International Journal of Radiation Oncology*Biology*Physics
Clinical InvestigationSalvage Reirradiaton With Stereotactic Body Radiotherapy for Locally Recurrent Head-and-Neck Tumors
Introduction
A combination of surgery, radiation therapy, and chemotherapy is generally used in the primary treatment of advanced head-and-neck cancer. Despite these aggressive treatment modalities, local recurrence or persistent disease is seen at rates as high as 3% to 50% 1, 2, 3, 4. For the treatment of local failure, surgery is not always feasible; and chemotherapy results in a response rate of 50% to 60%, with a median survival of 5 to 6 months 5, 6. Surgery, although not feasible in the majority of cases, improves prognosis in patients with previously irradiated, recurrent head-and-neck cancer 7, 8, 9. However the risk of local recurrence remains high even after salvage surgery, which necessitates additional treatment 7, 8, 9, 10, 11.
The location of the recurrences, the high doses used previously, and the limited tissue tolerances have resulted in serious concerns over normal tissue complications, and radiation oncologists have hesitated to use reirradiation in the treatment of recurrent head-and-neck cancers. However, with the advent of conformal techniques such as three- dimensional conformal radiotherapy (CRT) and intensity-modulated radiotherapy (IMRT), reducing the field size and applying cytotoxic doses have become possible. Recent studies using these technologies report response rates of 60% to 70%, with 10% to 40% of Grade 3 and 4 toxicities 12, 13, 14.
CyberKnife (Accuray, Sunnyvale, CA) is a relatively new image-guided stereotactic radiosurgery and body radiotherapy device. It enables the application of high doses of radiation precisely to tumors that are surgically unresectable or that have received previous radiotherapy. Lesions located close to the critical structures can be treated more effectively because of the rapid dose fall-off at the periphery. The use of stereotactic body radiotherapy (SBRT) in recurrent head-and-neck carcinoma is relatively new, and few centers have reported the treatment results. In this article, we present the results of reirradiation of locally recurrent head-and-neck cancer with an image-guided, fractionated, frameless SBRT technique.
Section snippets
Methods and Materials
From July 2007 to February 2009, 46 patients were treated with CyberKnife (Accuray, Sunnyvale, CA) in the Department of Radiation Oncology, Hacettepe University, Ankara, Turkey. All patients had recurrent, unresectable, and previously irradiated head-and-neck cancer. Before treatment, all patients underwent restaging using computed tomography (CT) and magnetic resonance imaging (MRI). Patients with a Karnofsky Performance Scale value ≥50 were treated with SBRT, and informed consent was obtained
Patient characteristics
A total of 46 patients were treated with SBRT from July 2007 to February 2009. There were 22 female and 24 male patients, with a median age of 53 years (range, 19–87 years). The primary tumor originated from the nasopharynx in 20 patients, oral cavity in 9, paranasal sinus in 7, larynx in 3, hypopharynx in 3, and other sites in 4 patients. The histopathologic diagnoses were squamous cell carcinoma in 30 patients (3 nonkeratinizing carcinoma of the nasopharynx) and adenoid cystic carcinoma in 7.
Discussion
In this article, we present the results of reirradiation with SBRT in 46 inoperable recurrent head-and-neck cancer patients. In the past, patients with inoperable recurrent head-and-neck cancer previously irradiated with high doses were mostly referred for palliative chemotherapy. However, with the advent of new technologies, there has been a renewed interest in reirradiation. In the treatment of recurrent head-and-neck cancer, doses >60 Gy are necessary for optimal salvage probability (15). It
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Conflict of interest: none.