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Interstitial High-dose-rate Brachytherapy for Recurrent and Previously Irradiated Head-and-Neck Cancer
Poster Viewing Abstracts S505
Volume 84 Number 3S Supplement 2012 aim of the study was to evaluate and compare survival outcomes in PDTC and ATC in a large population based sample group. Materials/Methods: Patients with PDTC and ATC diagnosed from 1973 to 2008 were obtained from Surveillance, Epidemiology, and End Results (SEER) database. All patients received radiation (RT) either as external beam (pre or post-operative) or radioisotopes (post-operative). Kaplan-Meier survival analysis and log-rank tests were used to evaluate the (1) effect of histology on overall survival (OAS) and cause-specific survival (CSS) and (2) influence of factors such as treatment, treatment sequence, race, sex, and age on survival outcomes by stratified histology. Results: A total of 1352 patients with PDTC and ATC were identified. There were 479 (35.4%) males and 873 (64.6%) females. PDTC constituted 52.4% patients vs 47.6% ATC. RT (external/implants etc) was a part of treatment in 58.9% and radioisotopes were utilized in 41.1% patients. Most (99.1%) patients received post-operative Radiation (external or radioisotopes). Median age was 63 years. Whites constituted 83.4% of the population. Median CSS was similar in the two groups (49m vs 32m in PDTC and ATC respectively, pZ0.14) but OAS showed a trend favoring PDTC (31m vs 23m, pZ0.06). Patients receiving radioisotopes showed a significantly better CSS in both PTDC and ATC (p<0.001) patients. On stratified analysis by histology, factors that predicted significantly improved CSS in both PDTC and ATC were adjuvant RT vs pre-op RT (pZ0.04 [PDTC], pZ0.001[ATC]) stage (p<0.001) and age (p<0.001). Hazard Ratio (for Thyroid cancer death) for each 1-year increase in age was 1.04 (95% CI Z 1.03, 1.05) and 1.03 (95% CI Z 1.03, 1.04) (P<0.0001) for PDTC and ATC respectively. Sex and ethnicity had no impact on CSS in either PDTC or ATC (pZNS). Conclusions: This is the first large population-based study comparing PDTC and ATC outcomes in patients that received radiation. Surgical resection, post-op RT and radioisotope use predicted improved CSS in both histologies. PDTC has a better OAS compared to ATC in this group of patients. Author Disclosure: S. Arora: None. P. Christos: None. A. Wernicke: None. D. Nori: None. K. Chao: None. B. Parashar: None.
2766 Interstitial High-dose-rate Brachytherapy for Recurrent and Previously Irradiated Head-and-Neck Cancer V. Rudzianskas,1 E. Juozaityte,1 A. Inciura,1 R. Kubilius,2 and S. Vaitkus3; 1 Lithuanian University of Health Sciences, Oncology Institute, Kaunas, Lithuania, 2Lithuanian University of Health Sciences, Department of Maxillofacial Surgery, Kaunas, Lithuania, 3Lithuanian University of Health Sciences, Department of Otorhinolaryngology, Kaunas, Lithuania Purpose/Objective(s): Treatment of recurrent previously irradiated head and neck cancer represent a difficult clinical challenge. In the majority of studies employing high-dose-rate brachytherapy (HDR-BRT) was used two daily fractions of 3 or 4 Gy to a total dose of 30 - 40 Gy. The aim of this study was to evaluate the results of hypofractionated accelerated CTguided interstitial HDR-BRT using 2.5 Gy per fraction. Materials/Methods: From December 2008 to March 2010, 30 patients were treated for recurrent squamous-cell head and neck cancer. The median time from the end of primary treatment to recurrence was 12 months (range 3-19 months). All patients had previously been treated with radical radiation therapy or concomitant chemoradiation with or without surgery. Before re-irradiation all patients were evaluated for eligibility and the following selection criteria were applied: 1) histologic proof of disease relapse; 2) Karnofsky Performance Score (KPS) 70; 3) no bony invasion by the tumor; 4) no evidence of distant metastases. Thirteen patients underwent surgical resection followed by HDR-BRT to the tumor bed. Seventeen patients were treated by HDR-BRT alone. All patients received 2.5 Gy twice per day to a total dose of 30 Gy. Results: The overall survival (OS) for the entire group at 1 and 2-years were 63% and 47%, local control (LC) - 73% and 67%, disease-free survival (DFS) - 60% and 53%. Patients treated with surgical resection and
HDR-BRT showed an improvement in 2-year LC (77% vs. 47%, p Z 0.013) and 2-year OS (62% vs. 35%, p Z 0.035) compared to the patients treated with HDR-BRT alone. Median overall survival for pre-treatment tumor volumes 36 cm3 was 22 months versus 9,2 months for > 36 cm3 (p Z 0.038). Grade III and IV late complications occurred in 3% of patients. No Grade V complications occurred. Conclusions: Interstitial HDR brachytherapy regimen using 2.5 Gy twice daily fractions to a total dose of 30 Gy has been shown to offer an effective treatment option for patient with recurrent previously irradiated head and neck cancer with low rate of late high Grade toxicity. Surgical resection has positive effect on survival and local control in the management of patients with recurrent head and neck cancer. Author Disclosure: V. Rudzianskas: None. E. Juozaityte: None. A. Inciura: None. R. Kubilius: None. S. Vaitkus: None.
