Clinical Investigation
IMRT Reirradiation of Head and Neck Cancer—Disease Control and Morbidity Outcomes

https://doi.org/10.1016/j.ijrobp.2008.04.021Get rights and content

Purpose

Institutional and cooperative group experience has demonstrated the feasibility of reirradiation for head and neck cancer. Limited data are available regarding the use of intensity-modulated radiotherapy (IMRT) for this indication. We reviewed our initial experience using IMRT for previously irradiated head and neck cancer patients.

Methods and Materials

Records of 78 consecutive patients reirradiated with IMRT for head and neck cancer between 1999 and 2004 were reviewed; 74 cases were analyzed. Reirradiation was defined as any overlap between original and new radiation treatment volumes regardless of the time interval between initial and subsequent treatment. Severe reirradiation-related toxicity was defined as toxic events resulting in hospitalization, corrective surgery, or patient death. Longitudinal estimates of survival were calculated by Kaplan-Meier technique.

Results

Twenty (27%) patients underwent salvage surgical resection and 36 (49%) patients received chemotherapy. Median follow-up from reirradiation was 25 months. Median time interval between initial radiation and reirradiation was 46 months. Median reirradiation dose was 60 Gy. Median lifetime radiation dose was 116.1 Gy. The 2-year overall survival and locoregional control rates were 58% and 64%, respectively. Severe reirradiation related toxicity occurred in 15 patients (20%); one treatment-related death was observed.

Conclusions

The use of IMRT for reirradiation of recurrent or second primary head and neck cancers resulted in encouraging local control and survival. Reirradiation-related morbidity was significant, but may be less severe than previously published reports using conventional techniques.

Introduction

Disease control and survival outcomes for nonoperative treatment of head and neck cancer have improved significantly with the use of aggressive combined chemoradiotherapy 1, 2. However, both locoregional disease failure (3) and secondary index cancers (which occur in up to 40% of successfully treated patients) (4) remain common.

Locoregional recurrences after definitive radiation treatment typically occur within high-dose treatment volumes signifying intrinsic tumor radioresistance 5, 6. Accordingly, patients typically fare best with salvage surgical resection, especially those with laryngeal disease 7, 8. Unfortunately, many recurrences present at an advanced stage and are unresectable. Treatment with chemotherapy alone provides nondurable responses, if any, in this setting 9, 10 and is reserved for palliative management. Numerous institutional reports 11, 12, 13, 14, 15, 16, 17 and recent cooperative group studies (18) have reported more encouraging salvage outcomes with the use of aggressive reirradiation and chemotherapy, with acceptable morbidity. Durable disease response and survival has been reproducibly demonstrated in a small (15–20%), but finite, minority of patients in these series.

Such reports have documented outcomes specific to reirradiation delivered with conventional techniques. Conventional delivery of even limited size fields confined to clinically evident disease can be challenging in cases where recurrent tumor closely approximates critical at-risk structures such as previously irradiated spinal cord. Initial experience with intensity modulated radiation therapy (IMRT) for primary treatment of head-and-neck disease has provided encouraging local control, survival, and toxicity outcomes 19, 20. Because IMRT permits extremely conformal delivery of definitive doses with sparing of neighboring normal tissues, it promises to improve both efficacy and morbidity in reirradiated patients. To test this hypothesis, we reviewed our initial 5-year experience using IMRT retreatment for locally recurrent or second primary head-and-neck disease.

Section snippets

Methods and Materials

We retrospectively reviewed the medical records of 78 consecutive patients who received IMRT reirradiation for either locoregionally recurrent or in-field second primary disease (including radiation-associated malignancies) between May 1999 and August 2004. Permission for data abstraction was obtained from our Investigational Review Board. Patients were excluded if information regarding the initial radiation treatment was not documented or if distant metastatic disease was present. Four

Patients

Patient characteristics are detailed in Table 1. Median age at the time of reirradiation was 61.8 years (range, 19.6–84.0 years). The majority of patients were male (70%), with a median follow-up from reirradiation of 25.4 months (range, 0.0–80.6 months). Sixty-seven (91%) patients were treated with curative intent, whereas the remainder was treated for palliation. The majority of patients had either oropharyngeal (41%) or nasopharyngeal carcinoma (16%). Fifty-seven patients (77%) had squamous

Discussion

Locoregional recurrences after radiotherapy represent a challenging clinical problem. Surgical resection, with or without adjuvant radiotherapy, provides the highest likelihood for successful salvage 7, 14, 22, 23, 24, 25. Unfortunately, many patients present with unresectable disease. Systemic therapy alone provides at most a 40% response rate (26). These responses are commonly transient, with median survival limited to 6–9 months.

Published experience with the use of full-dose reirradiation

Conclusions

This series presents initial disease control and survival results for IMRT reirradiation of locoregionally recurrent or in-field second primary head and neck cancers. Severe treatment-related morbidity was significant, but was less common than for previously published series using conventional techniques, suggesting an improved therapeutic ratio with the use of IMRT. Given the limitations of this retrospective institutional series, including small size and potential patient selection/treatment

References (34)

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  • Outcomes of re-irradiation for oral cavity squamous cell carcinoma

    2022, Biomedical Journal
    Citation Excerpt :

    The Radiation Therapy Oncology Group (RTOG) conducted two similar phase II trials of repeated concurrent chemoradiotherapy and found that a small but substantial percentage (16%–25.9%) of patients could survive at 2 years [12,13] following re-RT. However, most studies in Western populations have reported outcomes of re-RT for HN cancer with tumors originating from all anatomic subsites and even the nonsquamous subtype, and only 7%–32% of the patients had OC cancer [14–18]. Considering that different anatomic subsites or pathologic subtypes may result in different outcomes [19], we focused on OSCC and reviewed our previous re-RT experience as a benchmark for future clinical studies.

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Results from this work were presented at the 48th Annual Meeting of the American Society of Therapeutic Radiology and Oncology (ASTRO), November 5–9, 2006, Philadelphia, PA.

Partly supported by P01 CA06294, awarded by the National Cancer Institute.

Conflict of interest: none.

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