GEC-ESTRO recommendations for brachytherapy for head and neck squamous cell carcinomas

Postoperative high-dose-rate brachytherapy alone in stage T1-3N0M0 oral cancer with negative prognostic factors: A retrospective study

PURPOSE

To evaluate treatment outcomes and toxicity in patients with stage T1-3N0M0 oral cancer treated with surgery followed by high-dose-rate brachytherapy (HDR-BT).

METHODS AND MATERIALS

Retrospective study of 50 patients with stage T1-T3N0 tongue and floor-of-mouth cancer who underwent tumour excision (+ elective neck dissection) followed by postoperative HDR-BT due to the presence of negative prognostic factors (close or positive resection margins, lymphovascular and/or perineural invasion, deep invasion). The plastic tube technique (dose: 18 x 3 Gy b.i.d.) was used. Survival outcomes, toxicity, and prognostic factors were evaluated.

RESULTS

At a median follow-up of 81 months (range, 4-121), actuarial 5-year local control (LC), nodal control (NC) and progression-free survival (PFS) rates were 79%, 69%, and 64%. After salvage treatment (surgery + external beam radiotherapy), LC, NC, and PFS increased to 87%, 77%, and 72.3%, respectively. Five-year overall survival and cancer-specific survival (CSS) rates were 73% and 77%. Treatmentrelated toxicity included two cases of mandibular osteoradionecrosis and five cases of small soft tissue necrosis. T stage was significantly correlated with nodal control (p=0.02) and CSS (p=0.04). Tumour grade correlated with DFS (p=0.01).

CONCLUSION

Postoperative HDR-BT 18 x 3 Gy b.i.d. seems to be an effective method in patients with T1-3N0M0 oral cancer with negative prognostic factors after tumour resection.

GEC-ESTRO recommendations for head & neck cancer brachytherapy (interventional radiotherapy): 2nd update with focus on HDR and PDR

Modern brachytherapy (BT) is playing an important role in the multidisciplinary treatment of Head and Neck (H&N) cancer, as an organ- and function-preserving therapy. Low-dose-rate (LDR) technology has been replaced by modern remote afterloading and stepping source equipment using pulsed dose rate (PDR) or high dose rate (HDR) sources, improved image guidance and 3D treatment planning systems. This is an update of the previous GEC-ESTRO recommendations for H&N tumors, mainly applied to squamous carcinomas. Indications, results and recommended doses for different tumor sites are presented according to the published studies.

"High-risk" tumors of the lip treated with external beam radiotherapy and high-dose-rate brachytherapy: Long-term outcome

BACKGROUND

Radiotherapy is a well-established treatment for lip cancer, with external radiotherapy (EBRT) or brachytherapy (BT).

METHODS

This study evaluated outcome, tumor control, and aesthetics, for 101 patients with carcinoma of the lip, not suitable for surgery, treated with combined EBRT and BT.

RESULTS

Squamous cell carcinoma was seen in 78 patients, basal cell carcinoma in 15, and other histologies in 8 patients. Tumors were advanced: 73% in category T2-T4. Local control at 3 and 5 years was 89%. Local failure appeared in 4/56 patients (7%) with primary RT compared to 7/45 (16%) in those with prior surgery, regional recurrence in 5 patients. Toxicity was mild. Cosmetic outcome, 87 patients evaluated, was bad for 9/40 patients with upfront surgery compared to 1/47 for primary RT patients (p = 0.003). Seven patients died from lip cancer (7%), three with originally N+ disease (43%).

CONCLUSIONS

Combined EBRT and BT could be considered for lip tumors not candidates for surgery.

Feasibility of the analytical dose calculation method for Au-198 brachytherapy

PURPOSE

A dose calculation algorithm Computed Tomography (CT)-based analytical dose calculation method (CTanly), which can correct for subject inhomogeneity and size-dependent scatter doses, was applied to the 198Au seed. In this study, we evaluated the effectiveness of the CTanly method by comparing the gold standard Monte Carlo (MC) method and the conventional TG43 method on two virtual phantoms and patient CT images simulating oral cancer.

METHODS

As virtual phantoms, a water phantom and a heterogeneous phantom with soft tissue inserted cubic fat, lung, and bone were used. A 2-mm-thick lead plate was also inserted into the heterogeneous phantom as a dose attenuator. Virtual 198Au seeds and a 2-mm-thick lead plate were placed on the patient CT images. Dose distributions obtained via the TG43 and CTanly methods were compared with those of the MC by gamma analysis with 2%/2-mm thresholds. The computation durations were also compared.

RESULTS

In the water phantom, dose distributions comparable to those obtained via the MC method were obtained regardless of the algorithm. For the inhomogeneity phantom and patient case, the CTanly method showed an improvement in the gamma passing rate and dose distributions similar to those of the MC method were obtained. The computation time, which was days with the MC method, was reduced to minutes with the CTanly method.

CONCLUSIONS

The CTanly method is effective for 198Au seed dose calculations and takes a shorter time to obtain the dose distributions than the MC method.

Individualized 3D-printed applicators for magnetic resonance imaging-guided brachytherapy in nasal vestibule cancer

Background and purpose

Brachytherapy is treatment of choice for early stage nasal vestibule cancer. Over the years improvements were achieved by means of image guided target definition, interstitial implant techniques and also individual mold techniques. The aim of this study was to improve the technique of the implant so that the need for interstitial catheters can be limited by making use of patient individualized 3D-printed applicators.

Materials and Methods

In 19 patients 3D-printed applicators were used to deliver pulse dose rate (PDR) brachytherapy. All patients underwent computed tomography (CT) and magnetic resonance imaging (MRI). A pre-plan with tumor delineation and manually optimized catheter positions to achieve tumor coverage was made. Based on the pre-plan a 3D-printed applicator was manufactured. Dose was evaluated by several indices: Conformity Index, Healthy Tissues Conformity Index, Dose Homogeneity Index, Dose non-uniformity ratio, Conformal index and high dose (HD) index.

Results

A high target coverage was achieved, with a median V100%CTV of 99.1 % (range, 81.8-100 %) and median CI of 0.99 (range, 0.82-1.00), as well as a median V0.7GyGTV of 100 % (range, 93.0-100 %). The median HD was 0.39 (range, 0.20-0.83). Interstitial catheters were needed in 12 patients. None of the patients developed grade ≥ II toxicity within the median follow up of 18 months.

Conclusions

This study shows that using 3D-printed applicators limits the need for interstitial catheters and also limits the high doses in normal tissue.

Brachytherapy for rhabdomyosarcoma: Survey of international clinical practice and development of guidelines

BACKGROUND AND PURPOSE

The purpose of this study was to address the lack of published data on the use of brachytherapy in pediatric rhabdomyosarcoma by describing current practice as starting point to develop consensus guidelines.

MATERIALS AND METHODS

An international expert panel on the treatment of pediatric rhabdomyosarcoma comprising 24 (pediatric) radiation oncologists, brachytherapists and pediatric surgeons met for a Brachytherapy Workshop hosted by the European paediatric Soft tissue Sarcoma Study Group (EpSSG). The panel's clinical experience, the results of a previously distributed questionnaire, and a review of the literature were presented.

