Featured Case Studies 2005, Volume 2, Number 1

Recurrent Head and Neck Cancer: A Case for Retreatment to Relieve Severe Facial Pain

by > David Grisell, DO

Clinical problem

This 59-year-old man presented with locally recurring squamous carcinoma of the right tonsil one year following neoadjuvant radiation therapy and primary surgical resection in June 2003. He was treated with 4 cycles of Cisplatin/Taxotere as salvage therapy but with no response. Treatment was then changed to Taxol alone, but his disease progressed to the skull base with bone erosion shown on CT. He now presents with severe pain in the right face and temporal region, which is poorly controlled on high dose morphine. Physical examination reveals swelling in the right face and pharynx and cranial nerves V2 and VII deficits on the right. CT and MRI confirm a large mass involving the right parapharnygeal space eroding into the clivus, jugular foramen, and encasing the cartoid artery.


Treatment options

The principal options for salvage treatment of recurrent head and neck cancer are surgery, radiation therapy, chemotherapy, or combined treatment. All of these options are associated with substantial risk of toxicity and modest success at local control, but offer significant palliative benefit in some patients. In this case, surgery was not an option due to the location and extent of recurrence. Chemotherapy had already failed to produce any response. He was referred for consideration of stereotactic radiosurgery (SRS) for palliation.



Figure 1. An IMRST treatment plan was developed to treat the grossly visible tumor +1.0 cm margin (pink). Twelve separate beam directions were selected to avoid the brain and brainstem (previously treated to tolerance) and minimize dose to opposite parotid gland.

Comments

SRS was not recommended in this case due to the large size of the recurrent mass, the immediately adjacent critical structures, and the fact that the entire volume had received a previous substantial therapeutic dose of radiation. However, intensity modulated stereotactic radiotherapy (IMSRT) or fractionated SRS was offered with sensitizing 5FU chemotherapy, as an alternative associated with equal probability of benefit but lower risk. The Radiation Therapy Oncology Group (RTOG) has investigated re-irradtion with chemotherapy with mixed results(1), however this study used larger radiation fields and conventional radiation techniques. The patient chose to proceed with IMSRT to relieve his pain.


References
  • Horowitz E, HArris J, Langer C, Nicolaou N, Kies M, Curran Jr, W, Wong S, and Ang K: RTOG 9911: Phase II Study of Concurrent Chemotherapy and Re-Irradiation for Recurrent Head & Neck Cancer. 6th Intl' Conference on Head and Neck Cancer, Washington, DC, AHNS 6th Abstract Program Book, pp. 249, 2004
How to refer

Because of the specific nature and complexity of the services we provide, patients must have a consultation with one of our physicians prior to being referred to the center. To schedule an appointment with one of our physicians, please contact Precision Radiotherapy at 513-475-7777.