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Outcomes in Recurrent Head and Neck Cancer after Salvage Surgery and Flap Reconstruction with Postoperative Reirradiation (re-RT)
I. J. Radiation Oncology d Biology d Physics
S548
Volume 81, Number 2, Supplement, 2011
Materials/Methods: A prospective database of 223 patients with head and neck cancer treated on one of three protocols at the University of Chicago Medical Center between 1996 and 2005 was reviewed. Of these patients, 40 patients that underwent LN dissection with or without surgery to the primary lesion prior to chemoradiation were identified. Patients who did not undergo neck dissection or who underwent dissection after definitive chemoradiation were excluded. After dissection, patients were treated to a median dose of 60 Gy (range 30 - 75 Gy) administered in 1.5 Gy fractions twice daily during weeks 1, 3, 5, 7, and 9. Two protocols administered concurrent chemotherapy with paclitaxel, 5-FU, and hydroxyurea (n = 25 patients). The third protocol administered induction chemotherapy with carboplatin and paclitaxel followed by concurrent chemoradiation with Iressa, 5-FU, and hydroxyurea (n = 15); of these patients one was treated with induction chemotherapy prior to dissection. Locoregional control (LRC), distant metastasis-free survival (DMFS), and overall survival (OS) at 3 years were calculated using Kaplan-Meier analysis and compared by percentage of LN involvement using log-rank analysis. Results: Patients had a median of 26 lymph nodes resected and 49 months of follow up. The median age was 54 and 73% were male. Ninety percent of patients had Stage IVA disease (n = 36), while 8% (n = 3) had Stage IVB and 3% (n = 1) had Stage III disease. The distribution of primary lesions was oropharynx (n = 17), oral cavity (n = 13), cancer of unknown primary (n = 6), larynx/hypopharynx (n = 3), and maxillary sinus (n = 1). Overall 3 yr locoregional control (LRC) was 89%, 3 yr distant metastasis-free survival (DMFS) was 89%, and 3 yr overall survival (OS) was 70%. Patients with \20% lymph node involvement had improved overall survival at three years (3 yr OS = 77% vs 44%, p = 0.02) and trended towards improved locoregional control (3 yr LRC = 93% vs. 75%, p = 0.15). Percentage of LN involvement had no effect on DMFS. Furthermore, using Cox regression analysis, the absolute number of LN involved did not predict LRC or OS (HR = 0.93, p = 0.62; HR = 1.22, p = 0.81, respectively). Conclusions: In cases of advanced head and neck disease, these findings suggest that percentage of LN involvement greater than 20% may negatively predict LRC and OS. Therefore, the fraction of LN involved rather than the absolute number may warrant more aggressive local treatment in the post-operative setting. Author Disclosure: S. Rudra: None. M. Spiotto: None. M.E. Witt: None. E. Blair: None. K. Stenson: None. D.J. Haraf: None.
2704
Outcomes in Recurrent Head and Neck Cancer after Salvage Surgery and Flap Reconstruction with Postoperative Reirradiation (re-RT)
R. Rahmati, N. Lee, G. Linkov, A. Mohebati, D. Kraus Memorial Sloan-Kettering Cancer Center, New York, NY Purpose/Objective(s): Recurrent malignancies of the head and neck create a therapeutic challenge due to limited effective treatment options. Salvage surgery with adjuvant radiotherapy may offer extended locoregional control, palliation of symptoms, and the potential for cure. Our objective was to evaluate the outcomes of patients treated with salvage surgery with flap reconstruction followed by adjuvant re-RT. Materials/Methods: Retrospective outcomes analysis of patients treated with salvage surgery, flap reconstruction, and re-RT at Memorial Sloan-Kettering Cancer Center. Tumor histology, flap type, mode of reirradiation, acute and delayed toxicities, flap complications, and survival outcomes were calculated using Kaplan-Meier method. Results: From 1997 to 2010, 22 patients with recurrent head and neck cancer who had previously received a full course of head and neck radiation underwent salvage surgery with flap reconstruction. 64% were squamous cell carcinoma. Neck, paranasal sinuses, oral cavity, and parotid were the most common sites of recurrence (N = 5, 5, 3, 3 respectively). Reconstruction involved 14 microvascular free tissue transfers and 10 pedicled flaps, with 2 patients requiring a free flap and a pedicled flap. Among those treated with external beam re-RT, the pre-operative gross tumor volume, post-operative bed, and the entire flap were encompassed in the treatment volume. The median re-RT dose was 59.40 Gy (6 - 70 Gy). The median prior radiation dose to the head and neck was 60 Gy (22 - 70 Gy). 45% of the patients had IMRT. Three patients received IORT alone (median dose of 15 Gy) and 1 patient received brachytherapy alone (27 Gy). 27 % of patients received platinum based concurrent chemotherapy with re-RT. Mild mucositis (40%) was the most common acute re-RT toxicity. Long term re-RT sequelae involved 2 cases of temporal bone necrosis, 2 cases of chronic neuropathic pain, 1 case of persistent nasocutaneous fistula, and 1 case of hardware extrusion. There were no cases of flap breakdown or failure. Long term tracheostomy and gastrostomy tube dependence were observed in 27% and 41% of patients, respectively. With a median follow-up of 62 months for living patients, the 5 year rates of locoregional control and overall survival were 59%. Conclusions: Salvage surgery with flap reconstruction and postoperative reirradiation is an option for select recurrent head and neck cancer patients that received prior head and neck radiation. Utilization of vascularized tissue in a previously radiated field allows the delivery of a second therapeutic dose of radiotherapy with a reasonable toxicity profile. This treatment approach also affords the prospect of durable locoregional control of disease in this select population of recurrent head and neck cancer. Author Disclosure: R. Rahmati: None. N. Lee: None. G. Linkov: None. A. Mohebati: None. D. Kraus: None.
