Conformal re-irradiation of recurrent and new primary head-and-neck cancer

Re-irradiation versus systemic therapy for the management of local-regionally recurrent head and neck cancer

PURPOSE

The optimal management of local-regionally recurrent head and neck cancer that is not amenable to surgical resection is uncertain. We sought to compare outcomes among patients treated with and without re-irradiation in this setting.

METHODS AND MATERIALS

A review of institutional registries identified 65 patients with local-regionally recurrent squamous cell carcinoma of the head and neck who were ineligible for surgery. Forty patients (62 %) opted for re-irradiation with the remaining 25 patients (38 %) undergoing initial systemic therapy alone. All patients had measurable disease. Forty-three patients (66 %) were male and twenty-two (33 %) were female. The median age at the time of recurrence was 59 years (range, 39-84 years). The most common primary sites of disease were the oropharynx, (n = 25), oral cavity (N = 19), and nasopharynx (n = 11). The median interval from completion of prior radiation to the diagnosis of recurrent disease was 35 months (range, 2-102 months).

RESULTS

Re-irradiation improved 2-year overall survival, (32 % versus 11 %), progression-free survival (31 % versus 7 %), and local-regional control (39 % versus 3 %) compared to systemic therapy alone (p < 0.05, for both). The likelihood of developing any new grade 3+ toxicity was significantly higher among patients treated by re-irradiation compared to those treated by systemic therapy (53 % vs. 28 %, p < 0.001). There were 3 treatment-related fatalities, all of which occurred in the re-irradiation group. The incidence of grade 3+ late toxicity was 48 % and 12 % for patients in the re-irradiation and systemic therapy cohorts, respectively (p < 0.001).

CONCLUSION

Although re-irradiation improved overall survival compared to systemic therapy for appropriately selected patients with local-regionally recurrent head and neck cancer, the relatively high risk of toxicity must be considered.

Incidence of Carotid Blowout Syndrome in Patients with Head and Neck Cancer after Radiation Therapy: A Cohort Study

Carotid blowout syndrome (CBS) is a rare yet life-threatening complication that occurs after radiation therapy (RT). This study aimed to determine the incidence of CBS in patients with head and neck cancer (HNC) undergoing contemporary RT and to explore potential discrepancies in the risk of CBS between nasopharyngeal cancer (NPC) and non-NPC patients. A total of 1084 patients with HNC who underwent RT between 2013 and 2023 were included in the study. All patients were under regular follow-ups at the radio-oncology department, and underwent annual contrast-enhanced computed tomography and/or magnetic resonance imaging for cancer recurrence surveillance. Experienced neuroradiologists and vascular neurologists reviewed the recruited patients' images. Patients were further referred to the neurology department for radiation vasculopathy evaluation. The primary outcome of this study was CBS. Patients were categorized into NPC and non-NPC groups and survival analysis was employed to compare the CBS risk between the two groups. A review of the literature on CBS incidence was also conducted. Among the enrolled patients, the incidence of CBS in the HNC, NPC, and non-NPC groups was 0.8%, 0.9%, and 0.7%, respectively. Kaplan-Meier analysis revealed no significant difference between the NPC and non-NPC groups (p = 0.34). Combining the findings for our cohort with those of previous studies revealed that the cumulative incidence of CBS in patients with HNC is 5% (95% CI = 3-7%) after both surgery and RT, 4% (95% CI = 2-6%) after surgery alone, and 5% (95% CI = 3-7%) after RT alone. Our findings indicate a low incidence of CBS in patients with HNC undergoing contemporary RT. Patients with NPC may have a CBS risk close to that of non-NPC patients. However, the low incidence of CBS could be a potentially cause of selection bias and underestimation bias.

Stereotactic Body Radiotherapy in Recurrent and Oligometastatic Head and Neck Tumours

The treatment of head and neck cancers (HNCs) encompasses a complex paradigm involving a combination of surgery, radiotherapy, and systemic treatment. Locoregional recurrence is a common cause of treatment failure, and few patients are suitable for salvage surgery. Reirradiation with conventional radiation techniques is challenging due to normal tissue tolerance limits and the risk of significant toxicities. Stereotactic body radiotherapy (SBRT) has emerged as a highly conformal modality that offers the potential for cure while limiting the dose to surrounding tissue. There is also growing research that shows that those with oligometastatic disease can benefit from curative intent local ablative therapies such as SBRT. This review will look at published evidence regarding the use of SBRT in locoregional recurrent and oligometastatic HNCs.

