Stereotactic body radiation therapy for locally recurrent, previously irradiated nonsquamous cell cancers of the head and neck

Osteoradionecrosis Rates After Head and Neck Radiation Therapy: Beyond the Numbers

PURPOSE

Osteoradionecrosis (ORN) is a severe late complication of head and neck radiation therapy shown to have profound negative effect on the quality of life of cancer survivors. Over the past few decades, improvements in radiation delivery techniques have resulted in a decrease in the incidence of ORN. However, even with modern radiation therapy techniques, ORN remains an important clinical concern. In recent literature, there is a wide range of reported ORN rates from 0% to as high as 20%. With such a high level of variability in the reported incidence of ORN, oncologists often encounter difficulties estimating the risk of this serious radiation therapy toxicity.

METHODS AND MATERIALS

In this review, the authors present a summary of the factors that contribute to the high level of variability in the reported incidence of ORN.

RESULTS

Variable definition, variable grading, and heterogeneity of both study inclusion criteria and treatment parameters can each significantly influence the reporting of ORN rates.

CONCLUSIONS

Given numerous factors can affect the reported incidence of ORN, a thorough understanding of the clinical context behind the reported ORN rates is needed to comprehend the true risk of this important radiation therapy toxicity.

Stereotactic Body Radiotherapy in Recurrent and Oligometastatic Head and Neck Tumours

The treatment of head and neck cancers (HNCs) encompasses a complex paradigm involving a combination of surgery, radiotherapy, and systemic treatment. Locoregional recurrence is a common cause of treatment failure, and few patients are suitable for salvage surgery. Reirradiation with conventional radiation techniques is challenging due to normal tissue tolerance limits and the risk of significant toxicities. Stereotactic body radiotherapy (SBRT) has emerged as a highly conformal modality that offers the potential for cure while limiting the dose to surrounding tissue. There is also growing research that shows that those with oligometastatic disease can benefit from curative intent local ablative therapies such as SBRT. This review will look at published evidence regarding the use of SBRT in locoregional recurrent and oligometastatic HNCs.

Impact of hyperfractionated re-irradiation on quality of life in patients with recurrent or second primary head and neck cancer, a prospective single institutional study

Purpose

Describe the clinical outcome of hyperfractionated re-irradiation (HFRT) in patients with recurrent or second primary (SP) head and neck cancer (HNC).

Methods

This prospective observational study included HNC patients eligible for HFRT. Inclusion criteria: age ≥18 years, recurrent or SP HNC, planned re-irradiation and ability to respond to questionnaires. Patients received 1.5 Gy twice daily, five days a week for three (palliative) or four (curative/local control) weeks, total dose 45/60 Gy. Toxicity was scored with CTCAE v3 at baseline, end of treatment, at three, six, 12 and 36 months follow-up. Health-related quality of life (HRQoL) was measured with EORTC QLQ-C30 and EORTC QLQ-H&N35, pre-treatment and eight times until 36 months. In the main outcome (Global quality of life and H&N Pain), a change score of ≥10 was considered clinically significant, and p-values < 0.05 (two-sided) statistically significant. The Kaplan-Meier method was used for survival analyses.

Results

Over four years from 2015, 58 patients were enrolled (37 recurrent and 21 SP). All, but two patients completed treatment as planned. Toxicity (≥grade 3) increased from pre-treatment to end of treatment with improvement in the follow-up period. The mean Global quality of life (QoL) and H&N Pain scores were stable from pre-treatment to three months. Maintained/ improved Global QoL was reported by 60% of patients at three months and 56% of patients at 12 months. For patients with curative, local control and palliative intent, the median survival (range) was 23 (2-53), 10 (1-66) and 14 (3-41) months respectively. Of those alive, the proportion of disease-free patients at 12 and 36 months, were 58% and 48%, respectively.

Conclusion

Most HNC patients reported maintained HRQoL at three and 12 months after HFRT despite serious toxicity observed in many patients. Long-term survival can be achieved in a limited proportion of the patients.

A Prospective Phase II Study of Automated Non-Coplanar VMAT for Recurrent Head and Neck Cancer: Initial Report of Feasibility, Safety, and Patient-Reported Outcomes

Simple Summary

The delivery of higher radiation doses has been shown to increase local control, and ultimately survival, for head and neck cancer patients, but highly conformal dose distributions are necessary to minimize normal tissue toxicity. Varian’s HyperArc non-coplanar automated treatment planning and delivery technique has been shown to improve dose conformity for intracranial treatment, but its safety and efficacy for head and neck cancer treatment has yet to be verified. This study evaluates the initial results of a prospective clinical trial using HyperArc for recurrent head and neck cancer patients. We demonstrated that HyperArc can enable significant tumor dose escalation compared to conventional volumetric modulated arc therapy (VMAT) planning while minimizing the dose to organs at risk. Treatment delivery was feasible and safe, with minimal treatment-related toxicities and positive patient-reported quality of life measures.

