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Title: Intraoperative radiation therapy for recurrent head-and-neck cancer: The UCSF experience

Abstract

Purpose: To review a single-institutional experience with the use of intraoperative radiation therapy (IORT) for recurrent head-and-neck cancer. Methods and Materials: Between 1991 and 2004, 137 patients were treated with gross total resection and IORT for recurrence or persistence of locoregional cancer of the head and neck. One hundred and thirteen patients (83%) had previously received external beam radiation as a component of definitive therapy. Ninety-four patients (69%) had squamous cell histology. Final surgical margins were microscopically positive in 56 patients (41%). IORT was delivered using either a modified linear accelerator or a mobile electron unit and was administered as a single fraction to a median dose of 15 Gy (range, 10-18 Gy). Median follow-up among surviving patients was 41 months (range, 3-122 months). Results: The 1-year, 2-year, and 3-year estimates of in-field control after salvage surgery and IORT were 70%, 64%, and 61%, respectively. Positive margins at the time of IORT predicted for in-field failure (p = 0.001). The 3-year rates of locoregional control, distant metastasis-free survival, and overall survival were 51%, 46%, and 36%, respectively. There were no perioperative fatalities. Complications included wound infection (4 patients), orocutaneous fistula (2 patients), flap necrosis (1 patient), trismus (1 patient), andmore » neuropathy (1 patient). Conclusions: Intraoperative RT results in effective disease control with acceptable toxicity and should be considered for selected patients with recurrent or persistent cancers of the head and neck.« less

Authors:
 [1];  [2];  [3];  [4];  [5];  [2];  [2]
  1. Department of Radiation Oncology, University of California, San Francisco, Comprehensive Cancer Center, San Francisco, CA (United States). E-mail: allenmchen@yahoo.com
  2. Department of Radiation Oncology, University of California, San Francisco, Comprehensive Cancer Center, San Francisco, CA (United States)
  3. Department of Otolaryngology, Head and Neck Surgery, University of California, San Francisco, Comprehensive Cancer Center, San Francisco, CA (United States)
  4. Department of Pathology, University of California, San Francisco, Comprehensive Cancer Center, San Francisco, CA (United States)
  5. Department of Otolaryngology, Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA (United States)
Publication Date:
OSTI Identifier:
20850304
Resource Type:
Journal Article
Resource Relation:
Journal Name: International Journal of Radiation Oncology, Biology and Physics; Journal Volume: 67; Journal Issue: 1; Other Information: DOI: 10.1016/j.ijrobp.2006.08.038; PII: S0360-3016(06)02795-7; Copyright (c) 2007 Elsevier Science B.V., Amsterdam, Netherlands, All rights reserved; Country of input: International Atomic Energy Agency (IAEA)
Country of Publication:
United States
Language:
English
Subject:
62 RADIOLOGY AND NUCLEAR MEDICINE; BEAMS; CARCINOMAS; FAILURES; HEAD; HISTOLOGY; LINEAR ACCELERATORS; METASTASES; NECK; NECROSIS; PATIENTS; RADIATION DOSES; RADIOTHERAPY; REVIEWS; SURGERY; TOXICITY; WOUNDS