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.

A Systematic Review on Re-irradiation with Charged Particle Beam Therapy in the Management of Locally Recurrent Skull Base and Head and Neck Tumors

Purpose

To evaluate the clinical outcomes and treatment related toxicities of charged particle-based re-irradiation (reRT; protons and carbon ions) for the definitive management of recurrent or second primary skull base and head and neck tumors.

Materials and Methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were applied for the conduct of this systematic review. Published work in English language evaluating the role of definitive charged particle therapies in the clinical setting of reRT for recurrent or second primary skull base and head and neck tumors were eligible for this analysis.

Results

A total of 26 original studies (15 protons, 10 carbon ions, and 1 helium/neon studies) involving a total of 1,118 patients (437 with protons, 670 with carbon ions, and 11 with helium/neon) treated with curative-intent charged particle reRT were included in this systematic review. All studies were retrospective in nature, and the majority of them (n=23, 88 %) were reported as single institution experiences (87% for protons, and 90% for carbon ion-based studies). The median proton therapy reRT dose was 64.5 Gy (RBE 1.1) (range, 50.0 – 75.6 Gy ), while the median carbon ion reRT dose was 53.8 Gy (RBE 2.5 – 3.0) (range, 44.8 – 60 Gy ). Induction and/or concurrent chemotherapy was administered to 232 (53%) of the patients that received a course of proton reRT, and 122 (18%) for carbon ion reRT patients. ReRT with protons achieved 2-year local control rates ranging from 50% to 86%, and 41% to 92% for carbon ion reRT. The 2-year overall survival rates for proton and carbon ion reRT ranged from 33% to 80%, and 50% to 86% respectively. Late ≥ G3 toxicities ranged from 0% to 37%, with brain necrosis, ototoxicity, visual deficits, and bleeding as the most common complications. Grade 5 toxicities for all treated patients occurred in 1.4% (n= 16/1118) with fatal bleeding as the leading cause.

Conclusions

Based on current data, curative intent skull base and head and neck reRT with charged particle radiotherapy is feasible and safe in well-selected cases, associated with comparable or potentially improved local control and toxicity rates compared to historical reRT studies using photon radiotherapy. Prospective multi-institutional studies reporting oncologic outcomes, toxicity, and dosimetric treatment planning data are warranted to further validate these findings and to improve the understanding of the clinical benefits of charged particle radiotherapy in the reRT setting.

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

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

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.

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.

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

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

Intensity modulated proton therapy (IMPT) - The future of IMRT for head and neck cancer

Radiation therapy plays an integral role in the management of head and neck cancers (HNCs). While most HNC patients have historically been treated with photon-based radiation techniques such as intensity modulated radiation therapy (IMRT), there is a growing awareness of the potential clinical benefits of proton therapy over IMRT in the definitive, postoperative and reirradiation settings given the unique physical properties of protons. Intensity modulated proton therapy (IMPT), also known as "pencil beam proton therapy," is a sophisticated mode of proton therapy that is analogous to IMRT and an active area of investigation in cancer care. Multifield optimization IMPT allows for high quality plans that can target superficially located HNCs as well as large neck volumes while significantly reducing integral doses. Several dosimetric studies have demonstrated the superiority of IMPT over IMRT to improve dose sparing of nearby organs such as the larynx, salivary glands, and esophagus. Evidence of the clinical translation of these dosimetric advantages has been demonstrated with documented toxicity reductions (such as decreased feeding tube dependency) after IMPT for patients with HNCs. While there are relative challenges to IMPT planning that exist today such as particle range uncertainties and high sensitivity to anatomical changes, ongoing investigations in image-guidance techniques and robust optimization methods are promising. A systematic approach towards utilizing IMPT and additional prospective studies are necessary in order to more accurately estimate the clinical benefit of IMPT over IMRT and passive proton therapy on a case-by-case basis for patients with sub-site specific HNCs.