Abstract

This study reports the initial results for the first 15 patients on a prospective phase II clinical trial exploring the safety, feasibility, and efficacy of the HyperArc technique for recurrent head and neck cancer treatment. Eligible patients were simulated and planned with both conventional VMAT and HyperArc techniques and the plan with superior dosimetry was selected for treatment. Dosimetry, delivery feasibility and safety, treatment-related toxicity, and patient-reported quality of life (QOL) were all evaluated. HyperArc was chosen over conventional VMAT for all 15 patients and enabled statistically significant increases in dose conformity (R50% reduced by 1.2 ± 2.1, p < 0.05) and mean PTV and GTV doses (by 15.7 ± 4.9 Gy, p < 0.01 and 17.1 ± 6.0 Gy, p < 0.01, respectively). The average HyperArc delivery was 2.8 min longer than conventional VMAT (p < 0.01), and the mean intrafraction motion was ≤ 0.5 ± 0.4 mm and ≤0.3 ± 0.1°. With a median follow-up of 12 months, treatment-related toxicity was minimal (only one grade 3 acute toxicity above baseline) and patient-reported QOL metrics were favorable. HyperArc enabled superior dosimetry and significant target dose escalation compared to conventional VMAT planning, and treatment delivery was feasible, safe, and well-tolerated by patients.

Comparison of Intrafractional Motion in Head and Neck Cancer Between Two Immobilization Methods During Stereotactic Ablative Radiation Therapy by CyberKnife

Purpose

Maintaining immobilization to minimize spine motion is very important during salvage stereotactic ablative radiation therapy (SABR) for recurrent head and neck cancer. This study aimed to compare the intrafractional motion between two immobilization methods.

Patients and Methods

With a spine tracking system for image guiding, 9094 records from 41 patients receiving SABR by CyberKnife were obtained for retrospective comparison. Twenty-one patients were immobilized with a thermoplastic mask and headrest (Group A), and another 20 patients used a thermoplastic mask and headrest together with a vacuum bag to support the head and neck area (Group B). The intrafractional motion in the X (superior-inferior), Y (right-left), Z (anterior-posterior) axes, 3D (three-dimensional) vector, Roll, Pitch and Yaw in the two groups was compared. The margins of the planning target volume (PTV) to cover 95% intrafractional motion were evaluated.

Results

The translational movements in the X-axis, Y-axis, and 3D vector in Group A were significantly smaller than in Group B. The rotational errors in the Roll and Yaw in Group A were also significantly smaller than those in Group B; conversely, those in the Pitch in Group A were larger. To cover 95% intrafractional motion, margins of 0.96, 1.55, and 1.51 mm in the X, Y and Z axes, respectively were needed in Group A, and 1.06, 2.86, and 1.34 mm, respectively were required in Group B.

Conclusion

The immobilization method of thermoplastic mask and head rest with vacuum bag did not provide better immobilization than that without vacuum bag in most axes. The clinical use of 2 mm as a margin of PTV to cover 95% intrafractional motion was adequate in Group A but not in Group B.

Highly conformal reirradiation in patients with prior oropharyngeal radiation: Clinical efficacy and toxicity outcomes

BACKGROUND

Reirradiation of head and neck cancer is associated with high rates of locoregional failure and potentially severe treatment-related toxicity. We report our institutional experience of reirradiation using modern highly conformal radiotherapy approaches in patients with prior oropharyngeal radiation.

METHODS

We reviewed patients receiving curative-intent reirradiation with intensity-modulated radiation therapy, stereotactic body radiation therapy, and proton beam radiotherapy at our institution from 1999 to 2019. Disease control, survival, and toxicity rates following reirradiation were determined.

RESULTS

Sixty-nine patients were evaluated. Local control (LC), progression-free survival, and overall survival at 2 years following reirradiation were 77%, 35%, and 51%, respectively. Grade 3 or greater (G3+) late toxicities occurred in 46% of patients and 41% required feeding tube placement during or after reirradiation.

CONCLUSIONS

In select patients with prior oropharyngeal radiation, highly conformal reirradiation offers acceptable LC, but G3+ toxicity and out-of-field failure rates remain high. These findings warrant continued evaluation of new multimodality approaches to improve oncologic outcomes.

