Treatment of locally recurrent carcinoma of the nasopharynx

Features and Management of Osteoradionecrosis of the Skull Base A Systematic Review and Meta-Analysis

BACKGROUND

Skull base osteoradionecrosis (SBORN) is a rare but potentially devastating consequence of radiotherapy (RT) for head and neck tumors. This study aims to synthesize existing literature and analyze treatment outcomes among patients with SBORN.

METHODS

A systematic literature search was conducted following PRISMA guidelines. Adult patients with SBORN were included. Random effects modeling was used for meta-analysis.

RESULTS

Overall, 29 studies with 593 patients were included. Mean time to presentation of SBORN following RT was 84.3 months. Analysis of treatment modalities revealed 165 patients underwent conservative management, 258 surgery without free flap reconstruction, and 101 surgery with free flap reconstruction. Meta-analysis demonstrated a significantly lower death rate in patients who underwent free tissue transfer, compared to those who were managed conservatively (p < 0.01).

CONCLUSIONS

SBORN represents a challenging complication following radiotherapy of head and neck tumors. The consequences can be catastrophic; therefore, prompt identification and treatment are key. The use of vascularized free tissue transfer for patients with significant structural defects from SBORN may improve survivorship compared to conservative treatment measures; however, further research on treatment outcomes is warranted.

Aggressive Treatment Including Endonasal Surgical Sequestrectomy with Vascularized Nasoseptal Flap Can Improve Outcomes of Skull Base Osteoradionecrosis

Objective  Skull base osteoradionecrosis (SB-ORN) is a serious, potentially lethal complication of radiation therapy. We aimed to review the clinical characteristics and outcomes of SB-ORN according to the extent of treatment. Design  Retrospective analysis design was used for this study. Setting  The study was conducted in two tertiary care hospitals. Participants  Patients included who had been clinically diagnosed with SB-ORN from January 2006 to 2017. Main Outcome Measures  Clinical characteristics, including demographics, predisposing factors, presenting symptoms, radiological findings, treatment modalities, and treatment outcomes, were reviewed. Treatment was classified into conservative and aggressive types. Aggressive treatment included radical surgical removal of soft tissue and bony sequestrum with the placement of vascularized tissue. Treatment outcome was analyzed in terms of clinical control, survival, and carotid artery blow out. Results  Fifteen patients (11 males and 4 females) were identified during the study period. Eight patients were managed conservatively, whereas seven patients were managed with aggressive treatment. The 2-year survival was 75% in the aggressive treatment group and 15% in the conservative group (log-rank, p  = 0.049). The estimated 2-year blow out free rate was 46.7% for the conservative group and 100% for the aggressive group (log-rank, p  = 0.100). Conclusion  In patients with SB-ORN, aggressive management, including surgical removal of sequestrum and coverage with a pedicled flap, is associated with increased survival.

Outcomes for the treatment of locoregional recurrent nasopharyngeal cancer: Systematic review and pooled analysis

Despite advances in the treatment of primary nasopharyngeal carcinoma, locoregional recurrence (lrNPC) occurs at 10%-50% at 5 years. This review aims to evaluate salvage treatment for locally recurrent nasopharyngeal cancer. A literature search for all original articles published on the treatment of lrNPC from January 1990 to January 2021 was conducted. Pooled analysis was performed using a random effects model and assessed statistical heterogeneity of the combined results with I2 index. Overall, 66 studies were included for analysis. A total of 5286 patients treated with intensity-modulated radiation therapy (39%), conformal radiotherapy (31%), open nasopharyngectomy (12%), endoscopic nasopharyngectomy (10%), stereotactic radiosurgery (4%), and brachytherapy (4%) were included. Surgical therapy has similar overall survival outcomes to re-irradiation but with decreased treatment-related morbidity and mortality. Both surgical and re-irradiation for lrNPC have similar long-term survival. Surgical approaches to lrNPC may offer similar survival while avoiding treatment-associated morbidity and mortality.

Osteoradionecrosis of the skull base

Radiation therapy (RT) is often necessary for the treatment of head and neck cancers. Osteoradionecrosis (ORN) is a rare, but potentially serious complication of RT. RT leads to the destruction of vasculature in radiated tissue causing hypoxia and tissue necrosis. ORN can occur in any bone, but bones with naturally poor blood supply appear to be more susceptible. Bones of the skull base are susceptible, with ORN occurring in the anterior, central, and lateral skull base. Risk factors include cancer type and location, radiation dose, and a variety of patient factors. Patients often present with pain, bleeding, and foul odor and are typically found to have exposed and necrotic bone. Treatment options vary depending on the severity, but typically include pentoxifylline and vitamin E as well as surgical debridement, with less evidence supporting hyperbaric oxygen therapy. Recognition and prompt treatment of ORN will allow for improved patient outcomes.

Preserving the legacy of reirradiation: A narrative review of historical publications

PURPOSE

The purpose of this study is to illustrate the historical development of reirradiation during several decades of the 20th century, in particular between 1920 and 1960.

METHODS AND MATERIALS

We chose the format of a narrative review because the historical articles are heterogeneous. No systematic extraction of baseline data, treatment details, or follow-up care was possible in many cases.

RESULTS

Both hematological malignancies and solid tumors were treated with a second course of radiation therapy, and indications included local relapse, regional nodal recurrence, and second primary tumors developing in a previously treated region. The literature consists of retrospective single-institution analyses describing treatment approaches that included external beam radiation therapy, brachytherapy, or combinations thereof. Data on toxicities and survival were often provided. Breast cancer and gynecological, head and neck, brain, and skin tumors are among the entities included in this review.

CONCLUSIONS

The leading pioneers in the field are fully aware of many of the challenges we continue to debate today. These include the process of late tissue changes and development of personalized treatment approaches and better ways to select patients who are likely to benefit from a second course of radiation therapy.

Chemoradiotherapy for locally recurrent nasopharyngeal carcinoma: treatment outcome and prognostic factors

OBJECTIVE

To evaluate the treatment outcome of patients with locally recurrent nasopharyngeal carcinoma (NPC) treated with re-irradiation and chemotherapy.

METHODS

Between 1991 and 2004, 36 patients with locally recurrent NPC received re-irradiation and chemotherapy. The median re-irradiation dose was 37.9 Gy; the median total dose of prior irradiation and re-irradiation was 104.4 Gy. The outcome is studied retrospectively and also evaluated the prognostic factors and toxicities.

RESULTS

With a median follow-up of 40 months, 3-year overall survival (OS) was 58.3% and 3-year progression-free survival (PFS) was 25.0%. Patients aged <50 and of early stage at recurrence had a significantly better OS and PFS. Over Grade 3 of late toxicities were seen in patients received a total dose of >110 Gy.

CONCLUSIONS

Age and stage at recurrence were identified as prognostic factors for OS and PFS. Patients received external beam radiation therapy at a total dose of more than 110 Gy should be careful for severe late toxicities, and it is thought to be the optimal dose for recurrent tumor.

Final report of RTOG 9610, a multi-institutional trial of reirradiation and chemotherapy for unresectable recurrent squamous cell carcinoma of the head and neck

BACKGROUND

Our objectives were to determine the incidence of acute and late toxicities and to estimate the 2-year overall survival for patients treated with reirradiation and chemotherapy for unresectable squamous cell carcinoma of the head and neck (SCCHN).

METHODS

Patients with recurrent squamous cell carcinoma or a second primary arising in a previously irradiated field were eligible. Four weekly cycles of 5-fluorouracil 300 mg/m2 IV bolus and hydroxyurea 1.5 g by mouth were used with 60 Gy at 1.5 Gy twice-daily fractions. Toxicity was scored according to Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer (RTOG/EORTC) criteria.

RESULTS

Seventy-nine of the 86 patients enrolled were analyzable. The worst acute toxicity was grade 4 in 17.7% and grade 5 in 7.6%. Grade 3 and 4 late toxicities were found in 19.4% and 3.0%, respectively. The estimated cumulative incidence of grade 3 to 4 late effects occurring at >1 year was 9.4% (95% confidence interval [CI]: 0, 19.7) at 2 and 5 years. The 2- and 5-year cumulative incidence for grade 4 toxicity was 3.1% (95% CI: 0, 9.3). The estimated 2- and 5-year survival rates were 15.2% (95% CI: 7.3, 23.1) and 3.8% (95% CI: 0.8, 8.0), respectively. Patients who entered the study at >1 year from initial radiotherapy (RT) had better survival than did those who were <1 year from prior RT (median survival, 9.8 months vs 5.8 months; p = .036). No correlation was detected between dose received and overall survival. Three patients were alive at 5 years.

CONCLUSION

This is the first prospective multi-institutional trial testing reirradiation plus chemotherapy for recurrent or second SCCHN. The approach is feasible with acceptable acute and late effects. The results serve as a benchmark for ongoing RTOG trials.

Les carcinomes du nasopharynx : de la biologie à la clinique

Nasopharyngeal carcinomas (NPC) are very different from other head and neck cancers because of their specific multifactorial etiology and their geographic distribution. Epstein-Barr Virus (EBV) is implicated in oncogenesis of NPC in association with genetic alterations such as inactivation of the p16/Ink4, p19/ARF, RASSF1 or Blu genes. Tumoral tissues include a very abundant characteristic lymphoid infiltrate. Inflammatory cytokines are produced by both malignant and infiltrating cells. There is no efficient immune response against the tumor. On the opposite, infiltrating lymphocytes might play a role in tumor development. Serological methods and detection of circulating viral DNA are expected to become useful for early detection of relapse and on a longer term for primary screening. NPC are often diagnosed at a late stage because patients may remain asymptomatic for a long time. Computed tomography (CT scan) and magnetic resonance imaging (MRI) are complementary for the initial evaluation. Positron emission tomography (PET) is efficient for the evaluation of treatment efficiency and detection of relapses. Treatment is based on radiotherapy and chemotherapy. Their optimal use needs to be evaluated by phase III trials but positive results have been obtained by concomitant association of radiotherapy and chemotherapy. Targeted therapies are being studied with strategies based on disruption of viral latency, use of replicative adenoviruses or anti-tumor vaccination.

