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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4505_Библиотеки_им_академика_М_И_Перельмана
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Part 2 Site-Specifi c Indications and Techniques
SUGGESTED READINGS
Bataini JP, Rodriguez J, Jaulerry C, et al. Treatment of metastatic
neck nodes secondary to an occult epidermoid carcinoma of
the head and neck. Laryngoscope 1987;97:1080.
Boscolo-Rizzo P, Gava A, Da Mosto MC. Carcinoma metastatic to cer-
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a er combined modality therapy. Ann Surg Oncol 2007;14:1575.
Chen AM, Li BQ, Farwell DG, et al. Improved dosimetric and
clinical outcomes with intensity-modulated radiotherapy for
head-and-neck cancer of unknown primary origin. Int J Radiat
Oncol Biol Phys 2010;79(3):756–762.
Colletier PJ, Garden AS, Morrison WH, et al. Postoperative radia-
tion for squamous cell carcinoma metastatic to cervical lymph
nodes from an unknown primary site: outcomes and patterns
of failure. Head Neck 1998;20:674–681.
Coster JR, Foote RL, Olsen KD, et al. Cervical node metastasis of
squamous cell carcinoma of unknown origin: indications for
withholding radiation therapy. Int J Radiat Oncol Biol Phys
1992;23:743.
Davidson BJ, Spiro RH, Patel S, et al. Cervical metastases of occult
origin: the impact of combined modality therapy. Am J Surg
1994;168:395–399.
Erkal HS, Mendenhall WM, Amdur RJ, et al. Squamous cell car-
cinomas metastatic to cervical lymph nodes from an unknown
head-and-neck mucosal site treated with radiation therapy
alone or in combination with neck dissection. Int J Radiat
Oncol Biol Phys 2001;50:55.
Fletcher GH, Jesse RH, Perez CA. Cervical lymph node metasta-
sis: unknown primary cancer. In: Fletcher GH, ed. Textbook of
radiotherapy, 3rd ed. Philadelphia, PA: Lea & Febiger, 1980.
Frank SJ, Rosenthal DI, Petsuksiri J, et al. Intensity-modulated
radiotherapy for cervical node squamous cell carcinoma
metastases from unknown head-and-neck primary Site: M. D.
Anderson Cancer Center outcomes and patterns of failure. Int
J Radiat Oncol Biol Phys 2010;78(4):1005–1010.
Friesland S, Lind MG, Lundgren J, et al. Outcome of ipsilat-
eral treatment for patients with metastases to neck nodes of
unknown origin. Acta Oncol 2001;40:24.
Grau C, Johansen L, Jakobsen J, et al. Cervical lymph node metas-
tases from unknown primary tumours. Results from a national
survey by the Danish Society for Head and Neck Oncology.
Radiother Oncol 2000;55:121.
Jacobs CD, Pinto HA. Head and neck cancer with an occult primary
tumor. N Engl J Med 1992;326:58.
Klem ML, Mechalakos JG, Wolden SL, et al. Intensity-modulated
radiotherapy for head and neck cancer of unknown primary:
toxicity and preliminary e cacy. Int J Radiat Oncol Biol Phys
2008;70:1100.
Ligey A, Gentil J, Crehange G, et al. Impact of target volumes and
radiation technique on loco-regional control and survival for
patients with unilateral cervical lymph node metastases from
an unknown primary. Radiother Oncol 2009;93:483.
Lu H, Yao M, Tan H. Unknown primary head and neck cancer
treated with intensity-modulated radiation therapy: to what
extent the volume should be irradiated. Oral Oncol 2009;45:474.
Madani I, Vakaet L, Bonte K, et al. Intensity-modulated radio-
therapy for cervical lymph node metastases from unknown
primary cancer. Int J Radiat Oncol Biol Phys 2008;71:1158.
Marcial-Vega VA, Cardenes H, Perez CA, et al. Cervical metastases
from unknown primaries: radiotherapeutic management and
appearance of subsequent primaries. Int J Radiat Oncol Biol
Phys 1990;19:919.
Maulard C, Housset M, Brunel P, et al. Postoperative radiation
therapy for cervical lymph node metastases from an occult
squamous cell carcinoma. Laryngoscope 1992;102:884.