Carotid blowout syndrome: modern trends in management

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.

High-dose-rate interstitial brachytherapy in recurrent head and neck cancer: an effective salvage option

Purpose

High-dose-rate (HDR) interstitial brachytherapy has an established role in head and neck malignancies and offers good survival rates; however, there is scant data on improved local control (LC) and treatment-related complications in recurrent cases. We present our results in patients with recurrent head and neck cancers treated with HDR interstitial brachytherapy.

Material and methods

Twenty-five patients with recurrent head and neck cancers were treated with HDR interstitial brachytherapy using Iridium 192 between 2009 and 2016. Of these, 75% received radical brachytherapy, and 25% received external beam radiation therapy (EBRT) followed by brachytherapy boost. Treatment sites included oral cavity (15/25) and oropharynx (10/25). Median dose of 4.5 Gy was administered twice per day, with median total brachytherapy dose of 40.5 Gy in radical and 27 Gy for EBRT cases.

Results

With median follow-up of 25 months, 4 local recurrences were observed within first year of follow-up. Two-year local control and overall survival outcomes for the entire group were 75% and 68%, respectively. Local control rate with radical BRT vs. BRT as a boost following EBRT was found to be significant (2-year LCR 62% vs. 85%; p < 0.02). Dosimetric assessment revealed D₉₀ - 4.08 Gy, V₁₀₀ - 94.1%, V₁₅₀ - 24.7%, and V₂₀₀ - 10.1%. Xerostomia, altered taste, and dysphagia were the major complications commonly grade 1 and 2. Grade 3 toxicity was only 2%. Pre-treatment volume > 85 cc had a negative impact on overall survival (26 months vs. 12 months; p = 0.02), and interval time between primary and recurrence more than 15 months had an impact on the local control rate (p < 0.01).

Conclusions

Results of HDR interstitial brachytherapy have shown acceptable local control and overall survival rates along with tolerable toxicities and morbidity in recurrent head and neck cancers.

Clinical trials for treating recurrent head and neck cancer with boron neutron capture therapy using the Tsing-Hua Open Pool Reactor

Head and neck (HN) cancer is an endemic disease in Taiwan, China. Locally recurrent HN cancer after full-dose irradiation poses a therapeutic challenge, and boron neutron capture therapy (BNCT) may be a solution that could provide durable local control with tolerable toxicity. The Tsing-Hua Open Pool Reactor (THOR) at National Tsing-Hua University in Hsin-Chu, provides a high-quality epithermal neutron source for basic and clinical BNCT research. Our first clinical trial, entitled "A phase I/II trial of boron neutron capture therapy for recurrent head and neck cancer at THOR", was carried out between 2010 and 2013. A total of 17 patients with 23 recurrent HN tumors who had received high-dose photon irradiation were enrolled in the study. The fructose complex of L-boronophenylalanine was used as a boron carrier, and a two-fraction BNCT treatment regimen at 28-day intervals was used for each patient. Toxicity was acceptable, and although the response rate was high (12/17), re-recurrence within or near the radiation site was common. To obtain better local control, another clinical trial entitled "A phase I/II trial of boron neutron capture therapy combined with image-guided intensity-modulated radiotherapy (IG-IMRT) for locally recurrent HN cancer" was initiated in 2014. The first administration of BNCT was performed according to our previous protocol, and IG-IMRT was initiated 28 days after BNCT. As of May 2017, seven patients have been treated with this combination. The treatment-related toxicity was similar to that previously observed with two BNCT applications. Three patients had a complete response, but locoregional recurrence was the major cause of failure despite initially good responses. Future clinical trials combining BNCT with other local or systemic treatments will be carried out for recurrent HN cancer patients at THOR.

Evaluation of Reirradiation in Locally Advanced Head and Neck Cancers: Toxicity and Early Clinical Outcomes

Objectives

Locoregional recurrence is the predominant pattern of treatment failure in advanced head and neck cancers. Reirradiation is a useful modality to treat inoperable head and neck cancer patients with recurrent disease. The aim of the present study was to analyze the treatment toxicity and early clinical outcomes in patients undergoing reirradiation.