RESULTS

The survey indicated the most common use of brachytherapy to be in combination with tumor resection, followed by brachytherapy as sole local therapy modality. HDR was increasingly deployed in pediatric practice, especially for genitourinary sites. Brachytherapy planning was mostly by 3D imaging based on CT. Recommendations for patient selection, treatment requirements, implant technique, delineation, dose prescription, dose reporting and clinical management were defined.

CONCLUSIONS

Consensus guidelines for the use of brachytherapy in pediatric rhabdomyosarcoma have been developed through multicenter collaboration establishing the basis for future work. These have been adopted for the open EpSSG overarching study for children and adults with Frontline and Relapsed RhabdoMyoSarcoma (FaR-RMS).

Can interventional radiotherapy (brachytherapy) be an alternative to surgery in early-stage oral cavity cancer? A systematic review

PURPOSE

Brachytherapy (BT), also known as interventional radiotherapy (IRT), has proven its utility in the treatment of localized tumors. The aim of this review was to examine the efficacy of modern BT in early-stage oral cavity cancer (OCC) in terms of local control (LC), overall survival (OS), disease-free survival (DFS), cancer-specific survival (CSS), and safety.

METHODS

The SPIDER framework was used, with sample (S), phenomena of interest (PI), design (D), evaluation (E), and research type (R) corresponding to early-stage oral cavity cancer (S); BT (PI); named types of qualitative data collection and analysis (D); LC, OS, DFS, CSS, and toxicity (E); qualitative method (R). Systematic research using PubMed and Scopus was performed to identify full articles evaluating the efficacy of BT in patients with early-stage OCC. The studies were identified using medical subject headings (MeSH). We also performed a PubMed search with the keywords "brachytherapy oral cavity cancer, surgery." The search was restricted to the English language. The timeframe 2002-2022 as year of publication was considered. We analyzed clinical studies of patients with OCC treated with BT alone only as full text; conference papers, surveys, letters, editorials, book chapters, and reviews were excluded.

RESULTS

The literature search resulted in 517 articles. After the selection process, 7 studies fulfilled the inclusion criteria and were included in this review, totaling 456 patients with early-stage node-negative OCC who were treated with BT alone (304 patients). Five-year LC, DFS, and OS for the BT group were 60-100%, 82-91%, and 50-84%, respectively.

CONCLUSION

In conclusion, our review suggests that BT is effective in the treatment of early-stage OCC, particularly for T1N0 of the lip, mobile tongue, and buccal mucosa cancers, with good functional and toxicity profiles.

Brachytherapy on-a-chip: a clinically-relevant approach for radiotherapy testing in 3d biology

We describe the first microfluidic device for in vitro testing of brachytherapy (BT), with applications in translational cancer research. Our PDMS-made BT-on-chip system allows highly precise manual insertion of clinical BT seeds, reliable dose calculation using standard clinically-used TG-43 formalism and easy culture of naturally hypoxic spheroids in less than 3 days, thereby increasing the translational potential of the device. As the BT-on-chip platform is designed to be versatile, we showcase three different gold-standard post-irradiation bioassays and recapitulate, for the first time on-chip, key clinical observations such as dose rate effect and hypoxia-induced radioresistance. Our results suggest that BT-on-chip can be used to safely and efficiently integrate BT and radiotherapy to translational research and drug development pipelines, without expensive equipment or complex workflows.

[French national standard for the treatment of squamous cell carcinoma of upper aero-digestive tract - General principles of treatment]

OBJECTIVES

The management of upper aerodigestive tract cancers is a complex specialty. It is essential to provide an update to establish optimal care. At the initiative of the INCa and under the auspices of the SFORL, the scientific committee, led by Professor Béatrix Barry, Dr. Gilles Dolivet, and Dr. Dominique De Raucourt, decided to develop a reference framework aimed at defining, in a scientific and consensus-based manner, the general principles of treatment for upper aerodigestive tract cancers applicable to all sub-locations.

METHODOLOGY

To develop this framework, a multidisciplinary team of practitioners was formed. A systematic analysis of the literature was conducted to produce recommendations classified by grades, in accordance with the standards of the French National Authority for Health (HAS).

RESULTS

The grading of recommendations according to HAS standards has allowed the establishment of a reference for patient care based on several criteria. In this framework, patients benefit from differentiated care based on prognostic factors they present (age, comorbidities, TNM status, HPV status, etc.), conditions of implementation, and quality criteria for indicated surgery (operability, resectability, margin quality, mutilation, salvage surgery), as well as quality criteria for radiotherapy (target volume, implementation time, etc.). The role of medical and postoperative treatments was also evaluated based on specific criteria. Finally, supportive care must be organized from the beginning and throughout the patients' care journey.

CONCLUSION

All collected data have led to the development of a comprehensive framework aimed at harmonizing practices nationally, facilitating decision-making in multidisciplinary consultation meetings, promoting equality in practices, and providing a state-of-the-art and reference practices for assessing the quality of care. This new framework is intended to be updated every 5 years to best reflect the latest advances in the field.

Interstitial brachytherapy for lip carcinomas: Comparison between Ir-192 low-dose-rate and high-dose-rate treatment

PURPOSE

Low-dose-rate (LDR) and high-dose-rate (HDR) interstitial brachytherapy are known to be effective in the treatment of lip carcinomas. The aim of this study was to retrospectively compare oncologic and toxicity outcomes between the two techniques.

PATIENTS AND METHODS

From 2007 to 2018, patients at the Institut de cancérologie de Lorraine (France) who received exclusive or adjuvant interstitial brachytherapy for lip squamous carcinomas were studied. Two groups were defined: the LDR/PDR group, including patients treated with iridium-192 wires, or pulsed-dose rate technique, and the high-dose-rate group, with patients treated by high-dose-rate technique. The dose ranged between 50Gy and 65Gy (depending on previous surgery) for low-dose-/pulsed-dose rate treatments, and 39Gy for high-dose-rate (twice a day). Early, late toxicity events and oncologic control were reported.

RESULTS

Among the 61 patients whose data were analyzed retrospectively, 36 received the low-dose-/pulsed-dose rate treatment (59%) and 25 the high-dose-rate brachytherapy (41%). The median follow-up time was 44 months. At 36 months, the local control rates were 96.3% for LDR/PDR group and 100% for HDR (P=0.180). The regional control rates were 85.9% and 92% without any difference according to the two groups (P=0.179). The specific overall survival rate was 95.5% with no difference between groups. There were more grade 2 or higher mucositis in the HDR group than in LDR/PDR group (40% versus 16.7%, P=0.042). One case of grade 3 mucositis was recorded in each group. No grade 3 late complications were recorded. High-dose-rate brachytherapy reduced the length of hospitalization by 2 days (P<0.001).

CONCLUSION

High-dose- or low-dose-/pulsed-dose rate brachytherapy seemed to be as effective and well tolerated in our experience of 61 patients.

Pilot Evaluation of Perioperative High Dose Rate Brachytherapy in Head Neck Cancers

Perioperative high dose rate brachytherapy involves insertion of brachytherapy catheter over the tumor bed during surgical removal of disease followed by radiation in the postoperative period. It has applications in radiotherapy dose escalation or reirradiation and for extending the surgical margins. We report here initial results of treatment in five cases of locally advanced head and neck cancers.

Status of head and neck brachytherapy in Spain in 2022

PURPOSE

Brachytherapy (BT) has been used for many years for disease control in tumours of the head and neck area (H&N). It is currently performed with high dose rate (HDR) or pulsed dose rate (PDR), but its use has been reduced due to the implementation of new non-invasive external beam radiotherapy techniques such as intensity modulation (IMRT) and volumetric modulated arc therapy (VMAT) and the improvement of surgical techniques.