Mendenhall WM, Mancuso AA, Parsons JT, et al. Diagnostic
evaluation of squamous cell carcinoma metastatic to cervical
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ymph nodes from an unknown head and neck primary site.
Head Neck 1998;20:739.
Patel RS, Clark J, Wyten R, et al. Squamous cell carcinoma from an
unknown head and neck primary site. A “selective treatment”
approach.. Arch Otolaryngol Head Neck Surg 2007;133:1282.
Reddy SP, Marks JE. Metastatic carcinoma in the cervical lymph
nodes from an unknown primary site: results of bilateral neck
plus mucosal irradiation vs. ipsilateral neck irradiation. Int
J Radiat Oncol Biol Phys 1997;37:797.
Rusthoven KE, Koshy M, Paulino AC. e role of uorodeoxyglucose
positron emission tomography in cervical lymph node metastases from an unknown primary tumor. Cancer 2004;101:2641.
Strasnick B, Moore DM, Abemayor E, et al. Occult primary tumors.
e management of isolated submandibular lymph node
metastases. Arch Otolaryngol Head Neck Surg 1990;116:173.
Wang R, Goepfert H, Barber AE, et al. Unknown primary squa-
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Head Neck Surg 1990;116:1388.
Weir L, Keane T, Cummings B, et al. Radiation treatment of cer-
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factors. Radiother Oncol 1995;35:206.
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Treatment of Local–Regional
Recurrence
Key Points
• Up to recently, reirradiation for recurrent local or
regional disease has been widely discouraged because
of concerns of inducing very severe complications,
particularly neurologic de cits and carotid injury.
• Relatively favorable outcome of reirradiation in selected
patients with recurrent nasopharyngeal carcinoma
along with progress in conformal radiation technique
and emergence of radiobiological data have increased
enthusiasm for adopting reirradiation in selected
patients who are poor candidates for surgical salvage.
• Special attention is given to minimize the dose to
the spinal cord, brain stem, and, in patients with
nasopharyngeal cancer, the temporal lobes to prevent
devastating complications.
• Concurrent chemotherapy is recommended with
reirradiation unless medically contraindicated. Phase
II experiences of concurrent chemo-reirradiation
suggest this approach is feasible in carefully selected
patients and can yield modest long-term control rate,
but complications can be severe.
• e role of adjuvant reirradiation is controversial. Relative
indications for postoperative radiation in the unirradiated patient do not apply when considering reirradiation.
Only patients with a very high risk of recurrence
(i.e., positive margins or extensive so -tissue disease) are
selected for adjuvant postoperative reirradiation.
• In addition to the general indications for radiation,
the interval from the rst radiation course and the
health of the tissues to be irradiated should be considered in the decision-making process. Reirradiation is strongly discouraged if the interval between
the two courses is <6 months.
REIRRADIATION FOR LOCAL
RECURRENCE
Because of the technical complexity and high morbidity, surgical salvage for local recurrence of nasopharyngeal carcinoma
has been attempted in a few specialized centers and in highly
selected patients. Due to the lack of other options, many
centers have resorted to treating patients with localized local
recurrence with reirradiation. In our center, retreatment with
curative intent a er previous high-dose irradiation is o ered
to patients with relapse that is con ned to the nasopharynx
or with a limited extension to the adjacent parapharyngeal
space, skull base, or both
radiotherapy, particularly intensity-modulated radiotherapy
(IMRT) (see Case Studies 17-2 and 17-3), is now used to min-
imize the volume of normal tissues exposed to reirradiation
and thereby reduce the acute and late morbidity. Recurrences
above the skull base are o en di cult to reirradiate due to the
proximity to the brain stem and temporal lobes. Intracranial
disease may be amenable to reirradiation if the initial elds
did not encompass the cranial tissues (see Case Study 17-4).
(see Case Study 17-1). Conformal
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Part 2 Site-Specifi c Indications and Techniques
Case
Study
17-1
well until a year later when he presented with epistaxis.
Physical examination showed a small lesion in the le lateral wall, biopsy of which revealed a lymphoepithelioma.
He was referred to our center for workup and treatment.