Reirradiation for locally recurrent nasopharyngeal carcinoma: Treatment results and prognostic factors

PURPOSE

To analyze the results and evaluate the prognostic factors in the retreatment of locally recurrent nasopharyngeal carcinoma.

METHODS AND MATERIALS

Forty-one patients with locally recurrent nasopharyngeal carcinoma, who were reirradiated between 1979 and 2000, were retrospectively analyzed. There were 32 men and 9 women with median age of 46 years. Histologically, 9 tumors (22%) were World Health Organization (WHO) I, 17 (41.5%) WHO II, and 15 (36.5%) WHO III. According to the 1998 TNM staging system of the American Joint Committee on Cancer, the recurrent disease was Stage I in 5 (12.2%), Stage II in 11 (26.8%), Stage III in 6 (14.6%), and Stage IV in 19 (46.4%) patients. Treatment was delivered with 4-6 MV X-rays or Co-60 gamma rays. The median reirradiation dose was 50 Gy. Treatment was delivered at 1.8-2 Gy/fraction daily, 5 days a week. Chemotherapy was used in 41.5% of the patients.

RESULTS

Median follow-up was 23 months (range, 3-143 months). The 2-year and 5-year local progression-free and overall survival rates were 39%, 23%, 48%, and 28%, respectively. On univariate analysis, age (p = 0.04), total reirradiation dose (p = 0.0008) were significant prognostic factors for local progression-free rate. For overall survival age, total reirradiation dose, stage, T stage were significant. On multivariate analysis only total dose (p = 0.005) remained significant for local progression-free rate and total reirradiation dose (p = 0.02), interval to recurrence (p = 0.03), stage (p = 0.018) were significant for overall survival.

CONCLUSIONS

Early diagnosis of local recurrence and high-dose reirradiation (60 Gy) are crucial for improving the local control and survival.

Intraoperative radiation therapy in the multimodality approach to upper aerodigestive tract cancer

The cure rate of operable lung cancer and locally advanced head and neck cancer remains suboptimal, with a limited rate of local control despite improvements in the surgical removal of primary tumors and in methods for mediastinal lymph node dissection, in particular. The efficacy of adjuvant therapy, such as EBRT, has improved, and the immediate efficacy of new chemotherapeutic drugs is increasingly significant, although local recurrences remain frequent. Locoregional failure is not uncommon in upper aerodigestive tract cancers. Factors limiting radiocurability for locally advanced (stage III) lung cancer include mediastinal intolerance of irradiation (high risk of mediastinal fibrosis, which increases exponentially when levels of much more than 50 Gy are administered to the whole mediastinum) and the very high radiosensitivity of the healthy lung, which can develop fibrosis with relatively small or moderate doses starting at 18 to 20 Gy, and even more frequently when larger volumes are irradiated. Head and neck neoplasms are less difficult sites in which to administer doses of up to 70 Gy of external beam radiotherapy initially, but, like locoregionally recurrent lung cancers, they are not easily reirradiated with tumoricidal doses of EBRT. For these reasons, IORT seems to be a good option for increasing local control, because areas of [figure: see text] residual microscopic disease may be irradiated using IOERT approaches without affecting critical organs to the same extent. In addition, careful patient selection is paramount. Combined modality treatment regimens incorporating IORT may benefit patients with locally advanced disease. The ability of IORT to sterilize microscopic residual disease can enhance the "completeness" of resection and thus, theoretically, improve local control. Although distant disease dissemination remains by far the overriding issue, as newer effective agents emerge, local failure will continue to be a problem. Preliminary studies have demonstrated that IORT can be administered to patients who have locally advanced NSCLC and head and neck cancer, in the context of aggressive combined modality therapy, and is generally well tolerated. Long-term efficacy and benefit can only be determined in the setting of carefully designed clinical trials. (See the article by Thomas and Merrick elsewhere in this issue for further discussion of this topic.) Several relatively small, single-institution pilot studies exploring the utility and benefit of IORT for locally advanced upper aerodigestive tract cancers have been conducted. Clear conclusions have been difficult to determine because of the mixing of disease stages, varying degrees and completeness of surgical resection, varying radiation doses, different schemas, and other factors. Yet, given the major morbidity and mortality associated with locally recurrent lung cancer, methods of improving local control need to be pursued and refined. Encouraging preliminary data suggest that IOERT can be safely administered and may benefit local control. Based on several centers' expertise in the combined modality treatment of locally advanced lung cancer and familiarity with IORT, the UCSF Thoracic Oncology Program has proposed a multicenter phase 2 study incorporating IORT in a combined multimodality treatment schema for patients who have completely resected locally advanced stage IIIA and IIIB NSCLC (nonpleural effusion, non-N3) (Fig. 1). It is hoped that this study will commence in the upcoming year.

Initial experience using intensity-modulated radiotherapy for recurrent nasopharyngeal carcinoma

PURPOSE

To report our initial experience on the feasibility, toxicity, and tumor control using intensity-modulated radiotherapy (IMRT) for retreatment of recurrent nasopharyngeal carcinoma (NPC).

METHODS AND MATERIALS

A total of 49 patients with locoregional recurrent carcinoma in the nasopharynx were treated with IMRT between January 2001 and February 2002 at the Sun Yat-Sen University Cancer Center, Guangzhou, China. The average time to the nasopharyngeal recurrence was 30.2 months after initial conventional RT. The median isocenter dose to the nasopharynx was 70 Gy (range 60.9-78.0) for the initial conventional RT. All patients were restaged at the time of recurrence according to the 1992 Fuzhou, China staging system on NPC. The number of patients with Stage I, II, III and IV disease was 4, 9, 10, and 26, respectively. T1, T2, T3, and T4 disease was found in 4, 9, 11, and 25 patients, respectively. N0, N1, N2, and N3 disease was found in 46, 2, 0, and 1 patient, respectively. Invasion of the nasal cavity, maxillary sinus, ethmoid sinus, sphenoid sinus, and cavernous sinus and erosion of the base of the skull was found in 8, 1, 3, 8, 15, and 20 patients, respectively. The gross tumor volume (GTV) was contoured according to the International Commission on Radiation Units and Measurements (ICRU) Report 62 guidelines. The critical structures were contoured, and the doses to critical structures were constrained according to ICRU 50 guidelines. The GTV in the nasopharynx and positive lymph nodes in the neck received a prescription dose of 68-70 Gy and 60 Gy, respectively. All patients received full-course IMRT. Three patients who had positive lymph nodes were treated with five to six courses of chemotherapy (cisplatin + 5-fluorouracil) after IMRT.

RESULTS

The treatment plans showed that the percentage of GTV receiving 95% of the prescribed dose (V(95-GTV)) was 98.5%, and the dose encompassing 95% of GTV (D(95-GTV)) was 68.1 Gy in the nasopharynx. The mean dose to the GTV was 71.4 Gy. The average doses of the surrounding critical structures were much lower than the tolerable thresholds. At a median follow-up of 9 months (range 3-13), the locoregional control rate was 100%. Three cases (6.1%) of locoregional residual disease were seen at the completion of IMRT, but had achieved a complete response at follow-up. Three patients developed metastases at a distant site: two in the bone and one in the liver and lung at 13 months follow-up. Acute toxicity (skin, mucosa, and xerostomia) was acceptable according to the Radiation Therapy Oncology Group criteria. Tumor necrosis was seen toward the end of IMRT in 14 patients (28.6%).

CONCLUSION

The improvement in tumor target coverage and significant sparing of adjacent critical structures allow the feasibility of IMRT as a retreatment option for recurrent NPC after initial conventional RT. This is the first large series using IMRT to reirradiate local recurrent NPC after initial RT failed. The treatment-related toxicity profile was acceptable. The initial tumor response/local control was also very encouraging. In contrast to primary NPC, recurrent NPC reirradiated with high-dose IMRT led to the shedding of tumor necrotic tissue toward the end of RT. More patients and longer term follow-up are warranted to evaluate late toxicity and treatment outcome.

Nasopharyngeal carcinomas: an update

Among the group of head and neck cancers, nasopharyngeal carcinomas (NPC) represent a distinct entity in terms of their epidemiology, clinical presentation, biological markers, carcinogenic risk factors, prognostic factors, treatment and outcome. Undifferentiated NPC (UCNT), the most frequent histological type, is endemic in certain regions, especially in South East Asia. The disease has also been associated with the presence of the Epstein-Barr Virus (EBV). Although NPC is a radiosensitive and chemosensitive tumour, a substantial number of patients develop local recurrence or distant metastases. For patients with locoregional advanced disease, it is well known that conventional radiotherapy is insufficient in terms of both the local control rates and distant metastases. New techniques of radiation and new combined radiotherapy and chemotherapy modalities have been evaluated in numerous clinical trials in recent years. The purpose of this article is to review the current knowledge in terms of the epidemiology, biology, prognosis, management and outcome of patients with NPC.