Methods

Twenty patients of head and neck cancers with recurrences or second cancers were evaluated. Reirradiation was done using simultaneous integrated boost volumetric modulated arc therapy (SIB VMAT), intensity modulated radiotherapy (IMRT), or conventional radiotherapy using 6MV photons. Dose prescription ranged from 30 to 60 Gy in conventional fractionation.

Results

Seventeen males and three females were evaluated in this analysis. The median age of patients under study was 56.5 years. At time of analysis 8 patients (40%) had a complete response, 7 patients (35%) had progressive disease, and 25% had partial response or stable disease. Grade III-IV mucositis, dermatitis, xerostomia, dysphagia, and trismus were seen in 20%, 20%, 50%, 35%, and 45% patients, respectively, during retreatment. Patients receiving a radiotherapy dose less than 45 Gy showed a higher incidence of progressive disease (p = 0.01). The median disease-free survival for patients receiving reirradiation dose of ≥46 Gy was 19 ± 3.3 months (median ± S Error) compared to 8 ± 2.61 months for those with a dose prescription less than 45 Gy (p = 0.03). At 18-month follow-up 26% of patients undergoing reirradiation were disease-free.

Conclusions

Our results show improved tumor control using a prescription of doses ≥46 Gy in retreatment setting.

Trismus in patients with head and neck cancer: etiopathogenesis, diagnosis and management

BACKGROUND

Trismus indicates severely restricted mouth opening of any aetiology. A mouth opening of 35 mm or less should be regarded as trismus. Aim of this study was to review the etiopathogenesis, incidence, treatment and prevention of trismus in patients with head and neck cancer.

OBJECTIVE OF REVIEW

Trismus is frequently seen in patients suffering from malignant tumours of the head and neck. The reported prevalence of trismus in those patients varies considerably in the literature and ranges from 0 to 100% depending on the tumour site and extension. Trismus may worsen or remain the same over time, or the symptoms may reduce, even in the absence of treatment. When a patient presents with trismus after tumour treatment, it is important to determine whether the trismus is the result of the treatment, or is the first sign of a recurrence. Restricted mouth opening may impede inspection of the oral cavity as needed for dental care, and particularly for oncologic follow-up.

CONCLUSIONS

Mouth opening after radiotherapy (RT) decreases on average by approximately 20% compared to mouth opening prior to RT. The prevalence of trismus increases with increasing doses of RT to mastication structures. The use of intensity-modulated RT seems to lower the percentage and severity of RT-induced trismus. Treatment of trismus can be conservative (with either medical or physical therapy) or surgical. Exercise therapy is the mainstay of treatment and exercise should start as soon as possible after treatment. The prevention of trismus, rather than its treatment, is the most important objective.

Outcomes of patients with loco-regionally recurrent or new primary squamous cell carcinomas of the head and neck treated with curative intent reirradiation at Mayo Clinic

BACKGROUND

We reviewed outcomes of patients with loco-regionally recurrent (LRR) or new primary (NP) squamous cell carcinoma of the head and neck (SCCHN) treated at our institution with reirradiation (RRT).

METHODS

Patients received definitive RRT (DRRT) or post-operative RRT following salvage surgery (PRRT) from 2003 to 2011. Measured survival outcomes included loco-regional relapse free survival (LRFS) and overall survival (OS).

RESULTS

Among 81 patients (PRRT, 42; DRRT, 39), median PRRT and DRRT doses were 60 Gy (12-70 Gy) and 69.6 Gy (48-76.8 Gy). The majority of patients received IMRT-based RRT (n = 77, 95 %). With median follow-up of 78.1 months (95 % CI, 56-96.8 months), 2-year OS was 53 % with PRRT and 48 % with DRRT (p = 0.12); 23 % of patients were alive at last follow-up. LRFS at 2 years was 60 %, and did not differ significantly between PRRT and DRRT groups. A trend toward inferior LRFS was noted among patients receiving chemotherapy with RRT versus RRT alone (p = 0.06). Late serious toxicities were uncommon, including osteoradionecrosis (2 patients) and carotid artery bleeding (1 patient, non-fatal).