2705
Clinical Performance of Automated IMRT with High Intensity Flattening-Filter-Free Beams in Comparison to VMAT for Head and Neck Cancers
J. Duan, S. A. Spencer, S. Shen, I. A. Brezovich, J. A. Bonner University of Alabama at Birmingham, Birmingham, AL Purpose/Objective(s): To compare clinical performance of automated IMRT with high intensity flattening-filter-free (FFF) beams to volumetric modulated arc therapy (VMAT) for head-and-neck (HN) cancers. Materials/Methods: Ten patients with Stage III-IV squamous cell carcinoma of the head and neck were planned with fixed-field IMRT and VMAT (RapidArc, Varian Medical Systems) using 6 MV flattened, 6 MV FFF and 10 MV FFF photon beams at respective maximum dose rates of 600, 1400 and 2400 MU/minute. Seven equi-spaced fields were used for IMRT and two axial arcs were used for VMAT plans to deliver 70 Gy to the primary target and 54 Gy to the nodal target in 35 fractions. Identical dose constraints were used for IMRT and VMAT plans to ensure the objectivity of dosimetric evaluation. Treatment planning was
S548
Volume 81, Number 2, Supplement, 2011
Materials/Methods: A prospective database of 223 patients with head and neck cancer treated on one of three protocols at the University of Chicago Medical Center between 1996 and 2005 was reviewed. Of these patients, 40 patients that underwent LN dissection with or without surgery to the primary lesion prior to chemoradiation were identified. Patients who did not undergo neck dissection or who underwent dissection after definitive chemoradiation were excluded. After dissection, patients were treated to a median dose of 60 Gy (range 30 - 75 Gy) administered in 1.5 Gy fractions twice daily during weeks 1, 3, 5, 7, and 9. Two protocols administered concurrent chemotherapy with paclitaxel, 5-FU, and hydroxyurea (n = 25 patients). The third protocol administered induction chemotherapy with carboplatin and paclitaxel followed by concurrent chemoradiation with Iressa, 5-FU, and hydroxyurea (n = 15); of these patients one was treated with induction chemotherapy prior to dissection. Locoregional control (LRC), distant metastasis-free survival (DMFS), and overall survival (OS) at 3 years were calculated using Kaplan-Meier analysis and compared by percentage of LN involvement using log-rank analysis. Results: Patients had a median of 26 lymph nodes resected and 49 months of follow up. The median age was 54 and 73% were male. Ninety percent of patients had Stage IVA disease (n = 36), while 8% (n = 3) had Stage IVB and 3% (n = 1) had Stage III disease. The distribution of primary lesions was oropharynx (n = 17), oral cavity (n = 13), cancer of unknown primary (n = 6), larynx/hypopharynx (n = 3), and maxillary sinus (n = 1). Overall 3 yr locoregional control (LRC) was 89%, 3 yr distant metastasis-free survival (DMFS) was 89%, and 3 yr overall survival (OS) was 70%. Patients with \20% lymph node involvement had improved overall survival at three years (3 yr OS = 77% vs 44%, p = 0.02) and trended towards improved locoregional control (3 yr LRC = 93% vs. 75%, p = 0.15). Percentage of LN involvement had no effect on DMFS. Furthermore, using Cox regression analysis, the absolute number of LN involved did not predict LRC or OS (HR = 0.93, p = 0.62; HR = 1.22, p = 0.81, respectively). Conclusions: In cases of advanced head and neck disease, these findings suggest that percentage of LN involvement greater than 20% may negatively predict LRC and OS. Therefore, the fraction of LN involved rather than the absolute number may warrant more aggressive local treatment in the post-operative setting. Author Disclosure: S. Rudra: None. M. Spiotto: None. M.E. Witt: None. E. Blair: None. K. Stenson: None. D.J. Haraf: None.