Reirradiation of nasopharyngeal carcinoma with intracavitary mold brachytherapy: an effective means of local salvage

PURPOSE

To assess the role of intracavitary mold brachytherapy in salvaging local failure of nasopharyngeal carcinoma (NPC).

METHODS AND MATERIALS

The outcomes of 118 consecutive NPC patients with local failure treated with mold brachytherapy between 1989 and 1996 were retrospectively reviewed. Eleven patients received additional external radiotherapy.

RESULTS

All molds were tailor-made, and the whole procedure was performed under local anesthesia. Pharyngeal recess dissection was routinely performed to allow direct contact of the radioactive source with the pharyngeal recess, a common site of local failure. Initially, the molds were preloaded with 192Ir wires, but since 1992, the sources have been manually afterloaded; the mold has also been redesigned for better conformity, ease of insertion, and radiation safety. Using brachytherapy alone, 50-55 Gy was given for recurrence in 4-7 days; for persistence, 40 Gy was administered. The overall complete remission rate was 97%. The rates of 5-year local control, relapse-free survival, disease-specific survival, overall survival, and major complication were 85%, 68.3%, 74.8%, 61.3%, and 46.9%, respectively. Major complications included nasopharyngeal necrosis with headache, necrosis of cervical vertebrae with atlantoaxial instability, temporal lobe necrosis, and palsy of the cranial nerves. The afterloaded mold was as effective as the preloaded version, but with fewer complications.

CONCLUSIONS

Intracavitary mold brachytherapy was effective in salvaging NPC with early-stage local persistence or first recurrence.

Nasopharyngectomy for recurrent nasopharyngeal carcinoma: a review of 31 patients and prognostic factors

OBJECTIVES/HYPOTHESIS

Nasopharyngectomy is a well-established treatment option for recurrent nasopharyngeal carcinoma. Over a period of 4 years and 3 months, in a total of 43 patients, 45 nasopharyngectomies were performed. Thirty-one patients with follow-up ranging from 12 to 58 months were studied. Twenty-two patients (58%) survived; of these, 18 patients (82%) remained disease free. All patients who developed repeat recurrence or died (n = 12) had a high recurrent T-stage tumor, skull base involvement, multiple recurrences, positive surgical margins, or concurrent neck node metastasis. These factors are poor prognostic parameters and might mitigate the indications for aggressive salvage surgery. However, low recurrent T-stage tumor without neck metastasis carries a good prognosis. Modern minimally invasive surgery carries minimal morbidity. STUDY DESIGN A retrospective study was made to determine prognostic indicators in patients treated with salvage surgery for recurrent nasopharyngeal carcinoma.

METHODS

Medical records were analyzed for all patients who had received nasopharyngectomy for recurrent nasopharyngeal carcinoma from March 1997 to June 2001. They were followed up from March 1997 to January 2002. Recurrent T stage, nodal metastasis, surgical approach, surgical margins, and pathological nodal status, together with surgical mortality, morbidity, and the delivery of postoperative irradiation, were compared with survival.

RESULTS

In all, 43 patients underwent 45 nasopharyngectomies over a period of 4 years and 3 months. Patients with less than 1 year of follow-up were excluded. Four patients with residual disease, who represent a more favorable group, and five patients with planned debulking, nasopharyngectomy, and postoperative stereotactic irradiation were also excluded. The study group comprised 25 men and 6 women (ratio of 4:1) with age ranging from 26 to 69 years (mean age, 49.5 y). In 28 patients (90.3%), the recurrence of nasopharyngeal carcinoma was their first recurrence; in 3 patients (9.7%), the recurrences were second recurrences. Twenty-two patients (71%) survived, achieving a mean survival of 28.5 months. Nine patients died with a mean interval of 7.8 months (range, 1-14 mo). Of the nine patients who died, six (67%) had T3 or T4 tumor, four (44.4%) had concurrent recurrent neck disease, and five (55.5%) had positive surgical margins. Two patients died of perioperative meningitis. Fifteen (83.3%) of the 18 disease-free survivors had a low recurrent T-stage tumor. Mean intervals for development of repeat recurrence or distant metastasis were 16 and 7.9 months, respectively.

CONCLUSIONS

High recurrent T stage, skull base involvement, repeated recurrence before surgery, nodal metastasis, and positive surgical margins carry a poor prognosis. This is particularly evident with high T stage and concurrent nodal metastasis. However, patients with low T stage have a survival advantage and benefit most from surgical treatment.

Stereotactic radiosurgery for locally recurrent nasopharyngeal carcinoma

BACKGROUND

Stereotactic radiosurgery has been used to treat intracranial tumors. Recently, it has also been used for the treatment of head and neck tumors involving the base of skull, including recurrent NPC.

METHODS

From October 1994 to April 1999, 36 patients with recurrent NPC, were retreated by stereotactic radiosurgery. These patients received radiosurgery as a boost treatment after reirradiation for recurrence. The external RT dose ranged from 20 to 60 Gy. The tumor volume ranged from 3.58 to 24.6 cc. The target surface dose ranged from 8 to 20 Gy. The median follow-up was 22.1 months.

RESULTS

The 3-year local control rate was 56%. The 5-year overall survival was 49%. Persistence after radiosurgery had a worse survival than those who had secondary recurrence. Age and gender were marginally significant. No patient had new severe complications after retreatment. Four patients (11%) had nasopharyngeal necrosis after radiosurgery, none had nasal bleeding or headache, but a foul odor was present in one patient.

CONCLUSIONS

Conformal radiotherapy and stereotactic radiotherapy provide good local control and survival without severe complications for patients with recurrent NPC.

[Treatment of nasopharyngeal cancer: literature review]

The conventional radiotherapy and the associated treatments improved the prognostic of nasopharyngeal cancer. A better selection of the patients who must have a more aggressive treatment also probably contributed to this improvement. Even if a relation could be found between the locoregional relapse rate and the distant relapse rate, these two events remain often independent. It results from it that the improvement of local control rate necessarily does not result in a better control of the disease. The patients with a locally advanced tumor, with or not an invasion of the base of the skull and/or neurological symptoms, must have an aggressive locally treatment. This probably includes the increase in dose delivered to the tumor via a more conformational radiotherapy, a brachytherapy, radiotherapy in stereotaxic conditions or other techniques. Dose within the tumor must be at least 70 Gy and the prophylactic nodal dose, at least 50 Gy. CT scan and MRI are essential for delineating the volumes of interest. The protocols of hyperfractionated radiotherapy did not give convincing results. Association with chemotherapy allowed, on the other hand, an improvement of the prognostic locally advanced cancers. Neoadjuvant or adjuvant chemotherapy was largely used to attempt to limit the risks of systemic dissemination, but an improvement of results was not clearly demonstrated. An improvement of the rates of survival and control of the disease, on the other hand, was observed in a certain number of studies with the chemoradiotherapy. In the event of locoregional relapse, an aggressive attitude can allow the control of the disease in the absence of systemic dissemination. Salvage treatments are, however, disappointing for when distant relapse occurs which suggests a difference in chemosensitivity between primary tumor and metastasis.

Pulsed–dose rate brachytherapy with concomitant chemotherapy and interstitial hyperthermia in patients with recurrent head-and-neck cancer

PURPOSE

We attempted in our clinic to evaluate the efficacy and feasibility of a simultaneous application of a cis-platinum-based chemotherapy and interstitial hyperthermia to interstitial pulsed-dose rate (PDR) brachytherapy in patients with recurrent head-and-neck cancer.

METHODS AND MATERIALS

Between April 1999 and September 2001, 15 patients with recurrent head-and-neck cancer were treated with PDR brachytherapy, chemotherapy, and interstitial hyperthermia. All patients had received prior radiation therapy. A dose per pulse of 0.46 to 0.55 Gy was given up to a median total dose of 55 Gy. Simultaneously to the PDR brachytherapy, chemotherapy was given with cis-platinum 20 mg/m2 as a short i.v. infusion each day and 5-fluorouracil 800 mg/m2 by continuous infusion from Day 1 to Day 5. After the PDR brachytherapy was finished, all patients were treated with a single session of interstitial hyperthermia.

RESULTS

All the patients could receive the whole treatment. After treatment, only mild oral mucositis occurred. One patient developed soft tissue ulceration. None of the patients developed osteoradionecrosis. After a median follow-up of 6 months, the local tumor control rate was 80% (12 of 15), and the 2-year overall survival was 67% (10 of 15).

CONCLUSIONS

The intensification of the interstitial PDR brachytherapy with chemotherapy and hyperthermia is feasible and safe, and the preliminary results are encouraging.

The American Brachytherapy Society recommendations for high-dose-rate brachytherapy for head-and-neck carcinoma

PURPOSE

To develop recommendations for use of high-dose-rate (HDR) brachytherapy in patients with head-and-neck cancer.

METHODS

A panel consisting of members of the American Brachytherapy Society (ABS) performed a literature review, added information based upon their clinical experience, and formulated recommendations for head-and-neck HDR brachytherapy.

RESULTS

The ABS recommends the use of brachytherapy as a component of the treatment of head-and-neck tumors. However, the ABS recognizes that some radiation oncologists are reluctant to employ brachytherapy in the head-and-neck region because of the complexity of the postoperative management and concerns about radiation safety. In this regard, HDR eliminates unwanted radiation exposure and thereby permits unrestricted delivery of clinical care to these brachytherapy patients. The ABS made specific recommendations for previously untreated and recurrent head-and-neck cancer patients on patient selection criteria, implant techniques, target volume definition, and HDR treatment parameters (such as time, dose, and fractionation schedules). Suggestions were provided for treatment with HDR alone and in combination with external beam radiation therapy. It should be recognized that only limited experiences exist with HDR brachytherapy in patients with head-and-neck cancers. Therefore, some of these suggested doses have not been extensively tested in clinical practice. Hence, these guidelines will be updated as significant new outcome data are available. Any clinician following these guidelines is expected to use clinical judgment to determine an individual patient's treatment.

