Stereotactic radiotherapy for locally recurrent nasopharyngeal carcinoma

CT-guided 125I brachytherapy for locally recurrent nasopharyngeal carcinoma

Purpose: The study evaluated the feasibility, clinical effectiveness, and quality of life of computed tomography (CT)-guided 125I brachytherapy for locally recurrent nasopharyngeal carcinoma (NPC). Methods: We recruited 81 patients diagnosed with locally recurrent NPC after previous radiotherapy with or without chemotherapy. Thirty-nine patients received 125I brachytherapy (group A) and 42 received re-irradiation (IMRT, group B). The evaluated outcomes were local control, complications, and quality of life. Cox proportional hazards regression analysis was used to compare local tumor progression-free survival (LTPFS) and overall survival (OS) in the two treatment groups. Results: The median follow-up was 30 months (range, 5-68 months), median LTPFS was 21 in group A and 17 months in group B. The 1-, 2-, and 3-year OS in group A were 84.6%, 51.3%, 30.7%, and 85.7%, 50.0%, and 32.6% in group B. In group A, 10/39 patients (25.6%) experienced at least one ≥grade III complication; no grade V complications occurred. In group B, 28/42 (66.7%) experienced at least one ≥grade III complication and 6/42 (14.3%) died of severe grade V complications. No significant between-group difference existed in the Quality of Life score on the EORTC QLQ-H&N35 questionnaire before treatment. In group A, quality of life was significantly improved after treatment; but did not improve, or even deteriorated in group B. Conclusions: 125I brachytherapy was a feasible, safe, and effective treatment for locally recurrent NPC. 125I brachytherapy significantly reduced complications caused by re-irradiation and improved patients' quality of life.

Recurrent nasopharyngeal carcinoma: current management approaches

OBJECTIVES

Providing the primary recurrence is localized, salvage treatment is possible for nasopharyngeal carcinoma (NPC). This is a review of the experience of retreatment of this malignancy highlighting the roles of surgery and repeat radiotherapy.

METHODS

The Tumor Registry of the Prince of Wales Cancer Centre was audited for patients with an initial diagnosis of squamous/nonsquamous cell NPC who had primary treatment with radiotherapy, and now presented for retreatment. Features relating to patient, disease and treatment factors were evaluated. The primary end point was subsequent local control, and secondary endpoints were overall and cancer-specific survival.

RESULTS

Over a 30-year period 39 patients were eligible, with 25 receiving both primary and retreatment at Prince of Wales Hospital. There were 25 males and 14 females with a median age of 50 years. Thirty-six patients had radiotherapy, 4 had stereotactic radiosurgery, 5 had brachytherapy, and the remainder had external treatment. Surgery was performed in 10 patients, of whom 3 had this as the only retreatment modality. Radiotherapy doses for retreatment ranged from 15 Gy (stereotactic radiosurgery) to 71.28 Gy (mean fractionated dose). Local control was achieved in 16 patients giving an overall rate of 41.0%, and the 5-year overall survival rate was 33.3%. Treatment modality was a significant prognostic factor for local control (P < 0.001) and cancer-specific survival (P < 0.05).

CONCLUSION

The presence of local recurrence after definitive treatment of NPC may still be salvageable. The best outcomes with reirradiation occur in the context of limited volume recurrence and a disease-free interval greater than 18 months.

Comparison of single versus fractionated dose of stereotactic radiotherapy for salvaging local failures of nasopharyngeal carcinoma: a matched-cohort analysis

BACKGROUND

Local failure is an important cause of morbidity and mortality in nasopharyngeal carcinoma (NPC). Although surgery or brachytherapy may be feasible in selected cases, most patients with local failure require external beam re-irradiation. Stereotactic radiation using single or multiple fractions have been employed in re-irradiation of NPC, but the optimal fractionation scheme and dose are not clear.

METHODS

Records of 125 NPC patients who received salvage stereotactic radiation were reviewed. A matched-pair design was used to select patients with similar prognostic factors who received stereotactic re-irradiation using single fraction (SRS) or multiple fractions (SRM). Eighty-six patients were selected with equal number in SRS and SRM groups. All patients were individually matched for failure type (persistent or recurrent), rT stage (rT1-2 or rT3-4), and tumor volume (< or = 5 cc, >5-10 cc, or >10 cc). Median dose was 12.5 Gy in single fraction by SRS, and 34 Gy in 2-6 fractions by SRM.