2704
Outcomes in Recurrent Head and Neck Cancer after Salvage Surgery and Flap Reconstruction with Postoperative Reirradiation (re-RT)
R. Rahmati, N. Lee, G. Linkov, A. Mohebati, D. Kraus Memorial Sloan-Kettering Cancer Center, New York, NY Purpose/Objective(s): Recurrent malignancies of the head and neck create a therapeutic challenge due to limited effective treatment options. Salvage surgery with adjuvant radiotherapy may offer extended locoregional control, palliation of symptoms, and the potential for cure. Our objective was to evaluate the outcomes of patients treated with salvage surgery with flap reconstruction followed by adjuvant re-RT. Materials/Methods: Retrospective outcomes analysis of patients treated with salvage surgery, flap reconstruction, and re-RT at Memorial Sloan-Kettering Cancer Center. Tumor histology, flap type, mode of reirradiation, acute and delayed toxicities, flap complications, and survival outcomes were calculated using Kaplan-Meier method. Results: From 1997 to 2010, 22 patients with recurrent head and neck cancer who had previously received a full course of head and neck radiation underwent salvage surgery with flap reconstruction. 64% were squamous cell carcinoma. Neck, paranasal sinuses, oral cavity, and parotid were the most common sites of recurrence (N = 5, 5, 3, 3 respectively). Reconstruction involved 14 microvascular free tissue transfers and 10 pedicled flaps, with 2 patients requiring a free flap and a pedicled flap. Among those treated with external beam re-RT, the pre-operative gross tumor volume, post-operative bed, and the entire flap were encompassed in the treatment volume. The median re-RT dose was 59.40 Gy (6 - 70 Gy). The median prior radiation dose to the head and neck was 60 Gy (22 - 70 Gy). 45% of the patients had IMRT. Three patients received IORT alone (median dose of 15 Gy) and 1 patient received brachytherapy alone (27 Gy). 27 % of patients received platinum based concurrent chemotherapy with re-RT. Mild mucositis (40%) was the most common acute re-RT toxicity. Long term re-RT sequelae involved 2 cases of temporal bone necrosis, 2 cases of chronic neuropathic pain, 1 case of persistent nasocutaneous fistula, and 1 case of hardware extrusion. There were no cases of flap breakdown or failure. Long term tracheostomy and gastrostomy tube dependence were observed in 27% and 41% of patients, respectively. With a median follow-up of 62 months for living patients, the 5 year rates of locoregional control and overall survival were 59%. Conclusions: Salvage surgery with flap reconstruction and postoperative reirradiation is an option for select recurrent head and neck cancer patients that received prior head and neck radiation. Utilization of vascularized tissue in a previously radiated field allows the delivery of a second therapeutic dose of radiotherapy with a reasonable toxicity profile. This treatment approach also affords the prospect of durable locoregional control of disease in this select population of recurrent head and neck cancer. Author Disclosure: R. Rahmati: None. N. Lee: None. G. Linkov: None. A. Mohebati: None. D. Kraus: None.
2705
Clinical Performance of Automated IMRT with High Intensity Flattening-Filter-Free Beams in Comparison to VMAT for Head and Neck Cancers
J. Duan, S. A. Spencer, S. Shen, I. A. Brezovich, J. A. Bonner University of Alabama at Birmingham, Birmingham, AL Purpose/Objective(s): To compare clinical performance of automated IMRT with high intensity flattening-filter-free (FFF) beams to volumetric modulated arc therapy (VMAT) for head-and-neck (HN) cancers. Materials/Methods: Ten patients with Stage III-IV squamous cell carcinoma of the head and neck were planned with fixed-field IMRT and VMAT (RapidArc, Varian Medical Systems) using 6 MV flattened, 6 MV FFF and 10 MV FFF photon beams at respective maximum dose rates of 600, 1400 and 2400 MU/minute. Seven equi-spaced fields were used for IMRT and two axial arcs were used for VMAT plans to deliver 70 Gy to the primary target and 54 Gy to the nodal target in 35 fractions. Identical dose constraints were used for IMRT and VMAT plans to ensure the objectivity of dosimetric evaluation. Treatment planning was