Citation Formats

Chen, Allen M., Bucci, M. Kara, Singer, Mark I., Garcia, Joaquin, Kaplan, Michael J., Chan, Albert S., and Phillips, Theodore L. Intraoperative radiation therapy for recurrent head-and-neck cancer: The UCSF experience. United States: N. p., 2007. Web. doi:10.1016/j.ijrobp.2006.08.038.
Chen, Allen M., Bucci, M. Kara, Singer, Mark I., Garcia, Joaquin, Kaplan, Michael J., Chan, Albert S., & Phillips, Theodore L. Intraoperative radiation therapy for recurrent head-and-neck cancer: The UCSF experience. United States. doi:10.1016/j.ijrobp.2006.08.038.
Chen, Allen M., Bucci, M. Kara, Singer, Mark I., Garcia, Joaquin, Kaplan, Michael J., Chan, Albert S., and Phillips, Theodore L. Mon . "Intraoperative radiation therapy for recurrent head-and-neck cancer: The UCSF experience". United States. doi:10.1016/j.ijrobp.2006.08.038.
@article{osti_20850304,
title = {Intraoperative radiation therapy for recurrent head-and-neck cancer: The UCSF experience},
author = {Chen, Allen M. and Bucci, M. Kara and Singer, Mark I. and Garcia, Joaquin and Kaplan, Michael J. and Chan, Albert S. and Phillips, Theodore L.},
abstractNote = {Purpose: To review a single-institutional experience with the use of intraoperative radiation therapy (IORT) for recurrent head-and-neck cancer. Methods and Materials: Between 1991 and 2004, 137 patients were treated with gross total resection and IORT for recurrence or persistence of locoregional cancer of the head and neck. One hundred and thirteen patients (83%) had previously received external beam radiation as a component of definitive therapy. Ninety-four patients (69%) had squamous cell histology. Final surgical margins were microscopically positive in 56 patients (41%). IORT was delivered using either a modified linear accelerator or a mobile electron unit and was administered as a single fraction to a median dose of 15 Gy (range, 10-18 Gy). Median follow-up among surviving patients was 41 months (range, 3-122 months). Results: The 1-year, 2-year, and 3-year estimates of in-field control after salvage surgery and IORT were 70%, 64%, and 61%, respectively. Positive margins at the time of IORT predicted for in-field failure (p = 0.001). The 3-year rates of locoregional control, distant metastasis-free survival, and overall survival were 51%, 46%, and 36%, respectively. There were no perioperative fatalities. Complications included wound infection (4 patients), orocutaneous fistula (2 patients), flap necrosis (1 patient), trismus (1 patient), and neuropathy (1 patient). Conclusions: Intraoperative RT results in effective disease control with acceptable toxicity and should be considered for selected patients with recurrent or persistent cancers of the head and neck.},
doi = {10.1016/j.ijrobp.2006.08.038},
journal = {International Journal of Radiation Oncology, Biology and Physics},
number = 1,
volume = 67,
place = {United States},
year = {Mon Jan 01 00:00:00 EST 2007},
month = {Mon Jan 01 00:00:00 EST 2007}
}
  • Purpose: To report the use of high-dose-rate intraoperative radiation therapy (HDR-IORT) for recurrent head-and-neck cancer (HNC) at a single institution. Methods and Materials: Between July 1998 and February 2007, 34 patients with recurrent HNC received 38 HDR-IORT treatments using a Harrison-Anderson-Mick applicator with Iridium-192. A single fraction (median, 15 Gy; range, 10-20 Gy) was delivered intraoperatively after surgical resection to the region considered at risk for close or positive margins. In all patients, the target region was previously treated with external beam radiation therapy (median dose, 63 Gy; range, 24-74 Gy). The 1- and 2-year estimates for in-field local progression-freemore » survival (LPFS), locoregional progression-free survival (LRPFS), distant metastases-free survival (DMFS), and overall survival (OS) were calculated. Results: With a median follow-up for surviving patients of 23 months (range, 6-54 months), 8 patients (24%) are alive and without evidence of disease. The 1- and 2-year LPFS rates are 66% and 56%, respectively, with 13 (34%) in-field recurrences. The 1- and 2-year DMFS rates are 81% and 62%, respectively, with 10 patients (29%) developing distant failure. The 1- and 2-year OS rates are 73% and 55%, respectively, with a median time to OS of 24 months. Severe complications included cellulitis (5 patients), fistula or wound complications (3 patients), osteoradionecrosis (1 patient), and radiation-induced trigeminal neuralgia (1 patient). Conclusions: HDR-IORT has shown encouraging local control outcomes in patients with recurrent HNC with acceptable rates of treatment-related morbidity. Longer follow-up with a larger cohort of patients is needed to fully assess the benefit of this procedure.« less
  • Purpose: To analyze prognostic factors associated with survival in patients after intraoperative electrons containing resective surgical rescue of locally recurrent rectal cancer (LRRC). Methods and Materials: From January 1995 to December 2011, 60 patients with LRRC underwent extended surgery (n=38: multiorgan [43%], bone [28%], soft tissue [38%]) or nonextended (n=22) surgical resection, including a component of intraoperative electron-beam radiation therapy (IOERT) to the pelvic recurrence tumor bed. Twenty-eight (47%) of these patients also received external beam radiation therapy (EBRT) (range, 30.6-50.4 Gy). Survival outcomes were estimated by the Kaplan-Meier method, and risk factors were identified by univariate and multivariate analyses.more » Results: The median follow-up time was 36 months (range, 2-189 months), and the 1-year, 3-year, and 5-year rates for locoregional control (LRC) and overall survival (OS) were 86%, 52%, and 44%; and 78%, 53%, 43%, respectively. On multivariate analysis, R1 resection, EBRT at the time of pelvic rerecurrence, no tumor fragmentation, and non-lymph node metastasis retained significance with regard to LRR. R1 resection and no tumor fragmentation showed a significant association with OS after adjustment for other covariates. Conclusions: EBRT treatment integrated for rescue, resection radicality, and not involved fragmented resection specimens are associated with improved LRC in patients with locally recurrent rectal cancer. Additionally, tumor fragmentation could be compensated by EBRT. Present results suggest that a significant group of patients with LRRC may benefit from EBRT treatment integrated with extended surgery and IOERT.« less