CONCLUSIONS

Little has been published in the clinical literature on HDR brachytherapy in head-and-neck cancer. Based upon the available information and the clinical experience of the panel members, general and site-specific recommendations were offered. Areas for further investigations were identified.

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

PURPOSE

To review the outcome of head-and-neck cancer patients re-irradiated using conformal radiation.

PATIENTS AND METHODS

From 1983 to 1999, 60 patients with recurrent or new primary head-and-neck cancer received re-irradiation at the University of Michigan. Twenty patients were excluded due to the planned cumulative radiation dose being less than 100 Gy (18) and absence of prior radiation details (2), leaving 40 patients. Thirty-five patients were re-irradiated for unresectable disease, while 4 patients received adjuvant re-irradiation for high-risk disease. Thirty-eight patients had recurrences from previously treated cancer (19 regional, 14 local, 5 regional and local), and 2 patients had new primary tumors. The median time from the first course of radiation to re-irradiation was 21 months. Thirty-one patients (78%) were re-irradiated with curative intent, whereas 9 were treated with palliative intent. Re-irradiation was delivered using conformal techniques in the majority of patients and with concurrent chemotherapy in 14 patients. The median re-irradiation dose was 60 Gy. The median cumulative dose received was 121 Gy. Five patients (13%) did not complete their prescribed course of re-irradiation.

RESULTS

The median survival following completion of re-irradiation was 12.5 months. The 1- and 2-year actuarial survival rates were 51.1% and 32.6%, respectively. On multivariate analysis, palliative intent of treatment, tumor bulk, and tumor site other than nasopharynx or larynx were associated with worse survival. The patients treated for unresectable disease did no worse than those treated adjuvantly. The median times to relapse-free survival, local-regional recurrence (LRR)-free survival, and ultimate LRR-free survival (allowing for surgical salvage) were 3.9 months, 7.8 months, and 8.7 months, respectively. Seven patients (18%) are presently alive with no evidence of disease, with a median follow-up of 49.9 months (range 3.3-78.9). Severe radiation-induced complications were seen in 7 patients (18%). Two other patients developed orocutaneous fistulas in the presence of tumor recurrence. Moderate fibrosis and trismus were common.

CONCLUSION

Despite the use of conformal techniques, the prognosis of patients treated with re-irradiation is poor, and complications are not infrequent. A subset of patients is salvageable, and high-dose re-irradiation should be considered in selected patients.

Full dose reirradiation combined with chemotherapy after salvage surgery in head and neck carcinoma

BACKGROUND

The purpose of this study was to analyze the tolerance and efficacy of full dose reirradiation combined with chemotherapy in patients with head and neck carcinoma (HNC) with a high risk of recurrence after salvage surgery.

METHODS

Between 1991 and 1996, 25 patients having a recurrence or a second primary tumor in a previously irradiated area (> 45 grays [Gy]) were entered in this prospective study. All of them received salvage surgery and had a positive surgical margin and/or lymph node involvement with capsular rupture (N+R+). Adjuvant radiochemotherapy was given, delivering 60 Gy per 30 fractions with concomitant hydroxyurea and 5-fluorouracil. The median total cumulative dose of the 2 irradiations was 118 Gy. The median follow-up after the second irradiation was 66 months.

RESULTS

During the reirradiation course, Grade 3 and 4 mucositis were observed in 40% and 12%, respectively. Analysis of late effects (> 6 months after reirradiation) showed that 16% of the patients had osteoradionecrosis and 40% had Grade 2-3 cervical fibrosis (Radiation Therapy Oncology Group scoring system). The patterns of failure were as follows: local only (n = 9), lymph node only (n = 2), local and lymph node only (n = 1), and metastatic (n = 4). The 4-year survival rate after reirradiation was 43% (95% confidence interval, 25-62).

CONCLUSIONS

Full dose reirradiation combined with chemotherapy after salvage surgery in high risk patients with HNC was feasible with an "acceptable" toxicity and led to a relatively good 5-year survival rate. These results prompted the authors to initiate a multicentric randomized trial that is ongoing (GETTEC-GORTEC 99-01) to evaluate the benefit of adjuvant radiochemotherapy in these types of patients.

Recurrent head and neck cancer: retreatment of previously irradiated areas with combined chemotherapy and radiation therapy-results of a prospective study

PURPOSE

To prospectively test the effectiveness of combined chemotherapy and radiation therapy for recurrent head and neck cancer.

MATERIALS AND METHODS

In 32 patients, external-beam radiation therapy (2 Gy/d) was administered as a 5-day course with simultaneous hydroxyurea (1.5 g/d orally) and 5-fluorouracil (300 mg/m(2)/d bolus), followed by 9 days of rest. This cycle was repeated until a cumulative soft-tissue radiation dose of 110 Gy (including prior radiation therapy) was reached.

RESULTS

At a median follow-up of 18 months, three patients were alive, and 29 had died. The overall 1-year survival rate was 39%. The overall response rate was 41% (13 patients). Acute toxicity was low. According to World Health Organization and Radiation Therapy Oncology Group criteria, there were three cases of grade 3 mucositis or dermatitis and three cases of grade 3 or 4 neutropenia. Three patients had grade 3 late effects: one oral trismus, one jugular venous thrombosis, and one cerebral stroke.

CONCLUSION

The combination of simultaneous 5-fluorouracil and hydroxyurea infusion and local reirradiation is feasible for retreatment of recurrent head and neck tumors. This regimen provides short-term tumor control in most patients and long-term control in a few patients.

Brachytherapy for primary and recurrent nasopharyngeal carcinoma: 20 years' experience at Long Beach Memorial

PURPOSE

We evaluated treatment outcomes of patients with mostly locally advanced primary and recurrent cancer of the nasopharynx managed with interstitial and intraluminal brachytherapy.

METHODS AND MATERIALS

This is a retrospective analysis of 56 patients with cancer arising from the nasopharynx treated with interstitial and intracavitary afterloading brachytherapy from 1978 to 1997. Patients were divided into three treatment groups: 15 patients with primary cancer (Group 1), 34 patients with recurrent or persistent disease (Group 2), and 7 patients with cancer in the nasopharynx who had history of previous definitive radiation therapy to the nasopharynx for head and neck cancer (Group 3). Fifty-three percent of patients in Group 1 had 1992 AJCC Stage IV disease, and 49% of patients in Groups 2 and 3 had extensive disease (defined as T3, T4, or parapharyngeal extension). Group 1 received megavoltage radiation to 50-60 Gy followed by a boost to the primary site and neck (in cases of persistent neck disease) with a combination of interstitial and intracavitary brachytherapy (mean dose 33-37 Gy). Five patients received chemotherapy, and 6 patients received hyperthermia. Groups 2 and 3 patients were treated with brachytherapy implants (mean dose 50-58 Gy) without external beam radiation. Twenty-five patients received chemotherapy either before or during radiation, and 21 patients received hyperthermia.

RESULTS

The overall survival at 2, 5, and 10 years for patients in Group 1 was 79%, 61%, and 61%, respectively, and for patients in Groups 2 and 3 combined was 48%, 30%, and 20%, respectively. Cause-specific survival at 2, 5, and 10 years was 87%, 74%, and 74%, respectively, for patients in Group 1; and 82%, 60%, and 60%, respectively, for patients in Groups 2 and 3. Local control at 2, 5, and 10 years was 93%, 93%, and 77%, respectively, for patients in Group 1; and 81%, 59%, and 49%, respectively, for patients in Groups 2 and 3. Control in the neck at 2, 5, and 10 years was achieved in 93%, 93%, and 93% of patients, respectively, in Group 1; and 88%, 81%, and 81%, respectively, for patients in Groups 2 and 3. Disease-free survival was 87%, 74%, and 62%, respectively, for patients in Group 1, and 56%, 41%, and 34%, respectively, for patients in Groups 2 and 3. There were 4 peri-operative deaths. One death (2%) was attributable to the development of late complications. Forty-five percent of patients experienced some form of late complications.

CONCLUSION

Interstitial afterloading brachytherapy can provide effective treatment for nasopharyngeal cancers, especially for locally persistent/recurrent and locally extensive lesions.

Nasopharyngectomy in the treatment of recurrent nasopharyngeal carcinoma: a twelve-year experience

BACKGROUND

The incidence of recurrent nasopharyngeal carcinoma (NPC) after primary radiotherapy is considerable. The result of re-irradiation to the recurrent tumor is not satisfactory.

METHODS

Thirty-one patients who received nasopharyngectomy for treatment of their recurrent nasopharyngeal carcinoma (NPC) (rT1 to rT3) at the Prince of Wales Hospital during the period 1986 to 1997 were reviewed retrospectively. Eleven patients had nasopharyngectomy performed by the transoropalatal approach, 9 patients by the maxillary swing approach, and 11 patients by the mandibular approach.

