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CASE REPORT
Ahead of print publication  

Reirradiation and re-reirradiation in head-and-neck cancers: Learnings based on a case irradiated six times


1 Department of Radiation Oncology, Max Super Speciality Hospital, Ghaziabad, Uttar Pradesh, India
2 Department of Surgical Oncology, Max Super Speciality Hospital, Ghaziabad, Uttar Pradesh, India

Date of Submission11-May-2020
Date of Decision14-Jul-2020
Date of Acceptance30-Sep-2020
Date of Web Publication18-Aug-2021

Correspondence Address:
Dinesh Singh,
Department of Radiation Oncology, Max Super Specialty Hospital, W-3, Sector 1, Vaishali, Ghaziabad, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrt.JCRT_604_20

 > Abstract 


Second primary cancers and locoregional recurrences in head and neck cancers are common. Management is challenging owing to the effects of previous treatment. Locoregional therapy, whenever feasible, offers possibility of cure. We have managed a patient who has over a period of 15 years been treated seven times. Treatment included surgical resection four times, flap reconstruction thrice, postoperative radiation thrice, radiation therapy alone thrice. Brachytherapy has been used in two instances, intraoperative brachytherapy once and surface mould application once. Patient has maintained a good quality of life during these fifteen years but suffers from xerostomia and nasogastric tube dependence at present. The management of this patient teaches us important lessons in terms of using modern surgery and advances in radiation therapy for achieving good patient benefit.

Keywords: Intraoperative radiation therapy, recurrent head-and-neck cancer, reirradiation



How to cite this URL:
Singh D, Goel A, Chaudhary P, Subramaniam B. Reirradiation and re-reirradiation in head-and-neck cancers: Learnings based on a case irradiated six times. J Can Res Ther [Epub ahead of print] [cited 2021 Nov 28]. Available from: https://www.cancerjournal.net/preprintarticle.asp?id=324037




 > Introduction Top


Head-and-neck cancers are among the most common cancers in India. Tobacco is the major causative factor and causes field cancerization. With successful treatment of head-and-neck cancers, recurrences and second primaries are being seen with increasing frequency. The management of these is challenging as potentially curative treatment is based on locoregional modalities of surgery and radiation. Reconstructive surgery has led to significant improvement in surgical outcomes. There has been increasing use of reirradiation in recent years with acceptable morbidity. Here, we present our experience with a patient who has been treated multiple times with surgery and radiation and highlight the learnings from this case.


 > Case Report Top


The patient, a 45-year-old male, presented with an ulcer in the left lateral border of the tongue in the year 2005. He had a history of smoking, tobacco chewing, and alcohol intake. Biopsy and imaging confirmed nonmetastatic squamous cell carcinoma of the tongue (cT1N1M0). He underwent left hemiglossectomy and type I modified neck dissection (MND). Pathology report showed moderately differentiated squamous cell carcinoma (pT1N2). He received adjuvant three-dimensional conformal external beam radiation therapy (EBRT) (60 Gy/30 fractions) with concomitant chemotherapy (weekly cisplatin 35 mg/m2).

In 2010, after a gap of 5 years, he presented with odynophagia. Clinical, radiological, and pathological assessment confirmed a diagnosis of carcinoma right tonsil with right cervical lymph node metastases. Whole-body positron emission tomography-computed tomography (PET-CT) scan confirmed locoregional disease and the absence of distant metastases. He underwent transoral laser excision of the primary with right MND. Histopathological examination confirmed moderately differentiated squamous cell carcinoma of the right tonsil with infiltration of soft tissue and muscles, lymphovascular invasion, and metastasis to one jugular lymph node with extranodal extension. He received adjuvant EBRT (59.4 Gy/33 fractions, intensity-modulated radiotherapy using 6 MV photons) with concurrent chemotherapy.

After 4 years (2014), he developed a mucosal lesion in the left retromolar trigone. Biopsy was reported as a spindle cell variant of squamous cell carcinoma. Immunohistochemistry confirmed it to be sarcomatoid carcinoma. He underwent composite resection (wide excision with hemimandibulectomy) with pectoralis major myocutaneous (PMMC) flap reconstruction. Histopathology report confirmed a spindle cell variant of squamous cell carcinoma. He received adjuvant radiation therapy (60 Gy in 30 fractions, image-guided intensity-modulated radiation therapy, using 6 MV photons) to the primary tumor bed. Adjuvant radiation was given in view of atypical histology and a depth of invasion of 5 mm.

