FULL-DOSE REIRRADIATION FOR UNRESECTABLE HEAD AND NECK-CARCINOMA - EXPERIENCE AT THE GUSTAVE-ROUSSY-INSTITUTE IN A SERIES OF 169 PATIENTS

Purpose: To review our experience using full-dose external reirradiati on given with a curative intent for patients with unresectable head an d neck carcinoma (HNC). Patients and Methods: Between January 1980 and December 1996, 169 patients who presented with unresectable nonmetast atic HNC in a previously irradiated area were included in this series. The median time between the first and the second irradiation was 33 m onths. Reirradiation protocols were as follows: radio therapy alone (6 5 Gy over 6.5 weeks at 2 Gy/d), 27 patients; Vokes protocol, ie, five to six cycles of radiotherapy (median total dose, 60 Gy; 2 Gy/d) with simultaneous fluorouracil (5-FU) and hydroxyurea, 106 patients; and bi fractionated radiotherapy (median total dose, 60 Gy; 2 x 1.5 Gy/d) wit h concamitant mitomycin, 5-FU, and cisplatin, 36 patients. The median cumulative dose of the two irradiations was 120 Gy. Eighty-five percen t of the tumors were squamous cell carcinoma, 14% undifferentiated car cinoma of nasopharyngeal type, and 1% adenocarcinoma. Forty-four perce nt were local recurrences, 23% nodal recurrences, 14% both local and n odal, and 19% second primary tumors. Results: Mucositis grade 3 (World Health Organization [WHO]) was found in 32% and grade 4 in 14% of cas es. Four patients presented with neutropenia or thrombocytopenia (grad e 3 or 4 WHO). Late toxicities (> 6 months) were as follows: cervical fibrosis (grade 2 to 3 Radiation Therapy Oncology Group [RTOG]), 41%; mucosal necrosis, 21%; osteoradionecrosis, 8%; and trismus, 30%. Five patients died of carotid hemorrhage, apparently in complete remission. Six months after the onset of reirradiation, 37% of patients were in complete response. Patterns of failure were local only (53%), nodal on ly (20%), metastatic only (7%), and multiple (20%). Median follow-up t ime was 70 months. Overall survival rate (Kaplan-Meier) wets 21% (95% confidence interval [CI], 15% to 29%) at 2 years and 9% (95% CI, 5% to 16%) at 5 years. Median survival time was 10 months for the entire po pulation. Thirteen patients, of whom 12 were treated with the Vokes pr otocol, were long-term disease-free survivors. In ct multivariate anal ysis, the volume of the second irradiation was the only factor signifi cantly associated with the risk of death: relative risk = 1.8 (95% CI, 1.13 to 5.7) (P = .01). Conclusion: Full dose reirradiation combined with chemotherapy was feasible in patients with inoperable HNC. The in cidence and severity of late toxicity was markedly increased in compar ison to that observed after the first irradiation. Median survival was better than that generally obtained using palliative chemotherapy alo ne. A small proportion of patients were longterm disease-free survivor s. (C) 1998 by American Society of Clinical Oncology.