RESULTS

Most recurrences (29 of 31) were rT1 and rT2 tumors. No hospital mortality occurred. The common complications of nasopharyngectomy were palatal defect (17 of 31), trismus (15 of 31), otitis media with effusion (20 of 31), dysphagia (12 of 31), and nasal regurgitation (8 of 31). Nine surgical specimens had microscopic invasion of the resection margins. The 5-year actuarial overall survival, actuarial disease-free survival, and tumor control were 47%, 42%, and 43%, respectively. The administration of postoperative radiotherapy significantly enhanced survival and tumor control after nasopharyngectomy.

CONCLUSIONS

Nasopharyngectomy supplemented by postoperative radiotherapy achieved significant survival and tumor control with acceptable complications in selected recurrent NPC. It appears to be a better salvage treatment than re-irradiation alone for selected recurrent NPC.

Nasopharyngeal carcinoma: repeat treatment with conformal proton therapy--dose-volume histogram analysis

PURPOSE

To analyze control, survival, and complication rates of conformal proton radiation for recurrent nasopharyngeal carcinoma.

MATERIALS AND METHODS

Sixteen patients with nasopharyngeal carcinoma initially treated with 50.0-88.2 Gy photons were re-treated with protons to additional doses of 59.4-70.2 CGE. Local-regional control and survival were correlated with extent of relapse, recurrence versus persistence, and prescribed dose and were subjected to dose-volume histogram analysis. Mean follow-up was 23.7 months (range, 4-47 months).

RESULTS

Twenty-four-month actuarial overall and local-regional progression-free survival rates were both 50%. The 24-month actuarial overall survival rates for patients with "optimal" dose-volume histogram coverage versus "suboptimal" coverage were 83% and 17%, respectively (P = .006). Doses to critical structures were low (0-22.0 Gy); no central nervous system side effects supervened.

CONCLUSION

Adequate tumor coverage, as evaluated by using dose-volume histogram analysis, was found to be the most important variable influencing local-regional control and survival. No central nervous system complications were observed; increases in the dose to adjacent critical structures are being evaluated.

Stereotactic radiosurgery as a salvage treatment for locally persistent and recurrent nasopharyngeal carcinoma

BACKGROUND

The purpose of this work was to study the efficacy of stereotactic radiosurgery as a salvage treatment in patients with locally persistent and recurrent nasopharyngeal carcinoma (NPC).

METHODS

Between March 1996 and August 1997, 10 patients with locally persistent or recurrent NPC were treated by linac-based stereotactic radiosurgery. Four patients had radiosurgery for persistent disease after a first course of radiotherapy, 3 had radiosurgery as a boost after reirradiation for local recurrence, and 3 had radiosurgery for disease that recurred after reirradiation. The tumor volume ranged from 1.3 to 23.7 cc (median: 5.2). Treatment was prescribed at 80% isodose line and ranged from 12 to 18 Gy (median: 13.4), with a mean tumor surface dose ranged from 10-21 Gy (median: 14). The median clinical follow-up was 10.5 months (range 8-27), and the median imaging follow-up was 9.5 months (range 6-26).

RESULTS

One patient had complete regression of tumor after radiosurgery, five had reduction in tumor size, three had no change, and one had progression of tumor. The overall response rate to radiosurgery was 60% (6/10), with 10% (1/10) developing in-field progression. Excluding patients receiving radiosurgery as a boost treatment after reirradiation, the response rate was 57% (4/7) and none developed in-field progression. Only one patient developed a new cranial neuropathy in the absence of disease progression.

CONCLUSION

In selected patients with locally persistent or recurrent NPC, stereotactic radiosurgery can be considered as a salvage treatment with good short-term local control. The complications appear to be minimal except for treating recurrence in the cavernous sinus. Early results are encouraging although more experience and longer follow-up are still needed to better define the role of radiosurgery in the management of persistent and recurrent NPC.

Re-irradiation of head and neck tumors. Benefits and toxicities

Most patients with head and neck cancer that recurs after irradiation should be treated with curative surgery. In patients whose tumors are nonresectable, or if surgery would cause unacceptable morbidity, a trial of curative re-irradiation may be considered. Taking into account the overall poor prognosis of these patients and the high rate of late tissue toxicity, especially soft tissue necrosis, fistula formation, and potential nerve damage, patients should be carefully selected. Several sites, notably the larynx and nasopharynx, can be re-irradiated with a relatively high rate of locoregional tumor control. In other sites, several criteria may be used to select patients for curative re-irradiation: limited tumor size, a relatively long period since previous irradiation (a suitable, though arbitrary, minimal time period may be 1 year), good performance status, and lack of evidence of skin or soft tissue damage (skin fibrosis, atrophy or telangiectasis) by the previous irradiation course. Even when these selection criteria are used, the prognosis is poor, and long-term survival rates are low even if locoregional tumor control is achieved. Innovative strategies and techniques, including aggressive combined chemoradiation, hyperfractionation, and limiting the extent of irradiated tissues by using conformal irradiation, may improve locoregional control rates. It should be emphasized, however, that the only chance for achieving locoregional control and cure is through the delivery of a full dose of radiation, similar to the dose required for primary tumors. The delivery of a low radiation dose, commonly practiced to avoid complications, is expected to achieve palliation only.

Re-irradiation for recurrent rhabdomyosarcoma of the nasopharynx in a child

There are few clinical situations where high dose re-irradiation with curative intent is indicated in children. Because of the potential for serious late sequelae, re-irradiation is considered only in the unusual situation where there is just local recurrence and surgery and/or chemotherapy are unlikely to provide long-term control. The authors present a case of nasopharynx rhabdomyosarcoma in a child which recurred after high dose irradiation and chemotherapy and was then re-irradiated to a high dose. The child is well without any serious sequelae more than 13 years following completion of the second course of radiotherapy.

Concomitant chemotherapy and reirradiation as management for recurrent cancer of the head and neck

Thirty-five patients with inoperable recurrent head and neck cancer previously treated with definitive irradiation were treated with reirradiation and concomitant chemotherapy. Patient records were retrospectively reviewed to assess toxicity, response, and survival. Patients received one of three regimens: 1) 40 Gy total (2 Gy daily), 300 mg/m2 5-fluorouracil intravenous bolus, and 2 g hydroxyurea orally daily for 5 days; 2) 48 Gy total (1.2 Gy twice daily), 300 mg/m2 5-fluorouracil intravenous bolus, and 1.5 g hydroxyurea orally daily for 5 days; 3) 60 Gy total (1.5 Gy twice daily), 300 mg/m2 5-fluorouracil intravenous bolus, and 1.5 g hydroxyurea orally daily for 5 days. For all regimens, treatment was given only on weeks 1, 3, 5, and 7. Acute toxicity was mainly hematologic and was less severe with the lower hydroxyurea dose. Acute mucosal and skin toxicity was acceptable for all regimens. Late toxicity was noted in 4 of 17 patients who survived 12 months or more. Late effects were Radiation Therapy Oncology Group grade 3 or less. Fifteen of 35 patients achieved a complete response, and 11 of 35 patients achieved a partial response. The median survival rate was 10.5 months. There was no significant difference in responses or median survival between the groups. Reirradiation of head and neck cancer with 5-fluorouracil and hydroxyurea offers acceptable acute toxicity and minimal late effects. The clinical response rates and median survival are encouraging. Further investigation is warranted.

Re-irradiation for locally recurrent nasopharyngeal carcinoma

Since 1989, 17 patients have undergone re-irradiation for locally recurrent nasopharyngeal cancer (NPC). The dose currently administered externally is 39.6 Gy in 36 fractions (BID) followed by an intracavitary boost (15-20 Gy). Disease persisted in five out of five patients treated palliatively. Eleven of 12 patients treated with curative intent achieved local control.

Results and prognostic factors in the retreatment of locally recurrent nasopharyngeal carcinoma

PURPOSE

To review the results and evaluate the prognostic factors in the retreatment of locally recurrent nasopharyngeal carcinoma.

METHODS AND MATERIALS

We reviewed the records of 74 patients with locally recurrent nasopharyngeal carcinoma treated at the University of California, San Francisco between 1957 and 1995. The histologic types included squamous cell carcinoma in 6 (8.1%), nonkeratinizing carcinoma in 48 (64.9%), and undifferentiated carcinoma in 20 (27%) cases. The site of recurrence was in the primary in 46 (62.2%), in the neck nodes in 20 (27%), and in both sites in 8 (10.8%) patients. The recurrent disease was Stage I in 10 (13.5%), Stage II in 16 (21.6%), Stage III in 20 (27%), and Stage IV in 28 (37.9%) patients. Thirty-seven (50%) patients developed recurrence within 2 years and 58 (78.4%) within 5 years after initial treatment. Radiotherapeutic techniques used in the retreatment of primary recurrence consisted of external beam radiotherapy (EBRT), intracavitary brachytherapy, heavy-charged particle beam, and gamma knife, alone or in combination. Reirradiation doses ranged from 18 to 108 Gy, with a median dose of 60 Gy. Treatment of recurrent neck nodes consisted of radical neck dissection (RND) +/- intraoperative radiotherapy (IORT), or EBRT +/- hyperthermia, or chemotherapy +/- hyperthermia. Chemotherapy was used in 22 (30%) patients. Median follow-up was 20 months (range: 2 to 308 months).

RESULTS

The 3-, 5-, and 10-year actuarial overall survival following retreatment were 49, 37, 18%, respectively. Thirty-six patients (49%) were free of further local-regional recurrence after retreatment. The 3-, 5-, and 10-year local-regional progression-free rates were 52, 40, and 38%, respectively. On univariate analysis, histologic type (p < 0.0001), interval to recurrence (p = 0.034), and treatment modality for early-stage disease (p = 0.01) were significant prognostic factors for overall survival, with age being marginally significant (p = 0.053). For local-regional progression-free rate, only histology was significant (p = 0.035). On multivariate analysis, age (p = 0.026), histology (p = 0.015), and interval to recurrence (p = 0.030) were significant for overall survival, and only histology (p = 0.002) and presence of complications (p = 0.016) were significant for local-regional progression-free rate. Of the 64 reirradiated patients, late complications were documented in 29 (45%) patients. The late complications were permanent in 21 (33%) and severe in 15 (23%) patients.