Conventionally fractionated large volume head and neck re-irradiation using multileaf collimator-based robotic technique: A feasibility study

Purpose

To report on the feasibility and performance of conventionally fractionated multileaf collimator (MLC)-based robotic stereotactic body re-irradiation of the head and neck region using MLC-based Cyberknife (CK) technology.

Methods

Patients treated for recurrent or second primary head and neck cancer (HNC) with curative proton therapy to a target volume > 30 cm³ between 2011 and 2015 were included. MLC-based CK plans were generated using the CK M6 InCise2 MLC system. Dose statistics from MLC-based CK plans were compared to proton beam therapy (PBT) plans according to the following metrics: target coverage, target homogeneity index, gradient index, Paddick conformity index (CI), prescription isodose volume (PIV), treatment time (tTime) for one fraction as well as doses to organs at risk (OAR). Wilcoxon signed-rank test was used to compare dose metrics.

Results

Eight patients were included; the tumor sites included: salivary glands, pharynx (oropharynx, hypopharynx and retropharynx) and sinonasal cavities. Five of 8 patients were treated with multifield optimisation intensity modulated proton therapy, 3 were treated with passive scattering proton therapy. Median dose was 67 Gy (range 60-70) in 32 fractions (range 30-35). The median high-dose planning target volume (PTV) was 45.4 cm³ (range 2.4 - 130.2 cm³) and the median elective PTV was 91.9 cm³ (range 61.2 - 269.7 cm³). Overall, the mean target coverage (mean 98.3% vs. 96.2% for CK vs. PBT, respectively), maximum dose to PTV (mean 111% vs. 111%, p = 0.2) and mean dose to PTV (mean 104% vs. 104%) were similar across modalities. Highly conformal plans were achieved with both modalities, but mean CI was better with PBT (0.5 vs. 0.6 for CK vs. PBT, p = 0.04). Homogeneity and gradient indexes were similar between the 2 modalities; mean tTime with PBT and CK was 17 vs. 18 min, respectively (p = 0.7). Case-based study revealed that CK and PBT plans allowed for excellent sparing of OAR, with some clinical scenarios associated with better performance of CK while others with better performance of PBT.

Conclusion

Our study has demonstrated the dosimetric performance of large volume head and neck re-irradiation using MLC-based CK in various clinical scenarios. While conformity was generally better achieved with PBT, MLC-based CK allowed for high dose gradient leading to rapid dose drop-off and sparing of OAR. Conventionally fractionated MLC-based CK could be a competitive alternative in large volume head and neck re-irradiation that deserves further investigation in the clinical setting.

Long-Term Patient-Reported Quality of Life After Stereotactic Body Radiation Therapy for Recurrent, Previously-Irradiated Head and Neck Cancer

Objectives: Long-term quality-of-life data following stereotactic body radiation therapy (SBRT) for recurrent head and neck cancer (rHNC) is underreported. We report patient-reported quality-of-life (PR-QOL) after at least 1 year post-treatment. Methods and Materials: A retrospective review was performed on 64 patients receiving SBRT for previously-irradiated rHNC. PR-QOL was prospectively evaluated using the University of Washington Quality of Life Questionnaire. The mixed effects proportional odds model was used to assess post-treatment overall PR-QOL changes, as well as the effects of late toxicities, tumor volume > 25 cc, local failure, nodal recurrence, distant failure, prior neck dissection, performance status other than ECOG 0 or Karnofsky 100, sex, age >65, squamous vs. non-squamous primary histology, and specific organ recurrence. Results: SBRT had no significant effect on overall PR-QOL at days 1-90 post-treatment (SBRT effect 0.035, p = 0.93) and days 91-365 (SBRT effect -0.30, p = 0.45). Beyond day 365, overall PR-QOL was significantly worse than baseline (SBRT effect -0.77, p =.03). Grade ≥3 late toxicities (p = 0.0072) and tumor volume > 25 cc (p = 0.032) predicted significantly worse overall PR-QOL. Oral cavity recurrence predicted significant decrements in chewing (p = 0.0006), swallowing (p = 0.0301), and taste PR-QOL (p = 0.02). Nasal recurrence predicted significant decrements in taste PR-QOL (p = 0.030). Grade ≥3 late dysphagia predicted significant decline in chewing (p = 0.039) and swallowing (p = 0.0004). Grade ≥3 late osteonecrosis predicted significant differences in pain PR-QOL (p = 0.0026). Conclusion: PR-QOL across several domains declines immediately after SBRT for previously-irradiated rHNC before returning to baseline levels at 1 year. Long-term PR-QOL declines thereafter. Patients with grade ≥3 late toxicities or tumor volume >25 cc report reduced long-term overall PR-QOL, likely representing late disease progression. Specific organ recurrence and grade ≥3 late toxicities predict decrements in specific PR-QOL domains.

