Long-term outcome of re-irradiation with concomitant chemotherapy for locally recurrent squamous cell carcinoma of the head and neck

Reirradiation in head and neck cancers

Salvage surgery is the mainstay of treatment for recurrences or secondary primary tumors in areas that were irradiated earlier. However, locoregional recurrence remains the main cause of death after surgery. Adjuvant reirradiation dramatically reduces locoregional recurrences but the risk-benefit ratio seems to be advantageous mostly for residual microscopic disease. In contrast, the rate of distant metastasis among reirradiated patients indicates that the local treatment alone is not sufficient. Full-dose exclusive chemo-reirradiation (over 60 Gy) can cure a subset of patients when surgery is not feasible. However, reirradiation is associated with a significant rate of severe toxicity and should, therefore, be compared with chemotherapy in randomized trials. Accrual may be difficult because of selection biases such as tumor volume, small volumes (largest axis less than 3-4 cm) being more likely to be irradiated. In addition, patients in poor general condition with severe comorbidities, organ dysfunction, or incomplete healing after salvage surgery, are unlikely to benefit from reirradiation. Noteworthy volumes to be reirradiated must be established between the head and neck surgeon and the radiation oncologist: the definition of the clinical target volume should be taken into account, the natural history of recurrent tumors, especially with regard to extension modalities, and the absence of strict correlation between imaging and histological real extension. This is even more critical with the advent of new irradiation techniques. Chemotherapy associations and new radiosensitizing agents are also under investigation. Comparison between reirradiation modalities is difficult because most trials are phase 2 mono-institutional trials. As selection of patients is a key issue, only phase 3 multiinstitutional trials can provide definitive results.

Concurrent chemotherapy and re-irradiation for locoregionally recurrent head and neck cancer

Recurrent and second primary tumors arising within a previously radiated head and neck volume represent a difficult clinical scenario to manage. For patients who have resectable disease, surgery is the standard treatment. Chemotherapy is the standard for patients with unresectable or metastatic disease but offers no chance for cure. Re-irradiation (RRT) with concurrent chemotherapy is a potentially curative treatment option. In this article, we will review the basis for current chemoradiotherapy (CRT) regimens used in previously radiated patients, focusing on outcome and toxicity. Additionally, we will review radiotherapy techniques used in this setting and highlight the differences between definitive radiotherapy and RRT. Controversies, such as the utility of chemotherapy and RRT following surgical salvage, will be addressed. Finally, we will review investigations seeking to improve the therapeutic outcomes of patients treated with chemotherapy and RRT.

Toxicity and outcome analysis of patients with recurrent head and neck cancer treated with hyperfractionated split-course reirradiation and concurrent cisplatin and paclitaxel chemotherapy from two prospective phase I and II studies

BACKGROUND

Patients with local recurrences or new head and neck primary tumors in previously irradiated tissues have few options for salvage treatment. One option for select patients is to undergo reirradiation with concurrent chemotherapy. The purpose of this study is to report the initial clinical results of the Fox Chase phase I and II prospective reirradiation and chemotherapy studies.

METHODS

Between July 1996 and January 2002, 38 patients with locally recurrent unresectable squamous cell carcinoma of the head and neck were treated with concurrent chemotherapy and reirradiation on two prospective trials. All patients had received prior radiation therapy to the head and neck region (median dose, 64.2 Gy). Patients received cisplatin and paclitaxel along with hyperfractionated external beam radiation therapy to the site of recurrence.

RESULTS

The median follow-up was 10 months. The median survival was 12.4 months, with actuarial rates of overall survival of 50% and 35% at 1 and 2 years, respectively. During follow-up, 63% of patients experienced local progression of disease, all in the irradiated field. Actuarial progression-free survival at 1 year was 33%, with a median time to progression of 7.3 months. Acute grade 3 to 4 toxicity included neutropenia, nausea, emesis, and mucositis.

CONCLUSIONS

Hyperfractionated split-course reirradiation and concurrent cisplatin and paclitaxel chemotherapy demonstrates durable locoregional control in select patients, although late toxicity may occasionally be significant. Only sites of disease recurrence need to be covered in the reirradiation fields.

Long-term outcome of concurrent chemotherapy and reirradiation for recurrent and second primary head-and-neck squamous cell carcinoma

PURPOSE

To define favorable pretreatment characteristics for overall survival (OS), progression-free survival (PFS), locoregional control, and freedom from distant metastasis for patients with recurrent and second primary head-and-neck cancer treated with concomitant chemotherapy and reirradiation.