In 2016 (August), he had pain on the left side of the oral cavity with a small ulcer. Incisional biopsy was negative for malignancy, but his symptoms progressed, and excision biopsy was carried out, confirming malignancy (squamous cell carcinoma). Radical surgery (wide local excision with resection of the anterior mandible and free fibular osteomyocutaneous flap reconstruction) was carried out in February 2017. No adjuvant therapy was required.

In August 2017, he developed a small nodule in lower lip scar on the left side. Excisional biopsy was done, and it was reported as moderately differentiated squamous cell carcinoma. Options of wide excision or radiation were discussed. The patient opted for radiation therapy. He received radiation to a dose of 50 Gy in 25 fractions to area of recurrent tumor with 10 mm margin [Figure 1]a.
Figure 1: (a) Planning computed tomography scan of the face and neck showing dose color wash and tight margins for reirradiation, (b) Image showing brachytherapy catheters in situ for intraoperative radiation therapy, (c) Brachytherapy using surface mold for soft palate tumor (2020), (d) Isodose distribution of soft palate surface mold irradiation

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In February 2018, he was diagnosed with squamous cell carcinoma of the floor of the mouth, right. In view of previous history, it was decided to treat him with palliative intent chemotherapy. Three cycles of paclitaxel- and carboplatin-based chemotherapy did not lead to clinical benefit. The chemotherapy regimen was changed to paclitaxel, cisplatin, and 5-fluorouracil, and he received five cycles of the same. Due to toxicity, chemotherapy had to be stopped. PET-CT showed stable disease still localized to the right floor of the mouth. Surgical treatment with PMMC flap reconstruction was possible according to the surgical team. Since EBRT was not considered feasible, intraoperative brachytherapy was proposed. After counseling about the potential risks and benefits, the patient consented for the treatment.

Surgery was done in October 2018. Tracheostomy was created under local anesthesia; general anesthesia was induced, and wide excision of the tumor was carried out. Frozen section evaluation of margins was carried out. On confirmation of negative margins, Freiburg flap with brachytherapy catheters was placed at the tumor bed and fixed with sutures [Figure 1]b. The wound was temporarily covered with sterile adhesive dressing; the patient was shifted to a brachytherapy room with all aseptic precautions and continuous anesthesia and monitoring. Cone-beam CT scan was acquired on the linear accelerator and used for brachytherapy planning. A single dose of 10 Gy at 10 mm margin was administered using high-dose rate microselectron, and the patient was then shifted back to the operation theater. PMMC reconstruction was carried out, and the patient was shifted to the intensive care unit for postoperative recovery. Postoperative recovery was uneventful; the patient could be decannulated off the tracheostomy tube but has been dependent on a nasogastric tube for feeding.

In May 2020 (after a gap of 19 months), the patient was again diagnosed with squamous cell carcinoma of the soft palate. Again, brachytherapy has been carried out using surface mold applications with a custom-made applicator (made from dental wax) in five sittings of 5 Gy each, delivered over a period of 10 days [Figure 1]c and [Figure 1]d.

His tumor has shown good regression while he is maintaining good quality of life and is able to do all personal activities.


 > Discussion Top


Squamous cancers of the upper aerodigestive tract are one of the most common malignancies in the Indian subcontinent due to high incidence of tobacco use, especially nonsmoking tobacco.[1] Field cancerization is an important element of head-and-neck carcinogenesis.[2] Due to this, second primary cancers are common. In addition, locoregional recurrences are also common in head-and-neck cancers.

Many of these patients with locoregional recurrence or second primary cancer have localized disease and are potential candidates for further locoregional therapy. With progressive improvement in success of treatment for first cancers in the head-and-neck area, the number of patients presenting with potentially treatable local or locoregional disease is increasing significantly. Local modalities form the mainstay of curative treatment of head-and-neck cancers. Surgery and radiation are used either alone or in combination.[3] Systemic therapy has a limited role in curative treatment, being mostly restricted to a radiosensitizing role with radiation.