CONCLUSION

Retreatment using radiotherapy alone or in combination with other treatment modalities can achieve long-term local-regional control and survival in a substantial proportion of patients with locally recurrent nasopharyngeal carcinoma. Age, histology, and interval to recurrence were independent prognostic factors for overall survival, but only histology and presence of complications were significant for local-regional progression-free rate.

Locally recurrent nasopharyngeal carcinoma: treatment results for patients with computed tomography assessment

PURPOSE

To study the treatment outcome in patients with locally recurrent nasopharyngeal carcinoma as restaged by computed tomography (CT).

PATIENTS AND METHODS

One hundred forty patients with CT restaged locally recurrent nasopharyngeal carcinoma were reviewed. Patients were restaged at recurrence according to the AJCC stage classification with the following distribution: T1-T2:30%, T3:19%, T4:51%. Ninety-seven patients received reirradiation; among these 62 had external irradiation, 34 had brachytherapy, and 1 had both. Twelve patients received surgery. Thirty-one patients were treated with palliative intent and received either chemotherapy or supportive treatment only. Overall survival (OAS) and performance-adjusted survival (PAS, defined as surviving with a Karnofsky performance score [KPS] > 50) were calculated by Kaplan-Meier method. Multivariate analysis was performed using the Cox model.

RESULTS

The median survival for all patients was 23.8 months. After reirradiation, the 3-yr and 5-yr OAS rates were 46% and 36%, respectively. The corresponding PAS rates were 40% and 28%. The 3-yr OAS rates for recurrent T1-2, T3, and T4 disease after reirradiation were 71%, 42%, and 30%; the corresponding 5-yr OAS rates were 57%, 42%, 17%. The 3-yr and 5-yr OAS rates in patients receiving palliative treatments only were 19% and 0%, respectively. The 3-yr OAS rate after surgery was 42%. In the multivariate analysis, older age, recurrent T3-4 disease, and palliative treatment were unfavorable factors in predicting overall survival, whereas recurrent T3-4 disease, baseline KPS < 70, and palliative treatment were unfavorable factors in predicting PAS. A high complication rate was observed after reirradiation, with 34% of patients developing neurological sequel.

CONCLUSION

Aggressive treatment for locally recurrent nasopharyngeal carcinoma is warranted especially for those with disease confined to the nasopharynx. Survival after retreatment for more extensive disease remains poor but was still superior to supportive treatment only. Early diagnosis of local recurrence allows prompt administration of treatment and is associated with better outcome. Future studies should aim at improving the therapeutic ratio in the retreatment of recurrent disease especially in patients with more extensive local recurrence.

Linear accelerator radiosurgery for recurrent malignant tumors of the skull base

The efficacy of linear accelerator-based radiosurgery for patients who have preirradiated recurrent nasopharyngeal carcinomas and unresectable recurrent sarcomas invading the base of skull was assessed. Thirteen patients were treated: 8 patients had carcinomas arising from the nasopharynx (lymphoepithelioma, 4; squamous cell carcinoma, 2; adenoid-cystic, 2); 5 patients had sarcomas (rhabdomyosarcoma, 1; chordoma, 1; chondrosarcoma, 1; hemangiopericytoma, 2). All patients had had repeated tumor resections or irradiation, hindering any further conventional fractionated radiotherapy or surgery. Convergent-beam irradiation was performed with a modified linear accelerator (8-MeV photons). Because of irregular tumor configuration, multiple (up to seven) isocenters had to be used in 10 of 13 patients to match the target volume with the reference isodose (60%-80%). Each isocenter was irradiated with 6 to 10 arcs. The median planning target volume was 33 mL (4-128 mL) and the median dose was 15 Gy (9-24 Gy). Median survival time was 9 months in 8 patients who had recurrent nasopharyngeal carcinomas. Three patients who had complete or partial tumor remission survived 1.5 to 3.5 years. All of the sarcoma patients responded to radiosurgery. After a follow-up of 28 to 67 months, 4 of 5 patients are alive. This investigation demonstrates that radiosurgery is an effective tool in palliative treatment for patients who have recurrent, extensively pretreated nasopharyngeal cancer. Patients who have recurrent sarcomas of the base of skull may be treated for long-term palliation or even for cure.

Reirradiation for recurrent nasopharyngeal carcinoma: factors affecting the therapeutic ratio and ways for improvement

PURPOSE

To identify factors for maximizing local salvage and minimizing damages by reirradiation for recurrent nasopharyngeal carcinoma.

METHODS AND MATERIALS

654 patients with recurrent nasopharyngeal carcinoma treated by reirradiation during 1976-1992 were retrospectively analyzed. Various fractionation schedules had been used during primary treatment with the total dose ranging from 45.6-70 Gy, fractional dose (at different phases) 1.5-4.2 Gy, and overall time 36-101 days. The gap between the two courses ranged from 0.5-10.6 years. Eighty-two percent of patients were reirradiated with teletherapy, 6% brachytherapy, and 12% with both. For those treated with teletherapy alone, the total dose ranged from 7.5-70 Gy, fractional dose 1.8-5 Gy, and overall time 3-89 days.

RESULTS

The 5-year actuarial local salvage and complication-free rates were 23% and 52%, respectively. Multivariate analyses showed that the extensiveness of local recurrence was the most significant factor affecting local salvage, while T-stage of primary tumor also influenced prognosis. Choice of method for reirradiation and fractional effect during both courses affected the risk of late complications. For patients treated by teletherapy alone, the hazard of local failure decreased by 1.7% per Biological Effective Dose (assuming alpha/beta ratio = 10) of the second course, while radiation factors during primary radiotherapy had no significant effect. On the other hand, the risk of late complications was predominantly affected by the primary treatment: the hazard increased by 4.2% per Biological Effective Dose (assuming alpha/beta ratio = 3) of the first course, while the corresponding impact of reirradiation failed to reach statistical significance. Length of the gap between the two courses did not affect the outcome.

CONCLUSION

Early detection of local recurrence and adequate total dose by reirradiation are crucial for improving the chance of local salvage. Combination of teletherapy and brachytherapy should be considered whenever feasible and large fractional dose avoided to minimize late complications. Optimization of biological dose during primary treatment is important.

Radiosurgery for skull base malignancies and nasopharyngeal carcinoma

PURPOSE

Patients with skull base lesions present a challenging management problem because of intractable symptoms and limited therapeutic options. In 1989 we began treating selected patients with skull base lesions using linac stereotactic radiosurgery. In this study the efficacy and toxicity of this therapeutic modality is investigated.

METHODS AND MATERIALS

Forty-seven patients with 59 malignant skull base lesions were treated with linac radiosurgery between 1989 and 1995. Eleven patients were treated for primary nasopharyngeal carcinoma using radiosurgery as a boost (7 Gy-16 Gy, median: 12 Gy) to the nasopharynx after a course of fractionated radiotherapy (64.8-70 Gy) without chemotherapy. Another 37 patients were treated for 48 skull base metastases or local recurrences from primary head and neck cancers. Eight of these patients had 12 locally recurrent nasopharyngeal carcinoma lesions occuring 6-96 months after standard radiotherapy, including one patient with nasopharyngeal carcinoma who developed a regional relapse after radiotherapy with a stereotactic boost. Lesion volumes by CT or MRI ranged from 0 to 51 cc (median: 8 cc). Radiation doses of 7.0 Gy-35.0 Gy (median: 20.0 Gy) were delivered to recurrent lesions, usually as a single fraction.

RESULTS

All 11 patients who received radiosurgery as a nasopharyngeal boost after standard fractionated radiotherapy remain locally controlled (follow-up: 2-34 months, median: 18). However, one patient required a second radiosurgical treatment for regional relapse outside the initial radiosurgery volume. Thirty-three of 48 (69%) recurrent/metastatic lesions have been locally controlled, including 7 of 12 locally recurrent nasopharyngeal lesions. Follow-up for all patients with recurrent lesions ranged from 1 to 60 months (median: 9 months). Local control did not correlate with lesion size (p = 0.80), histology (p = 0.78), or radiosurgical dose (p = 0.44). Major complications developed after 5 of 59 treatments (8.4%), including three cranial nerve palsies, one CSF leak, and one trismus. Complications were not correlated with radiosurgical volume (p = 0.20), prior skull base irradiation (p = 0.90), or radiosurgery dose > 20 Gy (p = 0.49).

CONCLUSION

Stereotactic radiosurgery is a reasonable treatment modality for patients with skull base malignancies, including patients with primary and recurrent nasopharyngeal carcinoma. The dose distribution obtained with stereotactic radiosurgery provides better homogeneity than an intracavitary implant when used as a boost for nasopharyngeal lesions, especially lesions which involve areas distant to the nasopharyngeal mucosa.

[Hyperfractionated reirradiation after salvage surgery in cervico-facial carcinoma. Result of a pilot study in 14 patients]

PURPOSE

Between November 1988 and May 1992, 14 patients were enrolled in a pilot study to evaluate the feasibility and results of hyperfractionated reirradiation for the treatment of head and neck recurrences or of second primary tumors developed in a previously irradiated volume.