Dosimetric comparison of protons vs photons in re-irradiation of intracranial meningioma

OBJECTIVES

Re-irradiation of recurrent intracranial meningiomas represents a major challenge due to dose limits of critical structures and the necessity of sufficient dose coverage of the recurrent tumor for local control. The aim of this study was to investigate dosimetric differences between pencil beam scanning protons (PBS) and volumetric modulated arc therapy (VMAT) photons for intracranial re-irradiation of meningiomas.

METHODS

Nine patients who received an initial dose >50 Gy for intracranial meningioma and who were re-irradiated for recurrence were selected for plan comparison. A volumetric modulated arc therapy photon and a pencil beam scanning proton plan were generated (prescription dose: 15 × 3 Gy) based on the targets used in the re-irradiation treatment.

RESULTS

In all cases, where the cumulative dose exceeded 100 or 90 Gy, these high dose volumes were larger for the proton plans. The integral doses were significantly higher in all photon plans (reduction with protons: 48.6%, p < 0.01). In two cases (22.2%), organ at risk (OAR) sparing was superior with the proton plan. In one case (11.1%), the photon plan showed a dosimetric advantage. In the remaining six cases (66.7%), we found no clinically relevant differences in dose to the OARs.

CONCLUSIONS

The dosimetric results of the accumulated dose for a re-irradiation with protons and with photons were very similar. The photon plans had a steeper dose falloff directly outside the target and were superior in minimizing the high dose volumes. The proton plans achieved a lower integral dose. Clinically relevant OAR sparing was extremely case specific. The optimal treatment modality should be assessed individually.

ADVANCES IN KNOWLEDGE

Dose sparing in re-irradiation of intracranial meningiomas with protons or photons is highly case specific and the optimal treatment modality needs to be assessed on an individual basis.

Esthesioneuroblastoma: A Comprehensive Review of Diagnosis, Management, and Current Treatment Options

INTRODUCTION

Many controversies exist in the diagnosis and management of this aggressively malignant condition, mainly because of limited literature and lack of randomized control trials, resulting in nonstandardized treatment methods. We performed a comprehensive review of the literature to identify management approach and treatment options for esthesioneuroblastoma.

METHODS

An extensive review of the published literature was conducted in PubMed, OVID Medline, and EMBASE journals for studies of esthesioneuroblastoma. Terms for search included esthesioneuroblastoma (ENB) and olfactory neuroblastoma (ONB). No date restrictions were used.

RESULTS

The search yielded 3876 related articles. Cross-checking of articles led to exclusion of duplicate articles. The remaining 1170 articles were screened for their full text and English language availability. Of 609 full-text articles available, animal studies, irrelevant articles, and studies with mixed/confusing data were excluded. We finalized 149 articles pertaining to the topic, including 119 original research articles, 3 book chapters, 11 reviews, 9 case reports, and 7 case series.

CONCLUSIONS

Surgical resection followed by radiotherapy is the standard for treatment for higher-grade lesions. The endoscopic endonasal approach is gaining further recognition with more favorable outcomes and better survival than for open surgery. Postoperative radiotherapy is associated with the highest overall survival and shows benefit for patients with higher-stage disease and those who receive chemotherapy. Recurrence rates after treatment vary drastically in the literature and, therefore, prolonged follow-up with repeated imaging is recommended. Lifelong surveillance is recommended because of late recurrences associated with this tumor.

[Re-irradiation of head and neck cancers: Target volumes, technical evolutions and prospects]

Malignant tumors of the head and neck have a predominantly regional recurrence pattern, with most deaths resulting from this progression. Optimization of re-radiation in recurrence setting is a major objective for these patients. Extensive research has been carried out with the PubMed search engine to find publications dealing with this topic. The first attempts to reirradiate the ORL sphere date back to the 1980s and the first to be performed by intensity modulation conformational radiotherapy (IMRT) date back to the late 1990s. Compared to 3 dimensional conformal radiotherapy, IMRT improves clinical outcomes and reduces toxicity. In IMRT series, associated or not with concomitant chemotherapy, the locoregional control obtained at 2 years was of the order of 45 to 65% and the overall survival of 15 to 60%, depending on predictive factors. Grade 3 acute toxicity occurred on the order of 10 to 30% and late-grade 3 toxicity on the order of 15 to 50%. In a selected population with low volumes tumors, stereotactic re-irradiation at a minimum dose of 35Gy obtained outcome comparable to IMRT. Re-irradiation of head and neck tumors by proton therapy is rare. The toxicity rate appears to be lower than that usually seen after photon therapy. However, we do not have a long follow-up. This technique therefore remains reserved for search protocols and represents a future perspective in these situations.

