Brachytherapy for primary and recurrent nasopharyngeal carcinoma: 20 years' experience at Long Beach Memorial

Skin Sparing in Intensity-Modulated Radiation Therapy of Nasopharyngeal Carcinoma

Background and Purpose

Radiation therapy of nasopharyngeal carcinomas (NPCs) involves high doses to the target structures which are superficial to the skin surfaces. As a result, the skin toxicities involved are higher and sometimes worsens to such an extent that radiotherapy needs to be interrupted unplanned. This leads to a break in radiation therapy which overall affects the local control and cure rates. The aim of this study is to decrease the skin dose by contouring skin as an organ at risk (OAR) to include in inverse planning calculation.

Materials and Methods

Seventy-three cases of nasopharyngeal cancers were planned for 60 Gy to intermediate-risk planning target volume (PTVIntermediate) and 70 Gy to high risk (PTVHigh), by three different modes of Intensity-modulated radiation therapy (IMRT)- namely conventional sequential intensity-modulated radiation therapy (S-IMRT PH-I and PH-II), Skin Spared sequential intensity-modulated radiation therapy (SS-IMRT PH-I and PH-II), and Skin Spared simultaneously instantaneous boost intensity-modulated radiation therapy (SS-SIB IMRT). The plans were compared by dose volume histograms and dose statistics to the PTV as well as to the OAR's. For PTV, mean dose (Dmean), maximum dose (Dmax), and minimum dose (Dmin) were compared to check the homogeneity index (HI) while sparing the skin. For other OAR's Dmean, Dmax and dose to to 1 cubic cm was used for comparison. The skin doses to various volumes from volume to receive 5 Gy (V5) to volume to receive 70 Gy (V70) were evaluated and compared between the three techniques. Statistical analysis was done using one away ANOVA on the data editor SPSS Version 26.0 (SPSS Inc., Chicago, Illinois, USA) to evaluate the results. Continuous variables were expressed as mean ± standard deviation, and categorical variables were summarized as frequencies and percentages. Survival analysis was done by Kaplan-Meier Estimator.

Results

When the skin was considered as an OAR, the skin volume to receive 5, 10, 15, 20, 30, 40, 50, 60, 70 Gy was reduced by 6.5%, 6.5%, 6%, 11.5%, 7%, 6%, 6%, 5%, 2%, respectively, by SS-IMRT PH-I and II and 2%, 4.05%, 4%, 7%, 5%, 3%, 6%, 5%, 1%, respectively, by SS-SIB IMRT when both the SS techniques were compared with S-IMRT PH-I and II. Volume of skin to receive 20 Gy showed maximum reduction in SS-IMRT PH-I and II. A one-way ANOVA was carried out to find the differences in the skin doses between the three techniques. The skin dose in the two SS techniques, i.e., SS-IMRT PH-I and PH-II and SS-SIB IMRT was found significantly lower than that of IMRT plans without skin as an OAR, i.e., S-IMRT PH-I and PH-II (P = 0.000). The PTV doses were well within the 95%-107% of the prescribed dose (HI) and there were no significant differences in the means of the prescribed dose between the simple and skin spared IMRT techniques. The other OARs doses were also evaluated and there were no significant differences between the means of the doses among the techniques.

Conclusions

SS IMRT for NPC has demonstrated reduction in skin dose while using skin as an OAR in the optimization. Moreover, decreased skin dose can decrease the skin related toxicities provided there is no compromise on Target dose coverage and OAR dose. We recommend that skin should be contoured as an OAR for NPC, provided PTV is minimally 3-5 mm beneath skin surface, in order to have a better disease control with lesser toxicities and less unplanned treatment interruptions.

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.

Long-Term Outcomes of Three-Dimensional High-Dose-Rate Brachytherapy for Locally Recurrent Early T-Stage Nasopharyngeal Carcinoma

