Iodine-125 seed implantation as an adjunct to surgery in advanced recurrent squamous cell cancer of the head and neck

Efficacy of radioactive 125I seed implantation in treating inoperable or refused operation head and neck cancers

PURPOSE

This study aims to observe the curative effect of radioactive 125I seed implantation in treating inoperable or refused operation head and neck cancer.

METHODS

Data from 132 patients with head and neck malignant tumors underwent computed tomography-guided radioactive 125I seed implantation from April 2004 to August 2020 were analyzed retrospectively. The Kaplan-Meier method was used to calculate the local control and survival rates. The logarithmic rank test and the Cox proportional risk model were used for univariate and multivariate analysis, respectively.

RESULTS

A total of 132 patients were enrolled. All tumors were confirmed to be malignant through pathological analysis. Herein, we revealed that the seeds were implanted at the primary tumor site (23 cases, representing 17.4%), recurrent (9 cases, representing 6.8%), or metastatic lymph nodes (100 cases, representing 75.8%). Three months after the operation, 96 patients were evaluated as effective, whereas 36 patients were considered ineffective. The median local control time was 16 months; the local rates at 6, 12, 18, and 24 months were observed to be 75%, 47%, 35%, and 22%, respectively. The study reports a median survival period (OS) of 15 months. Additionally, the survival rates at 6, 12, 18, and 24 months were 61%, 42%, 31%, and 27%, respectively. Regarding side effects, skin or mucosal toxicity occurred in 14 patients. Grade I skin toxicity occurred in seven cases (5.3%), grade IV skin toxicity in one case (0.8%), grade I mucosal ulcer in four cases (3.0%), and grade I dry mouth in four cases (3.0%). The multivariate analysis showed that short-term efficacy and tumor site were independent prognostic factors (P < 0.001, 0.006, respectively). Additionally, the multivariate analysis showed that the independent OS influencing factors included D90, the longest tumor diameter, and short-term efficacy (P = 0.017, 0.001, <0.001).

CONCLUSION

Radioactive 125I seed implantation is a safe and effective salvage therapy for patients with inoperable or refused operation head and neck cancer.

Modular polymer platform as a novel approach to head and neck cancer therapy

Head and neck cancer is the sixth most common cancer in the world, with more than 300,000 deaths attributed to the disease annually. Aggressive surgical resection often with adjuvant chemoradiation is the cornerstone of treatment. However, the necessary chemoradiation treatment can result in collateral damage to adjacent vital structures causing a profound impact on quality of life. Here, we present a novel polymer of poly(lactic-co-glycolic) acid and polyvinyl alcohol that can serve as a versatile multidrug delivery platform as well as for detection on cross-sectional imaging while functioning as a fiduciary marker for postoperative radiotherapy and radiotherapeutic dosing. In a mouse xenograft model, the dual-layered polymer composed of calcium carbonate/thymoquinone was used for both polymer localization and narrow-field infusion of a natural therapeutic compound. A similar approach can be applied in the treatment of head and neck cancer patients, where immunotherapy and traditional chemotherapy can be delivered simultaneously with independent release kinetics.

Multi-Institutional Study Validates Safety of Intraoperative Cesium-131 Brachytherapy for Treatment of Recurrent Head and Neck Cancer

Introduction

Surgery is the primary treatment for resectable, non-metastatic recurrent head and neck squamous cell carcinoma (HNSCC). We explore the safety and oncologic benefit of intraoperative Cesium-131 (Cs-131) brachytherapy combined with salvage local and/or regional surgical resection.

Methods and Materials

Findings were reported from a single arm multi-institutional prospective phase 1/2 trial involving surgery plus Cs-131 (surgery + Cs-131) treatment. The results of two retrospective cohorts—surgery alone and surgery plus intensity modulated radiation therapy (surgery + ReIMRT)—were also described. Included patients had recurrent HNSCC and radiation history. Safety, tumor re-occurrence, and survival were evaluated.

Results

Forty-nine patients were enrolled in the surgery + Cs-131 prospective study. Grade 1 to 3 adverse events (AEs) occurred in 18 patients (37%), and grade 4 AEs occurred in 2 patients. Postoperative percutaneous endoscopic gastrostomy (PEG) tubes were needed in 10 surgery + Cs-131 patients (20%), and wound and vascular complications were observed in 12 patients (24%). No cases of osteoradionecrosis were reported in the surgery + Cs-131 cohort. We found a 49% 2-year disease-free survival at the site of treatment with a substantial number of patients (31%) developing metastatic disease, which led to a 31% overall survival at 5 years.

Conclusions

Among patients with local/regional recurrent HNSCC status-post radiation, surgery + Cs-131 demonstrated acceptable safety with compelling oncologic outcomes, as compared to historic control cohorts.

Clinical Trial Registration

ClinicalTrials.gov, identifiers NCT02794675 and NCT02467738.

Permanent Interstitial Cesium-131 Brachytherapy in Treating High-Risk Recurrent Head and Neck Cancer: A Prospective Pilot Study

Purpose/Objectives

To establish the feasibility and safety of intraoperative placement of cesium-131 (Cs-131) seeds for re-irradiation in recurrent head and neck cancer (HNC).

Methods

Patients with resectable recurrent HNC who were deemed to have a high risk of second recurrence were eligible. Immediately after tumor extirpation, seeds were implanted in the surgical bed based on the preoperative treatment plan with intraoperative adjustment. The surgical bed and the seeds were covered with a regional flap or microvascular free flap. A CT of the neck was obtained on postoperative day 1 for evaluation of the postoperative dose distribution. Patients were followed 1 and 3 months after surgery, then every 3 months in the first 2 years.