Head and Neck Tumor Control Probability: Radiation Dose-Volume Effects in Stereotactic Body Radiation Therapy for Locally Recurrent Previously-Irradiated Head and Neck Cancer: Report of the AAPM Working Group

PURPOSE

Stereotactic body radiation therapy (SBRT) has emerged as a viable reirradiation strategy for locally recurrent previously-irradiated head and neck cancer. Doses in the literature have varied, which challenges clinical application of SBRT as well as clinical trial design.

MATERIAL & METHODS

A working group was formed through the American Association of Physicists in Medicine to study tumor control probabilities for SBRT in head and neck cancer. We herein present a systematic review of the available literature addressing the dose/volume data for tumor control probability with SBRT in patients with locally recurrent previously-irradiated head and neck cancer. Dose-response models are generated that present tumor control probability as a function of dose.

RESULTS

Data from more than 300 cases in 8 publications suggest that there is a dose-response relationship, with superior local control and possibly improved overall survival for doses of 35 to 45 Gy (in 5 fractions) compared with <30 Gy.

CONCLUSION

Stereotactic body radiation therapy doses equivalent to 5-fraction doses of 40 to 50 Gy are suggested for retreatment.

Stereotactic Body Radiation Therapy for Recurrent Head and Neck Cancer

Stereotactic body radiation therapy (SBRT) offers a promising opportunity for cure and/or palliation to patients with recurrent head and neck cancer whose comorbidities, performance status, and history of prior treatment may preclude many other salvage options. Stereotactic body radiation therapy appears to have a favorable response and toxicity profile compared with other nonoperative salvage options for recurrent head and neck cancer. However, the risk of severe toxicity remains, with carotid blowout syndrome a unique concern, although the incidence of this complication may be minimized with alternating-day fractionation. The short overall treatment time and low rates of acute toxicity make SBRT an optimal vehicle to integrate with novel systemic therapies, and several phase II studies have used concurrent cetuximab as a radiosensitizer with SBRT with promising results. Ongoing studies aim to evaluate the potential synergistic effect of SBRT with immune checkpoint inhibitors in recurrent head and neck cancer.

Clinical outcomes after local field conformal reirradiation of patients with retropharyngeal nodal metastasis

BACKGROUND

The purpose of this study was to present our experience with retropharyngeal node reirradiation using highly conformal radiotherapy (RT).

METHODS

A retrospective screen of 2504 consecutively irradiated patients with head and neck malignancies between 2005 and 2015 identified 19 patients who underwent reirradiation for retropharyngeal node metastasis. Clinical and toxicity outcomes were assessed in these patients.

RESULTS

Thirteen patients (68%) had squamous cell carcinoma. Eleven patients (58%) received conventionally fractionated intensity-modulated radiotherapy (IMRT) or proton therapy, and 8 patients (42%) received single-fractionated or hypofractionated stereotactic RT. Fourteen patients (74%) received chemotherapy. Median follow-up was 14.7 months. The 1-year local control, locoregional control, overall survival, and progression-free survival rates were 100%, 94%, 92%, and 92%, respectively. Three patients (16%) experienced acute grade 3 toxicity and occurred in those treated with IMRT. There was no late grade ≥3 toxicity.

CONCLUSION

Retropharyngeal node reirradiation with conformal therapy is well tolerated and associated with excellent short-term disease control.

Survey of current practices from the International Stereotactic Body Radiotherapy Consortium (ISBRTC) for head and neck cancers

AIM

To provide a multi-institutional description of current practices of stereotactic body radiotherapy (SBRT) for head and neck cancer.

MATERIALS & METHODS

15 international institutions with significant experience in head and neck SBRT were asked to complete a questionnaire covering clinical and technical factors.

RESULTS

SBRT is used 10-100% of the time for recurrent primary head and neck cancer, and 0-10% of the time in newly diagnosed disease. Five centers use a constraint for primary disease of 3-5 cm and 25-30 cc. Nine institutions apply a clinical target volume expansion of 1-10 mm and 14 use a planning target volume margin of 1-5 mm. Fractionation regimens vary between 15 and 22 Gy in 1 fraction to 30-50 Gy in 5 or 6 fractions. The risk of carotid blowout quoted in the re-irradiation setting ranges from 3 to 20%.

CONCLUSION

There is considerable heterogeneity in patient selection and techniques in head and neck SBRT practice among experienced centers.