2767 Toxicity and Response Assessment With Prolonged Infusion Gemcitabine and Gefitinib With Intensity Modulated Radiation Therapy in Recurrent Head-and-Neck Squamous Cell Carcinoma – A Pilot Study P. Eswaran1 and A.S. Kumaravelu2; 1Dept. of Radiation Oncology Apollo Cancer Institute, Tamilnadu, India, 2Dept. of Palliative Care & Rehabilitation, Vinayaka Missions Kirupananda Variyar Medical College, Tamilnadu, India Purpose/Objective(s): Head and Neck Squamous Cell carcinomas (HNSCC) have a high percentage of loco-regional failure in the first 2 years of completion of treatment even with cisplatin based concurrent chemoradiation. A few percentage of the patients can be salvaged with second line chemotherapy / re-irradiation, although evidences show no significant difference in overall survival. We evaluated the feasibility of using Gemcitabine and Gefitinib along with Intensity modulated Radiation Therapy (IMRT) in recurrent HNSCC patients with good performance status. Materials/Methods: Between February 2006 and August 2011, 18 patients with recurrent HNSCC with good performance status were enrolled. All patients had been previously treated with conventional RT / 3D Conformal RT (up to 66 Gy) with weekly Cisplatin 40 mg/m2 or Cisplatin (80 mg/m2) and 5 FU (1000 mg/m2) chemotherapy regimens. At recurrence all patients were treated with prolonged infusion Gemcitabine (1 gm/m2 over 8 hours every 14 days) and daily Gefitinib 250 mg. Re-irradiation with IMRT was delivered to a dose of 41.4 - 50.4 Gy in 23 to 28 fractions. All recurrences were more than 12 months after completion of initial RT. 3 patients who had progressive disease but in good KPS were given Docetaxel for 6 cycles and then started on IMRT. Results: All 18 patients were available for evaluation. The main toxicity in this group were nonhematological: oral mucositis (Gr 3) - 18/18 (100%), alopecia (Gr 2) - 18/18 (100%), nausea (Gr 2) -11/18 (61%), rash (Gr 3) 2/18 (11%) and (Gr 2) - 15 /18 (83%), dermatitis (Gr 3) - 12/18 (66%). Hematological toxicity were: neutropenia (Gr 2) - 11/18 (61%), thrombocytopenia (Gr 2) - 14/18 (77%). None had febrile neutropenic episodes during the treatment. The overall treatment period ranged from 49 - 62 days (Median 56 days). 1 patient discontinued treatment due to mucositis at 36 Gy and was lost for follow up. Overall response rate was 100%, CR 8/18 (44.5%) and PR - 10/18 (55.5%). Conclusions: Re-irradiation with IMRT and concurrent prolonged infusion Gemcitabine and Gefitinib is effective and tolerable. This combination should be evaluated in larger sample size. Author Disclosure: P. Eswaran: None. A.S. Kumaravelu: None.
