Clinical Investigation
Salvage Reirradiaton With Stereotactic Body Radiotherapy for Locally Recurrent Head-and-Neck Tumors

Presented in part in abstract and poster form at the 51st Annual Meeting of the American Society for Therapeutic Radiology and Oncology, Nov 1–5, 2009, Chicago, IL.
https://doi.org/10.1016/j.ijrobp.2010.04.027Get rights and content

Purpose

In this study, we present our results of reirradiation of locally recurrent head-and-neck cancer with image-guided, fractionated, frameless stereotactic body radiotherapy technique.

Methods and Materials

From July 2007 to February 2009, 46 patients were treated using the CyberKnife (Accuray, Sunnyvale, CA) at the Department of Radiation Oncology, Hacettepe University, Ankara, Turkey. All patients had recurrent, unresectable, and previously irradiated head-and-neck cancer. The most prominent site was the nasopharynx (32.6%), and the most common histopathology was epidermoid carcinoma. The planning target volume was defined as the gross tumor volume identified on magnetic resonance imaging and computed tomography. There were 22 female and 24 male patients. Median age was 53 years (range, 19–87 years). The median tumor dose with stereotactic body radiotherapy was 30 Gy (range, 18–35 Gy) in a median of five (range, one to five) fractions.

Results

Of 37 patients whose response to therapy was evaluated, 10 patients (27%) had complete tumor regression, 11 (29.8%) had partial response, and 10 (27%) had stable disease. Ultimate local disease control was achieved in 31 patients (83.8%). The overall survival was 11.93 months in median (ranged, 11.4 – 17.4 months), and the median progression free survival was 10.5 months. One-year progression-free survival and overall survival were 41% and 46%, respectively. Grade II or greater long-term complications were observed in 6 (13.3%) patients. On follow-up, 8 (17.3%) patients had carotid blow-out syndrome, and 7 (15.2%) patients died of bleeding from carotid arteries. We discovered that this fatal syndrome occurred only in patients with tumor surrounding carotid arteries and carotid arteries receiving all prescribed dose.

Conclusions

Stereotactic body radiotherapy is an appealing treatment option for patients with recurrent head-and-neck cancer previously treated with radiation to high doses. Good local control with considerable 1-year survival is achieved with a relatively high rate of morbidity and related mortality.

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

References (31)

  • J. Xiao et al.

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

    Int J Radiat Oncol Biol Phys

    (2001)
  • J.K. Salama et al.

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

    Int J Radiat Oncol Biol Phys

    (2006)
  • J.W. Bailet et al.

    Nasopharyngeal carcinoma: Treatment results with primary radiation therapy

    Laryngoscope

    (1992)
  • W.K. Hong et al.

    Chemotherapy in head and neck cancer

    N Engl J Med

    (1983)
  • A.A. Forastiere et al.

    Randomized comparison of cisplatin plus fluorouracil and carboplatin plus fluorouracil versus methotrexate in advanced squamous-cell carcinoma of the head and neck: A Southwest Oncology Group study

    J Clin Oncol

    (1992)
  • Cited by (122)

    • Initial Data Pooling for Radiation Dose-Volume Tolerance for Carotid Artery Blowout and Other Bleeding Events in Hypofractionated Head and Neck Retreatments

      2021, International Journal of Radiation Oncology Biology Physics
      Citation Excerpt :

      At least a 6-month interval between prior and subsequent courses of irradiation is required in RTOG 3507,38 but patients have been successfully treated with as little as a 3-month interval in other studies.23,24 Lower extent of circumferential involvement of carotid or other major vessels by tumor <180° has been associated with a decreased risk,4,12 although this is not a uniform finding.23,24 The absence of skin invasion by the recurrent cancer, especially in postoperative patients5,39

    View all citing articles on Scopus

    Conflict of interest: none.

    View full text