Results

From November 2016 to September 2018, 15 patients were recruited and 12 patients received treatment per protocol. For the patients who had implants, the sites of initial recurrence included 10 neck alone, 1 neck and larynx, and 1 neck/peristomal. The median follow-up was 21.4 months. After surgery, patients remained hospitalized for a median of 6 days. There were no high-grade toxicities except two patients with wound complications requiring wound care. Eight patients had recurrences, three locoregional alone, three distant alone, and two with both locoregional and distant recurrences. Only one patient had an in-field failure. Five patients died, with 1- and 2-year overall survival of 75 and 58%.

Conclusions

Cs-131 implant after surgical resection in recurrent HNC is feasible and safe. There were no unexpected severe toxicities. Most failures were out-of-field or distant.

Clinical Trial Registration

ClinicalTrials.gov, identifier NCT02794675.

Brachytherapy of the head and neck: An University of California Los Angeles guide to morbidity reduction

The head and neck (H&N) region is among the most intricate and functional part of our anatomy. Major functional nerves and blood vessels with importance that affect the entire body emanate from the base of skull. Brachytherapy plays an important role as a single modality therapy in early cancer of the lip and oral cavity and a supplemental role in the pharynx or in advanced or recurrent disease. Morbidity in the H&N is intensely personal and disabling. Its avoidance is critical in determining the success or failure of a treatment program, and it is essential to preservation of quality of life. This article summarizes the current literature regarding morbidity related to H&N brachytherapy to aid patients and physicians to achieve optimal outcomes.

The effectiveness and prognostic factors of radioactive iodine-125 seed implantation for the treatment of cervical lymph node recurrence of esophageal squamous cell carcinoma after external beam radiation therapy

Purpose

To analyze factors influencing the efficacy of ¹²⁵I seed implantation in the treatment of in-field cervical lymph node recurrence of esophageal squamous cell carcinoma (ESCC) after external beam radiation therapy.

Material and methods

We conducted a retrospective review of 36 patients with in-field cervical metastatic lymph nodes recurrence of esophageal squamous cell carcinoma (CML-ESCC) after external beam radiation therapy treatment, who underwent ¹²⁵I seed implantation in our department from 2013 to 2019. Previous cumulative external irradiation dose ranged from 20 to 66 Gy (median, 60 Gy). The post-implant efficacy was evaluated by response evaluation criteria in solid tumors (RECIST) version 1.1, and an adverse event was evaluated by the Radiation Therapy Oncology Group (RTOG)/European Organization for Research and Treatment of Cancer Late Radiation Morbidity Score (EORTC). COX proportional hazards model was used to analyze risk factors affecting effectiveness.

Results

Among 36 patients, 31 patients (86.1%) received fluorouracil-based chemotherapy (1-6 cycles) after ¹²⁵I seed implantation. Local control rates at 3, 6, 12, and 24 months after implantation were 51%, 30%, 30%, and 18%, respectively, with a median of 9 months (95% CI: 6.106-11.894); survival rates after 3, 6, 12, and 24 months were 55%, 41%, 22%, and 22%, respectively, with a median of 8 months (95% CI: 5.753-10.247). Multivariate analysis showed that D₉₀ and short-term efficacy were independent factors related to local control and survival rate (p = 0.005, < 0.001, 0.010, < 0.001). There were 2 cases (5.6%) with grade 1 skin toxicity, 1 case (2.8%) with grade 4 skin toxicity, 3 cases (8.3%) with grade 1 mucosal ulcer, and 3 cases (8.3%) with grade 1 xerostomia.

Conclusions

¹²⁵I seed implantation as an effective salvage treatment shows definite efficacy and safety for patients with in-field cervical lymph node recurrence of ESCC after external beam radiation therapy.

The Effectiveness and Prognostic Factors of CT-Guided Radioactive I-125 Seed Implantation for the Treatment of Recurrent Head and Neck Cancer After External Beam Radiation Therapy

PURPOSE

To analyze the efficacy and safety of radioactive I-125 seed implantation in the treatment of recurrent head and neck tumors after radiation therapy.

METHODS AND MATERIALS

The data of 101 patients with recurrent head and neck cancer after radiation therapy who received computed tomography guided radioactive I-125 seed implantation were analyzed. The median previous cumulative external irradiation dose was 66 Gy, and the median dose to 90% of the target volume (D90) after operation was 117 Gy. The short-term efficacy was evaluated by Response Evaluation Criteria in Solid Tumors version 1.1, and the adverse event was evaluated by Common Terminology Criteria for Adverse Events version 4.0.

RESULTS

The 5-year local control rate was 26.6%, and the 5-year overall survival rate was 15.5%. Univariate analysis showed that factors related to local control rate included age, pathologic type, implantation site, lesion volume, and D90. The 5-year local control rate was 11.5% (2-year) if D90 was <120 Gy and 44.2% if D90 was ≥120 Gy (P = .001). Multivariate analysis showed that pathologic type, lesion volume, and D90 were independent factors related to local control (P = .002, 0, .014, respectively); Karnofsky performance status and lesion volume were independent factors associated with survival (P = .021 and 0, respectively). For the side effects, there were 26 cases of skin or mucosa ulceration (25.7%), 14 cases of pain (13.9%), and 2 cases of dry mouth (2%). The correlation between toxicity and dose had not been found.

