Proton Reirradiation: Expert Recommendations for Reducing Toxicities and Offering New Chances of Cure in Patients With Challenging Recurrence Malignancies

Local and regional recurrences are common following an initial course of radiotherapy, yet management of these recurrences remains a challenge. Reirradiation may be an optimal treatment approach for providing durable tumor control and even offering select patients with locoregional recurrences or new primary tumors a chance of cure, but photon reirradiation can be associated with considerable risks of high grade acute and late toxicities. The high conformality and lack of exit dose with proton therapy offer significant advantages for reirradiation. By decreasing dose to adjacent normal tissues, proton therapy can more safely deliver definitive instead of palliative doses of reirradiation, more safely dose escalate reirradiation treatment, and more safely allow for concurrent systemic therapy in the reirradiation setting. In this case-based analysis, renowned experts in the fields of proton therapy and of reirradiation present cases for which they recently employed proton reirradiation. This manuscript focuses on case studies in patients with lung cancer, head and neck malignancies, and pelvic malignancies. Considerations for when to deliver proton therapy in the reirradiation setting and the pros and cons of proton therapy are discussed, and the existing literature supporting the use of proton reirradiation for these disease sites is assessed.