2768 Adjuvant Hypofractionated Intensity Modulated Radiation Therapy (IMRT) After Resection of Regional Lymph Node (LN) Metastases in Patients With Malignant Melanoma of the Head and Neck C.L. Hallemeier,1 Y.I. Garces,1 M.A. Neben-Wittich,1 K.R. Olivier,1 J.A. Garcia,1 P.D. Brown,2 and R.L. Foote1; 1Mayo Graduate School of
Volume 84 Number 3S Supplement 2012 aim of the study was to evaluate and compare survival outcomes in PDTC and ATC in a large population based sample group. Materials/Methods: Patients with PDTC and ATC diagnosed from 1973 to 2008 were obtained from Surveillance, Epidemiology, and End Results (SEER) database. All patients received radiation (RT) either as external beam (pre or post-operative) or radioisotopes (post-operative). Kaplan-Meier survival analysis and log-rank tests were used to evaluate the (1) effect of histology on overall survival (OAS) and cause-specific survival (CSS) and (2) influence of factors such as treatment, treatment sequence, race, sex, and age on survival outcomes by stratified histology. Results: A total of 1352 patients with PDTC and ATC were identified. There were 479 (35.4%) males and 873 (64.6%) females. PDTC constituted 52.4% patients vs 47.6% ATC. RT (external/implants etc) was a part of treatment in 58.9% and radioisotopes were utilized in 41.1% patients. Most (99.1%) patients received post-operative Radiation (external or radioisotopes). Median age was 63 years. Whites constituted 83.4% of the population. Median CSS was similar in the two groups (49m vs 32m in PDTC and ATC respectively, pZ0.14) but OAS showed a trend favoring PDTC (31m vs 23m, pZ0.06). Patients receiving radioisotopes showed a significantly better CSS in both PTDC and ATC (p<0.001) patients. On stratified analysis by histology, factors that predicted significantly improved CSS in both PDTC and ATC were adjuvant RT vs pre-op RT (pZ0.04 [PDTC], pZ0.001[ATC]) stage (p<0.001) and age (p<0.001). Hazard Ratio (for Thyroid cancer death) for each 1-year increase in age was 1.04 (95% CI Z 1.03, 1.05) and 1.03 (95% CI Z 1.03, 1.04) (P<0.0001) for PDTC and ATC respectively. Sex and ethnicity had no impact on CSS in either PDTC or ATC (pZNS). Conclusions: This is the first large population-based study comparing PDTC and ATC outcomes in patients that received radiation. Surgical resection, post-op RT and radioisotope use predicted improved CSS in both histologies. PDTC has a better OAS compared to ATC in this group of patients. Author Disclosure: S. Arora: None. P. Christos: None. A. Wernicke: None. D. Nori: None. K. Chao: None. B. Parashar: None.
2766 Interstitial High-dose-rate Brachytherapy for Recurrent and Previously Irradiated Head-and-Neck Cancer V. Rudzianskas,1 E. Juozaityte,1 A. Inciura,1 R. Kubilius,2 and S. Vaitkus3; 1 Lithuanian University of Health Sciences, Oncology Institute, Kaunas, Lithuania, 2Lithuanian University of Health Sciences, Department of Maxillofacial Surgery, Kaunas, Lithuania, 3Lithuanian University of Health Sciences, Department of Otorhinolaryngology, Kaunas, Lithuania Purpose/Objective(s): Treatment of recurrent previously irradiated head and neck cancer represent a difficult clinical challenge. In the majority of studies employing high-dose-rate brachytherapy (HDR-BRT) was used two daily fractions of 3 or 4 Gy to a total dose of 30 - 40 Gy. The aim of this study was to evaluate the results of hypofractionated accelerated CTguided interstitial HDR-BRT using 2.5 Gy per fraction. Materials/Methods: From December 2008 to March 2010, 30 patients were treated for recurrent squamous-cell head and neck cancer. The median time from the end of primary treatment to recurrence was 12 months (range 3-19 months). All patients had previously been treated with radical radiation therapy or concomitant chemoradiation with or without surgery. Before re-irradiation all patients were evaluated for eligibility and the following selection criteria were applied: 1) histologic proof of disease relapse; 2) Karnofsky Performance Score (KPS) 70; 3) no bony invasion by the tumor; 4) no evidence of distant metastases. Thirteen patients underwent surgical resection followed by HDR-BRT to the tumor bed. Seventeen patients were treated by HDR-BRT alone. All patients received 2.5 Gy twice per day to a total dose of 30 Gy. Results: The overall survival (OS) for the entire group at 1 and 2-years were 63% and 47%, local control (LC) - 73% and 67%, disease-free survival (DFS) - 60% and 53%. Patients treated with surgical resection and
HDR-BRT showed an improvement in 2-year LC (77% vs. 47%, p Z 0.013) and 2-year OS (62% vs. 35%, p Z 0.035) compared to the patients treated with HDR-BRT alone. Median overall survival for pre-treatment tumor volumes 36 cm3 was 22 months versus 9,2 months for > 36 cm3 (p Z 0.038). Grade III and IV late complications occurred in 3% of patients. No Grade V complications occurred. Conclusions: Interstitial HDR brachytherapy regimen using 2.5 Gy twice daily fractions to a total dose of 30 Gy has been shown to offer an effective treatment option for patient with recurrent previously irradiated head and neck cancer with low rate of late high Grade toxicity. Surgical resection has positive effect on survival and local control in the management of patients with recurrent head and neck cancer. Author Disclosure: V. Rudzianskas: None. E. Juozaityte: None. A. Inciura: None. R. Kubilius: None. S. Vaitkus: None.
