2018-19 Section 7-Neoplastic and Inflammatory Diseases of the Head and Neck eBook

Reprinted by permission of Oral Oncol. 2017; 73:160-165.

Oral Oncology 73 (2017) 160–165

Contents lists available at ScienceDirect

Oral Oncology

journal homepage: www.elsevier.com/locate/oraloncology

Patient-oriented toxicity endpoints after head and neck reirradiation with intensity modulated radiation therapy Danielle N. Margalit a , ⁎ , Jonathan D. Schoenfeld a , Bhupendra Rawal b , Robert I. Haddad c , Paul J. Catalano b , Laura A. Goguen d , Nicole G. Chau c , Guilherme Rabinowits c , Jochen H. Lorch c , Donald J. Annino d , Roy B. Tishler a

MARK

a Department of Radiation Oncology, Dana-Farber/Brigham &Women ’ s Cancer Center, Boston, MA, United States b Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, United States c Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States d Division of Otolaryngology, Department of Surgery, Dana-Farber/Brigham &Women ’ s Cancer Center, Boston, MA, United States

A B S T R A C T

Objectives: To characterize speci fi c serious toxicities of reRT with intensity modulated radiation therapy (IMRT) for squamous cell carcinoma of the head and neck (SCCHN) and identify treatment-related predictors of toxicity for patient counseling and decision-making. Materials/Methods: 75 consecutive patients with recurrent or 2nd primary SCCHN received reRT from 8/2004- 02/2013. All patients had prior de fi nitive or postoperative RT. Objective endpoints of “ serious toxicity ” were de fi ned as: hospitalization during reRT, tracheotomy after reRT, hemorrhage, soft tissue complication requiring operative intervention, or other CTCAE grade ≥ 4 toxicity. Results: Patients received de fi nitive (n = 41,55%) or postoperative (n = 34,45%) reRT (median dose 60 Gy, range 59.4 – 70 Gy). Most patients (88%) had concurrent chemotherapy. With a median follow-up of 1.4 years, 39 (52%) patients had at least one serious toxicity: hospitalization during reRT (24%), surgically-managed soft tissue complication (19%), and/or urgent tracheotomy (18%). There were no grade 5 acute toxicities but there were 4 fatal hemorrhages (median 8.3 months) including 2 attributed to local-regional recurrence (LRR). Most patients (69%) had a percutaneous endoscopic gastrostomy (PEG) tube at last follow-up; those with a LRR had higher PEG tube-dependence rates (86% vs. 53%, p = 0.001). LRR, site of reRT, and laryngeal RT dose, were marginally associated with toxicity-risk. Conclusions: Patients considering reRT should be counseled on the high rate of PEG tube-dependence, and events of urgent tracheotomy, hospitalization, hemorrhage, and operative intervention, which typically occur months after reRT completion. Further study of baseline patient function and cumulative radiation dose to the larynx and other organs-at-risk may improve estimates of serious toxicity-risk after reRT.

Introduction

hospitalization, percutaneous endoscopic gastrostomy (PEG) tube-de- pendence, hemorrhage, tracheotomy or operative interventions for soft tissue necrosis. These are events that patients frequently inquire about during counseling on the risks and bene fi ts of reRT. Only RTOG 9610, the Phase II study of reRT with concurrent chemotherapy described the feeding-tube dependence at last follow-up of 70% [3] . Although few institutional series have assessed predictors of toxicity, the following have been shown to be associated with increased risk: concurrent chemotherapy [5] ,prior chemoradiotherapy [6] , radiation dose to the carotid artery [7] , higher reRT dose and de fi nitive (versus post- operative) reRT [8] . This study aims to provide data on the occurrence of speci fi c

Reirradiation (reRT) is a treatment option for select patients with recurrent or second primary squamous cell carcinoma of the head and neck (SCCHN) [1] and can result in prolonged disease control and even cure in select patients [2] . However, improvements in local-regional control rates must be balanced with the signi fi cant risks of treatment- related toxicity. Shared-decision making regarding the bene fi t of reRT must involve a discussion of possible side e ff ects of treatment and the time course over which these side e ff ects are likely to occur. Prior phase II/III reRT studies have characterized toxicity in terms of RTOG-grading [2 – 4] with less emphasis on the rates of

⁎ Corresponding author at: Dana 2-138, 450 Brookline Avenue, Boston, MA 0215, United States. E-mail address: dmargalit@lroc.harvard.edu (D.N. Margalit).

http://dx.doi.org/10.1016/j.oraloncology.2017.08.012 Received 14 June 2017; Received in revised form 16 August 2017; Accepted 19 August 2017

Available online 08 September 2017 1368-8375/ © 2017 Elsevier Ltd. All rights reserved.

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