CONCLUSIONS

OS of PRRT- and DRRT-treated patients in this series appears superior to the published literature. We used IMRT for the majority of patients, in contrast to several series and trials previously reported, which may account in part for this difference. Future studies should seek to improve outcomes among patients with LRR/NP SCCHN via alternative therapeutic modalities such as proton radiotherapy and by incorporating novel systemic agents.

Local Tumor Control and Normal Tissue Toxicity of Pulsed Low-Dose Rate Radiotherapy for Recurrent Lung Cancer: An In Vivo Animal Study

OBJECTIVES

This study investigates (1) local tumor control and (2) normal tissue toxicity of pulsed low-dose rate radiotherapy (PLDR) for recurrent lung cancer.

METHODS

For study 1, nude mice were implanted with A549 tumors and divided into the following 3 groups: (1) control (n = 10), (2) conventional radiotherapy (RT; n = 10), and (3) PLDR (n = 10). Tumor-bearing mice received 2 Gy daily dose for 2 consecutive days. Weekly magnetic resonance imaging was used for tumor growth monitoring. For study 2, 20 mice received 8 Gy total body irradiation either continuously (n = 10) or 40 × 0.2 Gy pulses with 3-minute intervals (n = 10).

RESULTS

For study 1, both conventional RT and PLDR significantly inhibited the growth of A549 xenografts compared with the control group (>35% difference in the mean tumor volume; P < .05). The PLDR results were slightly better than conventional RT (8% difference in the mean tumor volume; P > .05). For study 2, the average weight was 20.94 ± 1.68 g and 25.69 ± 1.27 g and the survival time was 8 days and 12 days for mice treated with conventional RT and PLDR (P < .05), respectively.

CONCLUSION

This study showed that PLDR could control A549 tumors as effectively as conventional RT, and PLDR induced much less normal tissue toxicity than conventional RT. Thus, PLDR would be a good modality for recurrent lung cancers.

ADVANCES IN KNOWLEDGE

This article reports our results of an in vivo animal investigation of PLDR for the treatment of recurrent cancers, which may not be eligible for treatment because of the dose limitations on nearby healthy organs that have been irradiated in previous treatments. This was the first in vivo study to quantify the tumor control and normal tissue toxicities of PLDR using mice with implanted tumors, and our findings provided evidence to support the clinical trials that employ PLDR treatment techniques.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Objective:

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

Method:

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

Results:

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

Conclusion:

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

Retrospective analysis of treatment outcomes following reirradiation in locoregionally recurrent head and neck cancer patients: A single institutional study

AIM

To present a retrospective analysis of treatment outcomes following reirradiation in locoregionally recurrent head and neck cancer patients at our institute.

METHODS

Thirty-one patients of head and neck cancer who presented with a locoregional recurrence from April 2007 to April 2012 underwent salvage reirradiation. Median dose of first-time radiation was 70 Gy. Median duration of gap between the first and second course of radiation was 45.6 months. The median dose of reirradiation was 60 Gy. Conformal radiotherapy technique in the form of intensity modulated radiotherapy was used in 60% (17) of patients. Fourteen patients received concurrent chemotherapy or immunotherapy.

RESULTS

After a median follow-up of 20.6 months, 12 patients were alive with no evidence of disease. The 3-year disease-free survival and overall survival were 28.7 and 48.5%, respectively. Acute and late toxicities were reported in 29 and 61% of patients, respectively. Severe grade 3 and 4 late complications were observed in nine patients but none of them led to mortality.

CONCLUSION

Reirradiation appears to be both feasible and well tolerated in patients treated with previous radiotherapy for recurrent and second primary head and neck cancer. Careful case selection for reirradiation based on patient's performance status and tumor characteristics is essential.

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.