RESULTS

Local control rate was better in SRM group although overall survival rates were similar. One- and 3-year local failure-free rates were 70% and 51% in SRS group compared with 91% and 83% in SRM group (p = 0.003). One- and 3-year overall survival rates were 98% and 66% in SRS group compared with 78% and 61% in SRM group (p = 0.31). The differences in local control were mainly observed in recurrent or rT2-4 disease. Incidence of severe late complications was 33% in SRS group vs. 21% in SRM group, including brain necrosis (16% vs. 12%) and hemorrhage (5% vs. 2%).

CONCLUSION

Our study showed that SRM was superior to SRS in salvaging local failures of NPC, especially in the treatment of recurrent and rT2-4 disease. In patient with local failure of NPC suitable for stereotactic re-irradiation, use of fractionated treatment is preferred.

Fractionated stereotactic radiotherapy as reirradiation for locally recurrent head and neck cancer

PURPOSE

We report early preliminary experience with CyberKnife radiosurgery (RS) as salvage treatment for locally recurrent head and neck cancer (HNC).

METHODS AND MATERIALS

Between March 2004 and August 2006, 36 patients (44 sites) were treated with CyberKnife RS as reirradiation for locally recurrent HNC. Treatment sites were as follows: nasopharynx (8), maxillary sinus (8), neck lymph nodes (8), skull base (7), nasal cavity (4), retropharyngeal lymph nodes (3), orbit (2), and others (4). Total doses administered were 18-40 Gy (median, 30 Gy) in 3 to 5 fractions to the 65%-85% isodose line for 3-5 consecutive days. Previous external radiation dose ranged from 39.6 to 134.4 Gy (median, 70.2 Gy). Gross tumor volume ranged from 0.2 to 114.9 cm(3) (median, 22.6 cm(3)). Median follow-up was 17.3 months.

RESULTS

Thirty-five of 44 sites were evaluated for response. Fifteen (42.9%) sites achieved complete response, 13 sites (37.1%) achieved a partial response, 3 (8.6%) sites maintained stable disease, and 4 sites (11.4%) showed tumor progression. Grade III acute complications were noted in 13 patients. Late complications were observed in three patients (1 bone necrosis, 2 soft tissue necrosis) during follow-up.

CONCLUSION

These preliminary results suggest that fractionated stereotactic radiosurgery is an effective treatment modality as a salvage treatment with good short-term local control. The early overall response rate is encouraging. However, more experience and a longer follow-up are necessary to determine the role of fractionated stereotactic radiosurgery as a salvage treatment of locally recurrent HNC and to define long-term complications.

Stereotactic radiosurgery as a salvage treatment for recurrent epipharyngeal carcinoma

Fourteen patients with recurrent epipharyngeal carcinoma (EPC) were treated by gamma knife stereotactic radiosurgery. The tumor volume ranged from 0.3 to 80 ml (median 18.9 ml). Treatment was done with a tumor margin dose of 10-27 Gy (median 15 Gy). The median follow-up period was 15 months (range 2-47 months). Ten patients were alive and 4 were dead at the end of the follow-up period. In 6 patients (43%), the tumor disappeared or decreased in size until the end of the follow-up period. In 2 (14%), the tumor remained unchanged in size. In 6 (43%), the tumor showed regression initially but was enlarged later. A second radiosurgery was performed in 4 of those 6 cases and the tumor decreased in size again in 3 of them. Thus, the overall control rate of local tumor was 79% (11/14). In selected patients with recurrent EPC, stereotactic radiosurgery can be considered as a salvage treatment producing local control.

Dosimetric and clinical results of three-dimensional conformal radiotherapy for locally recurrent nasopharyngeal carcinoma

PURPOSE

To assess the dosimetric and clinical results of three-dimensional conformal radiotherapy (3D CRT) for locally recurrent nasopharyngeal carcinoma (NPC).