METHODS

The Spanish Brachytherapy Group (GEB) has carried out a survey to find out the number of centres in Spain that continue to use BT in H&N and its indications and expectations for the future.

RESULTS

The results were presented at the XX GEB Consensus Meeting held on October 21, 2022, in Valencia (Spain) and it was confirmed that, although there are fewer and fewer centres that use BT in H&N, there are still units with extensive experience in this technique that should be positioned as referral centres.

CONCLUSION

It is necessary to carry out continuous work with other specialities involved, such as H&N surgeons, and other radiation oncologists, to improve the training of residents, both oncologists and medical physicists.

Dosimetric comparison of postoperative interstitial high-dose-rate brachytherapy and modern external beam radiotherapy modalities in tongue and floor of the mouth tumours in terms of doses to critical organs

BACKGROUND

The aim of the study was to dosimetrically compare interstitial high-dose-rate (HDR) brachytherapy (BT) and modern external beam radiotherapy modalities, as volumetric modulated arc therapy (VMAT) and stereotactic radiotherapy with Cyberknife (CK) of tumours of the tongue and floor of the mouth in terms of dose to the critical organs.

PATIENTS AND METHODS

In National Institute of Oncology, Budapest, between March 2013 and August 2022 twenty patients (11 male/9 female) with stage T1-3N0M0 tongue (n = 14) and floor of mouth (n = 6) tumours received postoperative radiotherapy because of close/positive surgical margin and/or lymphovascular and/or perineural invasion. High-dose-rate interstitial brachytherapy applying flexible plastic catheters with a total dose of 15 × 3 Gy was used for treatment. In addition to BT plans VMAT and stereotactic CK plans were also made in all cases, using the same fractionation scheme and dose prescription. As for the organs at risk, the doses to the mandible, the ipsilateral and the contralateral salivary glands were compared.

RESULTS

The mean volume of the planning target volume (PTV) was 12.5 cm3, 26.5 cm3 and 17.5 cm3 in BT, VMAT and CK techniques, respectively, due to different safety margin protocols. The dose to the mandible was the most favourable with BT, as for the salivary glands (parotid and submandibular) the CK technique resulted in the lowest dose. The highest dose to the critical organs was observed with the VMAT technique. The mean values of D2cm3 and D0.1cm3 for the critical organs were as follows for BT, VMAT and CK plans: 47.4% and 73.9%, 92.2% and 101.8%, 68.4% and 92.3% for the mandible, 4.8% and 6.7%, 7.3% and 13.8%, 2.3% and 5.1% for the ipsilateral parotid gland, 3.5% and 4.9%, 6.8% and 10.9%, 1.5% and 3.3% for the contralateral parotid gland, 7.3% and 9.4%, 9.0% and 14.3%, 3.6% and 5.6% for the contralateral submandibular gland.

CONCLUSIONS

The present results confirm that BT, despite being an invasive technique, is dosimetrically clearly beneficial in the treatment of oral cavity tumours and is a modality worth considering when applying radiotherapy, not only as definitive treatment, but also postoperatively. The use of the CK in the head and neck region requires further investigation.

Inverse planning optimization with lead block effectively suppresses dose to the mandible in high-dose-rate brachytherapy for tongue cancer

PURPOSE

In this study, we developed in-house software to evaluate the effect of the lead block (LB)-inserted spacer on the mandibular dose in interstitial brachytherapy (ISBT) for tongue cancer. In addition, an inverse planning algorithm for LB attenuation was developed, and its performance in mandibular dose reduction was evaluated.

METHODS

Treatment plans of 30 patients with tongue cancer treated with ISBT were evaluated. The prescribed dose was 54 Gy/9 fractions. An in-house software was developed to calculate the dose distribution based on the American Association of Physicists in Medicine (AAPM) Task Group No.43 (TG-43) formalism. The mandibular dose was calculated with consideration of the LB attenuation. The attenuation coefficient of the lead was computed using the PHITS Monte Carlo simulation. The software further optimized the treatment plans using an attraction-repulsion model (ARM) to account for the LB attenuation.

RESULTS

Compared to the calculation in water, the D2 cc of the mandible changed by - 2.4 ± 2.3 Gy (range, - 8.6 to - 0.1 Gy) when the LB attenuation was considered. The ARM optimization with consideration of the LB resulted in a - 2.4 ± 2.4 Gy (range, - 8.2 to 0.0 Gy) change in mandibular D2 cc.

CONCLUSIONS

This study enabled the evaluation of the dose distribution with consideration of the LB attenuation. The ARM optimization with lead attenuation further reduced the mandibular dose.

Therapeutic strategy for oncovirus-mediated oral cancer: A comprehensive review

Oral cancer is a neoplastic disorder of the oral cavities, including the lips, tongue, buccal mucosa, and lower and upper gums. Oral cancer assessment entails a multistep process that requires deep knowledge of the molecular networks involved in its progression and development. Preventive measures including public awareness of risk factors and improving public behaviors are necessary, and screening techniques should be encouraged to enable early detection of malignant lesions. Herpes simplex virus (HSV), human papillomavirus (HPV), Epstein-Barr virus (EBV), and Kaposi sarcoma-associated herpesvirus (KSHV) are associated with other premalignant and carcinogenic conditions leading to oral cancer. Oncogenic viruses induce chromosomal rearrangements; activate signal transduction pathways via growth factor receptors, cytoplasmic protein kinases, and DNA binding transcription factors; modulate cell cycle proteins, and inhibit apoptotic pathways. In this review, we present an up-to-date overview on the use of nanomaterials for regulating viral proteins and oral cancer as well as the role of phytocompounds on oral cancer. The targets linking oncoviral proteins and oral carcinogenesis were also discussed.

High-dose-rate brachytherapy at 3 Gy per fraction for lip carcinoma: Treatment outcomes and toxicity at 5-years

PURPOSE

Low-dose-rate brachytherapy (LDR-BT) is a well-established treatment for lip cancer. High-dose-rate (HDR)-BT is a promising alternative to LDR-BT, but data are limited. In this context, we retrospectively evaluated treatment outcomes in a series of patients who underwent HDR-BT for lip carcinoma between 2003 and 2021.

MATERIALS AND METHODS

A total of 32 patients were included in this study, with a median age of 73.5 years (range, 61 - 88). The indications for HDR-BT were as follows: primary treatment (n = 17), adjuvant treatment (n = 3), and recurrent disease after surgery (n = 12). The prescribed dose was 18 fractions of 3 Gy administered twice daily.

RESULTS

At a median followup of 45 months (range, 12 -232), the 5-year local recurrence-free interval was 96.9% (95% CI: 90.9-100%), the disease-free interval was 85% (95% CI: 70.9-99.1), and 5-year overall survival was 64.7% (95% CI: 44.7-84.8). Eleven patients died, all on age related comorbidities. Acute toxicity manifested as G1 dry desquamation in 6 patients (18.8%), G2 erythema in 10 patients (31.2%) and G3 confluent moist desquamation in 16 patients (50%). Late complications included G1 fibrosis (100% of cases). G1 and G2 depigmentation was observed in 8 (25%) and 6 (18%) patients, G1 telangiectasia occurred in 5 patients (16%).

