Head & neck cancer
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Transcript of Head & neck cancer
Recurrent Head & Neck Cancer and Nasopharyngeal cancer
- Rec Nasopharynx with ONLY local recurrence need treatment with Surgery/ RT
- High precision RT do have benefit in terms of toxicity
- Small Vol disease, Persistent local disease, treated with high dose (>50Gy), rT1-2
disease have better prognosis
- Prognostication is possible for recurrent disease treated with RT
- In favorable group, SBRT in recurrent localized nasopharynx provide relative long
term LC & survival
Carcinoma nasopharynx
• Localized NPX is treated with CT-RT: 66Gy/30# to primary & involved nodes and 54-60Gy/30# to uninvolved nodes
• Response assessment if done before 5 wks, <50% will be residual on biopsy• Majority (>70%) responds at 10-12 wks
• PET scan & endoscopy/ biopsy at 10-12 wks done for response assessment
Still- • 7-20% of NPX pt will have residual disease after CT-RT at 10-12 wks• Another group: local recurrence after CT-RT
• Pts with persistent disease at 12 wks had significantly lower LC rate (40 %), regional & distant metastasis-free rate (47 %), OS (54 %).
• They need additional treatment
Yu KH, et al. Head Neck. 2005;27(5):397–405.
Recurrent/ persistent Ca nasopharynxTwo distinct group
At 10-12 wks response assessment
Recurrent disease after CT-RT
Persistent only at Nasopharynx
Persistent NPX & LN
Recurrence only at Nasopharynx
RecurrenceNPX & LN Distant mets
Local Rx
Surgery- NasopharengectomyRT- IMRT OR SBRT/ fSRSPDTChemotherapy
Chemotherapy
Long term Follow up of Ca Nasopharynx (n=610)
Failure= 192/610 (31%)Local Failure ONLY= 52%Distance metastasis=27%
Death= 156/610Cause of death:Local Relapse only= 44%Distance mets= 28%
Local control after relapse improves survival
Sun JA et al, Asian Pacific J 2007
Management of ONLY local recurrence
- Surgery
- Nasopharengectomy- Re-RT:
- IMRT
- SBRT
- Intracavitary Brachytherapy
- Gold seed implant- Photodynamic therapy- Systemic therapy
No randomized study between diff techniquesNeed to depend only on prospective single centre reports
Surgery for Rec Nasopharynx
- ONLY few prospective reports - Skull base/ bone erosion & carotid artery erosion not considered for surgery- 5-Yr OS: 40-60%- 20% palatal fistula
Riaz N et al Radiat Oncol 2014
Concordance index= 0.68.
Normogram for prognostication of LRC after RT
Rec / residual Nasopharynx: 2-Yr LRC ≅70%
Liu et al. Radiation Oncology 2013
SBRT: persistent Nasopharyngeal Ca
N=35 ptsLocally recurrent NPC treated using FSRT with CKGTV= 2.6-64.0 ml (median, 7.9 ml)RT doses=24 to 45 Gy (median, 33 Gy) in 3 or 5#
At 5-Yr FU:- OS= 60%- LFFS= 79%- DPFS=74%- CR after CK=23 pt- Severe late toxicity (Grade 4 or 5)=5 pt
Only T stage at recurrence was an independent prognostic factor for OS
Yao Y et al, Radiat Oncol 2009
Rec Ca Naso: Ph II study with CK
N=136 NPC pts Residual lesions after RT (median, 70.0 Gy). Median time to FSRT =24.5 daysTumor vol =13.4 cm3FSRT dose =8.0-32.0Gy (median, 19.5 Gy)
Results:•5-Yr LFFS=92.5%•5-Yr FFDM=77%•5-Yr OS=76.2%•5-Yr DFS=73.6%•Late toxicity= 19 pt.
T stage at diagnosis & age: significant prognostic factor for OS & DFS
SBRT: Residual Nasopharyngeal Ca (n=136)
Liu et al. Radiation Oncology 2013
Riaz N et al Radiat Oncol 2014
July 1996 -April 2011, n=257 Median prior RT dose= 65 Gy Median time between RT = 32.4 months.Salvage surg= 157 (44%) & Conc RT= 172 (67%)Median re-RT dose = 59.4 Gy; IMRT=201 (78%) Median FU= 32.6 mo2-Yr LRC= 47% & OS= 43%,
Independent prognostic factor:1.Recurrent stage (P = 0.005)2.Non-oral cavity subsite (P < 0.001)3.Absent organ dysfunction (P < 0.001) 4.Salvage surgery (P < 0.001)5.Dose >50 Gy (P = 0.006)
Re-RT in Rec Nasopharynx (n=257)
Best group for Re-RT: Non oral cavity site small vol disease treated with salvage surgery & treated with Re-RT dose >50Gy
Scoring depends upon:1.Stage2.Volume3.Time to rec4.Persistent/ Rec
GroupsPoor: Score >0.5Intermediate: <0.5
Prognostication of Rec Naso ca treated with SBRT
Scoring done for Rec Ca Nasopharynx
Chua DT et al, BMC Cancer 2009
Prognostic scoring of Rec Naso ca treated with SBRT
Survival probability after SBRT depends upon prognostic group
Chua DT et al, BMC Cancer 2009
Outcome depends upon:1.Stage at Rec2.Residual Volume
Radiotherapy Techniques: Pros & Cons
Higher dose/Fr - Higher BED - Greater toxicity probability
High precision RT: - Better target coverage - Less spillage - Less dose to OARs
Impact of PTV margin on OAR dosage
Asselen B et al, Radiother Oncol 2002
•Oropharyngeal tumours accrued.
•Margin of 0, 3, 6, 9 cm given to CTV.
•IMRT planned with different PTV margin.