CONCLUSIONS

Radioactive I-125 seed implantation in the treatment of recurrent head and neck cancer after radiation therapy showed acceptable efficacy and safety. Nonsquamous carcinoma, small lesion volume, and high dose (D90) were correlated with better local control.

A systematic review of treating recurrent head and neck cancer: a reintroduction of brachytherapy with or without surgery

Purpose

To review brachytherapy use in recurrent head and neck carcinoma (RHNC) with focus on its efficacy and complication rates.

Material and methods

A literature search of PubMed, Ovid, Google Scholar, and Scopus was conducted from 1990 to 2017. Publications describing treatment of RHNC with brachytherapy with or without surgery were included. The focus of this review is on oncologic outcomes and the safety of brachytherapy in the recurrent setting.

Results

Thirty studies involving RHNC treatment with brachytherapy were reviewed. Brachytherapy as adjunctive treatment to surgical resection appears to be associated with an improved local regional control and overall survival, when compared with the published rates for re-irradiation utilizing external beam radiotherapy (RT) or brachytherapy alone. Safety data remains variable with different isotopes and dose rates with implantable brachytherapy demonstrating a tolerable side effect profile.

Conclusions

Although surgery remains a mainstay treatment for RHNC, intraoperative interstitial brachytherapy delivery as adjunctive therapy may improve the treatment outcome and may be associated with fewer complication rates as compared to reirradiation using external beam radiotherapy. Further investigations are required to elucidate the role of brachytherapy for RHNC.

High-dose-rate interstitial brachytherapy in recurrent head and neck cancer: an effective salvage option

Purpose

High-dose-rate (HDR) interstitial brachytherapy has an established role in head and neck malignancies and offers good survival rates; however, there is scant data on improved local control (LC) and treatment-related complications in recurrent cases. We present our results in patients with recurrent head and neck cancers treated with HDR interstitial brachytherapy.

Material and methods

Twenty-five patients with recurrent head and neck cancers were treated with HDR interstitial brachytherapy using Iridium 192 between 2009 and 2016. Of these, 75% received radical brachytherapy, and 25% received external beam radiation therapy (EBRT) followed by brachytherapy boost. Treatment sites included oral cavity (15/25) and oropharynx (10/25). Median dose of 4.5 Gy was administered twice per day, with median total brachytherapy dose of 40.5 Gy in radical and 27 Gy for EBRT cases.

Results

With median follow-up of 25 months, 4 local recurrences were observed within first year of follow-up. Two-year local control and overall survival outcomes for the entire group were 75% and 68%, respectively. Local control rate with radical BRT vs. BRT as a boost following EBRT was found to be significant (2-year LCR 62% vs. 85%; p < 0.02). Dosimetric assessment revealed D₉₀ - 4.08 Gy, V₁₀₀ - 94.1%, V₁₅₀ - 24.7%, and V₂₀₀ - 10.1%. Xerostomia, altered taste, and dysphagia were the major complications commonly grade 1 and 2. Grade 3 toxicity was only 2%. Pre-treatment volume > 85 cc had a negative impact on overall survival (26 months vs. 12 months; p = 0.02), and interval time between primary and recurrence more than 15 months had an impact on the local control rate (p < 0.01).

Conclusions

Results of HDR interstitial brachytherapy have shown acceptable local control and overall survival rates along with tolerable toxicities and morbidity in recurrent head and neck cancers.

Surgery Combined with Radiotherapy to Treat Spinal Tumors: A Review of Published Reports

Spinal tumors result in high morbidity and a high rate of lower limb paralysis. Both surgical therapy and radiation therapy (RT) are used to treat spinal tumors; however, how best to combine these two therapies to maximize the benefits and minimize the risks is still being debated. It is also difficult to decide the optimal timing, course and dose of RT, especially in pregnant women and children. The aim of this review is to assist surgeons who are dealing with spinal tumors by providing comprehensive information about advanced techniques for administering RT with greater precision and safety, and about the impact of various ways of combining surgery and RT on therapeutic outcomes. We here review published reports about treating spinal tumors with a combination of these two forms of therapy and attempt to draw appropriate conclusions concerning selection of optimal treatment protocols. Our conclusion is that postoperative radiotherapy, especially with high-precision, low-dose and multiple fractions, and brachytherapy are promising therapies to combined with surgery.

Neither high-dose nor low-dose brachytherapy increases flap morbidity in salvage treatment of recurrent head and neck cancer

Purpose

While brachytherapy is often used concurrently with flap reconstruction following surgical ablation for head and neck cancer, it remains unclear whether it increases morbidity in the particularly high risk subset of patients undergoing salvage treatment for recurrent head and neck cancer (RH&NC).

Material and methods

A retrospective chart review was undertaken that evaluated patients with RH&NC who underwent flap coverage after surgical re-resection and concomitant brachytherapy. The primary endpoint was flap viability, and the secondary endpoints were flap and recipient site complications.

Results

In the 23 subjects included in series, flap viability and skin graft take was 100%. Overall recipient site complication rate was 34.8%, high-dose radiation (HDR) group 50%, and low-dose radiation (LDR) group 29.4%. There was no statistically significant difference between these groups.

Conclusions

In patients who undergo flap reconstruction and immediate postoperative radiotherapy following salvage procedures for RH&NC, flap coverage of defects in combination with brachytherapy remains a safe and effective means of providing stable soft tissue coverage.

Clinical application of computed tomography-guided (125)I seed interstitial implantation for head and neck cancer patients with unmanageable cervical lymph node metastases

Background

To assess clinical application of computed tomography (CT)-guided ¹²⁵I seed implantation for patients who cannot endure or unwillingly receive repeated surgery, chemotherapy, or radiotherapy for unmanageable cervical lymph node metastases in head and neck cancer (HNC).