CONCLUSIONS

These data support the use of HDR-BT for lip cancer. The dose and fractionation schedule used in this study (18 fractions x 3 Gy twice daily) seems to be effective and safe.

Dose escalation in oropharyngeal cancer: a comparison of simultaneous integrated boost and brachytherapy boost

BACKGROUND

Local recurrence is the most common pattern of failure in head and neck cancer. It can therefore be hypothesised that some of these patients would benefit from an intensified local treatment, such as radiation dose escalation of the primary tumour. This study compares treatment and toxicity outcomes from two different boost modalities in oropharyngeal cancer: simultaneous integrated boost (SIB) and brachytherapy boost.

METHODS

Two hundred and forty-four consecutive patients treated with > 72 Gy for oropharyngeal squamous cell carcinoma between 2011 and 2018 at our institution were retrospectively analysed. Data on side effects were collected from a local quality registry and supplemented with a review of medical records. Patients receiving a brachytherapy boost first had external beam radiotherapy consisting of 68 Gy in 2 Gy fractions to the gross tumour volume (GTV), and elective radiotherapy to the neck bilaterally. The brachytherapy boost was typically given using pulsed dose rate, 15 fractions and 0.56-0.66 Gy per fraction [total dose in EQD2 = 75.4-76.8 Gy (α/β = 10)]. The typical dose escalated radiotherapy with external beam radiotherapy only, was delivered using SIB with 74,8 Gy in 2.2 Gy fractions [EQD2 = 76.0 Gy (α/β = 10)] to the primary tumour, 68 Gy in 2 Gy fractions to GTV + 10 mm margin and elective radiotherapy to the neck bilaterally.

RESULTS

Dose escalation by SIB was given to 111 patients and brachytherapy boost to 134 patients. The most common type of cancer was base of tongue (55%), followed by tonsillar cancer (42%). The majority of patients had T3- or T4-tumours and 84% were HPV-positive. The 5-year OS was 72,4% (95% CI 66.9-78.3) and the median follow-up was 6.1 years. Comparing the two different dose escalation modalities we found no significant differences in OS or PFS and these results remained after a propensity-score matched analysis was performed. The analysis of grade ≥ 3 side effects showed no significant differences between the two different dose escalation techniques.

CONCLUSIONS

We found no significant differences in survival or grade ≥ 3 side effects comparing simultaneous integrated boost and brachytherapy boost as alternative dose escalation modalities in the treatment of oropharyngeal cancer.

Photodynamic therapy treatment of oral cavity cancer in patients with comorbidities

We report the experience of radical treatment by photodynamic therapy of patients with squamous cell carcinoma of oral cavity with serious side diseases. Completed treatment of two patients with serious side diseases (HIV infection with associated pulmonary hypertension of high degree and cardiac pathology) suffered from cancer of oral cavity. Extensive surgical treatment and/or aggressive course of chemoradiation therapy were not indicated to them due to concomitant pathology. Both patients were diagnosed with squamous cell carcinoma of oral cavity, with appropriate stage Ist. сT1N0M0. Patients received treatment by photodynamic therapy with chorine photosensitizer in dose 1 mg/kg. Options of photodynamic were: output power – 1.5W, power density – 0.31 W/cm2, light dose – 300 J/cm2. After one time session of photodynamic therapy, in both cases full response was diagnosed (according to RECIST 1.1). In one case the second session of photodynamic therapy was performed due to concomitant disease of oral cavity – multiply lesions of leukoplakia and after was diagnosed full remission of all lesions. Major adverse event was pain during the first 5-7 days after treatment, curable by painkillers. Follow-up (IQR) was 12 and 18 month respectively with no evidence of progression. It is available to avoid extensive surgical treatment and aggressive course of chemoradiation therapy (as an alternative) with the use of photodynamic therapy. Photodynamic therapy is minimally invasive method of radical treatment of localized squamous cell carcinoma of oral cavity with minimal adverse events, and could be especially relevant in patients with serious concomitant diseases.

Results of sole postoperative interstitial, high-dose-rate brachytherapy of T1–2 tongue tumours

Purpose

To describe the results of treating tongue cancer patients with single postoperative interstitial, high-dose-rate (HDR) brachytherapy (BT) after resection.

Methods

Between January 1998 and April 2019, 45 patients with squamous cell histology, stage T1–2N0–1M0 tongue tumours were treated by surgery followed by a single HDR BT in case of negative prognostic factors (close or positive surgical margin, lymphovascular and/or perineural invasion). The average dose was 29 Gy (range: 10–45 Gy) and rigid metal needles were used in 11 (24%) and flexible plastic catheters in 34 cases (76%). Survival parameters, toxicities and the prognostic factors influencing survival were analysed.

Results

During a mean follow-up of 103 months (range: 16–260 months) for surviving patients, the 10-year local and regional control (LC, RC), overall survival (OS), and disease-specific survival (DSS) probabilities were 85, 73, 34 and 63%, respectively. The incidence of local grade 1, 2 and 3 mucositis was 23, 73 and 4%, respectively. As a serious (grade 4), late side effect, soft tissue necrosis developed in 3 cases (7%). In a univariate analysis, there was a significant correlation between lymphovascular invasion and RC (p = 0.0118) as well as cervical recurrence and DSS (p < 0.0001).

Conclusion

Sole postoperative HDR brachytherapy can be an effective method in case of negative prognostic factors in the treatment of early, resectable tongue tumours. Comparing the results of patients treated with postoperative BT to those who were managed with surgery or BT alone known from the literature, a slightly more favourable LC can be achieved with the combination therapy, demonstrating the potential compensating effect of BT on adverse prognostic factors, while the developing severe, grade 4 toxicity rate remains low.

Is There Still a Place for Brachytherapy in the Modern Treatment of Early-Stage Oral Cancer?

Simple Summary

Brachytherapy involves the direct application of radioactive sources to the tumour. This technique is characterised by a delivery of high dose of radiation to the target volume and simultaneous sparring of healthy tissues. Historically, low-dose-rate brachytherapy played an important role in the treatment of early-stage oral cancer, with treatment outcomes that were comparable to surgery. Interest in brachytherapy as a primary treatment for oral cancer has declined in recent years due to the emergence of better surgical techniques, to advances in external beam radiotherapy, and to concerns regarding toxicity of modern high-dose-rate brachytherapy. At present, the main indications for brachytherapy are in the postoperative setting due to the superior dose conformity and better quality of life offered by brachytherapy compared to external beam radiation therapy. Postoperative brachytherapy can be administered as a monotherapy in early-stage tumours (T1N0) and in combination with elective neck dissection or EBRT to treat larger or deeper tumours. Brachytherapy yields excellent results for lip carcinoma in older patients and in tumours with unfavourable localisations. Brachytherapy is an effective salvage therapy for local recurrences in previously-irradiated areas.