Background: Brachytherapy (BT) is one of the techniques available for retreatment of patients with locally recurrent nasopharyng eal carcinoma (rNPC). In this study, we evaluated the treatment outcome and late toxicities of three-dimensional high-dose-rate brachytherapy (3D-HDR-BT) for patients with locally rNPC. Materials and Methods: This is a retrospective study involving 36 patients with histologically confirmed rNPC from 2004 to 2011. Of the 36 patients, 17 underwent combined-modality treatment (CMT) consisting of external beam radiotherapy (EBRT) followed by 3D-HDR-BT, while the other 19 underwent 3D-HDR-BT alone. The median dose of EBRT for the CMT group was 60 (range, 50-66) Gy, with an additional median dose of BT of 16 (range, 9-20) Gy. The median dose for the 3D-HDR-BT group was 32 (range, 20-36) Gy. The measured treatment outcomes were the 5- and 10-year locoregional recurrence-free survival (LRFS), disease-free survival (DFS), overall survival (OS), and late toxicities. Results: The median age at recurrence was 44.5 years. The median follow-up period was 70 (range, 6-142) months. The 5-year LRFS, DFS, and OS for the entire patient group were 75.4, 55.6, and 74.3%, respectively, while the 10-year LRFS, DFS, and OS for the entire patient group were 75.4, 44.2, and 53.7%, respectively. The 10-year LRFS in the CMT group was higher than that in the 3D-HDR-BT-alone group (93.8 vs. 58.8%, HR: 7.595, 95%CI: 1.233-61.826, p = 0.025). No grade 4 late radiotherapy-induced toxicities were observed. Conclusions: 3D-HDR-BT achieves favorable clinical outcomes with mild late toxicity in patients with locally rNPC.

American Brachytherapy Society Task Group Report: Combined external beam irradiation and interstitial brachytherapy for base of tongue tumors and other head and neck sites in the era of new technologies

Irradiation plays an important role in the treatment of cancers of the head and neck providing a high locoregional tumor control and preservation of organ functions. External beam irradiation (EBI) results in unnecessary radiation exposure of the surrounding normal tissues increasing the incidence of side effects (xerostomy, osteoradionecrosis, and so forth). Brachytherapy (BT) seems to be the best choice for dose escalation over a short treatment period and for minimizing radiation-related normal tissue damage due to the rapid dose falloff around the source. Low-dose-rate BT is being increasingly replaced by pulsed-dose-rate and high-dose-rate BT because the stepping source technology offers the advantage of optimizing dose distribution by varying dwell times. Pulsed-dose and high-dose rates appear to yield local control and complication rates equivalent to those of low-dose rate. BT may be applied alone; but in case of high risk of nodal metastases, it is used together with EBI. This review presents the results and the indications of combined BT and EBI in carcinoma of the base of tongue and other sites of the head and neck region, as well as the role BT plays among other-normal tissue protecting-modern radiotherapy modalities (intensity-modulated radiotherapy, stereotactic radiotherapy) applied in these localizations.

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.

Customized individual applicators for endocavitary brachytherapy in patients with cancers of the nasal cavity, sinonasal region and nasopharynx

Brachytherapy has become an established therapeutic regimen for primary, persistent, recurrent and metastatic tumour disease in the head and neck region. This study presents the authors' preliminary experience with intracavitary brachytherapy by means of an individual silicone applicator in the treatment of patients with nasal, sinonasal, orbital and nasopharyngeal cancer. Between January 2001 and January 2013, twenty patients with cancer of the nasal cavity, the paranasal sinuses and nasopharynx underwent surgery and intracavitary brachytherapy with the aid of an individually manufactured silicone applicator in the Department of Otolaryngology, Head and Neck Surgery and in the Department of Radiotherapy and Radiooncology at the Saarland University Medical Center of Homburg, Germany. The tumour was localized in the nasal cavity/paranasal sinuses (15) affecting the orbit twice and the nasopharynx (5). There were 14 patients with squamous cell carcinoma, 2 patients with mixed tumours and one patient with adenocarcinoma, adenoid cystic carcinoma, mucosal melanoma or plasmocytoma. The majority of the patients presented with advanced disease (T3 or T4 tumours). In 18/20 patients, brachytherapy was performed as a boost technique, in the remaining two solely because of a previous radiation series. All surgical interventions were performed endonasally. Three to six weeks after surgery, a cast of the nasal cavity was created under general anaesthesia. Subsequently, an individual brachytherapy silicon applicator with two to four plastic tubes was manufactured. The radiation therapy was applied using the Ir-192 high-dose-rate-afterloading method (total dose 10-20 Gy) in two to five sessions, additionally in 18/20 patients a percutaneous radiotherapy with a total dose of 30-60 Gy was applied. After a mean duration of follow-up of 2 years, 7/20 patients experienced a local progression, 5/19 a regional recurrence in the neck nodes and 4/19 distant metastases. The 2-year survival was 57.3 %. No serious complications were reported. The silicone applicator was well tolerated by all patients. Because of the complexity of the sinonasal anatomy with the finding of mainly advanced tumours, the presented individual silicone brachytherapy applicator has proven to be useful and meaningful for endocavitary brachytherapy of malignancies of the nasal cavities, paranasal sinuses and nasopharynx.