Methods

Thirty-one consecutive patients received CT-guided ¹²⁵I seed implantation between February 2010 and December 2013. To evaluate the clinical efficiency, karnofsky performance score (KPS), numeric rating scale (NRS), and tumor volume at 3-, and 6-month post-implantation were compared with pre-implantation, along with local control rate (LCR), overall survival rate (OSR), and complications at 3, 6 months, 1, and 2 years.

Results

The tumor volume was obviously decreased at 3-, and 6-month post-implantation (21.23 ± 8.83 versus 9.19 ± 7.52 cm²; 21.23 ± 8.83 versus 6.42 ± 9.79 cm²; P < 0.05) compared with pre-implantation. The NRS was statistically reduced (3.06 ± 1.06 versus 7.77 ± 0.92; 2.39 ± 1.15 versus 7.77 ± 0.92; P < 0.05), while KPS was significantly improved (83.18 ± 5.97 versus 73.60 ± 7.90; 82.86 ± 5.43 versus 73.60 ± 7.90; P < 0.05) postoperatively at 3 and 6 months, respectively. The LCR at 3, 6 months, 1, and 2 years was 96.30, 83.87, 64.51, and 45.16 %, respectively. The OSR was 100, 100, 67.74, and 45.16 %, respectively. Three cases experienced grade I and two had grade II acute radiation toxicity.

Conclusions

CT-guided seed implantation may be feasible and safe for HNC patients whose neck nodes are not manageable by routine strategies with fewer complications, higher LCR, and significant pain relief.

Cesium-131 brachytherapy in high risk and recurrent head and neck cancers: first report of long-term outcomes

Purpose

The feasibility and efficacy of re-irradiation using contemporary radiation techniques to treat recurrent head and neck cancer has been demonstrated but the role of brachytherapy is unclear. Here we describe the use of ¹³¹Cs brachytherapy with concurrent salvage surgery in 18 patients.

Material and methods

Eligible patients underwent maximal gross resection of the tumor with implantation of brachytherapy seeds delivering a minimum dose of 80 Gy to the tumor bed. Rates of overall survival, locoregional progression free survival, disease-free survival, and radiation-induced toxicity were analyzed.

Results

Retrospective Kaplan-Meier analysis shows median overall survival was 15 months and disease free survival was 12 months. Two patients developed grade 3 toxicity; all other complications were grade 1-2 with no grade 4 or 5 complications.

Conclusions

Compared to prior literature, our study shows comparable rates of survival with a decreased rate of radiation-induced toxicity.

CT-guidance interstitial (125)Iodine seed brachytherapy as a salvage therapy for recurrent spinal primary tumors

Background

Management of spinal neoplasms has relied on open surgery and external beam radiotherapy (EBRT). Although primary spinal tumors are rare, their treatment remains a pervasive problem. This analysis sought to evaluate the safety and efficacy of CT-guided ¹²⁵I seed brachytherapy for recurrent paraspinous and vertebral primary tumors.

Methods

From November 2002 to June 2014, 17 patients who met the inclusion criteria were retrospectively reviewed. 14 (82.4%) had previously undergone surgery, 15 (88.2%) had received conventional EBRT and 3 (17.6%) had chosen chemotherapy. The number of ¹²⁵I seeds implanted ranged from 7 to 122 (median 79) with specific activity of 0.5-0.8 mCi (median 0.7 mCi). The post-plan showed that the actuarial D₉₀ of ¹²⁵I seeds were 90–183 Gy (median 137 Gy). The follow-up period ranged from 2 to 69 months (median 19 months). The local control rate was calculated by the Kaplan-Meier method.

Results

For 5 Chondrosarcomas, the 1-, 2-, 3-year local control rates were 75%, 37.5%, and 37.5%, respectively, with a median of 34 months (range, 4–39 months). For 4 chordomas, the local control rate was 50% with a median follow-up of 13 months (range, 3–17 months). For 3 fibromatosis, all of them were survival without local recurrence at the end of follow-up. During the follow-up period, 35.3% (6/17) died from metastases, 17.6% (3/17) developed local recurrence by 8, 14 and 34 months while 64.7% (11/17) remained alive. 100% experienced pain relief and normal or improved ambulation, without more than Frankel grade 3 radiation myelopathy.

Conclusions

Percutaneous ¹²⁵I seed implantation can be an alternative or retreatment for recurrent spinal primary tumors.

125I brachytherapy alone for recurrent or locally advanced adenoid cystic carcinoma of the oral and maxillofacial region

BACKGROUND AND PURPOSE

This retrospective study was to evaluate the local control and survival of (125)I brachytherapy for recurrent and/or locally advanced adenoid cystic carcinoma (ACC) of the oral and maxillofacial region.

PATIENTS AND METHODS

A total of 38 patients with recurrent and/or locally advanced ACC of the oral and maxillofacial region received (125)I brachytherapy alone from 2001-2010. Twenty-nine were recurrent cases following previous surgery and radiation therapy. The other 9 cases involved primary tumors. Overall, 12 tumors were located in the major salivary glands, 12 in the minor salivary glands, and 14 in the paranasal region, the nasal cavity or the skull base. The prescribed dose was 100-160 Gy.

RESULTS

Patients were followed for 12-122 months (median 51 months). The 2-, 5-, and 10-year local tumor control rates were 86.3, 59, and 31.5 %, respectively. The 2-, 5-, and 10-year overall survival rates were 92.1, 65 and 34.1 %, respectively. Tumors > 6 cm had significantly lower local control and survival rates. No severe complications were observed during follow-up.