METHODS

A total of 86 patients with locally recurrent NPC were retreated with 3D CRT. The median prescribed dose was 68 Gy with 2 Gy per fractionation. Dosimetric quality was evaluated with dose distribution in planning target volume (PTV) and specified organs at risk (OAR), dose conformity index (CI) and dose homogeneity index (HI). The actuarial rate of local failure-free (LFF), overall survival (OS) and major late toxicities (MLT) were estimated with Kaplan-Meier method. Multivariate analysis for prognosis was performed using the Cox regression proportional hazards model.

RESULTS

The mean dose to PTV averaged 66.8 Gy, and the dose to specified OAR was acceptable. The average value of CI and HI was 0.59 and 9.1%. The 5-year actuarial rate of LFF and OS was 71 and 40%, respectively. The 5-year actuarial incidence of MLT>or=Grade 3 and >or=Grade 4 were 100 and 49%, respectively. The major prognostic factors were T stage and the size of gross tumor volume (GTV). Advanced T stage and large GTV volume were associated with poor LFF and OS and high risk of MLT.

CONCLUSION

The dosimetric quality of 3D CRT for locally recurrent NPC is generally excellent. A relatively high local control was achieved with this technique. However, the incidence of late toxicities were not found to decrease as originally expected. Early diagnosis of the recurrence and reasonable definition of the target volume are crucial to achieve a better outcome.

Linear accelerator-based stereotactic radiosurgery for limited, locally persistent, and recurrent nasopharyngeal carcinoma: efficacy and complications

PURPOSE

To evaluate the efficacy and complication of linear accelerator-based stereotactic radiosurgery (SRS) when used as salvage treatment for early-stage persistent and recurrent nasopharyngeal carcinoma (NPC) after primary radiotherapy (RT).

MATERIALS AND METHODS

Between March 1998 and June 2001, 18 patients (15 men and 3 women; median age 46 years, range 32-84) with locally persistent or recurrent NPC confined to the nasopharynx (rT1) or with limited extension to the nasal fossa or parapharyngeal space (rT2) were treated by SRS. Thirteen patients had rT1 disease and 5 had rT2 disease. Most patients had disease not amenable to surgery or brachytherapy. All patients had undergone previous radical RT. Persistent disease was defined as tumor relapse within 4 months of completion of primary RT, and recurrence as tumor relapse beyond 4 months. Seven patients were treated for persistent disease, eight for a first recurrence, and three for a second recurrence. SRS was performed using multiple noncoplanar arcs of photons delivered to the target volume, which was defined by axial CT at a 3 mm thickness, supplemented by MRI in selected patients (67%). The median target volume was 5.3 cm(3) (range 2.2-16.9). The median SRS dose was 12.5 Gy (range 11-14) delivered to the 80% isodose line. All patients underwent serial nasopharyngoscopy and imaging after SRS. The median follow-up was 26 months (range 11-48).

RESULTS

After SRS, 16 (89%) of 18 patients had complete regression of tumor as assessed by nasopharyngoscopy and biopsy. Four patients with an initial complete response to SRS subsequently developed local relapse again, with one recurrence developing outside the target volume 8 months after SRS and three within the target volume at 6-26 months after SRS. Two patients with local disease controlled by SRS developed relapse in other sites (neck node and liver metastases). The actuarial 2-year local control rate after SRS was 72%. Patients treated for persistent disease had a better local control rate (100%; 7 of 7) than those treated for recurrent disease (46%; 5 of 11). Patients with rT1 disease also had a better outcome after SRS compared with those with rT2 disease, with a control rate of 77% (10 of 13) for rT1 disease and 40% (2 of 5) for rT2 disease. Treatments were well tolerated, with no acute side effects. One patient had radiologic evidence of temporal lobe necrosis, although the right temporal lobe had already received a high dose during prior RT. That patient also developed additional local recurrence and liver metastases and died. The actuarial 2-year survival rate was 86%.

CONCLUSIONS

Our preliminary results indicate that SRS is an effective treatment modality for persistent and recurrent early-stage NPC, with early control rates comparable to other salvage treatments such as brachytherapy and nasopharyngectomy. A modest SRS dose at 12.5 Gy also appears to be effective and is associated with minimal morbidities. More clinical experience and longer follow-up are needed to validate our results and to address fully the role of SRS in salvaging local failures of NPC.