  • Purpose: To report a 10-year update of our institutional experience with stereotactic body radiation therapy (SBRT) for reirradiation of locally recurrent head and neck cancer, focusing on predictors of toxicity. Methods and Materials: A retrospective review was performed on 291 patients treated with SBRT for recurrent, previously irradiated head and neck cancer between April 2002 and March 2013. Logistic regression analysis was performed to identify predictors of severe acute and late toxicity. Patients with <3 months of follow-up (n=43) or who died within 3 months of treatment (n=21) were excluded from late toxicity analysis. Results: Median time to death or last clinicalmore » follow-up was 9.8 months among the entire cohort and 53.1 months among surviving patients. Overall, 33 patients (11.3%) experienced grade ≥3 acute toxicity and 43 (18.9%) experienced grade ≥3 late toxicity. Compared with larynx/hypopharynx, treatment of nodal recurrence was associated with a lower risk of severe acute toxicity (P=.03), with no significant differences in severe acute toxicity among other sites. Patients treated for a recurrence in the larynx/hypopharynx experienced significantly more severe late toxicity compared with those with oropharyngeal, oral cavity, base of skull/paranasal sinus, salivary gland, or nodal site of recurrence (P<.05 for all). Sixteen patients (50%) with laryngeal/hypopharyngeal recurrence experienced severe late toxicity, compared with 6-20% for other sites. Conclusions: Salvage SBRT is a safe and effective option for most patients with previously irradiated head and neck cancer. However, patients treated to the larynx or hypopharynx experience significantly more late toxicity compared with others and should be carefully selected for treatment, with consideration given to patient performance status, pre-existing organ dysfunction, and goals of care. Treatment toxicity in these patients may be mitigated with more conformal plans to allow for increased sparing of adjacent normal tissues.« less
  • Patients with head and neck cancer who have a relapse of the disease above the clavicles can sometimes be salvaged by additional surgery. However, if all gross tumor cannot be removed during surgery or if the resection margins are unsatisfactory, the likelihood of salvage is remote, especially when postoperative radiotherapy is not feasible due to previous radiotherapy. Between 1979 and 1983, the authors employed intraoperative brachytherapy for 21 such patients. Sixteen patients had a recurrence after previous surgery and radiotherapy, and 5 after radical radiotherapy. All gross tumor could not be removed in 15 patients, whereas satisfactory margins could notmore » be obtained in 6. In 11 patients, they delivered radiotherapy by a temporary implant of iridium-192 (median dose 4,800 rads in 6 days). In 10 patients, radiotherapy was delivered by a permanent implant of iodine-125 (median activity 13 mCi). Three patients (14 percent) had a relapse within the surgical field, whereas six others (28 percent) had a relapse elsewhere or had development of metastases. Complications developed in four patients (19 percent) and were fatal in one patient. Our experience suggests that intraoperative brachytherapy can salvage certain high-risk patients with head and neck cancer.« less
  • Proton beam radiation has been used for cancer treatment since the 1950s, but recent increasing interest in this form of therapy and the construction of hospital-based and clinic-based facilities for its delivery have greatly increased both the number of patients and the variety of tumors being treated with proton therapy. The mass of proton particles and their unique physical properties (ie, the Bragg peak) allow proton therapy to spare normal tissues distal to the tumor target from incidental irradiation. Initial observations show that proton therapy is particularly useful for treating tumors in challenging locations close to nontarget critical structures. Specifically,more » improvements in local control outcomes for patients with chordoma, chonodrosarcoma, and tumors in the sinonasal regions have been reported in series using proton. Improved local control and survival outcomes for patients with cancer of the head and neck region have also been seen with the advent of improvements in better imaging and multimodality therapy comprising surgery, radiation therapy, and chemotherapy. However, aggressive local therapy in the proximity of critical normal structures to tumors in the head and neck region may produce debilitating early and late toxic effects. Great interest has been expressed in evaluating whether proton therapy can improve outcomes, especially early and late toxicity, when used in the treatment of head and neck malignancies. This review summarizes the progress made to date in addressing this question.« less