International Recommendations on Re-irradiation by Intensity-modulated Radiotherapy for Locally Recurrent Nasopharyngeal Carcinoma.

Abstract

Purpose Re-irradiation for locally recurrent nasopharyngeal carcinoma (NPC) is challenging as prior radiation dose delivered in the first course is often close to the tolerance limit of surrounding normal structures. A delicate balance between achieving local salvage and minimizing treatment toxicities is needed. However, high-level evidence is lacking as available reports are mostly retrospective studies on small series of patients. Pragmatic consensus guidelines, based on an extensive literature search and the pooling of opinions by leading specialists, will provide a useful reference to assist decision-making for these difficult decisions.Methods and materials A thorough review of available literature on recurrent NPC was conducted. A set of questions and preliminary draft guideline was circulated to a panel of international specialists with extensive experience in this field for voting on controversial areas and comments. A refined second proposal, based on a summary of the initial voting and different opinions expressed, was re-circulated to the whole panel for review and reconsideration. The current guideline was based on majority voting following repeated iteration for final agreement.Results The initial round of questions showed variations in clinical practice even among the specialists, reflecting the lack of high-quality supporting data and the difficulties in formulating clinical decisions. Through exchange of comments and iterative revisions, recommendations with high-to-moderate agreement were formulated on general treatment strategies and details of re-irradiation (including patient selection, targets contouring, dose prescription and constraints).Conclusion This paper provides useful reference on radical salvage treatment strategies for recurrent NPC and optimization of re-irradiation through review of published evidence and consensus building. However, the final decision by the attending clinician must include full consideration of an individual patient's conditions, understanding of the delicate balance between risk and benefits, and acceptance of risk of complications.