Examination at this time revealed a super cial
lesion con ned to the le lateral wall. ere was no
A 34-year-old man underwent radiation treatment for a T1 N0 M0 lymphoepithelioma
of the nasopharynx. He received 64.8 Gy in
36 fractions to the primary tumor and 45 Gy
in 25 fractions to the cervical nodes. He did
palpable lymphadenopathy. Workup for metastatic
disease was negative. He received external beam
irradiation with 25-MV x-rays through lateral–opposed
portals (Fig. 17-1A) to a dose of 25 Gy in 12 fractions.
is was followed by an intracavitary insertion of
source (18.75 mg radium equivalent) into a Te on ball
(Fig.17-1B,C) for 35.6 hours to deliver a dose of 50 Gy to
the mucosal surface (23 Gy at 0.5-cm depth). is patient
was alive without evidence of disease and without late
complications from this treatment 10 years later.
137
Cs
A B
C
Figure 17.1A-C
Chapter 17 Treatment of Local–Regional Recurrence
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277
Case
Study
17-2
ynx and le neck. He was reirradiated with IMRT and received
A 67-year-old man was diagnosed with WHO
type 3 nasopharynx carcinoma. He received a
combination of chemotherapy and radiation, but
discontinued treatment at 50 Gy due to toxicity.
He developed a recurrence in the right nasophar-
AB
concurrent cisplatin. A total dose of 66 Gy was administered
in 33 fractions to the gross tumor with 1-cm margin.
Figure 17-2 shows isodose distributions on a coronal (Fig. 17-2A) and axial (Fig. 17-2B) image. e maximum dose to the spinal cord was 20 Gy in 33 fractions. He
remains without disease 2 years from his retreatment.
Figure 17.2A,B
Case
Study
17-3
e restaging workup included a PET-CT scan
(Fig.17-3A), which revealed the recurrent disease con ned
to the right nasopharynx. Stage rT1 N0.
He was reirradiated with IMRT delivered with concurrent cisplatin.
As shown in Figure 17-3, two targets were de ned.
CTVHD (66 Gy, maroon colorwash) encompassed the gross
A 36-year-old man was treated in Asia with
radiation for undi erentiated carcinoma.
Treatment records were unavailable. He was
found to have recurrent disease on routine
follow-up evaluation 4 years later.
disease in the right nasopharynx with margin and CTVED
(60 Gy, blue colorwash) encompassed the le nasopharynx. Treatment was delivered in 33 fractions. Figure17-3
also shows isodose distributions in axial views, with
target volumes delineated, at the level of the tumor epicenter (Fig. 17-3B), inferior (Fig. 17-3C) and superior
(Fig.17-3D) nasopharynx, a sagittal view through midline
(Fig. 17-3E), and a coronal view through the nasopharynx
(Fig. 17-3F). As the previous records were unavailable,
doses to the brain stem and spinal cord were limited to
20 Gy. e patient has no evidence of disease 4 years a er
reirradiation.
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A
C
B
D
E
Figure 17.3A-E
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Figure 17.3F
Chapter 17 Treatment of Local–Regional Recurrence
279
Case
Study
17-4
numbness and was found to have a mass in the le cavernous sinus. Review of her portals revealed that the recurrent
tumor was located at the superior edge of the original portals (marginal recurrence) and much of the disease in the
cavernous sinus was unirradiated.
She was treated with three cycles of taxane- platin–based
induction chemotherapy achieving a partial response. Both
the initial and postchemotherapy MRIs were used for planning
of reirradiation by fusing them onto the retreatment planning
CT scan.
