Abstract
There is a growing body of literature using SBRT in the re-irradiation setting for locally recurrent H&N tumors. Doses vary, with best results/lowest toxicity ≥35 Gy in five fractions, given on alternating days. Toxicity rates of SBRT appear to be lower than with conventional techniques; however severe acute and late toxicities remain a challenge.
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1 Re-irradiation Literature
Study | Patients | Treatment | Median f/u | Outcomes |
|---|---|---|---|---|
Prospective studies | ||||
Vargo 2015 [1] | n = 50, recurrent H&N SCC, inoperable (majority OPX) Previous EBRT median 70 Gy Median time between recurrence 26 months Median tumor volume 36 cc | SBRT + concurrent cetuximab 40–44 Gy/5 fx, qod CTV = GTV PTV = CTV + 3–5 mm Rx dose: 95% PTV | 18 months | 60% 1 year local PFS 40% 1 year OS Toxicity: 6% G3 acute/late toxicity |
Comet 2012 [2] | n = 40, recurrent H&N SCC, inoperable Previous EBRT (median 66 Gy) Median time between recurrence 31 months Median PTV volume 64 cc | SBRT + concurrent cetuximab 6 Gy × 6 fx, qod CTV = GTV + 5 mm PTV = CTV + 1 mm Rx dose: 85% IDL | 25 months | 79% response rate 24% 2 years OS Late toxicity: no G4+ late toxicity |
Vargo 2012 [3] | n = 34, recurrent H&N cancer, inoperable (majority salivary gland, oral cavity) Previous EBRT median 61 Gy Median time between recurrence 53 months Median tumor volume 19 cc | SBRT Median 5 Gy × 8 fx, qod PTV = GTV Rx dose: 80% IDL (95% PTV coverage) | 10 months | 59% 1 year LC 59% 1 year OS Toxicity: 6% G3 late toxicity; no G4/G5 toxicity |
Heron 2009 [4] | n = 25, recurrent H&N SCC, inoperable (majority larynx) Previous EBRT median 65 Gy Median time between recurrence 13 months Median tumor volume 45 cc | SBRT 5 Gy × 5–9 fx, qod Rx dose: 80% IDL | Not specified | 76% response rate 6 months Median OS Late toxicity: no G3+ late toxicity |
Retrospective studies | ||||
n = 291, recurrent H&N cancer Previous EBRT median 68 Gy Median tumor volume 29 cc | SBRT ± concurrent cetuximab (~50% received) Median 44 Gy/5 fx, qod CTV = GTV PTV = CTV + 3–5 mm Rx dose: 80% IDL | 53 months | Toxicity: 11% ≥G3 acute; 19% ≥G3 late Larynx/hypopharynx: 50% ≥G3 late toxicity vs. 6–20% all other sites | |
Owen 2015 [7] | n = 184, recurrent H&N cancer, majority SCC (heterogeneous population) Median tumor volume 16 cc | SBRT Majority tx with EBRT + SBRT boost Median EBRT dose 61 Gy Boost: median 14 Gy × 1 fx Rx dose: 50% IDL | 17 months | 82% 1 year LC 41% 1 year OS Toxicity: 32% experienced late toxicity, including temporal lobe necrosis, CN palsy, facial numbness, and pain |
Rwigema 2011 [8] | n = 96, recurrent H&N cancer, inoperable Previous EBRT median 68 Gy Median tumor volume 24 cc | SBRT: Grp 1: 15–28 Gy/5 fx Grp 2: 30–36 Gy/5 fx Grp 3: 40 Gy/5 fx Grp 4: 44–50 Gy/5 fx | 14 months | Improved response rate with >40 Gy and tumor volume ≤25 cc |
2 Summary
There are variable disease sites, doses used, dose fractionation schemes, IDL prescription, and systemic therapy used in all of these studies. Severe toxicity was also somewhat variable, with frequencies as high as 50% in some studies. Long-term follow-up is needed to monitor for these late toxicities.
Several studies have looked at the combination of SBRT with cetuximab in the recurrent setting with good results. However, we recommend against the use of concurrent systemic therapy due to the concern of increasing toxicity, but it would be reasonable to study on a prospective trial.
References
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Judy, G.D., Chera, B.S. (2018). Re-irradiation. In: Kaidar-Person, O., Chen, R. (eds) Hypofractionated and Stereotactic Radiation Therapy. Springer, Cham. https://doi.org/10.1007/978-3-319-92802-9_16
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DOI: https://doi.org/10.1007/978-3-319-92802-9_16
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