Stereotactic body radiotherapy for head and neck cancer: an addition to the armamentarium against head and neck cancer

In the recent years, stereotactic body radiation therapy (SBRT) has emerged as a potential therapy for head and neck malignancies. Although early results appear to be promising, serious acute and late effects have been observed, mainly in patients who have had prior external beam radiotherapy. This review will discuss the radiobiology of SBRT, clinical rationale and outcomes for SBRT in head and neck cancers and focus on the benefits and potential limitations in both de novo and re-irradiation settings.

Single-fraction stereotactic body radiation therapy for sinonasal malignant melanoma

BACKGROUND

A rare head and neck disease that may benefit from definitive or palliative stereotactic body radiation therapy (SBRT) is sinonasal malignant melanoma. These tumors can be very aggressive and often lead to severe epistaxis and significant mass effect. Results from only a handful of head and neck sinonasal malignant melanoma treated with SBRT are available in the current literature.

METHODS

The following reports on 2 cases of sinonasal malignant melanoma that recurred postoperatively and were subsequently treated at Roswell Park with SBRT. Both were treated with a single fraction of 15 Gy.

RESULTS

Nearly instant relief of their chronic epistaxis and complete responses were seen in both patients. One patient is alive and free of disease 7 years after radiation.

CONCLUSION

These patients with sinonasal malignant melanoma achieved symptomatic relief of severe bleeding and airway issues from single-fraction SBRT. SBRT should be considered as a treatment option in patients with unresectable sinonasal malignant melanoma.

Re-irradiation of adenoid cystic carcinoma: analysis and evaluation of outcome in 52 consecutive patients treated with raster-scanned carbon ion therapy

BACKGROUND

Treatment of local relapse in adenoid cystic carcinoma (ACC) following prior radiation remains a challenge: without the possibility of surgical salvage patients face the choice between palliative chemotherapy and re-irradiation. Chemotherapy yields response rates around 30% and application of tumouricidal doses is difficult due to proximity of critical structures. Carbon ion therapy (C12) is a promising method to minimize side-effects and maximize re-treatment dose in this indication. We describe our initial results for re-irradiation in heavily pre-treated ACC patients.

METHODS

Patients treated with carbon ion therapy between 04/2010 and 05/2013 (N=52pts, median age: 54 a) were retrospectively evaluated regarding toxicity (NCI CTC v.4), tumour response (RECIST) and control rates. 48pts (92.3%) received carbon ions only, 4pts received IMRT plus C12.

RESULTS

4pts were treated following R1-resection, 43pts for inoperable local relapse. Most common tumour sites were paranasal sinus (36.5%), parotid (19.2%), and base of skull (17.3%). Pts received a median dose of 51GyE C12/63Gy BED and cumulative dose of 128Gy BED [67-182Gy] after a median RT-interval of 61months. Median target volume was 93ml [9-618ml]. No higher-grade (>°II) acute reactions were observed, 7pts showed blood-brain-barrier changes (°I/II: 8pts; °III: 2pts), 1 pt corneal ulceration, xerophthalmia 7pts, °IV bleeding 1 pt, tissue necrosis 2pts, otherwise no significant late reactions. Objective response rate (CR/PR) was 56.6%. With a median follow-up of 14months [1-39months] local control and distant control at 1a are 70.3% and 72.6% respectively. Of the 18pts with local relapse, 13pts have recurred in-field, 1 pt at the field edge, 3pts out of field, and one in the dose gradient.

CONCLUSION

Despite high applied doses, C12 re-irradiation shows moderate side-effects, response rates even in these heavily pre-treated patients are encouraging and present a good alternative to palliative chemotherapy. Though most local recurrences occur within the high-dose area, further dose escalation should be viewed with caution.

Stereotactic body radiotherapy for a large arteriovenous malformation of the head and neck

Large arteriovenous malformations (AVMs) of the head and neck present a treatment challenge. A 38-year-old woman presented with a large intraoral bleed from longstanding AVMs of the left infratemporal fossa and the right tongue, despite 10 prior surgeries and embolizations. She was treated with stereotactic body radiotherapy with a dose of 24 Gy in three weekly fractions. Four years later, she has had dramatic shrinkage of her AVM, no recurrent bleeding episodes, no further treatment required, and no significant late effects. Level of evidence: NA.

Stereotactic body radiotherapy for recurrent oropharyngeal cancer - influence of HPV status and smoking history

PURPOSE

HPV status and smoking history stratifies patients into 3 distinct risk groups for survival following definitive chemoradiotherapy. Local-regional recurrences are common patterns of failure across all 3 risk-groups. SBRT±cetuximab has emerged as a promising salvage strategy for unresectable locally-recurrent, previously-irradiated head-and-neck cancer (rHNC) relative to conventional re-irradiation±chemotherapy. However the influence of HPV and smoking remains unknown in the setting of re-irradiation.