CONCLUSION

(125)I brachytherapy is a feasible and effective modality for the treatment of locally advanced unresectable or recurrent ACC.

An investigation of 125I seed permanent implantation for recurrent carcinoma in the head and neck after surgery and external beam radiotherapy

BACKGROUND

A preliminary assessment was conducted of the feasibility, efficacy, and morbidity of 125I seed implantation for recurrent head and neck carcinoma after surgery and external beam radiotherapy.

METHODS

Nineteen patients with recurrent head and neck carcinomas underwent 125I seed implantation under ultrasound or computed tomography guidance. The actuarial D90 of 125I seed implantation ranged from 90 to 160 Gy (median, 131 Gy). The follow-up period ranged from 3 to 44 months (median, 11 months).

RESULTS

The median local control was 24 months (95% confidence interval, 10.2 to 37.8). The one- year, two-year and three-year local controls were 73.3%, 27.5% and 27.5%, respectively, whereas the one-year, two-year and three-year survival rates were 53.0%, 18.2% and 18.2%, respectively, and the median survival was 13 months (95% confidence interval, 6.6 to 19.4). A total of 26.3% of patients (5/19) died of local recurrence and 21.1% of patients (4/19) died of metastases. One suffered from a grade 1 skin reaction.

CONCLUSIONS

125I seed implantation is feasible and safe as a salvage treatment for patients with recurrent head and neck cancers. The high local control results and low morbidity merits further investigation.

CT-guided iodine-125 seed permanent implantation for recurrent head and neck cancers

BACKGROUND

To investigate the feasibility, and safety of 125I seed permanent implantation for recurrent head and neck carcinoma under CT-guidance.

RESULTS

A retrospective study on 14 patients with recurrent head and neck cancers undergone 125I seed implantation with different seed activities. The post-plan showed that the actuarial D90 of 125I seeds ranged from 90 to 218 Gy (median, 157.5 Gy). The follow-up was 3 to 60 months (median, 13 months). The median local control was 18 months (95% CI, 6.1-29.9 months), and the 1-, 2-, 3-, and 5- year local controls were 52%, 39%, 39%, and 39%, respectively. The 1-, 2-, 3-, and 5- survival rates were 65%, 39%, 39% and 39%, respectively, with a median survival time of 20 months (95% CI, 8.7-31.3 months). Of all patients, 28.6% (4/14) died of local recurrence, 7.1% (1/14) died of metastases, one patient died of hepatocirrhosis, and 8 patients are still alive to the date of data analysis.

CONCLUSION

CT-guided 125I seed implantation is feasible and safe as a salvage or palliative treatment for patients with recurrent head and neck cancers.

Interstitial 125I seeds implantation to treat spinal metastatic and primary paraspinal malignancies

Spinal cord metastatic malignancies and locally invasive paraspinal carcinomas were severe pain and disabling complications. The treatment modality was unclear. We retrospectively evaluated the safety and efficacy of (125)I seed implantation for spinal metastatic and paraspinal malignancies in our center. A total of 19 patients and 22 procedures were included in this study. Eight patients received a seed implant in an operation, and 11 patients were implanted percutaneously under CT-guidance. The number of (125)I seeds implanted ranged from 6 to 100, with a median of 26. The specific activity of (125)I seeds ranged from 0.45 to 0.80 mCi per seed, with a median of 0.5 mCi. The minimal peripheral doses of (125)I seed implantation were 90-140 Gy, with median of 120 Gy. Follow-up ranged from 3 to 69 months with a median of 22 months. All patients tolerated seed implantation well. The 1, 2, 3, and 5 year local control rates were 63%, 47%, 31%, and 3%, respectively, with a median of 22 months (3-61 months). The 1, 2, 3, and 5 year survival rates were 74%, 56%, 43%, and 43%, respectively, with a median of 33 months. Ten patients (52.6%) developed distant metastases. Two (10.5%) patients showed recurrence at 13 and 39 months. Seven (36.8%) patients were still alive, 84% (16/19) of patients had either normal or improved ambulation following seed implant. No myelopathies were encountered. Our study suggests a promising local therapy for a selected population of patients with spinal cord metastatic or paraspinal carcinoma.

High-dose-rate interstitial brachytherapy in recurrent and previously irradiated head and neck cancers—Preliminary results

PURPOSE

Although high-dose-rate brachytherapy (HDRBT) offers significant advantages over low dose rate brachytherapy, there are scant data on improved local control (LC) and treatment-related complications in patients with recurrent head and neck (H&N) cancers. We report our preliminary results in patients with recurrent H&N cancers treated with interstitial HDRBT.

METHODS AND MATERIALS

Thirty patients with recurrent H&N cancers were treated with HDRBT between September 2003 and October 2005. Seventy-seven percent (23/30) of the patients had either local or regional recurrence in the area of previous external beam radiation therapy. The treatment sites were oral cavity/oropharynx (11/30), neck (10/30), face/nasal cavity (6/30), and parotid bed (3/30). Whereas 18 patients underwent surgical resection followed by HDRBT, 3 patients were treated with combined external beam radiation and HDRBT, and the remaining 9 were treated with HDRBT alone. The dose and fractionation schedules used were 3.4Gy twice per day (b.i.d.) to 34Gy for postoperative cases, 4Gy b.i.d. to 20Gy when combined with 40-50Gy external beam, and 4Gy b.i.d. to 40Gy for definitive treatment. HDRBT was initiated 5 days after catheter placement to allow for tissue healing.

