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Postoperative radiotherapy with volumetric modulated arc therapy of lacrimal gland carcinoma: two case reports and literature review Ester Orlandi*,1, Silvia Takanen5, Tommaso Giandini2, Eva Iannacone1, Walter Fontanella3, Laura Locati4, Mauro Carrara2, Paolo Bossi4, Cristiana Bergamini4, Roberta Granata4, Vincenzo Tombolini5, Tullio Ibba3, Lisa Licitra4, Emanuele Pignoli2 & Carlo Fallai1
ABSTRACT Aims: To evaluate technical issues and clinical outcomes after postoperative volumetric-modulated arc therapy (VMAT) in two cases of malignant lacrimal gland cancer. Patients & methods: Patients were treated by postoperative VMAT and post-treatment clinical outcomes were followed-up to 18 months. Results: Dosimetric results were acceptable and acute toxicity was manageable in both patients. No evidence of disease was found at latest follow-up. One patient underwent corneal transplant for central corneal ulceration, experiencing reduction of visual acuity. Conclusion: Postoperative VMAT for treatment of lacrimal gland tumors offers improved outcome, with manageable side effects. In the context of photon beam radiotherapy, VMAT emerged as a valuable treatment option for these malignant tumors. Carcinoma of the lacrimal gland represents approximately 2% of all orbital neoplasms and less than 1% of all head and neck cancers (HNC) [1,2] . There are several histological types: adenoid cystic carcinoma (ACC), which is the most common histotype of the lacrimal apparatus [3] , accounting for 1.6% of all orbital tumors and for 29% of epithelial neoplasms of the lacrimal gland; carcinoma ex pleomorphic adenoma (Ca ex-PA), approximately 10% of the lacrimal tumors; adenocarcinoma (de novo), 5–10%; and mucoepidermoid carcinoma, 1–2% [4–7] . The clinical course of these malignant tumors is often aggressive. In contrast with their histological counterpart in salivary glands, lacrimal gland ACC show a higher rate of local recurrence (up to 75% of the cases) with intracranial spread along with distant metastases, and a mean survival of 1.5 years [8] . Moreover, patients with Ca ex-PA die within few years from diagnosis, with a mean survival of 3 years [1,9] . Lacrimal gland malignancies are currently treated by surgery followed by radiotherapy (RT) [2,10–12] . External beam RT (EBRT) represents the most common radiation therapy and is effective in preventing loco-regional recurrences, irrespective of the type of surgery adopted [13] . Due to the horseshoe-shaped target volume and the proximity to radiosensitive normal structures (organs at risk [OARs]) of lacrimal gland tumors, they are good candidate for advanced technologies in the context of EBRT, such as proton or heavy ion therapy and intensity-modulated radiation therapy (IMRT). Recently, the introduction of volumetric-modulated arc therapy (VMAT), a novel type of IMRT employing a linear accelerator to deliver a modulated rotational RT, further improved normal
KEYWORDS
• adenoid cystic carcinoma • carcinoma ex pleomorphic adenoma • dosimetric evaluation • lacrimal gland tumor • postoperative
intensity-modulated radiation therapy • treatment planning • VMAT
Units of Radiotherapy 2, Fondazione IRCCS Istituto Nazionale Tumori, Via Giacomo Venezian, 1, 20133 Milan, Italy Medical Physics, Fondazione IRCCS Istituto Nazionale Tumori, Via Giacomo Venezian, 1, 20133 Milan, Italy 3 Otolaringology & Head & Neck Surgery, Fondazione IRCCS Istituto Nazionale Tumori, Via Giacomo Venezian, 1, 20133 Milan, Italy 4 Head & Neck Medical Oncology, Fondazione IRCCS Istituto Nazionale Tumori, Via Giacomo Venezian, 1, 20133 Milan, Italy 5 Unit of Radiotherapy, Policlinico Umberto I, University “La Sapienza”, Viale del Policlinico, 155, 00186 Rome, Italy *Author for correspondence: Tel.: +39 0223903265; Fax: +39 022392472; [email protected] 1 2