METHODS/MATERIALS

Patients (n=30) with rHNC of the oropharynx salvaged with SBRT±cetuximab from August 2002 through August 2013 were retrospectively reviewed; HPV status was determined based on p16 staining of primary pathology.

RESULTS

At a median follow-up of 10months for surviving patients, the mean overall survival for all patients was 12.6 months. HPV positivity was a significant predictor of overall survival (13.6 vs. 6.88 months, p=0.024), while smoking status did not significantly impact overall survival (p=0.707).

CONCLUSION

HPV status remains a significant predictor of overall survival in the re-irradiation setting with HPV positive rHNC demonstrating superior overall survival following salvage SBRT±cetuximab.

Impact of pretreatment tumor growth rate on outcome of early-stage lung cancer treated with stereotactic body radiation therapy

PURPOSE

To determine the influence of pretreatment tumor growth rate on outcomes in patients with early-stage non-small cell lung cancer (NSCLC) treated with stereotactic body radiation therapy (SBRT).

METHODS AND MATERIALS

A review was conducted on 160 patients with T1-T2N0M0 NSCLC treated with SBRT at single institution. The patient's demographic and clinical data, time interval (t) between diagnostic and planning computed tomography (CT), vital status, disease status, and cause of death were extracted from a prospectively kept database. Differences in gross tumor volume between diagnostic CT (GTV1) and planning CT (GTV2) were recorded, and growth rate was calculated by use of specific growth rate (SGR). Kaplan-Meier curves were constructed for overall survival (OS). Differences between groups were compared with a log-rank test. Multivariate analyses were performed by use of the Cox proportional hazard model with SGR and other relevant clinical factors. Cumulative incidence was calculated for local, regional, and distant failures by use of the competing risk approach and was compared with Gray's test.

RESULTS

The median time interval between diagnostic and planning CT was 82 days. The patients were divided into 2 groups, and the median SGR was used as a cut-off. The median survival times were 38.6 and 27.7 months for the low and high SGR groups, respectively (P=.03). Eastern Cooperative Oncology Group performance status (P=.01), sex (P=.04), SGR (P=.03), and GTV2 (P=.002) were predictive for OS in multivariable Cox regression analysis and, except sex, were similarly predictive for failure-free survival (FFS). The 3-year cumulative incidences of regional failure were 19.2% and 6.0% for the high and low SGR groups, respectively (P=.047).

CONCLUSION

High SGR was correlated with both poorer OS and FFS in patients with early-stage NSCLC treated with SBRT. If validated, this measurement may be useful in identifying patients most likely to benefit from adjuvant therapy after SBRT.

Examining tumor control and toxicity after stereotactic body radiotherapy in locally recurrent previously irradiated head and neck cancers: implications of treatment duration and tumor volume

BACKGROUND

Stereotactic body radiotherapy (SBRT) has been studied in locally recurrent previously-irradiated head and neck cancers; however, the optimum fractionation and patient selection continues to be defined.

METHODS

Patients (n = 132) with locally recurrent head and neck cancer salvaged via SBRT ± cetuximab (median, 44 Gy/5 fractions) from November 2004 to May 2011 were retrospectively reviewed. Disease outcomes and toxicity were analyzed by predictive factors including treatment duration and tumor volume.

RESULTS

At a median 6-month follow-up (range, 0-55 months), treatment duration <14 days was associated with significantly improved recurrence-free survival (RFS) at the expense of increased late toxicity (p = .029). Tumor volume >25 cc remained a significant predictor of inferior survival and tumor control, and was associated with significantly more acute toxicity (p = .017) but no difference in late toxicity.

CONCLUSION

SBRT ± cetuximab achieves promising tumor control and survival with low rates of acute/late toxicity even for recurrences >25 cc. Prolongations in treatment time may decrease late toxicity at the expense of disease control.

Multi institutional phase II study of concomitant stereotactic reirradiation and cetuximab for recurrent head and neck cancer

PURPOSE

Recurrent head and neck cancer is associated to a poor survival prognosis. A high toxicity rate is demonstrated when surgery and/or radiotherapy and/or chemotherapy are combined. Furthermore, the duration of treatment is often not ethically compatible with the expected survival (median survival<1year). Normal tissues tolerance limits the use of reirradiation and stereotactic body radiotherapy (SBRT) could offer precise irradiation while sparing healthy tissues. After completion of a feasibility study, results of a multicentric study (Lille, Nancy & Nice) using SBRT with cetuximab are reported. The aim of the study was to deliver non toxic short course SBRT (2weeks) in order to get the same local control as the one demonstrated with longer protocols.

