2018-19 Section 7-Neoplastic and Inflammatory Diseases of the Head and Neck eBook

Oral Oncology 73 (2017) 160–165

D.N. Margalit et al.

How may proton beam therapy and stereotactic body RT (SBRT) be used to reduce toxicity risks amongst patients with recurrent SCCHN? For proton beam therapy, there is less previously irradiated tissue that receives medium to low-dose reirradiation which may translate to de- creased acute and late toxicities [12] . Yet the target tissue still needs to receive the prescribed dose or reirradiation, whether with protons or photons, such that there is still a risk of serious toxicity if the tumor is near or encasing vasculature, larynx, or other critical structures. Fur- ther data is needed to determine whether proton reRT is associated with lower toxicity risks compared with photon IMRT. For SBRT, the smaller volumes inherently limit the amount of ir- radiated normal tissue. Reported toxicity rates indicate that it can be relatively safe and tolerable with rates of grade ≥ 3 toxicity ranging from 6% – 33% [13,14] : Yet local-regional control remains a problem in the de fi nitive management of gross disease amongst these patients treated with SBRT. Temporary control of gross disease with a tolerable side e ff ect pro fi le and a convenient treatment schedule makes SBRT a good option, particularly amongst patients with a poor prognosis. While the study is limited by its retrospective nature and lack of patient reported quality of life data, it does, however, provide objective ‘ hard ’ endpoints of toxicity such as hospitalization, or operative pro- cedure. There is also complete follow-up for this relatively homo- geneous group of patients with mucosal primary SCCHN and it also represents one of the largest series of patients treated with IMRT-based reRT. There is a large proportion of patients treated adjuvantly, al- lowing for comparison with non-surgically salvaged patients in terms of toxicity outcomes. Lastly, due to the limitations of the electronic medical record and inconsistent reporting of baseline narcotic pain medication use, we were unable to assess the impact of reRT on pain medication-use. Patient counseling and shared decision-making must incorporate the risk of serious toxicities when deciding between curative-intent reRT versus palliative-intent systemic therapy. The toxicity and life- threatening implications of a local-regional recurrence must be weighed against the toxicity of treatment itself which involves a high likelihood of PEG tube-dependence, hospitalization during surgery, urgent tra- cheotomy, and operative repair of soft tissue damage. This data sup- ports the current paradigm of salvage surgery for resectable disease. Modalities such as proton therapy or SBRT, as well as careful radiation planning to minimize radiation dose to normal tissue such as the larynx and carotids may reduce the toxicity of reRT. Ultimately, studies of newer systemic agents, whether molecularly-targeted or immune- modulatory, will hopefully allow for a substantial dose reduction of reRT, minimizing the risk of such toxicities.

None declared.

Appendix A. Supplementary material

Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.oraloncology.2017.08. 012 .

References

[1] McDonald MW, Lawson J, Garg MK, et al. ACR appropriateness criteria retreatment of recurrent head and neck cancer after prior de fi nitive radiation expert panel on radiation oncology-head and neck cancer. Int J Radiat Oncol Biol Phys 2011;80:1292 – 8 . [2] Janot F, de Raucourt D, Benhamou E, et al. Randomized trial of postoperative re- irradiation combined with chemotherapy after salvage surgery compared with salvage surgery alone in head and neck carcinoma. J Clin Oncol : O ff J Am Soc Clin Oncol 2008;26:5518 – 23 . [3] Spencer SA, Harris J, Wheeler RH, et al. Final report of RTOG 9610, a multi-in- stitutional trial of reirradiation and chemotherapy for unresectable recurrent squamous cell carcinoma of the head and neck. Head Neck 2008;30:281 – 8 . [4] Langer CJ, Harris J, Horwitz EM, et al. Phase II study of low-dose paclitaxel and cisplatin in combination with split-course concomitant twice-daily reirradiation in recurrent squamous cell carcinoma of the head and neck: results of radiation therapy oncology group protocol 9911. J Clin Oncol : O ff J Am Soc Clin Oncol 2007;25:4800 – 5 . [5] Duprez F, Berwouts D, Madani I, et al. High-dose reirradiation with intensity- modulated radiotherapy for recurrent head-and-neck cancer: disease control, sur- vival and toxicity. Radiotherap Oncol : J Europ Soc Therapeut Radiol Oncol 2014;111:388 – 92 . [6] Choe KS, Haraf DJ, Solanki A, et al. Prior chemoradiotherapy adversely impacts outcomes of recurrent and second primary head and neck cancer treated with concurrent chemotherapy and reirradiation. Cancer 2011;117:4671 – 8 . [7] Garg S, Kilburn JM, Lucas Jr JT, et al. Reirradiation for second primary or recurrent cancers of the head and neck: Dosimetric and outcome analysis. Head Neck 2016;38(Suppl 1):E961 – 9 . [8] Hoebers F, Heemsbergen W, Moor S, et al. Reirradiation for head-and-neck cancer: delicate balance between e ff ectiveness and toxicity. Int J Radiat Oncol Biol Phys 2011;81:e111 – 8 . [9] Sulman EP, Schwartz DL, Le TT, et al. IMRT reirradiation of head and neck cancer- disease control and morbidity outcomes. Int J Radiat Oncol Biol Phys 2009;73:399 – 409 . [10] Margalit DN, Rawal B, Catalano PJ, et al. Patterns of failure after reirradiation with intensity-modulated radiation therapy and the competing risk of out-of- fi eld re- currences. Oral Oncol 2016. In press . [11] McDonald MW, Moore MG, Johnstone PA. Risk of carotid blowout after reirradia- tion of the head and neck: a systematic review. Int J Radiat Oncol Biol Phys 2012;82:1083 – 9 . [12] Romesser PB, Cahlon O, Scher ED, et al. Proton beam reirradiation for recurrent head and neck cancer: multi-institutional report on feasibility and early outcomes. Int J Radiat Oncol Biol Phys 2016;95:386 – 95 . [13] Vargo JA, Ferris RL, Ohr J, et al. A prospective phase 2 trial of reirradiation with stereotactic body radiation therapy plus cetuximab in patients with previously ir- radiated recurrent squamous cell carcinoma of the head and neck. Int J Radiat Oncol Biol Phys 2015;91:480 – 8 . [14] Lartigau EF, Tresch E, Thariat J, et al. Multi institutional phase II study of con- comitant stereotactic reirradiation and cetuximab for recurrent head and neck cancer. Radiotherap Oncol : J Europ Soc Therapeut Radiol Oncol 2013;109:281 – 5 .

Acknowledgements

Funding was provided by the Department of Radiation Oncology, Dana-Farber/Brigham & Women ’ s Cancer Center. Con fl ict of Interest

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