Refining Patient Selection for Reirradiation of Head and Neck Squamous Carcinoma in the IMRT Era: A Multi-institution Cohort Study by the MIRI Collaborative.
Ward MC, Riaz N, Caudell JJ, Dunlap NE, Isrow D, Zakem SJ, Dault J, Awan MJ, Vargo JA, Heron DE, Higgins KA, Beitler JJ, Marcrom S, Boggs DH, Hassanzadeh C, Reddy CA, Bonner JA, Yao M, Machtay M, Siddiqui F, Trotti AM, Lee NY, and Koyfman SA. Refining patient selection for reirradiation of head and neck squamous carcinoma in the imrt era: A multi-institution cohort study by the miri collaborative. Int J Radiat Oncol Biol Phys 2018; 100(3):586-594.
International journal of radiation oncology, biology, physics
PURPOSE: The therapeutic ratio of reirradiation for recurrent or second primary (RSP) squamous carcinoma of the head and neck may be improved in the intensity modulated radiation therapy (IMRT) era. However, patient selection for reirradiation remains challenging. We performed a multi-institution cohort study to investigate modern outcomes after IMRT-based reirradiation and to identify prognostic subgroups.
PATIENTS AND METHODS: Patients with RSP squamous carcinoma originating in a previously irradiated field (≥40 Gy) who underwent reirradiation with IMRT (≥40 Gy re-IMRT) were included. Locoregional failure and late toxicity were calculated using the Gray competing risk method. Cox proportional hazards regression was used to identify factors associated with overall survival (OS). Factors associated with OS were entered into a recursive partitioning analysis (RPA) for OS.
RESULTS: From 7 institutions, 412 patients were included. The median dose of re-IMRT was 60 Gy, and the median time between RT courses was 2.4 years. Chemotherapy was used in 76% of patients. The rates of grade ≥3, grade ≥4, and grade 5 acute toxicities were 19%, 4.4%, and 1.2%, respectively. The 2-year cumulative incidence of grade ≥3 late toxicity adjusted for the competing risks of recurrence or death was 14.2%. RPA identified 3 prognostic subgroups with distinct and homogenous OS (P2 years from their initial course of RT with resected tumors (2-year OS, 61.9%); class II included patients >2 years with unresected tumors or those ≤2 years and without feeding tube or tracheostomy dependence (2-year OS, 40.0%), and the remaining patients formed class III (2-year OS, 16.8%). Fifty-nine percent of class III patients underwent postoperative re-irradiation.
CONCLUSIONS: This study informs outcomes and expectations with IMRT-based reirradiation. The RPA classification identifies 3 distinct subgroups, which can guide patient selection for therapy and clinical trial design. RPA class III patients are not ideal candidates for protracted chemoradiation regardless of resection status.
Medical Subject Headings
Adult; Aged; Aged, 80 and over; Carcinoma, Squamous Cell; Cause of Death; Cohort Studies; Decision Trees; Female; Head and Neck Neoplasms; Humans; Male; Middle Aged; Multivariate Analysis; Neoplasm Recurrence, Local; Neoplasms, Second Primary; Patient Selection; Radiotherapy, Intensity-Modulated; Re-Irradiation; Regression Analysis; Time Factors; Young Adult