title: Proton therapy for reirradiation of progressive or recurrent chordoma.
abstract: OBJECTIVE
  To report the results in patients reirradiated with proton therapy for recurrent or progressive chordoma, with or without salvage surgery.
  
  
  METHODS
  A retrospective review of 16 consecutive patients treated from 2005 to 2012 was performed. All patients had received at least 1 prior course of radiation therapy to the same area, and all but 1 patient had at least 1 surgical resection for disease before receiving reirradiation. At the time of recurrence or progression, half of the patients underwent additional salvage surgery before receiving reirradiation. The median prior dose of radiation was 75.2 Gy (range, 40-79.2 Gy). Six patients had received prior proton therapy, and the remainder had received photon radiation. The median gross tumor volume at the time of reirradiation was 71 cm(3) (range, 0-701 cm(3)). Reirradiation occurred at a median interval of 37 months after prior radiation (range, 12-129 months), and the median dose of reirradiation was 75.6 Gy (relative biological effectiveness [RBE]) (range. 71.2-79.2 Gy [RBE]), given in standard daily fractionation (n=14) or hyperfractionation (n=2).
  
  
  RESULTS
  The median follow-up time was 23 months (range, 6-63 months); it was 26 months in patients alive at the last follow-up visit (range, 12-63 months). The 2-year estimate for local control was 85%, overall survival 80%, chordoma-specific survival 88%, and development of distant metastases 20%. Four patients have had local progression: 3 in-field and 1 marginal. Late toxicity included grade 3 bitemporal lobe radionecrosis in 1 patient that improved with hyperbaric oxygen, a grade 4 cerebrospinal fluid leak with meningitis in 1 patient, and a grade 4 ischemic brainstem stroke (out of radiation field) in 1 patient, with subsequent neurologic recovery.
  
  
  CONCLUSIONS
  Full-dose proton reirradiation provided encouraging initial disease control and overall survival for patients with recurrent or progressive chordoma, although additional toxicities may develop with longer follow-up times.
authors.affiliation: Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, Indiana; Indiana University Health Proton Therapy Center, Bloomington, Indiana. Electronic address: mmcdona2@iuhealth.org.
authors.forename: Mark W
authors.initials: MW
authors.lastname: McDonald
authors.forename: Okechuckwu R
authors.initials: OR
authors.lastname: Linton
authors.forename: Mitesh V
authors.initials: MV
authors.lastname: Shah
mesh_terms: D000328:Adult; D000368:Aged; D002817:Chordoma / Q000401:mortality / Q000473:pathology / Q000532:radiotherapy* / Q000601:surgery; D018450:Disease Progression; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000401:mortality / Q000532:radiotherapy*; D061766:Proton Therapy / Q000009:adverse effects / Q000379:methods*; D011879:Radiotherapy Dosage; D019233:Retreatment / Q000009:adverse effects / Q000379:methods; D012189:Retrospective Studies; D016879:Salvage Therapy / Q000379:methods; D013125:Spinal Neoplasms / Q000401:mortality / Q000473:pathology / Q000532:radiotherapy* / Q000601:surgery; D013997:Time Factors; D016896:Treatment Outcome; D047368:Tumor Burden