toxicity after high-dose fractionated reirradiation using intensity-modulated radiotherapy (IMRT) for recurrent head-and-neck cancer.

MATERIALS AND METHODS

Sixty consecutive patients were reirradiated with IMRT between 1997 and 2011. The median prescribed dose was 70 Gy in 35 daily fractions until 2004 and 69.12 Gy in 32 daily fractions thereafter. The median cumulative dose was 132 Gy. Sixty-seven percent of patients had non-metastatic stage IV disease. Surgery prior to reirradiation and concomitant systemic therapy was performed in 13 (22%) and 20 (33%) patients, respectively.

RESULTS

Median follow-up in living patients was 18.5 months. Actuarial 1-, 2- and 5-year locoregional control was 64%, 48% and 32%, respectively. Median overall (OS) and disease-free survival was 9.6 and 6.7 months, respectively. Actuarial 1-, 2- and 5-year OS was 44%, 32% and 22%, respectively. Seventeen (27%) and 2 (3%) patients had grade 3 and 4 acute toxicity, respectively. Cumulative incidence of late grade≥3 toxicity was 23%, 27% and 66% at 1, 2 and 5 years, respectively. In 4 patients, death was attributed to toxicity: fatal bleeding (n=2), aspiration pneumonia (n=1) and skin necrosis (n=1).

CONCLUSIONS

High-dose fractionated reirradiation with IMRT offers 5-year disease control and OS in recurrent head-and-neck cancer for 1/3 and 1/4 patients, respectively. Severe late toxicity after 1-2 and 5 years occurs in 1/4 and 2/3 patients, respectively.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Functional and quality-of-life outcomes after reirradiation for head and neck cancer

OBJECTIVES/HYPOTHESIS

To examine functional and quality-of-life outcomes for patients treated by reirradiation to the head and neck for recurrent or new primary cancers.

STUDY DESIGN

Retrospective review.

METHODS

The University of Washington Quality of Life Instrument (UW-QOL) scores were reviewed with swallow evaluations for 17 patients with biopsy-proven recurrent or new primary squamous cell carcinoma of the head and neck treated with reirradiation who were clinically without evidence of disease at a minimum follow-up of 1 year. All patients had received their initial radiation therapy to a median dose of 66 Gy (range, 60-72 Gy). The median interval between radiation courses was 30 months (range, 6-132 months). The median reirradiation dose was 60 Gy (range, 54-70 Gy).

RESULTS

At 1 year after reirradiation, the mean UW-QOL composite score was 67.0 (range, 22.1-83.5), which did not differ significantly from baseline (P = .57). The proportion of patients who rated their global quality of life as "very good" or "outstanding" at 1 year after reirradiation was 35%. The percentage of patients who reported their global quality of life as "good/fair" and "poor/very poor" were 59% and 6%, respectively.

CONCLUSIONS

The majority of survivors in this highly selected series were devoid of new impairment after reirradiation and were satisfied with their functional status. Although nearly all patients had side effects from their prior radiation course prior to reirradiation, no patient reported a decline in global quality of life from before reirradiation to 1 year post-treatment.

Multi institutional phase II study of concomitant stereotactic reirradiation and cetuximab for recurrent head and neck cancer

PURPOSE

Recurrent head and neck cancer is associated to a poor survival prognosis. A high toxicity rate is demonstrated when surgery and/or radiotherapy and/or chemotherapy are combined. Furthermore, the duration of treatment is often not ethically compatible with the expected survival (median survival<1year). Normal tissues tolerance limits the use of reirradiation and stereotactic body radiotherapy (SBRT) could offer precise irradiation while sparing healthy tissues. After completion of a feasibility study, results of a multicentric study (Lille, Nancy & Nice) using SBRT with cetuximab are reported. The aim of the study was to deliver non toxic short course SBRT (2weeks) in order to get the same local control as the one demonstrated with longer protocols.

METHODS AND MATERIALS

Patients with inoperable recurrent, or new primary tumor in a previously irradiated area, were included (WHO<3). Reirradiation (RT) dose was 36Gy in six fractions of 6Gy to the 85% isodose line covering 95% of the PTV with 5 injections of concomitant cetuximab (CT). All patients had previous radiotherapy, 85% had previous surgery and 48% previous chemotherapy.

RESULTS

Between 11/2007 and 08/2010, 60 were included (46 men and 14 women), 56 received CT+RT, 3 were not treated and 1 received only CT. Median age was 60 (42-87)) and all 56 patients had squamous carcinoma and received concomitant cetuximab. Mean time between previous radiotherapy and the start of SBRT was 38months. Cutaneous toxicity was observed for 41 patients. There was one toxic death from hemorrhage and denutrition. Median follow-up was 11.4months. At 3months, response rate was 58.4% (95% CI: 43.2-72.4%) and disease control rate was 91.7% (95% CI: 80.0-97.7%). The one-year OS rate was 47.5% (95% CI: 30.8-62.4).

CONCLUSION

These results suggest that short SBRT with cetuximab is an effective salvage treatment with good response rate in this poor prognosis population with previously irradiated HNC. Treatment is feasible and, with appropriate care to limiting critical structure, acute toxicities are acceptable. This combination may be the reference treatment is this population.

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

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.

Stereotactic Body Radiotherapy (SBRT) for primary and recurrent head and neck tumors

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.

Local ablative therapy of oligoprogressive disease prolongs disease control by tyrosine kinase inhibitors in oncogene-addicted non-small-cell lung cancer

INTRODUCTION

Many patients with oncogene-driven non-small-cell lung cancer (NSCLC) treated with tyrosine kinase inhibitors experience limited sites of disease progression. This study investigated retrospectively the benefits of local ablative therapy (LAT) to central nervous system (CNS) and/or limited systemic disease progression and continuation of crizotinib or erlotinib in patients with metastatic ALK gene rearrangement (ALK+) or EGFR-mutant (EGFR-MT) NSCLC, respectively.

METHODS

Patients with metastatic ALK+ NSCLC treated with crizotinib (n = 38) and EGFR-MT NSCLC treated with erlotinib (n = 27) were identified at a single institution. Initial response to the respective kinase inhibitors, median progression-free survival (PFS1), and site of first progression were recorded. A subset of patients with either nonleptomeningeal CNS and/or four sites or fewer of extra-CNS progression (oligoprogressive disease) suitable for LAT received either radiation or surgery to these sites and continued on the same tyrosine kinase inhibitors. The subsequent median progression-free survival from the time of first progression (PFS2) and pattern of progression were recorded.

RESULTS

Median progression-free survival in ALK+ patients on crizotinib was 9.0 months, and 13.8 months for EGFR-MT patients on erlotinib. Twenty-five of 51 patients (49%) who progressed were deemed suitable for local therapy (15 ALK+, 10 EGFR-MT; 24 with radiotherapy, one with surgery) and continuation of the same targeted therapy. Post-LAT, 19 of 25 patients progressed again, with median PFS2 of 6.2 months.

DISCUSSION

Oncogene-addicted NSCLC with CNS and/or limited systemic disease progression (oligoprogressive disease) on relevant targeted therapies is often suitable for LAT and continuation of the targeted agent, and is associated with more than 6 months of additional disease control.