Role of endocavitary brachytherapy with or without chemotherapy in cancer of the nasopharynx

PURPOSE

We previously reported our preliminary experience with nasopharyngeal cancer boosted after 60-70 Gy external beam radiotherapy (EBRT) by fractionated endocavitary brachytherapy (ECBT) to cumulative doses of 78-82 Gy. As for Stage III-IVB disease, cisplatin (CDDP)-based neoadjuvant chemotherapy (CHT) was given. The aim of the present study was to define the role of ECBT more accurately.

METHODS AND MATERIALS

Ninety-one patients with primary nasopharyngeal cancer, staged according to the 1997 UICC/AJCC classification system, were treated between 1991 and 2000 with 60-70 Gy external beam radiotherapy and 11-18 Gy ECBT. Of the 91 patients, 21 were treated in conjunction with CHT and 70 without CHT. Tumors were subdivided into undifferentiated (UD) and well, moderately, and poorly differentiated (WMP-D) subtypes. Treatment results were analyzed for local control (LC), disease-free survival (DFS), freedom from distant metastasis, and overall survival (OS).

RESULTS

A univariate and multivariate Cox regression analysis found stage, treatment period, age, and grade significant for LC, DFS, and OS. At 2 years, for Stage I-IIB (1st period, 1991-1996), the LC, DFS, and OS were 96%, 88%, and 80%, respectively, vs. 65%, 46%, and 52% for Stage III-IVB. For the 2nd treatment period (1996-2000; CHT for Stage III-IVB), the LC, DFS, and OS at 2 years was 100%, 90%, and 61% (Stage I-IIB), respectively, vs. 86%, 74%, and 66% (Stage III-IVB). Three prognostic groups (PGs) were constructed. For the 1991-1996 period, at 2 years, patients in the good PG (UD Stage I-IIB disease) had 100% LC and 92% OS; those in the intermediate PG (UD Stage III-IVB or WMP-D Stage I-IIB), had 94% LC and 71% OS; and those in the poor PG (WMP-D Stage III-IVB) had 47% LC and 40% OS. For the 1996-2000 period, at 2 years, the good PG had 100% LC and 88% OS; the intermediate PG had 100% LC and 64% OS; and the poor PG had 71% LC and 60% OS.

CONCLUSION

For Stage I-IIB disease treated between 1991 and 2000, at 3 years, the LC and OS was 97% and 67%, respectively. The results with 77-81 Gy without CHT warrant EBRT combined with ECBT to remain our standard of care for Stage I-IIB disease. For N2-3 and/or T3-4 tumors, in addition to high doses of RT, neoadjuvant CHT was administered as of 1996. For the 1991-2000 period, at 3 years, the LC was 86% and the OS was 72% with CHT, with little extra morbidity; they were 68% and 35% without CHT. Because of better target coverage and sparing, T3-4 tumors are currently boosted by stereotactic RT to 81.2 Gy.

Chemotherapy and high–dose-rate brachytherapy in the management of advanced cancers of the nasopharynx

PURPOSE

The aim of this study was to calculate the costs of chemotherapy and high-dose-rate brachytherapy in advanced-stage nasopharyngeal cancer. It is argued whether the effect of chemotherapy and this type of high-dose, high-precision radiation therapy is worth the costs.

METHODS AND MATERIALS

Clinical results of Stage III-IVB nasopharyngeal cancer in patients treated between 1991 and 2000 are reported. Treatment was broken down into five categories: workup, chemotherapy, preparation of radiation therapy, and application of radiation. For each category, costs were computed. Nasopharyngeal cancer treatment costs were compared with costs previously reported on patients treated for cancers of the oral cavity, larynx, and oropharynx.

RESULTS

With the addition of neoadjuvant chemotherapy and high cumulative doses of radiation (77-81 Gy) with brachytherapy, disease-free survival increased from 48% to 74% (p=0.002), and overall survival increased from 35% to 72% (p=0.005). The Rotterdam protocol has been implemented stepwise: as of 1991, costs per patient increased from 4521 Euros (US$5023; 2001 exchange rate [December]: 1 Euro approximately 0.88 US$) for conventional external beam radiation therapy to 13,728 Euros (US$15,253) in 2000 for combinations of chemotherapy, conventional external beam radiation therapy, and brachytherapy. In case of stereotactic radiotherapy, the cost was 14,516 Euros (US$16,495).