Figure 17-4A shows an axial slice on the pretreatment
MRI. e gross disease was contoured in two separate volumes. e red contour surrounds the disease in the cavern-
ous sinus, and the aqua contour surrounds the disease in
A 43-year-old woman was treated for stage T1
N1 nasopharyngeal carcinoma with induction
chemotherapy followed by hyperfractionated
radiation regimen delivering 74 Gy in 69 fractions. Five years later, she presented with facial
the brain stem (brown contour). Figure 17-4B shows the
postchemotherapy volume. e red and aqua contours
represent pretreatment volumes fused onto this MRI and
thegreen contour delineates the residual abnormality on
the postchemotherapy scan. Figure 17-4C demonstrates the
contours fused onto the CT planning scan. Doses were prescribed to these targets without expansion. Daily setup was
veri ed with CT guidance. e residual disease was treated
to 64 Gy, the prechemotherapy volume outside the brain
stem to 60 Gy, and the prechemotherapy volume abutting
the brain stem to 46 Gy. Treatment was delivered in 32 fractions, with concurrent weekly carboplatin. Figure 17-4 also
shows isodose distributions on an axial (Fig. 17-4D) and on
coronal views through the cavernous sinus (Fig. 17-4E) and
brain stem (Fig. 17-4F). Noncoplanar beams were used, so
low dose can be appreciated in the superior aspect of the
brain. e dose constraints on the brain stem were varied,
with more tolerance allowed superiorly outside the initial
radiation portal. e patient remains well 3 years later.
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A
C
B
D
E
Figure 17.4A-F
F
Chapter 17 Treatment of Local–Regional Recurrence
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281
For nonnasopharyngeal head and neck cancers, sur-
ery is generally the preferred treatment for operable
g
local–regional recurrence. However, oncologists have been
gradually more inclined to consider retreating selected
patients with local–regional recurrence who are poor candidates for surgery
of reirradiation for recurrent nasopharyngeal carcinoma
coupled with several additional advances have increased
its use. First, the introduction of highly conformal radiation technology such as IMRT reduces radiation exposure
to critical normal tissues drastically. Second, the emergence
of consistent data showing that chemotherapy can enhance
tumor response to radiation (see Chapter 1) encourages the
use of combined therapy in this setting. Finally, experimental
studies have shown that normal organs, including the central
nervous systems, have relatively large capacity to recover
from occult radiation injury within a year.
Case
Study
17-5
additional 20 Gy. One year later, he developed a local recurrence and underwent surgical salvage. Disease extended to
the palate and pharynx. ere was lymphovascular invasion,
but the nal margins were negative. erefore, it was elected
to observe him. One year later, he presented with odynophagia. Workup revealed multifocal disease in the le base of
tongue, and he was thought to be a poor candidate for surgery and was dispositioned to receive reirradiation.
(seeCase Study 17-5). e long-term data
A 78-year-old man underwent surgical resection of a T3 N0 squamous cell carcinoma of the
right retromolar trigone. is was followed by
postoperative radiation given using a three- eld
technique to 50 Gy and an ipsilateral boost to an
TREATMENT STRATEGY
AND PLANNING
Nasopharyngeal Carcinoma
Most reirradiation experience has been gained from the
treatment of this disease. Super cial recurrent tumors are
generally treated with combinations of conformal external
beam irradiation and brachytherapy, whereas thicker lesions
are treated with conformal external beam irradiation alone.
e target volume for the external beam irradiation
encompasses the clinically and radiologically detectable
recurrent disease with 1- to 2-cm margins. When combined
with brachytherapy, the external beam component is delivered rst with the aim of attening the tumor to allow better placement of the intracavitary source and to improve
brachytherapy dose distribution.
A PET-CT simulation was performed. Sites of disease within the tongue as shown in Figure 17-5A,B
(green arrows) were outlined as GTV (aqua colorwash).
Due to the lymphovascular space invasion and multifocal nature of the disease, CTVHD (maroon colorwash)
encompassed GTV with a relatively generous margin. The prescription dose to CTVHD was 66 Gy given
in 33 fractions with concurrent weekly carboplatin.
Figure 17-5 also illustrates contours and isodoses in
axial, sagittal, and coronal views (Fig. 17-5C–F). The spinal cord dose was limited to 20 Gy. The patient remains
without disease 2years later, though he is dependent on
gastrostomy for nutritional intake.
A
Figure 17.5A,B
B
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C
E
Figure 17.5C-F
D
F
Chapter 17 Treatment of Local–Regional Recurrence
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283
Endocavitary brachytherapy component is delivered
with an 8 × 3 mm
placed into the nasopharynx under general anesthesia. Four
sizes of Te on balls (diameters: 1.5, 2.0, 2.5, and 3.0 cm) are
available. e largest that can be inserted snugly is chosen to
improve the depth dose distribution.