10.2217/FON.14.148 © 2014 Future Medicine Ltd
Future Oncol. (2014) 10(14), 2111–2120
part of
ISSN 1479-6694
2111
Case Series Orlandi, Takanen, Giandini et al. tissue sparing, target coverage and delivery efficiency, compared with conventional IMRT in HNC [14] . Here, we report and discuss the technical aspects and clinical outcome of the use of postoperative VMAT in two cases of malignant lacrimal gland tumors referring to our Institution. We also review the most recent literature on RT for carcinoma of lacrimal gland. Case presentation ●●Case 1
In November 2011, a 44-year-old man was admitted to the ophthalmology division of the hospital closest to his home, complaining of gradually progressive double vision and visual acuity reduction, as well as swelling of the left upper eyelid in the last 3 months. MRI of the head showed an expansive lesion, sized 35 × 25 × 16 mm, at the level of superolateral region of the left orbit. The lesion likely originated from the lacrimal gland. It was characterized by an inhomogeneous contrast enhancement, and was inducing the caudal and anterior displacement of the lateral rectus muscle and eyeball, respectively, with no involvement of the optic nerve. Bone erosion of skull base was not found at orbit computed tomography (CT) scan. An incisional biopsy of the lacrimal gland was performed and the pathologist diagnosed ACC with perineural invasion. No regional or distant metastases were evident upon total body CT. Clinical stage was cT2 N0 MX, according to the American Join Committee on Cancer staging manual (7th Edition) [15] . In December 2011, the patient underwent left orbitotomy, with ipsilateral lacrimal gland resection, followed by plate osteosynthesis. Histopathology confirmed the diagnosis of ACC, with cribriform and tubular aspects, perineural invasion and extension in the soft tissues. Macroscopic lesion was 99% and V95% >95%, respectively); and no more than 20% of PTV received more than 110% of the PTD (V110%
Postoperative radiotherapy with volumetric modulated arc therapy of lacrimal gland carcinoma: two case reports and literature review Ester Orlandi*,1, Silvia Takanen5, Tommaso Giandini2, Eva Iannacone1, Walter Fontanella3, Laura Locati4, Mauro Carrara2, Paolo Bossi4, Cristiana Bergamini4, Roberta Granata4, Vincenzo Tombolini5, Tullio Ibba3, Lisa Licitra4, Emanuele Pignoli2 & Carlo Fallai1
ABSTRACT Aims: To evaluate technical issues and clinical outcomes after postoperative volumetric-modulated arc therapy (VMAT) in two cases of malignant lacrimal gland cancer. Patients & methods: Patients were treated by postoperative VMAT and post-treatment clinical outcomes were followed-up to 18 months. Results: Dosimetric results were acceptable and acute toxicity was manageable in both patients. No evidence of disease was found at latest follow-up. One patient underwent corneal transplant for central corneal ulceration, experiencing reduction of visual acuity. Conclusion: Postoperative VMAT for treatment of lacrimal gland tumors offers improved outcome, with manageable side effects. In the context of photon beam radiotherapy, VMAT emerged as a valuable treatment option for these malignant tumors. Carcinoma of the lacrimal gland represents approximately 2% of all orbital neoplasms and less than 1% of all head and neck cancers (HNC) [1,2] . There are several histological types: adenoid cystic carcinoma (ACC), which is the most common histotype of the lacrimal apparatus [3] , accounting for 1.6% of all orbital tumors and for 29% of epithelial neoplasms of the lacrimal gland; carcinoma ex pleomorphic adenoma (Ca ex-PA), approximately 10% of the lacrimal tumors; adenocarcinoma (de novo), 5–10%; and mucoepidermoid carcinoma, 1–2% [4–7] . The clinical course of these malignant tumors is often aggressive. In contrast with their histological counterpart in salivary glands, lacrimal gland ACC show a higher