Abstract

Brachytherapy (BT) involves the direct application of radioactive sources to the tumour. This technique is characterised by a steep dose gradient, the delivery of high-dose radiation to the target volume centre, and the sparing of surrounding healthy tissues. Low-dose-rate (LDR) BT and manual afterloading played an important role in the treatment of early-stage oral cancer, with treatment outcomes that were comparable to surgery. Interest in BT as a primary treatment for oral cancer has declined in recent years due to the emergence of better surgical techniques, the switch from LDR BT to high-dose-rate (HDR) BT (which has a higher risk of complications), and to advances in external beam radiotherapy (EBRT). At present, the main indications for BT are in the postoperative setting due to the superior dose conformity and better quality of life offered by BT versus EBRT. Postoperative BT can be administered as monotherapy in early-stage (T1N0) cancers and in combination with elective neck dissection or EBRT to treat larger or deeper tumours. BT yields excellent results for lip carcinoma in older patients and in tumours with unfavourable localisations. BT is an effective salvage therapy for local recurrences in previously-irradiated areas. Despite its many advantages, brachytherapy is a complex treatment requiring meticulous technique and close cooperation between the radiation oncologist, physicist, and surgeon.

Radiotherapy for oral cavity cancers

Intensity modulated radiation therapy and brachytherapy are standard techniques of irradiation for the treatment of oral cavity cancers. These techniques are detailed in terms of indication, planning, delineation and selection of the volumes of interest, dosimetry and patients positioning control. This is an update of the guidelines of the French Society of Radiotherapy Correspondence.

Best practice in brachytherapy

The 2020 recommendations for good brachytherapy procedures ("Recorad") are updated based on the 2016 article. This new brachytherapy article took into account recent data published in the literature as well as international recommendations. The different brachytherapy steps are successively described from the treatment preparation (brachytherapy technique prescription; procedure and material, dedicated images for planification, dose distribution analysis and validation) to the end of the procedure as well as post-treatment surveillance.

Management of oropharyngeal squamous cell carcinoma

This article reviews the various treatment options, by primary or postoperative external radiotherapy and by brachytherapy for the p16-negative oropharyngeal squamous cell carcinoma. Dose levels, fractionation and association with systemic treatments are presented. The need for neck node dissection post local treatment is discussed, as well as specificities for the management of p16-positive tumours. Guidelines for target volume selection and delineation are thoroughly elaborated. Last, the management by radiotherapy of locoregional recurrences is discussed.

Long term outcomes of Carcinoma Buccal Mucosa treated with High Dose Rate Interstitial Brachytherapy

PURPOSE

To analyze the long-term local control, overall survival and toxicity in Carcinoma Buccal Mucosa patients treated with interstitial brachytherapy.

METHODS AND MATERIALS

This analysis included patients diagnosed as Carcinoma Buccal Mucosa on biopsy and treated with radical brachytherapy or External Beam Radiotherapy (EBRT) followed by brachytherapy boost. All patients received High dose rate (HDR) interstitial brachytherapy. The total dose was 35 Gy in ten fractions for brachytherapy alone. Patients who received EBRT (50-54 Gy) were boosted by brachytherapy to a dose of 18-24 Gy in 6-8 fractions. All patients were treated using CT based planning.

RESULTS

Between 2007 to 2017, a total of 24 patients of Carcinoma Buccal Mucosa received HDR interstitial brachytherapy either alone or as a boost. Majority of the patients were tobacco chewers (80%). 17(71%) patients were clinical stage T2N0M0 and 7(29%) were clinically T1N0M0. At a median follow up of 7 years (3-12 years), the local control rate was 100% in stage I and 88% in stage II. The 5 year overall survival rate was 80%. Two patients developed nodal recurrence and one patient developed distant metastasis within two years of treatment. Tumor size and brachytherapy technique (radical vs. boost) did not impact local control or overall survival (p > 0.05). Majority of the acute toxicities were Grade 1 and 2. One patient developed osteoradionecrosis of the mandible.

CONCLUSIONS

Interstitial brachytherapy in early-stage Buccal Mucosa cancer either alone or as a boost provides excellent long term local control and overall survival. The acute and late toxicities are acceptable with majority of the patients presenting with Grade 1 or 2 toxicity.

High dose interstitial brachytherapy for treatment of carcinoma of the lip as an alternative to surgery: a case report

Lip cancer (LC) is the most common cancer of the oral cavity and is the second most common in the head and neck. Brachytherapy (BT) is a good treatment option for this type of cancer because it administers high doses of radiation to the target. BT has similar cure and survival rates as surgery for the same type of cancer, but it often produces more favourable aesthetic results, especially when the tumour is treated in its early stages. We present a case of a patient diagnosed with stage II lower LC who refused surgical treatment. Instead, high-dose-rate interstitial BT was performed with ¹⁹²Ir. A 2-year post-treatment follow-up indicated there were neither serious complications nor recurrence of cancer during that period.

ACR-ABS-ASTRO practice parameter for the performance of radionuclide-based high-dose-rate brachytherapy

PURPOSE

This practice parameter aims to detail the processes, qualifications of personnel, patient selection, equipment, patient and personnel safety, documentation, and quality control and improvement necessary for an HDR brachytherapy program.

METHODS AND MATERIALS

This practice parameter was revised collaboratively by the American College of Radiology (ACR), the American Brachytherapy Society (ABS), and the American Society for Radiation Oncology (ASTRO).

RESULTS

Brachytherapy is a radiotherapeutic modality in which radionuclide or electronic sources are used to deliver a radiation dose at a distance of up to a few centimeters by surface, intracavitary, intraluminal, or interstitial application. Brachytherapy alone or combined with external beam radiotherapy plays an important role in the management and treatment of patients with cancer. High-dose-rate (HDR) brachytherapy uses radionuclides, such as iridium-192, at dose rates of ≥12 Gy/hr to a designated target point or volume, and it is an important treatment for a variety of malignant and benign conditions. Its use allows for application of high doses of radiation to defined target volumes with relative sparing of adjacent critical structures.

CONCLUSIONS

HDR brachytherapy requires detailed attention to personnel, equipment, patient and personnel safety, and continuing staff education. Coordination between the radiation oncologist and treatment planning staff and effective quality assurance procedures are important components of successful HDR brachytherapy programs.

Salvage brachytherapy with or without external beam radiotherapy for oral or oropharyngeal squamous cell carcinomas in previously irradiated areas: carcinologic and toxicity outcomes of 25 patients

Purpose

The aim of this study was to assess outcomes of salvage brachytherapy for oral and oropharyngeal squamous cell carcinoma in previously irradiated areas.

Material and methods

This was a retrospective study with 25 patients, treated between 1997 and 2016 for primary (21 cases) or recurrent (4 cases) oral or oropharyngeal squamous cell carcinomas in previously irradiated areas. Fifteen patients were treated with salvage brachytherapy (BT) alone, while 10 patients additionally received external beam radiotherapy (EBRT). Median BT dose was 45 Gy (range, 15-64 Gy), and a median total cumulative dose was 57 Gy (range, 40-70 Gy). Patient age, tumor stage, radiotherapy dose, and time between first treatment and recurrence were analyzed as prognostic factors.

Results

Median overall survival (OS) was 16 months. Patients with less advanced (T1) tumors survived significantly longer (27 vs. 14.5 months, p = 0.046). Five patients experienced a local recurrence, and only one of them was treated with a total dose greater than 60 Gy. In multivariate analysis, patients with T1 lesions had a significant higher OS rate compared to patients with larger lesions (HR = 6.25, 95% CI: 1.18-33.1%, p = 0.031). Patients who received more than 60 Gy had a non-significant, 80% increased OS than those treated with a lower dose (p = 0.072). There was four grade 3 acute toxicities, and no grade 3 or more late toxicities.