137
Cs source a erloaded in a Te on ball
Oropharyngeal Carcinoma
Most cases are treated with external beam irradiation alone.
e target volume encompasses the clinically and radiologically detectable recurrent disease with 1- to 2-cm margins.
Small volume disease in the tonsil or base of tongue may be
suitable for combination of external beam with brachytherapy or, in rare cases, brachytherapy alone.
Technique
e majority of patients are now treated with IMRT. e treatment setup is similar to primary radiotherapy as described in
individual sites in preceding chapters. Brie y, the gross target
volume (GTV) is de ned based on the clinical information. One
or two clinical targets (CTVs) are de ned. CTV
GTV with 1- to 2-cm margins. Smaller margins are used if constrained by proximity to neural structures. e general policy is
not to systematically administer comprehensive elective irradiation in retreatment setting. erefore, CTVED is individualized.
For external beam irradiation alone, a dose of 66 Gy
in 33 fractions is prescribed to CTVHD. When applicable,
CTVED generally receives 54 to 60 Gy. In general, the cumulative external beam dose to the temporal lobes is kept
below 105 Gy to minimize the risk of brain necrosis. If the
interval between the two courses of radiation is >2 years,
includes the
HD
the cumulative dose to the spinal cord and brain stem is kept
below 65 Gy. More stringent dose constraints are adopted for
shorter intervals. When combined with brachytherapy, the
prescribed external beam dose is 20 to 30 Gy in 10 to 15 fractions depending on the thickness of the recurrent lesion and
the previous radiation dose.
For endocavitary brachytherapy for nasopharyngeal
carcinoma, the prescribed dose is 40 to 50 Gy (a er external
beam) delivered at a dose rate of 0.4 to 0.6 Gy/h.
ADJUVANT REIRRADIATION
Strategy
Recommendation for adjuvant reirradiation is complex as its
role has not been clearly de ned. Factors to consider include
the amount of previously irradiated tissue removed by the
surgery, the degree of radiation changes in the remaining tissue, and the extent of reconstruction. Patients with extensive
surgical resection that removes substantial amounts of previously irradiated tissues and those with free aps reconstruction that covers the carotid vessels or bones are more suitable
for reirradiation. Only patients considered to be at considerable high risk for recurrence are selected for adjuvant
reirradiation
positive margins or extensive extranodal extension.
Patients who develop isolated nodal recurrences may
be suitable for surgery and perioperative brachytherapy
(Case Study 17-7). We have predominantly used low–dose
rate brachytherapy in conjunction with a neck dissection
with the wound closed with a rotational pectoralis major ap.
(Case Study 17-6). ese indications include
Case
Study
17-6
developed local recurrence 1 year later and underwent
resection with negative margins. ree months later,
she developed a second recurrence in the le posterior
tongue (Fig. 17-6A, green arrow) and le level I neck node
(Fig.17-6B, red arrow). She was treated with a partial glos-
sectomy, partial mandibulectomy, le neck dissection, and
free ap reconstruction. Histologic examination revealed
squamous carcinoma in the tongue and so tissues of le
level IA and B regions but margins were negative. She was
A 32-year-old woman was diagnosed with
le oral tongue cancer. She was treated with
partial glossectomy and postoperative IMRT
administering 60 Gy in 30 fractions to the
primary tumor bed and upper neck. She
treated with postoperative reirradiation with concurrent
cisplatin.
As the prior treatment was relatively limited to the le
tongue and upper neck, it was felt that elective reirradiation
would be bene cial with a relatively low risk for severecomplication. Target volumes were designed similar to the routine postoperative situation (see Chapter 6), but the dose
constraint for the spinal cord was set at 20 Gy rather than
the usual 45 Gy. CTV
colorwash), and CTVED (yellow colorwash) were prescribed
60 Gy, 57 Gy, and 54 Gy, respectively. Figure 17-6 also shows
contours and isodose distributions on axial (Fig. 17-6C),
sagittal (Fig. 17-6D), and coronal (Fig. 17-6E) views through
the tongue. She remains without disease 3 years later.
(maroon colorwash), CTVID (blue
HD
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