Modern head and neck brachytherapy: from radium towards intensity modulated interventional brachytherapy

Intensity modulated brachytherapy (IMBT) is a modern development of classical interventional radiation therapy (brachytherapy), which allows the application of a high radiation dose sparing severe adverse events, thereby further improving the treatment outcome. Classical indications in head and neck (H&N) cancers are the face, the oral cavity, the naso- and oropharynx, the paranasal sinuses including base of skull, incomplete resections on important structures, and palliation. The application type can be curative, adjuvant or perioperative, as a boost to external beam radiation as well as without external beam radiation and with palliative intention. Due to the frequently used perioperative application method (intraoperative implantation of inactive applicators and postoperative performance of radiation), close interdisciplinary cooperation between surgical specialists (ENT-, dento-maxillary-facial-, neuro- and orbital surgeons), as well interventional radiotherapy (brachytherapy) experts are obligatory. Published results encourage the integration of IMBT into H&N therapy, thereby improving the prognosis and quality of life of patients.

Salvage endoscopic nasopharyngectomy and intensity-modulated radiotherapy versus conventional radiotherapy in treating locally recurrent nasopharyngeal carcinoma

BACKGROUND

Although endoscopic nasopharyngectomy and intensity-modulated radiotherapy (IMRT) have been reported to be useful in treating isolated local recurrent nasopharyngeal carcinoma (NPC), their efficacy needs to be revaluated with comparison to 2D conventional radiotherapy (RT).

METHODS

Four hundred ten patients with recurrent NPC were retrospectively analyzed, among whom the patients underwent IMRT, endoscopic nasopharyngectomy, and 2D conventional RT.

RESULTS

The 5-year overall survival (OS) and distant metastasis-free survival were significantly higher in endoscopic nasopharyngectomy and IMRT groups than in 2D conventional RT group both in the entire series and in the subgroup of patients with recurrent T1 to 2 NPC (p < .05), except in the subgroup of recurrent T3 to 4 stratifications (IMRT vs 2D conventional RT; 28.8% vs 16.8%; p = .351). Furthermore, endoscopic nasopharyngectomy was associated with better OS than IMRT in the recurrent T1 to 2 subgroup (79.2% vs 62.1%; p = .007). Multivariate analysis indicated therapeutic modality was an independent predictor of OS and distant metastasis-free survival (p < .001).

CONCLUSION

Endoscopic nasopharyngectomy and IMRT are associated with an improved OS and distant metastasis-free survival of patients with recurrent NPC compared to 2D conventional RT in early recurrent disease.

Brachytherapy boost in loco-regionally advanced nasopharyngeal carcinoma: a prospective randomized trial of the International Atomic Energy Agency

Abstact

Radiotherapy for head and neck cancer

Treatment for patients with head and neck cancer requires a multidisciplinary approach. Radiotherapy is employed as a primary treatment or as an adjuvant to surgery. Each specific subsite dictates the appropriate radiotherapy techniques, fields, dose, and fractionation scheme. Quality of life is also an important issue in the management of head and neck cancer. The radiation-related complications have a tremendous impact on the quality of life. Modern radiotherapy techniques, such as intensity-modulated radiotherapy and image-guided radiotherapy, can offer precise radiation delivery and reduce the dose to the surrounding normal tissues without compromise of target coverage. In the future, efforts should be made in the exploration of novel strategies to improve treatment outcome in patients with head and neck cancer.

High-dose-rate intraluminal brachytherapy during preoperative chemoradiation for locally advanced rectal cancers

AIM: To determine the feasibility and safety of high dose rate intraluminal brachytherapy (HDR-ILBT) boost during preoperative chemoradiation for rectal cancer.

METHODS: Between 2008 and 2009, thirty-six patients with locally advanced rectal cancer (≥ T3 or N+), were treated initially with concurrent capecitabine (825 mg/m² oral twice daily) and pelvic external beam radiotherapy (EBRT) (45 Gy in 25 fractions), then were randomized to group A; HDR-ILBT group (n = 17) to receive 5.5-7 Gy × 2 to gross tumor volume (GTV) and group B; EBRT group (n = 19) to receive 5.4 Gy × 3 fractions to GTV with EBRT. All patients underwent total mesorectal excision.

RESULTS: Grade 3 acute toxicities were registered in 12 patients (70.6%) in group A and in 8 (42.1%) in group B. Complete pathologic response of T stage (ypT0) in group A was registered in 10 patients (58.8%) and in group B, 3 patients (15.8%) had ypT0 (P < 0.0001). Sphincter preservation was reported in 6/9 patients (66.7%) in group A and in 5/10 patients (50%) in group B (P < 0.01). Overall radiological response was 68.15% and 66.04% in Group A and B, respectively. During a median follow up of 18 mo, late grade 1 and 2 sequelae were registered in 3 patients (17.6%) and 4 patients (21.1%) in the groups A and B, respectively.