•NTCP for xerostomia applied.
•Reducing PTV margin from 6 to 3 mm reduces
NTCP for xerostomia by 20%.
Reducing PTV margin reduces NTCP
SBRT Conf RT P-value
n 24 27
Method CK Conf RT
Dose 30Gy/5#/1wk 56Gy/28#/5wk
2-Yr LC 82% 80% P=0.6
2-Yr Dis specific Sur
64% 47% P=0.4
Late Toxicity (Gr-3)
21% 48% P=0.04
Serious late Toxicity
12.5% 14.8% P=0.8
Ozygit G et al, IJROBP 2010
Retrospective analysis: Survival function similar between SBRT & CRT SBRT is safer in terms of toxicity
Retrospective analysisRecurrent Nasopharynx (n=51)Median FU: 2 yrs
Comparison of CRT Vs SBRT
IMSRT have better OAR sparing and HI parameter
Factors influencing outcome with SBRT
- Dose
- Volume
- T Stage at recurrence
- Time gap between recurrence
- Persistent vs recurrent disease
Re-RT in H&N Cancer: LC & Dose effect: Pittspurg Exp
Rwigema et al. Am J Clic Oncol 2011
Up to 50Gy/5# is feasible with SBRTHigher dose is associated with better LC & 2&3-Yr Survival
Re-RT in H&N Cancer: LC & Volume effect: Pittsburg Exp
Rwigema et al. Am J Clic Oncol 2011
Lower vol persistent/ recurrent disease responds better with SBRT
Median follow-up was 20.3 months.
Gr-1 Gr-2 P-value
Disease Persistent recurrent
n 34 56
Method CK Non-co Arc
Dose 18Gy/3# 48Gy/6#
CR 66% 63%
3-Yr LFFS 89% 75%% P=0.037
3-Yr Dis specific Sur
80% 46% P=0.04
3-Yr PFS 72% 43% P=0.048
Toxicity Gr3 8% 25% P=0.05
Yu S et al. IJROBP 2007
Rec Naso Ca: Persistent Vs Recurrent (n=90)
Persistent Nasopharyngeal Ca responds better with SBRT
Yu S et al. IJROBP 2007
Rec Naso Ca: Vol effect (n=90)
Low Vol Nasopharyngeal Ca responds better with SBRT
Failure pattern after SBRT in Rec Naso Ca (n=90)
Wang et al. Head & Neck Oncology 2012
Rec Volume contouring with PET scan (n=45)
With PET scan contouring: 5 mm margin covers the Recurrent Vol
Wang K et al. Radiat Oncol 2013
Wang et al. Head & Neck Oncology 2012
Failure after SBRT: Patterns
Re-RT with SBRT: Toxicities
- Brain necrosis: temporal lobe
-Cranial Nr palsy
-Severe haemorrhage
-Bone & skin necrosis
-Carotid blow out syndrome
Incidence: 5-8%
N= 484 re-irradiation sessions 2000-2010 with CKIncidence= 32 (8.4%) Median survival time =0.1 mo & 1-Ys OS= 37.5%
Factors:1.Elder age2.Skin invasion3.Necrosis/infection
Carotid blowout syndrome
Re-RT in tumor is located adjacent carotid artery need attention
Yamazaki H et al Radiat Oncol 2013
Group=1: •Daily SBRT•N=43•CBS= 7•Median OS= 11 mo
Prevention of Carotid blowout syndrome (Re-RT=75)
Reduce CBS:•Alternate day SBRT•Carotid contact <180deg•Max Carotid dose <34Gy•Skin intact•No infection•Low Vol rec disease
Group=2•Alternate day SBRT•N=32•CBS= 4•Median OS= 23 mo
Yazici et al. Radiation Oncology 2013
Dosimetric studyNode negative H& N cancer (Ca Tonsil) (T3 N0M0)
IMRT: 46 Gy/23#PTV: Primary+ Level I-IV bilateral LN
IMRT boost: 24 Gy/6#PTV: Primary
HDR brachy: 24 Gy/6#PTV: Primary
CK boost: 24 Gy/6#PTV: Primary
Comparison between boost plans:1)Target Coverage2)OAR dose (spinal cord & parotid dose)
(n=11)
- No difference in maximum spinal cord dose and mean
parotid doses between HDR & CK boost plans
- In IMRT plan, higher ipsi-lateral parotid dose
Comparison of three plans (Dose: 24 Gy/6#)
IMRT boost HDR boost CK boost
Spinal cord Dmax (Gy) 7.4 1.2 1.5
Ipsi-lateral parotid Mean dose (Gy)
8.3 3.1 2.1
Conta-lateral parotid Mean dose (Gy)
3.7 1.4 1.7
(n=11)Dutta et al; CK Society meeting San Francisco 2010
Infra-temporal fossa recurrence Infra-temporal fossa recurrence
60 yr old from Kolkata
K/C/O Ca R buccal mucosa Treated with surgery, adj RT
Post RT 1 year recurrence in R ITF region
RE-RT with CyberKnife: 30 Gy/5#/1 wk
Post RT 6 month FU: Controlled disease
Excellent radiological & clinical response
Infra-temporal fossa recurrence (36 mo FU) Infra-temporal fossa recurrence (36 mo FU)
Take home message- Rec Nasopharynx with ONLY local recurrence need treatment with Surgery/ RT
- High precision RT do have benefit in terms of toxicity
- Small Vol disease, Persistent local disease, treated with high dose (>50Gy), rT1-2
disease have better prognosis
- Prognostication is possible for recurrent disease treated with RT
- In favorable group, SBRT in recurrent localized nasopharynx provide relative long
term LC & survival
- However, distant metastasis may offset the impact of local treatment
- Need prospective randomized studies to ascertain role of different modalities