Due to relatively late presentation of disease, majority of the patients in India receive both surgical and radiation treatment. When treatment decisions are made for recurrence or second primary tumors, two major challenges are there: reconstruction of the surgical defect and feasibility of reirradiation. Extent of resection may be limited in second and subsequent surgical procedures due to the presence of previous surgical scars, flaps, and irradiated tissue.[4] Need for adjuvant radiation in such cases is significantly high. However, the fear of radiation-related morbidity is there in view of reirradiation and consists of soft-tissue necrosis, osteoradionecrosis, severe fibrosis, radiation myelopathy, xerostomia, dental problems, and swallowing difficulty.

The head-and-neck area still permits reirradiation due to relatively high vascularity. It is recommended to have a time gap between two courses of radiation therapy. In addition, subsequent courses of radiation are delivered to limited fields and with reduced doses, taking into consideration doses already received by the tissues. The use of conformal radiation with intensity modulation and image guidance allows for safer delivery of radiation in this setting.[5]

In our case, the patient has undergone treatment seven times over a period of 13 years [Table 1]. Surgery has been a component of treatment four times, reconstruction has been carried out thrice (pedicle flaps twice and free flap once), and radiation has been used six times (unilateral face and neck twice, localized EBRT twice, and brachytherapy twice). The patient has tolerated the treatment reasonably well but suffers from xerostomia and swallowing dysfunction. No radiation-related necrosis has been observed till date, and he has good quality of life other than dependence on a feeding tube.
Table 1: Chronological details of locoregional therapy including radiation parameters

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 > Conclusions Top


The management of this patient is a lesson in the intricacies of head-and-neck cancer management, and we would like to share the learnings from this case with the oncology community. We feel that the following lessons from the management of this patient are important takeaways.

  • Multiple courses of radiation therapy to the face and neck area can be administered if radiation delivery is limited to area at risk, dose to organs at risk is minimized using computerized planning, and narrow treatment margins are used with the help of intensity-modulated and image-guided therapy
  • Brachytherapy is a useful adjunct in the management of such cases, as has been evident in this patient. Brachytherapy offers the highest degree of conformity and minimal dose to normal surrounding tissues. Innovative approaches such as intraoperative delivery and surface mold allowed us to extend the life of our patient with good quality of life
  • Patients with locally advanced, non-metastatic disease do benefit from locoregional therapy. Such treatments may not completely cure the disease but provide good local control and improve quality of life
  • A positive attitude of the patient as well as the treating team is important to maintain the morale
  • Reconstruction using pedicled and free flaps brings unirradiated tissue to the field and allows for better tolerance to radiation in the setting of reirradiation.


Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

We would like to acknowledge the support of our staff and other team members involved in the treatment of the patient. The journey would not have been successful without the immense support and faith, which the patient and attendant had shown in us and the whole treating team.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
Sharma JD, Baishya N, Kataki AC, Kalita CR, Das AK, Rahman T. Head and neck squamous cell carcinoma in young adults: A hospital-based study. Indian J Med Paediatr Oncol 2019;40 (suppl S1):18-22.  Back to cited text no. 1
    
2.
Slaughter DP, Southwick HW, Smejkal W. Field cancerization in oral stratified squamous epithelium; clinical implications of multicentric origin. Cancer 1953;6:963.  Back to cited text no. 2
    
3.
Chaudhary P, Gupta S, Leekha N, Tandon R, Nandy M, De S. Pattern of occurrence and treatment outcome of second primary malignancies: A single center experience. South Asian J Cancer 2017;6:137-8.  Back to cited text no. 3
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4.
Chim H, Salgado CJ, Seselgyte R, Wei FC, Mardini S. Principles of head and neck reconstruction: An algorithm to guide flap selection. Semin Plast Surg 2010;24:148-54.  Back to cited text no. 4
    
5.
Kim YS. Reirradiation of head and neck cancer in the era of intensity-modulated radiotherapy: Patient selection, practical aspects, and current evidence. Radiat Oncol J 2017;35:1-5.  Back to cited text no. 5
    


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