International journal of radiation oncology, biology, physics 2018-03-01
Volume, Dose, and Fractionation Considerations for IMRT-based Reirradiation in Head and Neck Cancer: A Multi-institution Analysis.
Abstract
Purpose
Limited data exist to guide the treatment technique for reirradiation of recurrent or second primary squamous carcinoma of the head and neck. We performed a multi-institution retrospective cohort study to investigate the effect of the elective treatment volume, dose, and fractionation on outcomes and toxicity.
Methods and materials
Patients with recurrent or second primary squamous carcinoma originating in a previously irradiated field (≥40 Gy) who had undergone reirradiation with intensity modulated radiation therapy (IMRT); (≥40 Gy re-IMRT) were included. The effect of elective nodal treatment, dose, and fractionation on overall survival (OS), locoregional control, and acute and late toxicity were assessed. The Kaplan-Meier and Gray's competing risks methods were used for actuarial endpoints.
Results
From 8 institutions, 505 patients were included in the present updated analysis. The elective neck was not treated in 56.4% of patients. The median dose of re-IMRT was 60 Gy (range 39.6-79.2). Hyperfractionation was used in 20.2%. Systemic therapy was integrated for 77.4% of patients. Elective nodal radiation therapy did not appear to decrease the risk of locoregional failure (LRF) or improve the OS rate. Doses of ≥66 Gy were associated with improvements in both LRF and OS in the definitive re-IMRT setting. However, dose did not obviously affect LRF or OS in the postoperative re-IMRT setting. Hyperfractionation was not associated with improved LRF or OS. The rate of acute grade ≥3 toxicity was 22.1% overall. On multivariable logistic regression, elective neck irradiation was associated with increased acute toxicity in the postoperative setting. The rate of overall late grade ≥3 toxicity was 16.7%, with patients treated postoperatively with hyperfractionation experiencing the highest rates.
Conclusions
Doses of ≥66 Gy might be associated with improved outcomes in high-performance patients undergoing definitive re-IMRT. Postoperatively, doses of 50 to 66 Gy appear adequate after removal of gross disease. Hyperfractionation and elective neck irradiation were not associated with an obvious benefit and might increase toxicity.
Related Questions
What's the role of contralateral neck re-irradiation in the post-op setting for someone with a remote history of head and neck cancer who underwent definitive RT with elective dose to the bilateral neck now with a new primary s/p surgery with ipsilateral neck dissection requiring post op chemo radiation for bony involvement and ENE?
In a reirradiation setting, I would not offer elective RT. Even if the new primary approached or crossed midline, I would refrain from reirradiating a neck that was subject to prior RT in the 50 Gy range.
How would you treat a second HPV related oropharyngeal squamous cell cancer in a patient previoulsy treated and cured of a HPV related SCC of the tonsil treated with chemoradiation?
At our institution, recurrent or second primary head and neck cancers are discussed at a multidisciplinary tumor board whenever possible. We review prior radiation records, physician's notes, and pre-treatment imaging to attempt to come to a consensus whether it is truly a second primary or perhaps ...
How would you manage recurrent laryngeal cancer after previous larynx xrt if surgical salvage not an option?
Re-RT for recurrent laryngeal cancer when surgery is not an option was first proposed by CC Wang (IJROBP 1993;26:783-5). He reported reasonable local control rates and stated, at the conclusion of “Radiation Therapy Results†in his paper, that “significant radiation sequelae… were not encoun...
What dose and fractionation do you use in the setting of head and neck reirradiation?
We have traditionally treated recurrent HNC with full standard fractionated RT concurrent with chemo. In recent years we have transitioned to SBRT, typically 40 Gy in 5 fractions. The use of SBRT is more convenient; current data suggest that both methods achieve similar tumor control rates and simil...