Conclusions

Multimodal treatment, including salvage BT, may offer a curative option for selected patients with an acceptable risk of severe toxicity for the treatment of primary or recurrent tumors in previously irradiated areas.

Recommendations for intraoperative mesh brachytherapy: Report of AAPM Task Group No. 222

Mesh brachytherapy is a special type of a permanent brachytherapy implant: it uses low-energy radioactive seeds in an absorbable mesh that is sutured onto the tumor bed immediately after a surgical resection. This treatment offers low additional risk to the patient as the implant procedure is carried out as part of the tumor resection surgery. Mesh brachytherapy utilizes identification of the tumor bed through direct visual evaluation during surgery or medical imaging following surgery through radiographic imaging of radio-opaque markers within the sources located on the tumor bed. Thus, mesh brachytherapy is customizable for individual patients. Mesh brachytherapy is an intraoperative procedure involving mesh implantation and potentially real-time treatment planning while the patient is under general anesthesia. The procedure is multidisciplinary and requires the complex coordination of multiple medical specialties. The preimplant dosimetry calculation can be performed days beforehand or expediently in the operating room with the use of lookup tables. In this report, the guidelines of American Association of Physicists in Medicine (AAPM) are presented on the physics aspects of mesh brachytherapy. It describes the selection of radioactive sources, design and preparation of the mesh, preimplant treatment planning using a Task Group (TG) 43-based lookup table, and postimplant dosimetric evaluation using the TG-43 formalism or advanced algorithms. It introduces quality metrics for the mesh implant and presents an example of a risk analysis based on the AAPM TG-100 report. Recommendations include that the preimplant treatment plan be based upon the TG-43 dose calculation formalism with the point source approximation, and the postimplant dosimetric evaluation be performed by using either the TG-43 approach, or preferably the newer model-based algorithms (viz., TG-186 report) if available to account for effects of material heterogeneities. To comply with the written directive and regulations governing the medical use of radionuclides, this report recommends that the prescription and written directive be based upon the implanted source strength, not target-volume dose coverage. The dose delivered by mesh implants can vary and depends upon multiple factors, such as postsurgery recovery and distortions in the implant shape over time. For the sake of consistency necessary for outcome analysis, prescriptions based on the lookup table (with selection of the intended dose, depth, and treatment area) are recommended, but the use of more advanced techniques that can account for real situations, such as material heterogeneities, implant geometric perturbations, and changes in source orientations, is encouraged in the dosimetric evaluation. The clinical workflow, logistics, and precautions are also presented.

Perioperative high dose rate brachytherapy in head and neck cancers: case report and review of clinical application

Perioperative high dose rate brachytherapy is a radiotherapy treatment technique which involves intraoperative insertions of brachytherapy catheters into the tumor bed during the surgical resection followed by treatment in the post-operative period. We report here two cases to highlight its use in the primary treatment and reirradiation of head and neck cancers.

A review of dosimetric impact of implementation of model-based dose calculation algorithms (MBDCAs) for HDR brachytherapy

To obtain dose distributions more physically representative to the patient anatomy in brachytherapy, calculation algorithms that can account for heterogeneity are required. The current standard AAPM Task Group No 43 (TG-43) dose calculation formalism has some clinically relevant dosimetric limitations. Lack of tissue heterogeneity and scattered dose corrections are the major weaknesses of the TG-43 formalism and could lead to systematic dose errors in target volumes and organs at risk. Over the last decade, model-based dose calculation algorithms (MBDCAs) have been clinically offered as complementary algorithms beyond the TG43 formalism for high dose rate (HDR) brachytherapy treatment planning. These algorithms provide enhanced dose calculation accuracy by using the information in the patient's computed tomography images, which allows modeling the patient's geometry, material compositions, and the treatment applicator. Several researchers have investigated the implementation of MBDCAs in HDR brachytherapy for dose optimization, but moving toward using them as primary algorithms for dose calculations is still lagging. Therefore, an overview of up-to-date research is needed to familiarize clinicians with the current status of the MBDCAs for different cancers in HDR brachytherapy. In this paper, we review the MBDCAs for HDR brachytherapy from a dosimetric perspective. Treatment sites covered include breast, gynecological, lung, head and neck, esophagus, liver, prostate, and skin cancers. Moreover, we discuss the current status of implementation of MBDCAs and the challenges.

Is Brachytherapy Feasible After Head and Neck Cancer Reconstructive Surgery? Preliminary Report

The purpose of the study was to evaluate the influence of interstitial postoperative brachytherapy for the vitality and quality of flaps used for reconstruction of tissue defects after head and neck cancer salvage resection. We aimed at presenting six consecutive patients with recurrent squamous cell carcinoma in head and neck region who underwent salvage surgery and tissue reconstruction with a regional or free flap followed by brachytherapy. Reconstruction was performed with a free radial forearm flap in 2 cases, with a free thigh flap in 2 cases, and with a myocutaneous lateral upper arm flap in the next 2 cases. In all patients, pulsed-dose-rate brachytherapy was used with a median value of 0.7 Gy (range 0.6–0.8 Gy) per pulse and a median total dose of 20 Gy (range 20–40 Gy). In the analyzed group, there were no serious wound and flap complications after brachytherapy. In one case, peripheral skin necrosis was noticed. No revision surgery was needed but only surgical debridement of the necrotic margins. All wounds healed within 14 days after surgery as well as donor sites which healed within 4 weeks. Based upon our data, pulsed-dose-rate brachytherapy seems to be a safe option that can be performed at the site of reconstruction in immediate postoperative period with minimal wound complications and with no impact on flap survival. Further clinical study based on larger patient series is needed to present statistically proven results.

Pulsed Dose Rate Brachytherapy of Lip Carcinoma: Clinical Outcome and Quality of Life Analysis

Simple Summary

Lip cancer accounts for 25–30% of all oral cancers, with 23,000 new cases per year in the world. Carcinomas of the lip can be successfully treated with different methods: surgery, external beam radiotherapy (EBRT) and brachytherapy. The choice of the treatment depends on the tumor size, location and expected functional and esthetic results with each option, but also depends on treatment type accessibility. There are no randomized studies comparing these different treatment strategies. In this article, we investigated the complications and outcomes of patients treated with interstitial pulsed dose rate brachytherapy in our institution.

Abstract

Purpose: Lip carcinoma represents one of the most common types of head and neck cancer. Brachytherapy is a highly effective therapeutic option for all stages of lip cancers. We report our experience of pulsed dose rate brachytherapy (PDR) as treatment of lip carcinoma. Methods and Materials: this retrospective single center study included all consecutive patients treated for a lip PDR brachytherapy in our institution from 2010 to 2019. The toxicities and outcomes of the patients were reported, and a retrospective quality of life assessment was conducted by phone interviews (FACT H&N). Results: From October 2010 to December 2019, 38 patients were treated in our institution for a lip carcinoma by PDR brachytherapy. The median age was 73, and the majority of patients presented T1-T2 tumors (79%). The median total dose was 70.14 Gy (range: 60–85 Gy). With a mean follow-up of 35.4 months, two patients (5.6%) presented local failure, and seven patients (19%) had lymph node progression. The Kaplan–Meier estimated probability of local failure was 7.2% (95% CI: 0.84–1) at two and four years. All patients encountered radiomucitis grade II or higher. The rate of late toxicities was low: three patients (8.3%) had grade II fibrosis, and one patient had grade II chronic pain. All patients would highly recommend the treatment. The median FACT H&N total score was 127 out of 148, and the median FACT H&N Trial Outcome Index was 84. Conclusions: This study confirms that an excellent local control rate is achieved with PDR brachytherapy as treatment of lip carcinoma, with very limited late side effects and satisfactory functional outcomes. A multimodal approach should help to improve regional control.