METHODS AND MATERIALS

Patients with inoperable recurrent, or new primary tumor in a previously irradiated area, were included (WHO<3). Reirradiation (RT) dose was 36Gy in six fractions of 6Gy to the 85% isodose line covering 95% of the PTV with 5 injections of concomitant cetuximab (CT). All patients had previous radiotherapy, 85% had previous surgery and 48% previous chemotherapy.

RESULTS

Between 11/2007 and 08/2010, 60 were included (46 men and 14 women), 56 received CT+RT, 3 were not treated and 1 received only CT. Median age was 60 (42-87)) and all 56 patients had squamous carcinoma and received concomitant cetuximab. Mean time between previous radiotherapy and the start of SBRT was 38months. Cutaneous toxicity was observed for 41 patients. There was one toxic death from hemorrhage and denutrition. Median follow-up was 11.4months. At 3months, response rate was 58.4% (95% CI: 43.2-72.4%) and disease control rate was 91.7% (95% CI: 80.0-97.7%). The one-year OS rate was 47.5% (95% CI: 30.8-62.4).

CONCLUSION

These results suggest that short SBRT with cetuximab is an effective salvage treatment with good response rate in this poor prognosis population with previously irradiated HNC. Treatment is feasible and, with appropriate care to limiting critical structure, acute toxicities are acceptable. This combination may be the reference treatment is this population.

Stereotactic body radiation therapy in the re-irradiation situation--a review

Although locoregional relapse is frequent after definitive radiotherapy (RT) or multimodal treatments, re-irradiation is only performed in few patients even in palliative settings like e.g. vertebral metastasis. This is most due to concern about potentially severe complications, especially when large volumes are exposed to re-irradiation. With technological advancements in treatment planning the interest in re-irradiation as a local treatment approach has been reinforced. Recently, several studies reported re-irradiation for spinal metastases using SBRT with promising local and symptom control rates and simultaneously low rates of toxicity. These early data consistently indicate that SBRT is a safe and effective treatment modality in this clinical situation, where other treatment alternatives are rare. Similarly, good results have been shown for SBRT in the re-irradiation of head and neck tumors. Despite severe late adverse effects were reported in several studies, especially after single fraction doses >10 Gy, they appear less frequently compared to conventional radiotherapy. Few studies with small patient numbers have been published on SBRT re-irradiation for non-small cell lung cancer (NSCLC). Overall survival (OS) is limited by systemic progression and seems to depend particularly on patient selection. SBRT re-irradiation after primary SBRT should not be practiced in centrally located tumors due to high risk of severe toxicity. Only limited data is available for SBRT re-irradiation of pelvic tumors: feasibility and acceptable toxicity has been described, suggesting SBRT as a complementary treatment modality for local symptom control.

Clinical outcomes of single or oligo-fractionated stereotactic radiotherapy for head and neck tumors using micromultileaf collimator-based dynamic conformal arcs

PURPOSE

To assess the clinical outcomes of single or oligo-fractionated stereotactic radiotherapy (SRT) using dynamic conformal arcs (DCA) for head and neck tumors (HNTs).

METHODS

Thirty-four consecutive patients with 35 lesions treated between 2005 and 2009 were retrospectively evaluated, of whom 85.7 % had recurrent or metastatic disease, and 45.7 and 34.3 % had previous radiotherapy and surgery, respectively. The median SRT dose was 22.3 Gy (11.2-32.8) in 2-4 fractions with a median interval of 7 days and 10.4 Gy (9.2-12.4) in one fraction. SRT was combined with upfront conventionally fractionated RT in 48.6 % of patients.

RESULTS

The median follow-up periods were 18.4 months (2-84.1) for the entire cohort and 49.6 months for the survivors. The 1- and 2-year local control (LC) rates were 84.3 and 70.5 %, with the 1- and 2-year overall survival (OS) rates of 78.6 and 51.6 %. LC was significantly better for tumor volumes <25.6 cm(3) (p = 0.001). OS was significantly longer in patients without any disease outside the SRT site (p < 0.001), whereas LC after the SRT did not affect the OS. Late adverse events occurred in 9 patients, including cranial nerve (CN) injury (grade 3/4) in 2, brain radionecrosis in 5 (grade 1), and fatal bleeding in 2 patients harboring uncontrolled lesions abutting the carotid artery.

CONCLUSIONS

DCA-based SRT can confer relatively long-term LC with acceptable toxicity in selected patients with HNTs. The patients with CN involvement or tumor volume ≥25.6 cm(3) were deemed unsuitable for this treatment regimen.