RESULTS

With a median followup of 12 months, 6 local recurrences were observed 1-10 months after the procedure. The 2-year LC and overall survival outcomes for the entire group were 71% and 63%, respectively. Patients treated with surgical resection and HDRBT had an improved 2-year LC compared to the patients treated with HDRBT+/-external beam radiation alone (88% vs. 40%, p=0.05). Six Grade II and four Grade III complications were noted in five patients, all observed in the postoperative HDRBT group.

CONCLUSION

The preliminary results of HDRBT indicate an acceptable LC and morbidity in recurrent H&N cancers. A planned surgical resection followed by HDRBT is associated with improved tumor control in these high-risk patients. Based on these encouraging results, prospective clinical trials are warranted using HDRBT in recurrent H&N cancers to decrease late toxicity.

The role of interstitial brachytherapy with salvage surgery for the management of recurrent head and neck cancers

BACKGROUND

The role of interstitial brachytherapy (IBT) in the salvage surgical management of regional lymphatic metastases for head and neck cancer has not been defined to date. To further explore its therapeutic benefit in the management of head and neck squamous cell carcinoma, the authors reviewed their experience utilizing IBT at the M. D. Anderson Cancer Center.

METHODS

A retrospective chart review of all patients who were received IBT for cervical recurrences of head and neck cancer was undertaken. Twenty-two patients were identified; all patients underwent neck dissection and intraoperative placement of afterloading catheters as part of the salvage treatment. Soft tissue reconstruction was performed when necessary. The duration and dosage of salvage brachytherapy was reviewed, and the overall disease-free survival rates were determined.

RESULTS

All patients had been treated with external beam radiation therapy prior to recurrence, with an average dose of 65 grays (Gy), and 46% of patients had undergone prior neck dissection. The median time to regional recurrence after definitive treatment was 30 months. Soft tissue coverage of the surgical bed with a muscle flap, most commonly a pectoralis major flap, was performed in 19 of 22 patients. The median IBT dose was 60 Gy over a total duration of 4 days. Postoperative complications were few, and there were no perioperative deaths. Recurrences in the reirradiated necks occurred in 27% of patients.

CONCLUSIONS

Regional recurrences are common after multimodality treatment for head and neck cancer and are challenging to manage. Although its role has not been defined clearly, salvage neck dissection with IBT is beneficial in the management of recurrent lymphatic metastases of upper aerodigestive tract carcinomas.

Reconstruction after soft tissue sarcoma resection in the setting of brachytherapy: a 10-year experience

Management of recurrent soft tissue sarcomas often involves surgical resection and adjuvant brachytherapy. This study reviews our experience in the management of these patients and proposes a logical approach toward reconstruction. All patients who underwent soft tissue sarcoma resection, adjuvant brachytherapy, and soft tissue flap reconstruction (pedicled or free) during the 10-year period from 1991 to 2000 were included in this study. There were 17 patients (14 male, 3 female) with a mean age of 51 years (range, 16-80 years). Soft tissue sarcomas were distributed in the lower extremity (n = 9), upper extremity (n = 5), and trunk (n = 3). Reconstruction was accomplished by regional transposition flaps (n = 10) and free tissue transfer (n = 7). The average defect size was 143 cm. Patients received 5 to 12 (mean, 8) brachytherapy catheters. The brachytherapy dose delivered ranged from 1600 to 4500 cGy (mean, 3773 cGy). Brachytherapy catheters were loaded with radioactive sources between 5 and 7 days postoperatively. All flaps in this series survived. One patient required return to the operating room for revision of a venous thrombosis with flap salvage. Closed suction drainage tubes were left in place until after the brachytherapy catheters were removed to avoid dislodging the catheters. Two patients developed postradiation partial-thickness skin necrosis with delayed secondary wound healing. This study demonstrates that soft tissue reconstruction in the setting of sarcoma resection and brachytherapy catheter placement is safe and efficacious. Postoperative wound healing complications can be minimized through coordination among the ablative surgeon, reconstructive surgeon, and radiation oncologist. Specifically, placement of microvascular anastomoses well away from the radiation target area is indicated whenever possible. Finally, removal of closed suction drainage tubes should be deferred until after the brachytherapy catheters are removed to minimize complications resulting from catheter dislodgement.

Microsurgical Free Flap Reconstruction Outcomes in Head and Neck Cancer Patients after Surgical Extirpation and Intraoperative Brachytherapy

OBJECTIVES

The management of recurrent or persistent head and neck cancer poses a challenging problem. Salvage surgery for these individuals consists of ablative surgery, interstitial brachytherapy, and microsurgical free flap reconstruction. This study reviews complications after such reconstruction.

METHODS

We reviewed 139 consecutive head and neck cancer patients undergoing free flap reconstruction from January 1994 to May 2002. These included 66 patients with recurrent head and neck cancer undergoing intraoperative brachytherapy (IOBT) and free flap reconstruction and 73 undergoing free flap reconstructions only. A total of 142 reconstructions were performed, with three patients in IOBT group receiving two free flap reconstructions per patient, giving us a total of 69 reconstructions in the IOBT group versus 73 in the non-IOBT group. Nine patients were excluded from the IOBT group because of nonsynchronous use of brachytherapy and reconstruction, and 10 patients were excluded from the other group because they had prior radiotherapy or surgical treatment, leaving us with a total of 123 reconstructions, 60 in the IOBT group and 63 in the non-IOBT group. The IOBT group patients received iodine Vicryl seed implants, palladium seed implants, or both, to deliver an average dose of 79.3 +/- 31.8 Gy (mean +/- 1SD) to the surgical bed.