[Reirradiations of head and neck cancers: state of the concept and ways of development]

The treatment of local recurrence or second primary developed in irradiated area in the field of head and neck carcinoma, should be planned and organized through multidisciplinary discussions. The outcome of such a clinical situations benefits from second line and advanced technology treatments. Only a few patients are amenable to salvage surgery, hence radiation therapy, combined or not with chemotherapy, takes a major role in these indications. This overview of the literature describes recent development in this field, aiming to improve local control while the sparing of organ at risk remains an important goal. Radiation therapy is currently implementing major new technologies set to improve external beam irradiation with new concepts on dose, fractionation, intensity modulated radiation therapy and stereotactic approach - as well as in brachytherapy. Apart from dedicated studies, the great heterogeneity of the treated patients should be underlined and taken into consideration. However, current data confirm the feasibility of reirradiation with acceptable local control and toxicity.

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.

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

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.

Practical considerations in the re-irradiation of recurrent and second primary head-and-neck cancer: who, why, how, and how much?

Despite progress in surgical and reconstructive techniques, as well as advances in radiotherapy delivery methods, a significant proportion of patients irradiated for head-and-neck cancer develop locoregional recurrence. These patients are also at high risk of developing new second primary cancers of the head and neck. Because of the heterogeneity of this population with respect to disease-related and patient-related factors, such as previous treatment, tumor recurrence site, disease extent, and performance status, the optimal treatment of locoregionally recurrent or second primary cancers of the head and neck remains to be defined. Although surgical resection typically constitutes the mainstay of treatment, effective salvage therapy is often precluded by anatomic inaccessibility and the risk of perioperative complications. Although chemotherapy alone has traditionally been considered an alternative to surgery, the response rates have been poor, with nearly all patients dying of disease progression within months. Similarly, salvage therapy using re-irradiation has historically been avoided because of concerns regarding toxicity. Although the results of more recent studies using contemporary treatment techniques and conformal delivery methods have been somewhat more promising, the role of re-irradiation after previous full-course radiotherapy is still considered investigational by many. Numerous questions remain unanswered, and practical guidelines for clinical decision-making are sparse.

Second course of radiation for new primary head-and-neck cancer: population-based study of survival

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.

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

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.

Concurrent cetuximab with stereotactic body radiotherapy for recurrent squamous cell carcinoma of the head and neck: a single institution matched case-control study

PURPOSE

Locally recurrent head and neck squamous cell carcinoma can be treated with curative intent by surgical salvage or reirradiation with or without chemotherapy. We have previously demonstrated the feasibility and safety of stereotactic body reirradiation at our institution; however, efficacy has been unsatisfactory. Based on the successful combination of cetuximab with radiotherapy in locally-advanced squamous cell carcinoma of the head and neck, we compared stereotactic body radiotherapy alone with combination therapy, using concomitant cetuximab with stereotactic body radiotherapy, to enhance clinical efficacy while minimizing toxicity.

METHODS

In a retrospective-matched cohort study, we compared 2 groups of patients treated over a 6-year period with stereotactic body radiation therapy alone (n=35) or with weekly cetuximab infusion during stereotactic body radiotherapy (n=35), and evaluated clinical response, local control, overall survival, and toxicity. Cox proportional hazard models were used to assess independent prognostic factors.

RESULTS

The median follow-ups for patients alive at last contact were 21.3 months and 24.8 months for stereotactic body radiotherapy only (n=13) and stereotactic body radiotherapy plus cetuximab (n=22), respectively. Our results indicate that cetuximab conferred an overall survival advantage (24.5 vs. 14.8 months) when compared with the stereotactic body radiotherapy alone arm, without a significant increase in grade 3/4 toxicities. This survival advantage was also observed in the subgroup that had received cetuximab therapy during their prior therapeutic regimen.

CONCLUSIONS

Our results suggest an overall survival benefit of concomitant cetuximab with stereotactic body radiotherapy in locally recurrent head and neck squamous cell carcinoma, and suggest a role in this setting. Concomitant cetuximab with stereotactic body radiotherapy is a reasonable approach for unresectable recurrent squamous cell carcinoma of the head and neck, and should be tested in prospective randomized trials to validate its clinical efficacy.

Risk of carotid blowout after reirradiation of the head and neck: a systematic review

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.