METHODS AND MATERIALS

Our study population comprised a subset of 115 previously irradiated patients without overt metastases from 304 poor-prognosis head-and-neck cancer patients treated in seven consecutive phase I-II protocols. Of the 115 patients, 49, who had undergone surgical resection, were treated with a median of four cycles of concurrent chemotherapy and reirradiation and 66, who had not undergone surgical resection, were treated with a median of five cycles. The following regimens were used: 5-fluorouracil and hydroxyurea concurrent with reirradiation (FHX) (n=14), cisplatin plus FHX (n=23), paclitaxel plus FHX (n=42), gemcitabine plus paclitaxel and 5-fluorouracil concurrent with reirradiation (n=26), and irinotecan plus FHX (n=10).

RESULTS

The median lifetime radiation dose was 131 Gy. The median follow-up for surviving patients was 67.4 months (range, 18.5-158.7). The median OS and PFS was 11 and 7 months (range, 0.2-158.7), respectively. The 3-year OS, PFS, locoregional control, and freedom from distant metastasis rate was 22%, 33%, 51%, and 61%, respectively. Multivariate analysis identified reirradiation dose, triple agent (cisplatin-, paclitaxel-, or gemcitabine-containing chemotherapy), and surgery before protocol treatment as independently prognostic for OS, PFS, and locoregional control. Triple-agent chemotherapy was prognostic for freedom from distant metastasis. Nineteen patients died of treatment-related toxicity, five of these of carotid hemorrhage.

CONCLUSION

For recurrent and second primary head-and-neck cancer, trimodality therapy with surgery, concurrent chemotherapy, and reirradiation for a full second dose offers potential for long-term survival. Owing to the substantial toxicity and lack of an optimal regimen, reirradiation of recurrent head-and-neck cancer should be limited to clinical trials.

Treatment of recurrent head and neck cancer: re-irradiation or chemotherapy?

For most patients with head and neck cancer, locoregional disease recurrence carries an extremely poor prognosis and has severe adverse effects on quality of life. Only a few patients are suitable for salvage surgery and, even in selected cases, the success rate is low. Most patients are managed by supportive palliative care, or with palliative chemotherapy. In the UK, re-irradiation is rarely used because of concerns about treatment-related toxicity and lack of efficacy. Despite this, a significant body of evidence suggests that re-irradiation may have a higher probability of achieving local control than other treatments. In this review, we discuss the use of re-irradiation in patients with locally recurrent head and neck cancer, and present the pertinent data.

Reirradiation alternating with docetaxel and cisplatin in inoperable recurrence of head-and-neck cancer: a prospective phase I/II trial

PURPOSE

Inoperable locoregional recurrences of head-and-neck cancer in a previously irradiated volume represent a therapeutic dilemma. Chemotherapy alone has no curative potential, whereas reirradiation and concurrent chemoradiation can salvage a small fraction of patients. Mucosal toxicity of concurrent chemoradiation requires substantial dose reduction of chemotherapy. Alternating chemoradiation offers the chance to give both full-dose chemotherapy and radiotherapy. The latter may provide a particular advantage for recurrent, potentially radiation resistant tumors. The feasibility and efficacy of a full-dose docetaxel containing alternating chemoradiation schedule was tested.

PATIENTS AND METHODS

Twenty-seven patients (Karnofsky performance status score >/=70%) with histologically proven recurrent squamous cell cancer that occurred >/= 6 months in a previously irradiated area (>/= 60 Gy) were considered unresectable and unsuitable for brachytherapy. Alternating chemoradiation consisted of 3 cycles of docetaxel 60 mg/m(2) d1 and cisplatin 15 mg/m(2) d2-5, q d22, and involved field radiotherapy 2.0 Gy every day d8-12, d15-19, d29-33, and d36-40 (40.0 Gy total dose). Dose reduction of docetaxel to 50 mg/m(2) was necessary, because of hematologic toxicity in the first 12 patients.

RESULTS

Alternating chemoreirradiation was applied as planned in 12 of 27 patients, with reirradiation completed per protocol in 81%. Overall, patients received 83% of the intended dose of docetaxel and 73% of cisplatin. Third-degree common toxicity criteria mucositis occurred in 15%, leukopenia of >/= third degree by common toxicity criteria in 37%, and 3 early deaths were observed. Median time to follow-up, time to local progression, median survival, and 3-year survival rates were 42 months, 10 months, 10 months, and 18%, respectively.

CONCLUSIONS

Alternating chemoreirradiation in recurrences of head-and-neck cancer resulted in 80% overall response with acceptable toxicity. A significant minority of patients had durable tumor control with a chance of long-term survival.