2767 Toxicity and Response Assessment With Prolonged Infusion Gemcitabine and Gefitinib With Intensity Modulated Radiation Therapy in Recurrent Head-and-Neck Squamous Cell Carcinoma – A Pilot Study P. Eswaran1 and A.S. Kumaravelu2; 1Dept. of Radiation Oncology Apollo Cancer Institute, Tamilnadu, India, 2Dept. of Palliative Care & Rehabilitation, Vinayaka Missions Kirupananda Variyar Medical College, Tamilnadu, India Purpose/Objective(s): Head and Neck Squamous Cell carcinomas (HNSCC) have a high percentage of loco-regional failure in the first 2 years of completion of treatment even with cisplatin based concurrent chemoradiation. A few percentage of the patients can be salvaged with second line chemotherapy / re-irradiation, although evidences show no significant difference in overall survival. We evaluated the feasibility of using Gemcitabine and Gefitinib along with Intensity modulated Radiation Therapy (IMRT) in recurrent HNSCC patients with good performance status. Materials/Methods: Between February 2006 and August 2011, 18 patients with recurrent HNSCC with good performance status were enrolled. All patients had been previously treated with conventional RT / 3D Conformal RT (up to 66 Gy) with weekly Cisplatin 40 mg/m2 or Cisplatin (80 mg/m2) and 5 FU (1000 mg/m2) chemotherapy regimens. At recurrence all patients were treated with prolonged infusion Gemcitabine (1 gm/m2 over 8 hours every 14 days) and daily Gefitinib 250 mg. Re-irradiation with IMRT was delivered to a dose of 41.4 - 50.4 Gy in 23 to 28 fractions. All recurrences were more than 12 months after completion of initial RT. 3 patients who had progressive disease but in good KPS were given Docetaxel for 6 cycles and then started on IMRT. Results: All 18 patients were available for evaluation. The main toxicity in this group were nonhematological: oral mucositis (Gr 3) - 18/18 (100%), alopecia (Gr 2) - 18/18 (100%), nausea (Gr 2) -11/18 (61%), rash (Gr 3) 2/18 (11%) and (Gr 2) - 15 /18 (83%), dermatitis (Gr 3) - 12/18 (66%). Hematological toxicity were: neutropenia (Gr 2) - 11/18 (61%), thrombocytopenia (Gr 2) - 14/18 (77%). None had febrile neutropenic episodes during the treatment. The overall treatment period ranged from 49 - 62 days (Median 56 days). 1 patient discontinued treatment due to mucositis at 36 Gy and was lost for follow up. Overall response rate was 100%, CR 8/18 (44.5%) and PR - 10/18 (55.5%). Conclusions: Re-irradiation with IMRT and concurrent prolonged infusion Gemcitabine and Gefitinib is effective and tolerable. This combination should be evaluated in larger sample size. Author Disclosure: P. Eswaran: None. A.S. Kumaravelu: None.
2768 Adjuvant Hypofractionated Intensity Modulated Radiation Therapy (IMRT) After Resection of Regional Lymph Node (LN) Metastases in Patients With Malignant Melanoma of the Head and Neck C.L. Hallemeier,1 Y.I. Garces,1 M.A. Neben-Wittich,1 K.R. Olivier,1 J.A. Garcia,1 P.D. Brown,2 and R.L. Foote1; 1Mayo Graduate School of