ACR appropriateness criteria retreatment of recurrent head and neck cancer after prior definitive radiation expert panel on radiation oncology-head and neck cancer

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.

Methotrexate Revisited—in Recurrent Head and Neck Cancer

Aims

Response of single agent chemotherapy in improving quality of life in patients with recurrent head and neck cancers.

Methods and material

This is a study of the 18 patients with advanced cancers of head and neck, who had failed earlier attempts of radical treatment with Surgery, Radiotherapy ± chemotherapy and have residual or recurrent tumours, were treated with single agent Injection Methotrexate 50 mg/m2 weekly. Follow up visit complaints and clinical examination details were recorded. History regarding pain, speech and diet was collected for every visit. Severity of pain was divided with the National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE) version 3.0 pain scales. Symptom control was done with analgesics, antiemetic and infection control.

Results

Weekly single agent chemotherapy with injection Methotrexate has significantly improved the quality of life of patients. 38.8% of patients have shown good response with decrease in the tumour bulk by more than 50% and other 39% of patients have stable disease on Injection Methotrexate. 22.2% patients have shown disease progression on single agent chemotherapy. Overall 83.3% patients have shown improvement in Quality of life in terms of symptomatic control. After 6 weekly treatments with injection methotrexate 63% patients were pain free with 16% patients reported decrease in pain. 87.5% of patients have shown improvement in speech and diet. Improvement in symptoms has shown decrease in depression in cancer patients. Grade 3 toxicity observed was Neutropenia (11.1%), anaemia (11.1%) and Mucositis (16.6%) which was managed adequately. Median survival with good quality of life is 5.4 months.

Conclusions

Single agent methotrexate chemotherapy on an out-patient basis can provide good quality of life. Decrease in pain along with improvement in speech and diet has shown decrease in incidence of depression and overall positive impact on psychosocial status. Few cases have shown sustained regression of gross disease adding to maintained quality of life with better socio-economic compliance.

Outcome after re-irradiation of head and neck cancer patients

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Efficacy and toxicity of reirradiation using intensity-modulated radiotherapy for recurrent or second primary head and neck cancer

BACKGROUND

Patients with locally recurrent squamous cell cancer of the head and neck (SCCHN) are reported to have a poor prognosis and limited therapeutic options. Optimal management is selectively applied and morbid. Both surgical resection and chemoradiotherapy are reported to result in median survivals of approximately 12 months. Intensity-modulated radiotherapy (IMRT) is a highly conformal approach for delivering RT. This study reported the experience of the Dana-Farber Cancer Institute (DFCI) with IMRT-based chemoradiotherapy with or without surgery for locally recurrent SCCHN.

METHODS

The current study was a retrospective study of all patients treated at DFCI who were diagnosed with nonmetastatic second primary or recurrent SCCHN and who received reirradiation based on IMRT. The primary endpoint was overall survival (OS), and secondary endpoints were locoregional (LRC) and distant control and acute and chronic toxicity.

RESULTS

Thirty-five patients were treated from August 2004 until December 2008. Recurrent disease was treated in the oral cavity (4 patients), larynx/hypopharynx (13 patients), oropharynx (7 patients), nasopharynx (2 patients), and neck (9 patients). The median radiation dose was 60 Gray (Gy), and all patients received concurrent chemotherapy. The median follow-up was 2.3 years. The 2-year actuarial OS and LRC rates were 48% and 67%, respectively. Approximately 91% and 46%, respectively, of all patients developed at least 1 acute and late grade 3 toxicity. Four (11%) late deaths occurred in patients with no evidence of disease (2 aspiration events, 1 oropharyngeal hemorrhage, and 1 infectious death).

CONCLUSIONS

Aggressive chemoradiotherapy with IMRT was found to be feasible and resulted in favorable survival outcomes in comparison with published reports. Acute and late toxicities were substantial. The apparently improved LRC appears to carry a significant risk of developing late complications.

Fractionated stereotactic body radiation therapy in the treatment of previously-irradiated recurrent head and neck carcinoma: updated report of the University of Pittsburgh experience

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.

Fractionated stereotactic radiosurgery for reirradiation of head-and-neck cancer

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.