CONCLUSIONS

Costs for cancer in the nasopharynx vary from 14,528 Euros (US$16,509) to 15,316 Euros (US$17,405) in case of brachytherapy and stereotactic radiotherapy, respectively, if follow-up costs are added. The treatment cost for other head and neck sites was 21,858 Euros (US$24,126). Given the improvement in survival, the sparing capabilities of current high-dose, high-precision radiotherapy techniques, and the favorable cost profile compared with other sites, it is argued that costs should not be considered prohibitive for the introduction of chemotherapy and high-technology-based radiotherapy in advanced nasopharyngeal cancer.

Salvage treatment for persistent and recurrent T1-2 nasopharyngeal carcinoma by stereotactic radiosurgery

OBJECTIVE

To study the efficacy of stereotactic radiosurgery in salvaging early-stage persistent and recurrent nasopharyngeal carcinoma (NPC) after primary radiotherapy.

METHODS

A prospective single-arm study evaluating the response and outcome of patients with rT1-2 NPC treated by stereotactic radiosurgery. Eleven patients with rT1-2 were treated by radiosurgery between March 1998 and March 2000. Four patients were treated for persistent disease occurring within 4 months after primary radiotherapy, six were treated for first recurrence, and one for third recurrence. Six patients had rT1 disease and five had rT2 disease. Most patients had disease not amenable to brachytherapy, surgery, or external re-irradiation. The median target volume was 5.8 cc (range, 3.3-16.9). Radiosurgery was performed with multiple noncoplanar arcs of photon, with a median dose of 12.5 Gy delivered to the 80% isodose line (range, 12-14 Gy). Median follow-up time after radiosurgery was 18 months (range, 9-30).

RESULTS

Nine patients had complete regression of tumor as assessed by imaging, nasopharyngoscopy, and biopsy; one patient had partial regression of tumor; whereas one patient had static disease. The overall response rate was 91% (10 of 11) and the complete response rate was 82% (9 of 11). Two patients with complete response subsequently had local relapse develop, with one recurrence outside the treated volume 8 months after radiosurgery, and the other within the treated volume 6 months after radiosurgery. One patient with a partial response had neck node recurrence develop. Temporal lobe necrosis occurred in one patient but probably represents sequelae of primary radiation after reviewing the dosimetry. Ten patients are still alive, whereas one patient with local relapse had distant metastases develop and died. The estimated 1-year local control rate after radiosurgery was 82%.

CONCLUSIONS

Our preliminary results indicate that stereotactic radiosurgery is an effective treatment modality for persistent and recurrent T1-T2 NPC, and early control rate seems to be comparable to other salvage treatments. More clinical experiences and longer follow-up are still needed to validate our results and to address fully the role of radiosurgery in salvaging local failures of NPC.

Fractionated stereotactic radiosurgery for 50 patients with recurrent or residual nasopharyngeal carcinoma

PURPOSE

This study was conducted to evaluate the clinical value of fractionated stereotactic radiosurgery (FSRS) as a boost treatment in 44 patients with residual or recurrent nasopharyngeal carcinoma after conventional radiotherapy (70-80 Gy) or a second course of radiotherapy (50 Gy) or as salvage treatment in 6 patients with recurrent nasopharyngeal carcinoma after a first or second course of radiotherapy at the primary site.

METHODS AND MATERIALS

From September 20, 1995 to December 30, 1998, 50 patients were treated with FSRS with 6 MV of photons. The total FSRS dose was 14-35 Gy (median dose 24) prescribed at 1-4 centers on the 60-90% isodose curves normalized to the isocenter by multiple fractions of 6-8, 12, or 15 Gy, with interfraction intervals of 4-6 days.

RESULTS

Thirty-eight patients (76%) had a complete tumor response, 9 (18%) had a partial response, and 3 (6%) were not assessable. The overall rate of survival was 83.6% at 1 year, 65.0% at 2 years, and 59.6% at 3 years. The overall disease-free survival rate among patients with residual tumor was 89.94% at 1 year, 73.97% at 2 years, and 73.97% at 3 years. Patients who were treated for recurrent lesions or who received FSRS as salvage therapy had a 46.53% rate of disease-free survival at both 1 and 2 years after therapy.

CONCLUSION

FSRS is strongly indicated for recurrent or residual nasopharyngeal carcinoma at the primary site.