rate of local recurrence (up to 75% of the cases) with intracranial spread along with distant metastases, and a mean survival of 1.5 years [8] . Moreover, patients with Ca ex-PA die within few years from diagnosis, with a mean survival of 3 years [1,9] . Lacrimal gland malignancies are currently treated by surgery followed by radiotherapy (RT) [2,10–12] . External beam RT (EBRT) represents the most common radiation therapy and is effective in preventing loco-regional recurrences, irrespective of the type of surgery adopted [13] . Due to the horseshoe-shaped target volume and the proximity to radiosensitive normal structures (organs at risk [OARs]) of lacrimal gland tumors, they are good candidate for advanced technologies in the context of EBRT, such as proton or heavy ion therapy and intensity-modulated radiation therapy (IMRT). Recently, the introduction of volumetric-modulated arc therapy (VMAT), a novel type of IMRT employing a linear accelerator to deliver a modulated rotational RT, further improved normal
KEYWORDS
• adenoid cystic carcinoma • carcinoma ex pleomorphic adenoma • dosimetric evaluation • lacrimal gland tumor • postoperative
intensity-modulated radiation therapy • treatment planning • VMAT
Units of Radiotherapy 2, Fondazione IRCCS Istituto Nazionale Tumori, Via Giacomo Venezian, 1, 20133 Milan, Italy Medical Physics, Fondazione IRCCS Istituto Nazionale Tumori, Via Giacomo Venezian, 1, 20133 Milan, Italy 3 Otolaringology & Head & Neck Surgery, Fondazione IRCCS Istituto Nazionale Tumori, Via Giacomo Venezian, 1, 20133 Milan, Italy 4 Head & Neck Medical Oncology, Fondazione IRCCS Istituto Nazionale Tumori, Via Giacomo Venezian, 1, 20133 Milan, Italy 5 Unit of Radiotherapy, Policlinico Umberto I, University “La Sapienza”, Viale del Policlinico, 155, 00186 Rome, Italy *Author for correspondence: Tel.: +39 0223903265; Fax: +39 022392472; [email protected] 1 2
10.2217/FON.14.148 © 2014 Future Medicine Ltd
Future Oncol. (2014) 10(14), 2111–2120
part of
ISSN 1479-6694
2111
Case Series Orlandi, Takanen, Giandini et al. tissue sparing, target coverage and delivery efficiency, compared with conventional IMRT in HNC [14] . Here, we report and discuss the technical aspects and clinical outcome of the use of postoperative VMAT in two cases of malignant lacrimal gland tumors referring to our Institution. We also review the most recent literature on RT for carcinoma of lacrimal gland. Case presentation ●●Case 1
In November 2011, a 44-year-old man was admitted to the ophthalmology division of the hospital closest to his home, complaining of gradually progressive double vision and visual acuity reduction, as well as swelling of the left upper eyelid in the last 3 months. MRI of the head showed an expansive lesion, sized 35 × 25 × 16 mm, at the level of superolateral region of the left orbit. The lesion likely originated from the lacrimal gland. It was characterized by an inhomogeneous contrast enhancement, and was inducing the caudal and anterior displacement of the lateral rectus muscle and eyeball, respectively, with no involvement of the optic nerve. Bone erosion of skull base was not found at orbit computed tomography (CT) scan. An incisional biopsy of the lacrimal gland was performed and the pathologist diagnosed ACC with perineural invasion. No regional or distant metastases were evident upon total body CT. Clinical stage was cT2 N0 MX, according to the American Join Committee on Cancer staging manual (7th Edition) [15] . In December 2011, the patient underwent left orbitotomy, with ipsilateral lacrimal gland resection, followed by plate osteosynthesis. Histopathology confirmed the diagnosis of ACC, with cribriform and tubular aspects, perineural invasion and extension in the soft tissues. Macroscopic lesion was 99% and V95% >95%, respectively); and no more than 20% of PTV received more than 110% of the PTD (V110%