MATERIALS AND METHODS

All patients underwent a surgical resection for the treatment of their recurrence or second cancer. Reirradiation was proposed because of positive margins and/or lymph node metastasis with extra-capsular spread. The planned reirradiation dose was 60 Gy over 5 weeks, with two daily fractions of 1.2 Gy delivered 6-8 hours apart.

RESULTS

Of the 14 patients, 10 received the reirradiation scheduled dose (ie, 60 Gy). All patients experienced an acute mucositis that never led to disruption of the treatment. Ten patients died 3 to 41 months after reirradiation (mean: 14 months), three were disease-free 48 to 71 months after reirradiation and one was alive with local progressive disease 74 months after reirradiation. The overall local control rate within the reirradiated volume was 43%. The 24- and 36-month overall survival rates were 50 and 35%, respectively. Overall, 13 late complications were noted: four were grade 1, seven were grade 2, and two were grade 3. Three patients still alive in September 1993 and whose initial files were available were enrolled in an additional study to assess from dose-volume histograms the cumulative doses delivered by the two irradiations.

CONCLUSION

Despite poor local control, reirradiation using a hyperfractionation schedule with high dose level is feasible in terms of acute and late toxicity.

Transcervico-mandibulo-palatal approach for surgical salvage of recurrent nasopharyngeal cancer

BACKGROUND

Local relapse of nasopharyngeal carcinoma is a difficult problem of management that is usually treated by re-irradiation. Surgical salvage is rarely offered, judging by the paucity of reports in the literature.

METHODS

This article reviews the six previously described methods of performing nasopharyngectomy and recounts experience with a series of seven patients using a transcervico-mandibulo-palatal approach, which is described.

RESULTS

The results of this small series show survivorship and morbidity which seem to compare favorably with other published surgical treatment options.

CONCLUSIONS

If retreatment with radiotherapy is not favored, the transcervico-mandibulo-palatal approach may be a suitable method of surgical salvage for small, locally recurrent, nasopharyngeal cancer.

High dose rate intracavitary brachytherapy in the treatment of nasopharyngeal carcinoma

A retrospective study on 61 patients, with local persistent or recurrent nasopharyngeal carcinoma (NPC), treated during 1990-1992 with high dose rate intracavitary brachytherapy alone or combined with external irradiation, is presented. All 39 patients with persistent disease were treated solely with brachytherapy. The actuarial 3-year local failure-free survival (LFFS) rates of the persistent and recurrent groups were 82% and 45% respectively. The corresponding disease specific survival rates were 82% and 62%. Fifteen patients with recurrence received the combined modality treatment and their 3-year LFFS rate was 65%. Three out of 7 patients treated by brachytherapy could be controlled locally. The total dose given to the floor of sphenoid was an important predictor of local control. Of the 23 patients with persistent disease treated with < 17.5 Gy to this area, 6 failed locally as opposed to none of the 16 patients receiving a higher dose (p = 0.031). For those with recurrence treated by the combined modality, none of the 7 patients given >/= 57.5 Gy recurred while 5 local failures were observed among those receiving a smaller dose (p = 0.041). The general implications of these results for the treatment of NPC recurrence are discussed.

Hyperfractionation in the reirradiation of head and neck cancers. Result of a pilot study

Between November 1988 and May 1992, 19 patients were enrolled in a pilot study to evaluate feasibility and results of a hyperfractionated reirradiation in the treatment of head and neck recurrences or second primary tumors developed in previously irradiated volume. Patients were divided in two groups according to the initial treatment before reirradiation: group 1 included 14 patients treated with radical surgery and reirradiated because histological evidence of positive margins and/or extra capsular spread of tumor in lymph node metastases; group 2 included five patients treated with three cycles of CDDP-5FU for unresectable tumors and reirradiated because they experienced a complete or good partial (> or = 80%) response after chemotherapy. The reirradiation planned dose was 60 Gy in 5 weeks, with two daily fractions of 1.2 Gy spaced by 6-8 h intervals. Reirradiation was delivered exclusively with photon beams in 17 cases and with a combination of photon and electron beams in two cases. Follow-up ranged from 3 to 45 months with a median of 17 months. Of the 19 patients, 13 received the reirradiation scheduled dose of 60 Gy. For the six remaining patients, the reirradiation doses ranged from 45.6 to 57.6 Gy. All patients experienced an acute mucositis which never led to interruption of treatment. Of the 14 patients of group 1, 10 died 3-41 months after reirradiation (mean: 14 months), three were disease-free 16-37 months after reirradiation and one patient was alive with local progressive disease 39 months after the reirradiation. The overall local control within reirradiated volume was 36% before and 43% after salvage surgery. For all group 1 patients, 12- and 24-month overall survival was 64 and 36%, respectively (mean: 21 months). All patients of group 2 presented a local failure within the reirradiated volume. Three of them died 12, 16 and 25 months after reirradiation, while two of them were alive with progressive disease 25 and 30 months after reirradiation, respectively. The mean survival was 22 months. Overall, 15 late complications were noted: five grade 1, eight grade 2 and two grade 3. There was no lethal complication. Four patients alive in September 1993, and whose initial technical files were available, were enrolled in an additional study to assess the cumulative doses delivered by the two irradiations. Despite disappointing loco-regional control rates, a reirradiation of 60 Gy using a hyperfractionated schedule is feasible in terms of acute and late toxicity.

Undifferentiated nasopharyngeal cancer (UCNT): current diagnostic and therapeutic aspects

Undifferentiated carcinoma of the nasopharynx (UCNT) is a particular head and neck epidermoid lineage tumor related to the Epstein Barr Virus (EBV). It has geographically selective endemic epidemiologic features, without relation to external carcinogens. Its systemic agressiveness is the source of most disease-related demises, because radiotherapy achieves excellent local control and a significant percentage of cure in patients with exclusive locoregional disease. Difference in the staying systems currently in use, the recent changes in imaging and radiotherapy technology, and the lack of distinction between UCNT and squamous cell carcinoma (SCC) of the nasopharynx in Western literature reports make for some difficulty in therapeutic results evaluation when analyzing available literature. Its chemosensitivity is a relatively recent acknowledged fact, and its use in metastatic patients results in a high percentage of objective responses, many of long duration. Neoadjuvant cisplatin-based chemotherapy seems to be of benefit, but outstanding controversies in this regard will be soon answered through ongoing phase III trials. After a review of the current literature of all the above-mentioned aspects of this fascinating nosologic entity, our own experience, both in metastatic and locoregional disease patients is analyzed.

High-dose reirradiation of head and neck cancer with curative intent

PURPOSE

This study evaluates the response of new or recurrent head and neck cancers and the response of associated normal tissues to high dose reirradiation with curative intent.

METHODS AND MATERIALS

From 1964 to 1991, 15 patients with in-field new second head and neck cancers and 85 patients with recurrent head and neck cancers have had high-dose reirradiation that overlapped with previously irradiated volumes. Reirradiation was given only to patients with no more than apparent minimal clinical radiation effects from the first radiation course. The reirradiation consisted of external beam only in 82 patients, external beam plus intracavitary or interstitial implant irradiation in 14 patients, and interstitial implant irradiation only in four patients. The combined overlapping dose from both the initial and subsequent irradiation (including brachytherapy) was 69-89 Gy in 14 patients, 90-99 Gy in 15 patients, 100-119 Gy in 27 patients, and 120 Gy or greater in 44 patients. Four patients had areas of overlap that received greater than 180 Gy.

RESULTS

The actuarial 5-year survival was 37% for patients with new second primary cancers and 17% for patients with recurrent cancers. Loco-regional tumor control was achieved in 60% of the patients with new tumors and in 27% of the patients with recurrent tumors. Nine of the 100 patients developed severe adverse normal tissue effects from the reirradiation.

CONCLUSION

High-dose reirradiation of head and neck cancers can be successful curative treatment in a significant proportion of patients. It is associated with substantial but acceptable risks in properly selected patients.

Application of stereotactic radiosurgery to the head and neck region

Nasopharyngeal carcinoma recurrent following primary radiation therapy has been treated with surgery and reirradiation. Reirradiation is often limited by the tolerance of structures previously treated. Radiosurgery was used to boost the recurrent site while avoiding critical structures. Seven patients were evaluated for treatment. Three patients met requirements for treatment. The lesions invaded the parapharyngeal region, the base of skull, cavernous sinus, cranial nerves, or carotid artery. Treatment included a radiosurgery boost utilizing multiple isocenters, noncoplanar arcs, and arc weighting, to yield a plan conforming to the tumors while avoiding critical anatomical structures. The patients tolerated the procedure well with minor acute side effects. Follow-up included magnetic resonance imaging (MRI) and positron emission tomography (PET). Two lesions responded, and one had no significant change. One patient had a regional recurrence. Two patients had distance recurrence. Long term side effects include trismus, parotiditis, ear fullness, hemorrhage, and pain. Radiosurgery may improve the local control rate of such lesions, however, with the severe long term complications of single fraction radiosurgery in the head and neck region this procedure may be more beneficial if the treatment is fractionated.

Retrospective analysis of patients with nasopharyngeal carcinoma treated during 1976-1985: survival after local recurrence

PURPOSE

To study the value of re-irradiation, the overall survival and pattern of failures for patients with nasopharyngeal recurrence.

