A simple strategy to decrease fatal carotid blowout syndrome after stereotactic body reirradiaton for recurrent head and neck cancers

Abstract

BackgroundThis study aimed to compare the therapeutic outcomes and fatal carotid blow out syndrome (CBOS) incidence rates between two different stereotactic body radiotherapy (SBRT) protocols.MethodsThe study included 75 patients with inoperable locally recurrent head and neck cancer treated with SBRT in our department between June 2007 and March 2011. The first 43 patients were treated sequentially (group I). Then our SBRT protocol was changed due to the high rate of CBOS, and the following 32 patients were treated every other day in a prospective institutional protocol (group II).ResultsMedian overall survival in group I and group II was 11 months and 23 months, respectively (P = 0.006). We observed 11 cases of CBOS. Only 1 of 7 patients (14%) with CBOS survived in group I, whereas 2 of 4 patients (50%) in group II remain alive. CBOS free median overall survivals were 9 months, and 23 months in group I and group II respectively (P = 0.002). The median radiation dose received by the carotid artery in patients with CBOS was 36.5 Gy (range: 34–42.8 Gy), versus 34.7 Gy (range: 0–44 Gy) in the patients that didn’t have CBOS (P = 0.15). CBOS did not occur in any of the patients with a maximum carotid artery radiation dose <34 Gy.ConclusionsEvery other day SBRT protocol for re-irradiation of recurrent head and neck cancer is promising in terms of decreasing the incidence of fatal CBOS.

A Prospective Phase 2 Trial of Reirradiation With Stereotactic Body Radiation Therapy Plus Cetuximab in Patients With Previously Irradiated Recurrent Squamous Cell Carcinoma of the Head and Neck

“…Earlier reports from the SBRT literature have reported higher rates of carotid blowout syndrome (26,27) not seen in our experience or in the French experience (21,28). This may relate in part to differences in fractionation schema where SBRT was delivered every other day rather than every day (29,30). Although the protocol did not specifically exclude patients or handle the carotid differently, larger retrospective series have examined clinical factors that may help in future patient selection to lower the potential risk of this often-fatal complication (31).…”

Predictors of severe long-term toxicity after re-irradiation for head and neck cancer

“…We also did not observe a dose effect on survival in our results, likely because we met or exceeded a commonly accepted cutoff of 60 Gy in virtually all patients. Re-irradiation toxicity profiles also appear promising from more modern series using hypo-fractionated stereotactic body radiotherapy (SBRT), particularly those utilizing an every other day treatment schedule [23]. In a report of the Pittsburgh experience using SBRT with or without concurrent cetuximab, cumulative acute and late toxicity rates (grade 3 or higher) were 12% and 7%, respectively [19].…”

Reirradiation of head and neck cancer using modern highly conformal techniques

“…However, there were still several studies reporting G5 toxicities, including carotid artery rupture. 65 The 2 studies that used daily SBRT treatment and had high carotid artery rupture rates reported predictors of carotid artery rupture: tumor envelopment 180 degrees around the carotid artery 49 and ulceration. In another study on 107 patients who also received a median of 30 Gy in 5 daily fractions, 10% developed carotid artery rupture, and there was an 8% G5 toxicity rate.…”