title: Reirradiation for recurrent nasopharyngeal carcinoma: factors affecting the therapeutic ratio and ways for improvement.
abstract: OBJECTIVE
  To identify factors for maximizing local salvage and minimizing damages by reirradiation for recurrent nasopharyngeal carcinoma.
  
  
  METHODS
  654 patients with recurrent nasopharyngeal carcinoma treated by reirradiation during 1976-1992 were retrospectively analyzed. Various fractionation schedules had been used during primary treatment with the total dose ranging from 45.6-70 Gy, fractional dose (at different phases) 1.5-4.2 Gy, and overall time 36-101 days. The gap between the two courses ranged from 0.5-10.6 years. Eighty-two percent of patients were reirradiated with teletherapy, 6% brachytherapy, and 12% with both. For those treated with teletherapy alone, the total dose ranged from 7.5-70 Gy, fractional dose 1.8-5 Gy, and overall time 3-89 days.
  
  
  RESULTS
  The 5-year actuarial local salvage and complication-free rates were 23% and 52%, respectively. Multivariate analyses showed that the extensiveness of local recurrence was the most significant factor affecting local salvage, while T-stage of primary tumor also influenced prognosis. Choice of method for reirradiation and fractional effect during both courses affected the risk of late complications. For patients treated by teletherapy alone, the hazard of local failure decreased by 1.7% per Biological Effective Dose (assuming alpha/beta ratio = 10) of the second course, while radiation factors during primary radiotherapy had no significant effect. On the other hand, the risk of late complications was predominantly affected by the primary treatment: the hazard increased by 4.2% per Biological Effective Dose (assuming alpha/beta ratio = 3) of the first course, while the corresponding impact of reirradiation failed to reach statistical significance. Length of the gap between the two courses did not affect the outcome.
  
  
  CONCLUSIONS
  Early detection of local recurrence and adequate total dose by reirradiation are crucial for improving the chance of local salvage. Combination of teletherapy and brachytherapy should be considered whenever feasible and large fractional dose avoided to minimize late complications. Optimization of biological dose during primary treatment is important.
authors.affiliation: Department of Radiotherapy, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong.
authors.forename: A W
authors.initials: AW
authors.lastname: Lee
authors.forename: W
authors.initials: W
authors.lastname: Foo
authors.forename: S C
authors.initials: SC
authors.lastname: Law
authors.forename: Y F
authors.initials: YF
authors.lastname: Poon
authors.forename: W M
authors.initials: WM
authors.lastname: Sze
authors.forename: S K
authors.initials: SK
authors.lastname: O
authors.forename: S Y
authors.initials: SY
authors.lastname: Tung
authors.forename: W H
authors.initials: WH
authors.lastname: Lau
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001918:Brachytherapy; D002294:Carcinoma, Squamous Cell / Q000532:radiotherapy*; D002586:Cesium / Q000627:therapeutic use; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009303:Nasopharyngeal Neoplasms / Q000532:radiotherapy*; D009364:Neoplasm Recurrence, Local / Q000532:radiotherapy*; D011832:Radiation Injuries / Q000209:etiology; D011879:Radiotherapy Dosage; D012189:Retrospective Studies; D016879:Salvage Therapy; D017211:Treatment Failure
chemical_list: D002586:Cesium