High-dose-rate brachytherapy for facial skin cancer: Outcome and toxicity assessment for 71 cases

PURPOSE

In France, the reference technique for skin cancer was low-dose-rate brachytherapy (BT) delivered via iridium wire. At the end of their commercialization in 2015 we have replaced them by high-dose-rate (HDR) BT via interstitial catheters. We assessed efficacy and tolerance as soon as this technique was implemented.

METHODS AND MATERIALS

Patients received 7 Gy on the first day, followed by 8 × 4 Gy over the next 4 days for exclusive BT and 9 × 4 Gy over 5 days for post-operative BT.

RESULTS

Sixty-six patients of median age 81 years received a total of 58 primary BT and 13 post-operative BT for non-melanoma facial skin cancers. Implantation was without difficulty. Median follow up was 15.3 months. Two patients died of intercurrent diseases before first follow up. For the others, 98.5% showed complete response and 3% local recurrence after a median of 20.5 months. Four patients had grade 3 acute dermatitis and three patients had grade 3 mucositis. All the Grade 3 toxicities were resolved within 3 months. A late significant hypopigmentation occurred in 4 patients.

CONCLUSIONS

HDR BT is efficient and well-tolerated with good cosmetic results. HDR catheters are similar with iridium wires in terms of technical difficulty.

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.

Results of postoperative interstitial brachytherapy of resectable floor of mouth tumors

PURPOSE

The purpose of this study was to describe the results of postoperative sole interstitial brachytherapy (BT) in patients with resectable floor of mouth tumors.

METHODS AND MATERIALS

Between January 1998 and December 2017, 44 patients with squamous cell histology, stage T1-3N0-1M0 floor of mouth tumor were treated by excision of the primary lesion with or without neck dissection followed by sole high-dose-rate tumor bed BT with an average dose of 22.7 Gy (10-45 Gy) using rigid metal needles (n = 14; 32%) or flexible plastic catheters (n = 30; 68%).

RESULTS

During a median followup time of 122 months for surviving patients, the probability of 5- and 10-year local and regional tumor control, overall survival (OS), and disease-specific survival (DSS) was 89% and 89%, 73% and 67%, 52% and 32%, 66% and 54%, respectively. In univariate analysis, lymphovascular invasion was a negative predictor of regional tumor control (p = 0.0062), DSS (p = 0.0056), and OS (p = 0.0325), whereas cervical recurrence was associated with worse DSS (p < 0.0001) and OS (p < 0.0001). The incidence of local Grade 1, 2, and 3 mucositis was 25%, 64%, and 11%, respectively. Grade 4 side effect, that is soft tissue necrosis occurred in four cases (9%).

CONCLUSIONS

Results of postoperative sole high-dose-rate BT of floor of mouth tumors are comparable with those reported with low-dose-rate BT, and this method could improve local tumor control and DSS compared with exclusive surgical treatment.

Brachytherapy for Oral Cavity Cancers in the Era of Intensity-Modulated Radiotherapy: Save it or Shelve it

Head and neck cancer treatment includes a multidisciplinary approach involving all specialties. Surgery and radiotherapy are equally effective in controlling small tumors. Intensity-modulated radiotherapy (IMRT) and interstitial brachytherapy (ISBT) play an important role in the treatment of head and neck cancers. Both are proved to be highly conformal techniques of radiotherapy. Our aim is to compare dosimetric aspects of ISBT alone, IMRT alone, and IMRT combined with ISBT in early stage node negative oral cavity cancer. Ten cases of histopathologically proven early stage node negative oral cavity cancer were treated with external beam therapy followed by interstitial brachytherapy boost or ISBT alone. All these patients had undergone computerized tomography (CT) planning for brachytherapy. Retrospectively, these images were utilized, and three sets of plans were done for each patient's CT image set. Group A was IMRT alone plans, groups B had combined IMRT with ISBT boost, and group C was ISBT alone plans. Dosimetric details such as target coverage, dose to critical organs, and conformity index were compared between the three sets of plans. The mean values of the doses to the critical organs with IMRT alone and IMRT with ISBT boost were brainstem 10.40 Gy and 9.20 Gy, spinal cord 19.20 Gy and 16.10 Gy, mandible 62.99 Gy and 66.50 Gy, and I/L and C/L parotids were 6.03 Gy and 5.50 Gy and 5.70 Gy and 5.10 Gy where as in ISBT alone plans mean values were brainstem 1.30 Gy, spinal cord 1.40 Gy, mandible 36.50 Gy, I/L, and C/L parotids were 1.60 Gy and 1.00 Gy. Conformity index (CI) between IMRT and ISBT plans were 0.8580 and 0.7140 respectively. With comparable CI values, doses to critical organs appear to be in favor of ISBT plans as opposed to IMRT, and this was found to be statistically significant. Brachytherapy shows a dosimetric advantage over IMRT in this setting and could be translated to a benefit in terms of toxicities, organ preservation, and cosmesis in the actual clinical scenario. However, whether this would translate to significant benefit in terms of clinical outcome needs to be still verified.

Brachytherapy in head and neck malignancies: Indian Brachytherapy Society (IBS) recommendations and guidelines

PURPOSE

Brachytherapy (BT) forms major treatment modality in squamous cell carcinoma of head and neck cancers (HNC). However, there is a dearth of literature and guidelines for the use in various indications. High-dose-rate brachytherapy (HDR-BT) in Indian scenario is an important treatment modality, and the recommendations in this guidelines aim to provide the necessary recommendations for the use of HDR-BT for uniform application across the country in patients with HNC.

MATERIAL AND METHODS

A panel consisting of members of the Indian Brachytherapy Society (IBS), based on their clinical experience was invited. The process involved defining important steps, precautions, target volumes and indications, thorough literature review, and discussion with fellow members. The guidelines were established and formulated the recommendations for HDR-BT based on available evidences and individual experience for sites, relevant to Indian settings.

RESULTS

The IBS recommends the use of HDR brachytherapy as a part of treatment of head and neck tumors. The scope of these guidelines and recommendations included practical suggestions, ensuring efficient use of brachytherapy treatment as radical with external beam radiotherapy (EBRT) boost, palliative and adjuvant as definitive, or re-radiation as salvage for HNC in India. The IBS has made specific site-wise recommendations for previously untreated and recurrent HNC patients on their selection criteria, implant techniques, target volume definition, and HDR treatment parameters, such as time, dose rate, total dose, and fractionation schedules. Limited experience exists with HDR-BT in patients with head and neck cancers in India and across the globe.

CONCLUSIONS

IBS provided a consensus statement and guidelines for the head and neck brachytherapy and believed that these recommendations will overcome the fear of practicing radiation oncologists. This should generate interest amongst students and will help radiation oncologists all across the country to use the art of brachytherapy carefully in HNC patients, with better curative and salvage options.

