Patterns of Failure After Intensity Modulated Radiation Therapy in Head and Neck Squamous Cell Carcinoma of Unknown Primary: Implication of Elective Nodal and Mucosal Dose Coverage

Mona Kamal, MD, PhD; Abdallah S.R. Mohamed, MD, MSc; Clifton David Fuller, MD, PhD; Erich M. Sturgis, MD, MPH; Faye M. Johnson, MD, PhD; William H. Morrison, MD; G. Brandon Gunn, MD; Katherine A. Hutcheson, PhD; Jack Phan, MD, PhD; Stefania Volpe, MD; Sweet Ping Ng, MBBS, FRANZCR; Jae Phan, BA; Carlos Cardenas, PhD; Renata Ferrarotto, MD; Steven J. Frank, MD; David I. Rosenthal, MD; Adam S. Garden, MD

Advances in Radiation Oncology (Sep 2020)

Patterns of Failure After Intensity Modulated Radiation Therapy in Head and Neck Squamous Cell Carcinoma of Unknown Primary: Implication of Elective Nodal and Mucosal Dose Coverage

Mona Kamal, MD, PhD,
Abdallah S.R. Mohamed, MD, MSc,
Clifton David Fuller, MD, PhD,
Erich M. Sturgis, MD, MPH,
Faye M. Johnson, MD, PhD,
William H. Morrison, MD,
G. Brandon Gunn, MD,
Katherine A. Hutcheson, PhD,
Jack Phan, MD, PhD,
Stefania Volpe, MD,
Sweet Ping Ng, MBBS, FRANZCR,
Jae Phan, BA,
Carlos Cardenas, PhD,
Renata Ferrarotto, MD,
Steven J. Frank, MD,
David I. Rosenthal, MD,
Adam S. Garden, MD

Affiliations

Mona Kamal, MD, PhD: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Clinical Oncology and Nuclear Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
Abdallah S.R. Mohamed, MD, MSc: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Clinical Oncology and Nuclear Medicine, Faculty of Medicine, University of Alexandria, Alexandria, Egypt; MD Anderson Cancer Center/UTHealth Graduate School of Biomedical Sciences, Houston, Texas
Clifton David Fuller, MD, PhD: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas; MD Anderson Cancer Center/UTHealth Graduate School of Biomedical Sciences, Houston, Texas
Erich M. Sturgis, MD, MPH: Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
Faye M. Johnson, MD, PhD: Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas; The University of Texas Graduate School of Biomedical Sciences, Houston, Texas
William H. Morrison, MD: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
G. Brandon Gunn, MD: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
Katherine A. Hutcheson, PhD: Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
Jack Phan, MD, PhD: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
Stefania Volpe, MD: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas; European Institute of Oncology IRCCS, Division of Radiation Oncology, Milano, Italy
Sweet Ping Ng, MBBS, FRANZCR: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
Jae Phan, BA: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas; Rice University, Houston, Texas
Carlos Cardenas, PhD: Department of Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
Renata Ferrarotto, MD: Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
Steven J. Frank, MD: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
David I. Rosenthal, MD: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
Adam S. Garden, MD: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas; Corresponding author: Adam S. Garden, MD

Journal volume & issue: Vol. 5, no. 5
pp. 929 – 935

Abstract

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Purpose: We evaluated the geometric and dosimetric-based distribution of mucosal and nodal recurrences in patients with metastatic head and neck squamous cell carcinoma to cervical lymph nodes of unknown primary after intensity modulated radiation therapy using validated typology-indicative taxonomy. Methods and Materials: We reviewed the data of 260 patients who were irradiated between 2000 and 2015 and had a median follow-up time for surviving patients of 61 months. The mucosal and nodal recurrences were manually delineated on computed tomography images demonstrating the recurrences. The images were overlaid on the treatment plan using deformable image registration. The locations of the recurrences were determined relative to the original planning target volumes and doses using centroid-based approaches. Subsequently, the pattern of failures were classified into 5 types based on combined spatial and dosimetric criteria: A (central high dose), B (peripheral high dose), C (central elective dose), D (peripheral elective dose), and E (extraneous dose). For patients with type A failure with simultaneous nontype A lesions, the overall pattern of failures was defined as type A. Results: Thirty-two patients had mucosal or nodal recurrences. The most common clinical nodal stage was N2b (66%). Preradiation therapy neck dissections were performed in 6 patients. The median dose delivered to clinical tumor volume 1 was 66 Gy. The majority (84%) had total/partial pharyngeal mucosa elective irradiation. Twenty-three patients had nodal recurrences, 8 had mucosal recurrences, and 1 had both nodal and mucosal recurrences. Twenty-one patients (91%) had type A nodal failure, and 7 of the mucosal failures (89%) were type C. Conclusions: The majority of nodal recurrences occurred within the high-dose area, demanding the need for identification of radioresistant areas within malignant nodes. Future studies should focus on either dose escalation of high-risk volumes or novel radiosensitizers.

Published in Advances in Radiation Oncology

ISSN: 2452-1094 (Online)
Publisher: Elsevier
Country of publisher: United States
LCC subjects: Medicine: Medicine (General): Medical physics. Medical radiology. Nuclear medicine; Medicine: Internal medicine: Neoplasms. Tumors. Oncology. Including cancer and carcinogens
Website: http://www.journals.elsevier.com/advances-in-radiation-oncology/

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