Twice-daily reirradiation for recurrent and second primary head-and-neck cancer with gemcitabine, paclitaxel, and 5-fluorouracil chemotherapy

PURPOSE

We previously demonstrated the efficacy of concurrent gemcitabine, paclitaxel, and 5-fluorouracil in conjunction with twice-daily (1.5-Gy) radiotherapy delivered on alternating weeks (TFGX(2)) in locally advanced head-and-neck cancer. Here, we report the clinical outcome and late toxicity of TFGX(2) in a subset of patients previously irradiated to the head and neck.

METHODS AND MATERIALS

Twenty-nine previously irradiated patients, presenting with recurrent or second primary head-and-neck cancer, underwent TFGX(2). Twelve patients underwent attempted surgical resection before chemoradiotherapy, 10 of whom were left with no measurable disease. Patients with measurable disease received a median radiation dose of 72 Gy; those with no measurable disease received a median dose of 61 Gy. The cumulative dose ranged from 74.4 to 156.4 Gy (mean, 125.7 Gy; median, 131.0 Gy).

RESULTS

The median follow-up was 19.1 months (50.9 months for living patients). The 5-year overall survival rate was 34.5%, and the locoregional control rate was 54.5%. In patients with measurable disease at treatment, the 5-year overall survival and locoregional control rate was 26.3% and 45.1%, respectively, compared with 50.0% (p = 0.14) and 70% (p = 0.31), respectively, for those with no measurable disease. Measurable disease and radiation dose were highly statistically significant for overall survival and locoregional control on multivariate analysis. Of 14 patients assessable for late toxicity, 3 developed Grade 4-5, 8 Grade 2-3, and 3 Grade 0-1 toxicity.

CONCLUSION

Aggressive reirradiation with chemotherapy in locally advanced head-and-neck cancer provides a chance for long-term cure at the expense of toxicity. Attempted surgical resection before chemoradiotherapy improved disease control and survival.

Phase I Study of Concomitant Chemoradiotherapy with Irinotecan, 5-FU., and Hydroxyurea for Patients with Advanced and/or Recurrent Head and Neck Cancer

PURPOSE

We sought to investigate CPT-11 as a promising agent to our established regimen of 5-fluorouracil (5-FU), hydroxyurea, and hyperfractionated radiation therapy. A phase I study was conducted to determine the maximum tolerated dose and dose-limiting toxicities of this regimen.

PATIENTS AND METHODS

Eligible patients included patients with poor prognosis advanced head and neck cancer who required radiation therapy. All patients were treated on a 14-day cycle. Each patient received 5-FU (600 mg/m(2)/d), hydroxyurea (500 mg orally every 12 hours), radiation therapy twice daily (150 cGy each fraction), and CPT-11 at a starting dose of 5 mg/m(2)/d for 5 consecutive days followed by a 9-day break. CPT-11 was escalated in five mg/m(2)/d increments. Dose-limiting toxicity was defined as grade 4 hematologic toxicity, persistent grade 4 dermatitis and mucositis, grade 4 diarrhea despite maximal pharmacologic intervention, and inability to receive full-dose chemotherapy with the next cycle of treatment. Fourteen patients were treated at maximum tolerated dose to verify the recommended phase II dose.

RESULTS

Between August 1998 and August 2001, 31 patients with advanced and/or recurrent head and neck cancer were enrolled. Cohorts of nine, four, three, and 14 patients were treated at 5-, 10-, 15-, and 10-mg/m(2)/d dose levels of CPT-11. The 5- and 10-mg/m(2)/d dose levels were well tolerated All three patients treated at 15 mg/m(2)/d experienced neutropenic dose-limiting toxicity during cycles 1-2.

DISCUSSION

The maximum tolerated dose and recommended phase II dose of CPT-11 with hyperfractionated radiation therapy is 10 mg/m(2)/d.

Reirradiation of recurrent head and neck cancers with curative intent

In patients with recurrent, previously irradiated head and neck cancer, the traditional therapy of palliative single- or multi-agent chemotherapy yields a 30% to 40% response rate with median survival durations of 8 to 10 months. However, long-term survival is rarely observed. Reirradiation with or without concurrent chemotherapy is currently under investigation as a treatment option in these patients. While reirradiation without chemotherapy appears to be effective in recurrent nasopharynx cancer cases, the use of concomitant chemotherapy with reirradiation appears to offer improved outcomes based on phase I/II data in other head and neck sites. Recent studies indicate that long-term survival of patients is possible following reirradiation in a minority of cases despite severe acute and chronic toxicities. Reirradiation with chemotherapy is appropriate for patients with a goal of long-term local control of disease and curative intent, despite the risk of significant acute and late toxicities.