METHODS AND MATERIALS

All the 891 patients with local recurrence following radiotherapy for nasopharyngeal carcinoma during 1976-1981 were retrospectively analyzed. Only 70% of them had local failure alone at the time of detection, and the T-stage distribution (by Ho's system) was 31% rT1, 16% rT2, 51% rT3, and 1% rT?. Seven hundred and six (79%) patients had been re-irradiated with various techniques and doses. Among those who failed, 50 had further irradiation.

RESULTS

The overall 5- and 10-year actuarial cancer-specific survival rates were 14% and 9%, respectively. Patients with rT3 disease had the worst prognosis. Successful local salvage was achieved in 32% of those re-irradiated (26% of the whole series). The highest control rate was achieved by those treated with external radiotherapy to 60 Gy (equivalent) or above. Only 8/50 patients responded to the third course of radiotherapy. The cumulative incidence of late post-re-irradiation sequelae was 24%, and the treatment mortality rate 1.8%. Besides local failure, 54% had regional relapse and/or distant metastasis. Thus, only 16% of recurrent patients were totally disease-free at final assessment.

CONCLUSION

The overall prognosis for patients with nasopharyngeal recurrence was grave. High dose re-irradiation could achieve successful local salvage in a substantial number of patients with early recurrence, but late complications did occur. Furthermore, high incidence of failure at other sites was observed.

Results of chemotherapy plus external reirradiation in the treatment of locally advanced recurrences of nasopharyngeal carcinoma

Between 1982 and 1991, 16 patients with recurrent cancer of the nasopharynx were treated with chemotherapy (CT) and radiotherapy (RT). All patients had received prior RT (45-69, 30 Gy). According to rTNM there were three rT2, one rT3 and 12 rT4. 5 patients were N1. Reirradiation (12-46 Gy, mean: 28) started 3-4 weeks after CT (2-6 cycles of different combinations), but 2 cases involved concomitant therapy. Out of 16 patients 7 had complete response (CR) (43.7%), 7 partial response and 2 no response. Statistically significant prognostic factors for obtaining CR were time of relapse and response to initial CT. Median duration of CR was 22+ months (9-64+). Failures at primary site occurred in 3 patients, 2/2 of those receiving CT without platinum compounds and 1/5 of other ones, with statistically significant difference in local recurrence free-survival between the two groups. Two- and 3-year actuarial overall survival were 28% and 10%. Rates of disease-free survival were 17% and 8%, respectively. The acute toxicity was generally mild. No central nervous system damage or radiation-induced myelitis were observed in survivors.

Retrospective analysis of 5037 patients with nasopharyngeal carcinoma treated during 1976-1985: overall survival and patterns of failure

This is a retrospective analysis of 5037 patients with squamous cell carcinoma of the nasopharynx treated during the years 1976-1985. The stage distribution according to Ho's classification was 9% Stage I, 13% II, 50% III, 22% IV, and 6% Stage V. Only 4488 (89%) patients had a full course of megavoltage radiation therapy. The median equivalent dose to the nasopharyngeal region was 65 Gy and cervical region in node-positive patients 53 Gy. Seventy percent (906/1290) of the node-negative patients had no prophylactic neck irradiation. The overall actuarial 10-year survival rate was 43%, and the corresponding failure-free survival 34%. Altogether, 4157 (83%) patients achieved complete remission lasting more than 6 months, but 53% (2205/4157) of them relapsed after a median interval of 1.4 years. The 10-year actuarial local, regional, and distant failure-free rates were 61%, 64%, and 59%, respectively. Thirty-eight percent (338/891) of all patients with local recurrence achieved second local remission. The local complete remission rate with aggressive re-irradiation alone was 47% (333/706). But 37% (124/338) of the responders recurred the second time. The incidence of distant failure correlated significantly with both the N-stage and the T-stage, with the highest (57%) occurring in patients with N3 disease. The incidence of nodal relapse in node-negative patients was 11% (44/384) among those given prophylactic neck irradiation, but 40% (362/906) among those without. Therapeutic irradiation achieved a complete regional remission rate of 90% (306/339). However, despite successful salvage, these patients had a significantly higher distant failure rate than those without nodal relapse, even if they remained local-failure-free (21% vs 6%). Patients treated during 1981-1985 achieved significantly better treatment results than those treated during 1976-1980, especially in terms of the overall survival (57% vs 47% at 5-year), the overall failure-free survival (42% vs 35% at 5-year), and the local failure-free rate (70% vs 63% at 5-year). The possible contributing factors are discussed.

Re-treatment of nasopharyngeal carcinoma in 53 patients

Fifty-three patients with locally recurrent or persistent nasopharyngeal carcinoma were re-treated with megavoltage radiation therapy at The University of Texas M. D. Anderson Cancer Center from 1954 through 1989. The time from initial treatment to re-treatment ranged from 2 to 189 months (median 33 months). Documented local disease was confined to the nasopharynx in 27 patients (Group 1), while in the other 26 patients there was local spread beyond the nasopharynx (Group 2). At the time of re-treatment, nodal disease was present in 27 of the 53 cases. Forty-two patients were re-treated with external beam therapy alone and 11 with a component of brachytherapy. Re-treatment doses specified at the nasopharyngeal vault ranged from 27.5 to 99 Gy (median 57 Gy), and total cumulative dose ranged from 80 to 160 Gy (median 112 Gy). Overall 5-year actuarial local control (LC), disease-free survival (DFS), and survival rates were 35%, 18%, and 21%, respectively. Patients with Group 1 disease did better than those with Group 2 disease in terms of 5-year survival, 32% versus 9% (p = 0.01) and 5-year DFS, 23% versus 12% (p = 0.002). Nodal status at the time of re-treatment did not predict for LC or survival. The 5-year survival of patients with lymphoepitheliomas was 28% compared with 13% for patients with squamous cell carcinomas (p = 0.04). Eight patients developed severe complications from re-treatment, of which five involving the brain (two), spinal cord (one), and lower cranial nerves (two) were fatal. The incidence of severe complications was related to the total cumulative dose of external beam irradiation: 4% for patients receiving doses less than or equal to 100 Gy compared with 39% for those patients who received doses greater than 100 Gy (p = 0.066). Beginning in 1977, a combination of external beam therapy (20 to 30 Gy) and intracavitary cesium (40 to 50 Gy surface dose) was used in selected cases: 9 of the 53 patients were re-treated with this combination. Of these, 7 achieved LC with a follow-up of 7 to 102 months and none sustained a severe complication. Five-year actuarial LC, DFS, and survival in this group were 67%, 44% and 60% respectively.

Recurrent locally advanced nasopharyngeal carcinoma treated with heavy charged particle irradiation

Between June 1981 and May 1990, 11 patients with recurrent locally advanced nasopharyngeal carcinoma were treated with heavy charged particle radiation at Lawrence Berkeley Laboratory. All patients had previously undergone full course radiotherapy to a median dose of 70.2 Gy [range 61-81 Gy]. Median time to recurrence was 18.2 months. At the time of heavy charged particle radiotherapy treatment, all had evidence of invasion of the base of skull and 7 of 11 had cranial nerve deficits. None of the patients were candidates for brachytherapy because of tumor extent or poor geometry. The tumor histology was squamous cell carcinoma in 10 patients and lymphoepithelioma in one patient. Ten of the 11 patients had received chemotherapy prior to re-irradiation. The heavy charged particle tumor dose delivered ranged from 31.80 GyE to 62.30 GyE (average 50.25 GyE, median 50 GyE). Local control was achieved in 45%. Median survival was 42 months. Actuarial survival was 59% at 3 years and 31% at 5 years (Kaplan-Meier). There were no fatal complications. The results in treating locally advanced recurrent nasopharyngeal carcinoma with heavy charged particles appear superior to those reported by others using photon therapy.

Radical neck dissection in nasopharyngeal carcinoma

We report a series of 37 patients who had radical neck dissection for residual or recurrent lymph node metastasis from nasopharyngeal carcinoma after radiotherapy. The operation was performed despite high doses of pre-operative radiotherapy. There was no operative mortality and the morbidity was 13% (2 prolonged chylous drainage, 3 sloughing of neck flap). The risk of sloughing of neck flap was significantly related to previous lymph node biopsy, which should be avoided if at all possible. In 35% of patients, the lymph node was densely adherent to neighbouring structures. In the 28 patients who had single lymph node clinically, 29% had multiple neck node involvement noted during operation; another 14% were documented only on histological examination. Radical neck dissection rather than excision alone is justified for the clinically solitary lymph node.

Nasopharyngeal carcinoma: treatment of neck node recurrence by radiotherapy

The records of 91 nasopharyngeal carcinoma patients who were treated with external radiotherapy for recurrent neck node disease were reviewed. All patients had received prior radiotherapy for cervical nodal disease or prophylactic neck irradiation. The node size (product of the greatest perpendicular diameters) at the time of treatment for nodal relapse ranged from 1cm2 to 35cm2 (median 2.25cm2). The radiation dose ranged from 823 RETs to 1949 RETs (median 1520 RETs). The recurrent node size and radiation dose were found significant prognostic factors for local control. The local tumour control for nodes 4cm2 or smaller was 51% at five years, for nodes greater than 4cm2 was 16% at 18 months (p = 0.01). The overall 5 year survival was 19.7%. Radiation dose greater than 1600 RETs was significantly associated with better survival for patients with recurrent nodes measured 4cm2 or smaller, but higher radiation dose did not improve the survival of patients with recurrent nodes greater than 4cm2. Because of the dilemma of suboptimal control resulting from inadequate radiation dose when compared with surgical treatment, and possible radiation complication from higher dose, surgery should be the treatment of choice for neck node recurrence after primary radiotherapy for nasopharyngeal carcinoma.