CLINICAL INVESTIGATIONHead and Neck
INTRAOPERATIVE RADIATION THERAPY FOR RECURRENT
HEAD-AND-NECK CANCER: THE UCSF EXPERIENCE
ALLEN M. CHEN, M.D.,* M. KARA BUCCI, M.D.,* MARK I. SINGER, M.D.,†JOAQUIN GARCIA, M.D.,‡
MICHAEL J. KAPLAN, M.D.,§ALBERT S. CHAN, C.M.D., R.T.T.,* AND THEODORE L. PHILLIPS, M.D.*
Departments of *Radiation Oncology,†Otolaryngology, Head and Neck Surgery, and‡Pathology, University of California,
San Francisco, Comprehensive Cancer Center, San Francisco, CA;§Department of Otolaryngology, Head and Neck Surgery,
Stanford University School of Medicine, Stanford, CA
Purpose: To review a single-institutional experience with the use of intraoperative radiation therapy (IORT) for
recurrent head-and-neck cancer.
Methods and Materials: Between 1991 and 2004, 137 patients were treated with gross total resection and IORT
for recurrence or persistence of locoregional cancer of the head and neck. One hundred and thirteen patients
(83%) had previously received external beam radiation as a component of definitive therapy. Ninety-four patients
(69%) had squamous cell histology. Final surgical margins were microscopically positive in 56 patients (41%).
IORT was delivered using either a modified linear accelerator or a mobile electron unit and was administered
as a single fraction to a median dose of 15 Gy (range, 10–18 Gy). Median follow-up among surviving patients was
41 months (range, 3–122 months).
Results: The 1-year, 2-year, and 3-year estimates of in-field control after salvage surgery and IORT were 70%,
64%, and 61%, respectively. Positive margins at the time of IORT predicted for in-field failure (p ? 0.001). The
3-year rates of locoregional control, distant metastasis-free survival, and overall survival were 51%, 46%, and
36%, respectively. There were no perioperative fatalities. Complications included wound infection (4 patients),
orocutaneous fistula (2 patients), flap necrosis (1 patient), trismus (1 patient), and neuropathy (1 patient).
Conclusions: Intraoperative RT results in effective disease control with acceptable toxicity and should be
considered for selected patients with recurrent or persistent cancers of the head and neck.© 2007 Elsevier Inc.
Intraoperative radiation, Head and neck, Cancer.
Despite progress in surgical and reconstructive techniques
as well as advances in radiation therapy delivery methods, a
significant proportion of patients with head-and-neck cancer
develop locoregional recurrence or experience disease per-
sistence after completion of definitive therapy (1–4). Al-
though the competing risk of developing distant metastasis
is fairly high, up to 60% of this population will die as a
direct consequence of uncontrolled tumor growth at the
primary site (5). In addition, locoregional recurrences can
potentially impact patient quality of life, not only serving as
a source of functional impairment, but also as a morbid
reminder of disease presence. Nevertheless, the optimal
treatment for locally recurrent or persistent cancer of the
head and neck remains to be defined, largely because of the
heterogeneity of this population with respect to disease-
related and patient-related factors such as previous treat-
ment, site of tumor recurrence, disease extent, and perfor-
mance status. Although surgical resection generally forms
the mainstay of treatment, effective salvage therapy is often
precluded by anatomic inaccessibility, prior radiation ther-
apy, and the risk of postsurgical complications (6). Indeed,
published rates of successful surgical salvage range from
15% to 65% (7–9). Understandably, most physicians view
the opportunity for salvage as a balance between the modest
prospects of disease cure and preservation of quality of life.
In an attempt to improve the rate of successful salvage,
we have been performing intraoperative radiation therapy
(IORT) at the University of California, San Francisco
(UCSF) in conjunction with salvage surgery for locally
recurrent and persistent cancer of the head and neck since
1991. The advantage of IORT in this particular setting is
that normal tissue surrounding the tumor bed can be man-
ually retracted and directly shielded. This visualization al-
lows treatment with radiation even after prior delivery of
full courses of conventional external beam radiation ther-
apy. In addition, there are purported radiobiologic advan-
tages, which may result in enhanced tumor control (10). The
Reprint requests to: Allen M. Chen, M.D., Coastal Radiation
Oncology, Inc., 100 Casa St., Suite C, San Luis Obispo, CA
93405. E-mail: firstname.lastname@example.org
Theodore L. Phillips, M.D., is a member of the board of direc-
tors for Intraop Corporation, Santa Clara, CA.
Conflict of interest: none.
Received June 15, 2006, and in revised form Aug 16, 2006.
Accepted for publication Aug 17, 2006.
Int. J. Radiation Oncology Biol. Phys., Vol. 67, No. 1, pp. 122–129, 2007
Copyright © 2007 Elsevier Inc.
Printed in the USA. All rights reserved
0360-3016/07/$–see front matter
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