Reirradiation with Robotic Stereotactic Body Radiotherapy for Recurrent Nasopharyngeal Carcinoma

  • Published : 2014.04.30


Background: Recurrent nasopharyngeal carcinoma (NPC) after previous radiotherapy is challenging. There is no standard approach for salvage treatment. Here we present toxicity and treatment results for recurrent NFC patients who underwent fractionated stereotactic radiotherapy (FSRT) as second line radiotherapy (RT). Materials and Methods: Between April 2009 and July 2012, 24 patients, with a male to female ratio of 3:1, were treated with CykerKnife$^{(R)}$ FSRT for recurrent NFC in our institution. Seven out of 24 patients had metastatic recurrent disease. Median age was 53 years (range, 20-70 years). Initial RT dose was 70Gy. The time period between initial RT and FSRT was a median of 33.2 months. The median prescription dose for FSRT was 30Gy (range, 24-30 Gy) in a median of 5 fractions (range, 4-6). Results: The median follow-up for all patients was 19.5 months (IQR: 12.2.-29.2 months). The locoregional control; progression free survival and overall survival (OS) rates for 1-, 2- and 3-year were 64%, 38%, 21%; 60%, 30%, 17% and 83%, 43%, 31%, respectively. Median OS for the entire cohort was 22 months (95% CI: 16.5-27.5). On multivariate analysis recurrent tumor stage was the only prognostic factor for OS (p=0.004). One patient exhibited grade III temporal lobe necrosis. One died because of grade IV mucositis and overlapping infection. Conclusions: The treatment of recurrent NPC is controversial. Fractionated stereotactic radiotherapy is promising. However, the published trials are heterogeneous with respect to the selection criteria and treatment details. Prospective studies with long term follow-up data are warranted.