Interventional radiotherapy (brachytherapy) achieves very good long-term quality of life in children and adolescents with soft-tissue sarcoma

BACKGROUND

Effective local therapy (surgery, radiation) and systemic multidrug chemotherapy are mandatory for curing childhood sarcoma. The standard radiation therapy for pediatric patients with soft-tissue sarcoma (STS) is external beam radiotherapy (EBRT). Because EBRT may cause long-term side effects with adverse effects on the patients' health and quality of life (QoL), alternative strategies are required. Interventional radiotherapy (IRT; brachytherapy) is established as a standard treatment for several tumors in adulthood. Single-center series have reported low levels of late effects and improved QoL in survivors treated with IRT in childhood. However, IRT is still applied infrequently in pediatric patients.

METHODS

Thirty patients with STS were treated with IRT between 1992 and 2012 at the University Hospital Schleswig Holstein, Germany. Five patients were lost to follow-up, and 25 patients (mean age at time of data collection 24.8 years [range, 10.7-36.1]) could be analyzed focusing on overall survival and QoL (EORTC-C30 questionnaire). For more detailed information regarding general and health-specific questions, a separate questionnaire was developed.

RESULTS

Nineteen of 25 patients were alive 13.4 [1.6-25.2] years after first cancer disease, and the three-year overall survival was 76% (SE, 0.09). The score of QoL/global health status (76.2 [16.6-100]) in our patients outvalues the European (66.1) and equals the German (75.9) reference value.

CONCLUSION

IRT is an effective treatment option for pediatric patients with localized STS. Its role among other radiation dose-sparing techniques such as proton beam therapy has to be defined in prospective studies.

Image-guided interstitial brachytherapy boost for keratinizing squamous cell carcinoma of inferior wall of the nasopharynx

High-dose-rate interstitial brachytherapy (HDR-ISBT) is relatively rarely applied for the head and neck cancer because of its anatomical complexity and difficulty of applicator placement. However, its dose distribution is more confined even better than intensity-modulated radiation therapy (IMRT) and can deliver a higher dose while sparing surrounding normal tissues. In this case report, the effectiveness of HDR-ISBT as a boost following IMRT for keratinizing squamous cell carcinoma of nasopharynx was presented. A 76-year-old female who suffered from cT3N0M0 keratinizing squamous cell carcinoma of the nasopharynx was treated with definitive concurrent chemoradiation therapy involving IMRT. However, physical examination and laryngoscope fibre finding showed evident residual tumour at 60 Gy of IMRT, then, boost HDR-ISBT was proposed. After delivering 66 Gy of IMRT, CT image-guided HDR-ISBT 4 Gy in a single fraction was performed under local anaesthesia and sedation. MRI taken 5 months after HDR-ISBT showed remarkable shrinkage of the primary tumour. After HDR-ISBT, the remaining session of IMRT was delivered from the next day until 70 Gy in 35 fractions. It was demonstrated that boost HDR-ISBT combined with IMRT for keratinizing squamous cell carcinoma of the nasopharynx was performed safely and showed favourable efficacy.

A multicenter prospective phase II study of postoperative hypofractionated stereotactic body radiotherapy (SBRT) in the treatment of early-stage oropharyngeal and oral cavity cancers with high risk margins: the STEREO POSTOP GORTEC 2017-03 trial

Background

Primary surgery is usually the mainstay treatment in early-stage oropharyngeal and oral cavity cancer. Typically, neck surgery is performed. Negative tumor margins are recommended (> 5 mm). If feasible, re-resection of any positive margin is preferred. Otherwise, postoperative radiotherapy is required. Adjuvant postoperative radiotherapy can be limited to the primary site for patients with pT1-T2 tumors and negative neck exploration. Currently, both fractionated external beam radiotherapy and brachytherapy can have a role in the postoperative management of early-stage oropharyngeal and oral cavity cancer with high risk margins. Another possible alternative could be postoperative stereotactic body radiotherapy (SBRT). The aim of this study is to evaluate postoperative SBRT in the treatment of early-stage oropharyngeal and oral cavity cancer with high risk margins.

Methods

The STEREO POSTOP study is a national, open-label, non-randomized phase II trial within the GORTEC network. Patients with early-stage oropharyngeal and oral cavity cancers with high risk margins indicating the need for postoperative radiation are eligible for enrollment. SBRT consists of a total dose of 36 Gy in 6 fractions over 2 weeks. The primary endpoint is severe late toxicity defined as 2-year toxicity of grade ≥ 3 according to CTCAE V4.03 classification. The secondary endpoints include acute toxicity (≤ 3 months), local and locoregional control, disease-free and overall survival, quality of life of patients, nutritional impact and predictive factors of toxicity. The experimental design chosen is a one-step Fleming plan design without interim analysis as the primary endpoint will be evaluated at a 2-year follow-up. Ninety patients will be recruited. The study was started in January 2018 with a 4-year enrollment period and an estimated completion in January 2024.

Discussion

This study is the first prospective trial to evaluate head and neck cancer postoperative SBRT in the setting of early-stage oropharyngeal and oral cavity cancers with high risk margins. SBRT is an attractive option because it delivers a highly conformal dose of radiation in a limited number of fractions (like brachytherapy but with less contraindication), with steep dose gradients resulting in reduced normal tissue irradiation and with a short overall treatment time.

Trial registration

Clinicaltrials.gov: NCT03401840, registered on 17-1-2018. Identifier in French National Agency for the Safety of Medicines and Health Products (ANSM): N°ID - RCB 2017-A02058–45, registered on July 2017.

Protocol version: Version 3 dated from 25th November 2019.

Single-fraction image-guided high-dose-rate brachytherapy for head and neck cancer: three cases of palliative brachytherapy

Purpose

To present a small series of cases, in which single-fraction image-guided high-dose-rate (HDR) brachytherapy was provided as palliative treatment for inoperable head and neck cancer cases.

Material and methods

We used this technique to treat 3 patients with symptomatic head and neck cancer (tongue cancer, gingival metastasis of osteosarcoma, and external auditory canal cancer), who were not eligible for a definitive treatment. The purpose of palliative brachytherapy in all 3 patients was the relief of symptoms such as difficulty in eating, talking, and hearing. All patients were treated with computed tomography (CT) image-guided interstitial HDR brachytherapy under local anesthesia in an outpatient setting, with a single dose of 10 Gy.

Results

Satisfactory palliative effects were achieved in all cases without serious side effects. The palliative effects were sustained in 2 patients until death, and 1 patient lived for 39 weeks before a relapse.

Conclusions

Our palliative treatment technique appears to be safe, effective, and less invasive, and could be a treatment option for symptomatic patients with head and neck cancer.

Modern development of high-dose-rate brachytherapy

Brachytherapy is an invasive therapy with placement of radiation source into or near the tumor. The difference between planning target volume and clinical target volume is minimal, and the dose out of the tumor reduces rapidly due to the inverse-square law. High-dose-rate brachytherapy enables three-dimensional image guidance, and currently, tumor dose as well as doses of the surrounding normal structures can be evaluated accurately. High-dose-rate brachytherapy is the utmost precision radiation therapy even surpassing carbon ion therapy. Biological disadvantages of high-dose rate have been overcome by the fractional irradiation. High-dose-rate brachytherapy is indispensable in the definitive radiation therapy of cervical cancer. Also in prostate cancer and breast cancer, high-dose-rate brachytherapy plays a significant role. Brachytherapy requires techniques and skills of radiation oncologists at the time of invasive placement of the radiation source into the tumor area. Education of young radiation oncologists is most urgent and important.