RESULTS

All patients were followed for evidence of local wound complications. The IOBT group showed multiple complications in 23 (38.33%) of 60 reconstructions, the most common being wound dehiscence in 11. This, when compared with the non-IOBT group complications (15.87%), was found to be statistically significant (chi test, P <.01).

CONCLUSION

IOBT increases the rate of complications in patients undergoing microvascular free tissue transfer. This, however, should not deter or alter the aggressiveness of cancer therapy used for managing recurrent head and neck cancer.

Interstitial low-dose-rate brachytherapy as a salvage treatment for recurrent head-and-neck cancers: long-term results

PURPOSE

Recurrent cancers of the head and neck within previously irradiated volume pose a serious therapeutic challenge. This study evaluates the response and long-term tumor control of recurrent head-and-neck cancers treated with interstitial low-dose-rate brachytherapy.

METHODS AND MATERIALS

Between 1979 and 1997, 220 patients with prior radiation therapy with or without surgery for primary tumors of the head and neck were treated for recurrent disease or new primary tumors located within previously irradiated volumes. A majority of these patients had inoperable diseases with no distant metastasis. There were 136 male and 84 female patients, and median age was 56 years. All patients had previously received radiation therapy as the primary treatment or adjuvant treatment following surgery, with a median dose of 57.17 cGy (range, 39-74 cGy). The salvage brachytherapy consisted of a low-dose-rate, afterloading Iridium(192) implant, which delivered a median minimum tumor dose of 53 Gy to a mean tumor volume of 68.75 cm(2). Sixty percent of the patients also received interstitial hyperthermia, and 40% received concurrent chemotherapy as a radiosensitizing and potentiating agent.

RESULTS

At a minimum 6-month follow-up, local tumor control was achieved in 77% (217/282) of the implanted tumor sites. The 2, 5, and 10-year disease-free actuarial survival rates for the entire group were 60%, 33%, and 22%, respectively. The overall survival rate for the entire group at 5 years was 21.7%. Moderate to severe late complications occurred in 27% of the patients.

CONCLUSION

It has been estimated that approximately 20-30% of head-and-neck cancer patients undergoing definitive radiation therapy have recurrence within the initial treatment volume. Furthermore, similar percentages of patients who survive after successful irradiation develop new primary tumors of the head and neck or experience metastatic neck disease. A majority of such patients cannot be treated with a repeat course of external beam irradiation because of limited normal tissue tolerance, leading to unacceptable morbidity. However, in a select group of these patients, salvage interstitial brachytherapy may play an important role in providing patients with durable palliation and tumor control, as well as a chance for cure.

The American Brachytherapy Society recommendations for high-dose-rate brachytherapy for head-and-neck carcinoma

PURPOSE

To develop recommendations for use of high-dose-rate (HDR) brachytherapy in patients with head-and-neck cancer.

METHODS

A panel consisting of members of the American Brachytherapy Society (ABS) performed a literature review, added information based upon their clinical experience, and formulated recommendations for head-and-neck HDR brachytherapy.

RESULTS

The ABS recommends the use of brachytherapy as a component of the treatment of head-and-neck tumors. However, the ABS recognizes that some radiation oncologists are reluctant to employ brachytherapy in the head-and-neck region because of the complexity of the postoperative management and concerns about radiation safety. In this regard, HDR eliminates unwanted radiation exposure and thereby permits unrestricted delivery of clinical care to these brachytherapy patients. The ABS made specific recommendations for previously untreated and recurrent head-and-neck cancer patients on patient selection criteria, implant techniques, target volume definition, and HDR treatment parameters (such as time, dose, and fractionation schedules). Suggestions were provided for treatment with HDR alone and in combination with external beam radiation therapy. It should be recognized that only limited experiences exist with HDR brachytherapy in patients with head-and-neck cancers. Therefore, some of these suggested doses have not been extensively tested in clinical practice. Hence, these guidelines will be updated as significant new outcome data are available. Any clinician following these guidelines is expected to use clinical judgment to determine an individual patient's treatment.

CONCLUSIONS

Little has been published in the clinical literature on HDR brachytherapy in head-and-neck cancer. Based upon the available information and the clinical experience of the panel members, general and site-specific recommendations were offered. Areas for further investigations were identified.

The role of brachytherapy for palliation

The goal of palliative radiation is to alleviate symptoms in a short amount of time and maintain an optimal functional and quality-of-life level while minimizing toxicity and patient inconvenience. Despite advances in multimodality antineoplastic therapies, failure to control the tumor at its primary site frustratingly remains the predominant source of morbidity and mortality in many patients with cancer. Escalation of doses of radiation using external beam irradiation has been shown to improve local tumor control, but limits are imposed by the tolerance of normal surrounding structures. The highly conformal nature of brachytherapy enables the radiation oncologist to accomplish safe escalation of radiation doses to the tumor while minimizing doses to normal surrounding structures. Thus, by enhancing the potential for local control, brachytherapy used alone or as a supplement to external beam radiation therapy retains a significant and important role in achieving the goals of palliation. Proper patient selection, excellent technique, and adherence to implant rules will minimize the risk of complications. The advantages realized with the use of brachytherapy include good patient tolerance, short treatment time, and high rates of sustained palliation. This article reviews various aspects of palliative brachytherapy, including patient selection criteria, implant techniques, treatment planning, dose and fractionation schedules, results, and complications of treatment. Tumors of the head and neck, trachea and bronchi, esophagus, biliary tract, and brain, all in which local failure represents the predominant cause of morbidity and mortality, are highlighted.

