Group 10 Research Proposal

Working Title

Usage of lattice radiation therapy in recurrent head and neck cancer to reduce the risk of carotid
blowout syndrome

Problem Statement

The problem is the elevated risk of CBS for recurrent head and neck cancers due to previous
IMRT treatment.

Purpose Statement

The purpose of this research is to determine if a single fraction boost of LRT followed by a
conventional IMRT head and neck treatment course would reduce dose to the carotid artery
compared to the full course of retreatment the patient received.

The goal of this study is to:

The goal of this study is to show the effect LRT has on the dose to the carotid artery by using a
non-uniform dose escalation to the tumor.

Summary

Intensity modulated radiation therapy (IMRT) has been the standard of treatment used
over the years to treat head and neck cancers. With this advanced technology, patients have been
living longer after their diagnosis and experiencing recurrences in their primary tumor site.
Research has shown as many as 2.6% of patients with head and neck cancer recurrence are at
risk of carotid blowout syndrome (CBS) upon retreatment due to previous IMRT treatment. 1
Although there is no consensus on maximum dose to the carotid artery with retreatment,
 2

researchers have found that D0.1 cc > 47.6 Gy has led to CBS. 2 Common total doses for a full
course head and neck tumor can range from 60 – 70 Gy. With a second course of radiation
administered due to recurrence, the patient can receive doses from 120 – 140 Gy total.

In this case study, we will discuss a patient who was originally treated to the retromolar
trigone for 60 Gy in 30 fractions. The patient experienced recurrence to the same site in addition
to positive bilateral neck nodes (level II) and supraclavicular nodes requiring an additional
course of treatment. The patient was retreated with Volumetric Arc Therapy (VMAT) totaling 70
Gy in 35 fractions exceeding dose to the carotid artery.

The problem is that patients undergoing reirradiation for head and neck cancer recurrence
are at elevated risk of CBS due to previous IMRT treatments. Lattice Radiation Therapy (LRT)
could be an alternative option for patients. Lattice RT is a spatially fractionated radiation therapy
(SFRT) that utilizes a 3D configuration of alternating high dose and low dose regions within the
tumor volume. A dose escalation study has shown patients with recurrence and bulky disease
treated with a one to three fraction LRT boost, totaling a dose between 16-20 Gy, followed by a
full course of treatment with a total dose between 45-66 Gy.3

As this technique continues to evolve, additional research needs to be done to evaluate

the effectiveness of this treatment in head and neck cancers regarding lowering organs at risk
(OAR). The purpose of this research is to determine if a single fraction boost of LRT followed
by a conventional head and neck treatment course is a viable retreatment option that would
reduce dose to the carotid artery in comparison to the two full course treatments the patient
received for their recurrent head and neck cancer at the same treatment site.

References

1. Woody NM, Bricker A, Joshi N, et al. Carotid blowout in a patient with nasopharyngeal
carcinoma treated with SBRT re-irradiation for local recurrence using twice weekly
treatment. J Radiosurg SBRT. 2015;3(4):325-329.
2. Ling DC, Vargo JA, Gebhardt BJ, et al. Dose-response modeling the risk of carotid bleeding
events after stereotactic body radiation therapy for previously irradiated head and neck
cancer. J Radiosurg SBRT. 2019;6(2):83-89.
 3

3. Amendola B, Perez N, Wu X, Amendola M. Preliminary experience with lattice radiation

therapy in locally advanced head and neck cancer. Miami, FL: The Radiosurgery
Society;2022.
4. Grams M, Owen D, Park S, et al. VMAT grid therapy: a widely applicable planning
approach. ScienceDirect. 2021;11(3):339-347. https://doi.org/10.1016/jprro.2020.10.007
5. Zhang H, Wu X, Chang S, Megooni A, Donnelly E, Ahmed M, et al. Photon GRID Radiation
Therapy: A Physics and Dosimetry White Paper from the Radiosurgery Society (RSS)
GRID/LATTICE, Microbeam and FLASH Radiotherapy Working Group. Radiat Res.
2020;194(6):665-677. https://doi.org/10.1667/RADE-20-00047.1