  1. Wei WI (2003). Cancer of the nasopharynx: functional surgical salvage. World J Surg, 27, 844-8.
  2. Sun JD, Chen CZ, Chen JZ et al (2012). Long term outcomes and prognostic factors of n0 stage nasopharyngeal carcinoma: a single institutional experience with 610 patients. Asian Pac J Cancer Prev, 13, 2101-7.
  3. Teo PM, Kwan WH, Chan AT, et al (1998). How successful is high-dose (> or=60gy) reirradiation using mainly external beams in salvaging local failures of nasopharyngeal carcinoma? Int J Radiat Oncol Biol Phys, 40, 897-913.
  4. Wang CC (1987). Reirradiation of recurrent nasopharyngeal carcinoma. Treatment techniques and results. Int J Radiat Oncol Biol Phys, 13, 953-6.
  5. Wu SX, Chua DT, Deng ML, et al (2007). Outcome of fractionated stereotactic radiotherapy for 90 patients with locally persistent and recurrent nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys, 69, 761-9.
  6. Xiang L, Wang Y, Xu BQ et al (2013). Preliminary results of a phaseI/II study of simultaneous boost irradiation radiotherapy for locally advanced nasopharyngeal carcinoma. Asian Pac J Cancer Prev, 14, 7569-76.
  7. Xiao J, Xu G, Miao Y (2001). Fractionated stereotactic radiosurgery for 50 patients with recurrent or residual nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys, 51, 164-70.
  8. Oksuz DC, Meral G, Uzel O, Cagatay P, Turkan S (2004). Reirradiation for locally recurrent nasopharyngeal carcinoma: treatment results and prognostic factors. Int J Radiat Oncol Biol Phys,60, 388-94.
  9. Lee AW, Law SC, Foo W, et al (1993). Retrospective analysis of patients with nasopharyngeal carcinoma treated during 1976-1985: survival after local recurrence. Int J Radiat Oncol Biol Phys, 26, 773-82.
  10. Low JS, Chua ET, Gao F, Wee JT (2006). Stereotactic radiosurgery plus intracavitary irradiation in the salvage of nasopharyngeal carcinoma. Head Neck, 28, 321-9.
  11. Lu TX, Mai WY, Teh BS, et al (2004). Initial experience using intensity-modulated radiotherapy for recurrent nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys, 58, 682-7.
  12. Ozyigit G, Cengiz M, Yazici G, et al (2011). A retrospective comparison of robotic stereotactic body radiotherapy and three-dimensional conformal radiotherapy for the reirradiation of locally recurrent nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys, 8, 263-8.
  13. Pai PC, Chuang CC, Wei KCW, et al (2002). Stereotactic radiosurgery for locally recurrent nasopharyngeal carcinoma. Head Neck, 24, 748-53.
  14. Phua Chee Ee V, Tan BS, Tan AL (2013) et al. Dose planning study of target volume coverage with intensity- modulated radiotherapy for nasopharyngeal carcinoma: Penang General Hospital experience. Asian Pac J Cancer Prev, 14, 2243-8.
  15. Pryzant RM, Wendt CD, Delclos L, Peters LJ (1992). Retreatment of nasopharyngeal carcinoma in 53 patients. Int J Radiat Oncol Biol Phys, 22, 941-7.
  16. Seo Y, Yoo H, Yoo S, et al (2009). Robotic system-based fractionated stereotactic radiotherapy in locally recurrent nasopharyngeal carcinoma. Radiother Oncol, 93, 570-4.
  17. Jin Y, Cai XY, Shi YX, et al (2012). Comparison of five cisplatinbased regimens frequently used as the first-line protocols in metastatic nasopharyngeal carcinoma. J Cancer Res Clin Oncol, 138, 1717.
  18. Hao SP, Tsang NM, Chang KP, et al (2008). Nasopharyngectomy for recurrent nasopharyngeal carcinoma: a review of 53 patients and prognostic factors. Acta Otolaryngol, 128, 473-81.
  19. Hong WK, Bromer RH, Amato DA et al (1985). Patterns of relapse in locally advanced head and neck cancer patients who achieved complete remission after combined modality therapy. Cancer, 56, 1242-5.<1242::AID-CNCR2820560603>3.0.CO;2-Z
  20. Huang TR, Zhang SW, Chen WQ et al (2012). Trends in nasopharyngeal carcinoma mortality in China, 1973-2005. Asian Pac J Cancer Prev, 13, 2495-502.
  21. Kirkpatrick JP, Meyer JJ, Marks LB (2008). The linear-quadratic model is inappropriate to model high dose per fraction effects in radiosurgery. Semin Radiat Oncol, 18, 240-3.
  22. Koutcher L, Lee N, Zelefsky M, et al (2010). Reirradiation of locally recurrent nasopharynx cancer with external beam radiotherapy with or without brachytherapy. Int J Radiat Oncol Biol Phys ,76,130-7.
  23. Kua VF, Ismail F, Chee Ee Phua V et al (2013). Carboplatin/5-fluorouracil as an alternative to cisplatin/5-fluorouracil for metastatic and recurrent head and neck squamous cell carcinoma and nasopharyngeal carcinoma. Asian Pac J Cancer Prev, 14, 1121-6.
  24. Law SC, Lam WK, Ng MF, et al (2002). Reirradiation of nasopharyngeal carcinoma with intracavitary mold brachytherapy: an effective means of local salvage. Int J Radiat Oncol Biol Phys, 54, 1095-113.
  25. Lee AW, Foo W, Law SC, et al (1997). Reirradiation for recurrent na-sopharyngeal carcinoma: factors affecting the therapeutic ratio and ways for improvement. Int J Radiat Oncol Biol Phys, 38,43-52.
  26. Chua DT, Sham JST, Leung LHT, Au GKH (2005). Reirradiation of nasopharyngeal carcinoma with intensity-modulated radiotherapy. Radiother Oncol, 77, 290-4.
  27. Chee Ee Phua V, Loo WH, Yusof MM et al (2013). Treatment outcome for nasopharyngeal carcinoma in University Malaya Medical Centre from 2004-2008. Asian Pac J Cancer Prev, 14, 4567-70.
  28. Chua DT, Hung KN, Lee V, Ng SC, Tsang J (2009). Validation of a prognostic scoring system for locally recurrent nasopharyngeal carcinoma treated by stereotactic radiosurgery. BMC Cancer, 9, 131.
  29. Chua DT, Sham JS, Kwong PW, Hung KN, Leung LH (2003). Linear accelerator-based stereotactic radiosurgery for limited, locally persistent, and recurrent nasopharyngeal carcinoma: efficacy and complications. Int J Radiat Oncol Biol Phys, 56, 177-83.
  30. Danesi G, Zanoletti E, Mazzoni A (2007). Salvage surgery for recurrent nasopharyngeal carcinoma. Skull Base, 17, 173-80.
  31. DeConti RC, Schoenfeld D (1981). A randomized prospective comparison of intermittent methotrexate, methotrexate with leucovorin, and a methotrexate combination in head and neck cancer. Cancer, 48, 1061-72.<1061::AID-CNCR2820480502>3.0.CO;2-X
  32. El-Sherbieny E, Rashwan H, Lubis SH et al (2011). Prognostic factors in patients with nasopharyngeal carcinoma treated in Hospital Kuala Lumpur. Asian Pac J Cancer Prev, 12, 1739-43.
  33. Fontanesi J, Hetzler D, Ross J (1989). Effect of dose rate on local control and complications in the reirradiation of head and neck tumors with interstitial iridium-192. Int J Radiat Oncol Biol Phys, 17, 365-9.
  34. Fowler JF (1989). The linear-quadratic formula and progress in fractionated radiotherapy. Br J Radiol, 62, 679-94.
  35. Chang KP, Hao SP, Tsang NM, Ueng SH (2004). Salvage surgery for locally recurrent nasopharyngeal carcinoma-a 10-year experience. Otolaryngol Head Neck Surg, 4,497-502.
  36. Brenner DJ (2008). The linear-quadratic model is an appropriate methodology for determining isoeffective doses at large doses per fraction. Semin Radiat Oncol, 18, 234-9.
  37. Cetindag MF, Dizman A, Ozdogan Z et al (2012). Stereotactic reirradiation of recurrent nasopharyngeal carcinoma using robotic stereotactic body radiotherapy system: preliminary results. Int J Hematol, 22, 23-30.
  38. Chang JT, See LC, Liao CT et al (2000). Locally recurrent nasopharyngeal carcinoma. Radiother Oncol, 54, 135-42.
  39. Cheah SK, Lau FN, Yusof MM et al (2013). Treatment outcome with brachytherapy for recurrent nasopharyngeal carcinoma. Asian Pac J Cancer Prev, 14, 6513-8.

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