The role of brachytherapy in head and neck cancer

By precision dose delivery to a well-defined target, brachytherapy fulfills the complementary goals of delivering sufficient dose for tumor cell kill while sparing normal adjacent structures. The unique properties of this modality, either used alone or implemented in a combined modality setting with surgery or external-beam irradiation, offer an ideal means of enhancing the therapeutic ratio by exploiting the effect of local therapies while respecting normal tissue tolerance. Brachytherapy also provides an effective technique for the retreatment of patients with recurrent, persistent, or second primary head and neck malignant tumors in a previously irradiated region. The benefits of this treatment modality are reflected in excellent reported local control rates, shortened overall treatment times, reduced functional deficits, improved quality of life, and decreased costs. Successful brachytherapy relies, however, on close collaborative efforts between radiation oncologists and surgeons, careful assessment of the patient, precise planning, and technique that adheres to the rules of a system. Brachytherapy has been clearly identified as an effective, safe, and appealing modality in the treatment of head and neck malignancies.

Wound complications associated with brachytherapy for primary or salvage treatment of head and neck cancer

Brachytherapy can be employed in the primary or salvage treatment of head and neck cancer. The advantage of brachytherapy is the stereotactic limitation of radiation exposure to noninvolved tissues. Wound complications associated with brachytherapy have been discussed only sporadically in the literature. This retrospective study examines 28 patients, 20 for initial treatment and eight for salvage, with varying site and stage head and neck cancer treated with brachytherapy in addition to external beam radiation therapy and/or surgery. The overall complication rate was 50% (14/28), with infection and minor flap breakdown being the most common problems. Tumor site in the primary treatment group was the only significant factor in wound complications. In the salvage group complications were minor and primarily related to flap coverage of brachytherapy catheters.

Brachytherapy in orbital tumors

PURPOSE

To evaluate whether the use of iridium-192 brachytherapy would reduce the incidence of complications noted with external beam radiation therapy in patients with orbital tumors.

METHODS AND MATERIALS

This study is a retrospective review of a clinical series of 25 patients with various orbital tumors treated with brachytherapy between 1988 and 1995.

RESULTS

Patients were observed for an average of 40 months (range, 16-88 months) during which one patient died of metastatic disease and 24 patients are alive with no evidence of disease. Recurrent disease was observed in four patients. In 3 patients, exenteration was necessary and in 22 patients, the eye was preserved. The visual acuities after therapy ranged from no light perception to 20/20 (average, 20/40).

CONCLUSIONS

Since brachytherapy has been used as an alternative to exenteration, the results of this treatment have been excellent in most patients. However, in advanced disease, external radiation therapy or even mutilating surgery still remains inevitable.

Applications of brachytherapy in head and neck cancer

Brachytherapy offers the radiation oncologist the opportunity to deliver high doses of radiation to the tumor, with minimal doses to the surrounding normal tissue. This combination enhances the therapeutic ratio. It allows for enhanced tumor control, with minimal toxicity. When utilized, it often allows for tumor control without the need for resection. This is especially important in the head and neck. Resection of organs such as the lip, oral tongue, base-of-tongue, and other sites can cause significant functional and cosmetic morbidity. The ability to save these structures, using radiation therapy instead of surgery, can provide excellent tumor control and optimal quality-of-life outcome. In situations of recurrent disease, especially when prior radiation has been given, brachytherapy is often the only way to re-irradiate certain areas. This can be done alone, or in combination with surgery. Therefore, brachytherapy becomes an important component of the treatment of recurrent disease. This broad overview of the use of brachytherapy in head and neck cancer will include applications in the primary as well as the recurrent disease setting.

Interstitial iodine 125 in advanced recurrent squamous cell carcinoma of the head and neck with follow-up evaluation of carotid artery by ultrasound

We retrospectively reviewed our experience with 24 patients in the treatment of advanced recurrent squamous cell carcinoma of the head and neck, using salvage surgery and intraoperative iodine 125 (125I) implantation. Surgical complications and survival results were compiled and compared with those of other studies. The long-term effect of 125I on the carotid artery was evaluated by ultrasound. We had a major complication rate of 21% and an overall complication rate of 50%. Our 2-year overall and determinate survivals were 29% and 50%, respectively. Within the survival group, carotid ultrasounds were obtained to evaluate the long-term effect of 125I. All ultrasounds obtained at least 1 year from the time of treatment showed minimal or no change from the contralateral side. We conclude that intraoperative 125I and salvage surgery are an acceptable treatment for recurrent squamous cell carcinoma with minimal complication and effect on the carotid artery.

Management of carotid artery rupture by monitored endovascular therapeutic occlusion (1988-1994)

The reported mortality (40%) and neurologic morbidity (25%) rates for carotid rupture remain unacceptably high. This study was conducted to assess the impact of endovascular detachable balloon occlusion and the changing characteristics of carotid rupture in head and neck surgery. Between January 1, 1988, and June 30, 1994, 18 carotid ruptures were identified in 15 patients. Etiologic factors included radical surgery, radiation therapy, wound complications, and recurrent or persistent carcinoma. In 15 of 18 instances of carotid rupture, patients survived without major neurologic sequelae. After the introduction of endovascular techniques in 1991, the 12 patients whose hemorrhage was definitively managed through permanent balloon occlusion survived without significant neurologic sequelae. Endovascular occlusion techniques in the monitored patient may significantly improve the outcome after carotid rupture.