CONCLUSION: HDR-ILBT was found to be effective dose escalation technique in preoperative chemoradiation for rectal cancers, with higher response rates, downstaging and with manageable acute toxicities.

High-Dose-Rate Intracavitary Brachytherapy Boost for Early T Stage Nasopharyngeal Carcinoma{PRIVATE}

PURPOSE

To investigate any possible therapeutic gain from dose escalation with brachytherapy for early T stage nasopharyngeal carcinoma (NPC).

METHODS AND MATERIALS

One hundred forty-five patients with T1-2b N0-3 NPC were boosted with high-dose-rate intracavitary brachytherapy after completion of two-dimensional external radiotherapy (ERT) during the period from 1999 to 2003. To compare the efficacy of brachytherapy boost, another 142 patients with T1-2b N0-3 disease who were treated with ERT alone during 1994 to 1999 were evaluated. All patients were treated with ERT to a total dose of 66 Gy in 6.5 weeks. The brachytherapy boost group was given 10-12 Gy in 2 weekly fractions.

RESULTS

Dose escalation beyond 66 Gy with brachytherapy boost was shown to improve local control and survival. The 5-year actuarial local failure-free survival, regional failure-free survival, distant metastasis-free survival, progression-free survival, cancer-specific survival, and overall survival rates for the brachytherapy group and the control group were 95.8% and 88.3% (p = 0.020), 96% and 94.6% (p = 0.40), 95% and 83.2% (p = 0.0045), 89.2% and 74.8% (p = 0.0021), 94.5% and 83.4% (p = 0.0058), and 91.1% and 79.6% (p = 0.0062), respectively. The 5-year major-complication-free survival rate was 89.5% for the brachytherapy group and 85.6% for the control group (p = 0.23).

CONCLUSIONS

For patients who are treated with two-dimensional treatment techniques, dose escalation with brachytherapy boost improves local control and overall survival of patients with T1-T2a and possibly non-bulky T2b disease.

Brachytherapy for primary and recurrent nasopharyngeal carcinoma: treatment techniques and results

PURPOSE

Nasopharyngeal cancer is the commonest head and neck cancer in Tunisia treated with radiotherapy. A dose effect relationship is established in this tumor. The aim of this study is to describe our Low-dose-rate endocavitary brachytherapy using a personalized mold called Tunis applicator.

PATIENTS AND METHODS

Seven patients (4 males and 3 females) with histologically confirmed undifferentiated nasopharyngeal carcinoma (UCNT) were treated between 2002 and 2005. Five patients with primary cancer and 2 with recurrent disease received external beam radiation followed by endocavitary brachytherapy. The mean applied dose of endocavitary brachytherapy was 5.5 Gy for primary site after external beam radiation (70-74 Gy) and 30 Gy for recurrent disease after external beam radiation (38 Gy). We have developed a personalized applicator with a balloon to optimize the placement of sources and a better conformity using the computer tomography scanning. Critical normal structures were identified on orthogonal radiographs and the dose was optimized to avoid excessive doses to these structures.

RESULTS

With a follow up of 18 months (8-41), only one local failure was observed, 3 years after external beam radiation therapy for a recurrent disease. Moderate grade mucositis was seen in most patients. One patient was diagnosed with bulb necrosis.

CONCLUSION

Endobrachytherapy can provide effective treatment for nasopharyngeal carcinoma with an easy application of the brachytherapy procedure.

Salvage re-irradiation for recurrent head and neck cancer

PURPOSE

To present a retrospective review of treatment outcomes for recurrent head and neck (HN) cancer patients treated with re-irradiation (re-RT) at a single medical center.

METHODS AND MATERIALS

From July 1996-September 2005, 105 patients with recurrent HN cancer underwent re-RT at our institution. Sites included were: the neck (n = 21), nasopharynx (n = 21), paranasal sinus (n = 18), oropharynx (n = 16), oral cavity (n = 9), larynx (n = 10), parotid (n = 6), and hypopharynx (n = 4). The median prior RT dose was 62 Gy. Seventy-five patients received chemotherapy with their re-RT (platinum-based in the majority of cases). The median re-RT dose was 59.4 Gy. In 74 (70%), re-RT utilized intensity-modulated radiation therapy (IMRT).

RESULTS

With a median follow-up of 35 months, 18 patients were alive with no evidence of disease. The 2-year loco-regional progression-free survival (LRPFS) and overall survival rates were 42% and 37%, respectively. Patients who underwent IMRT, compared to those who did not, had a better 2-year LRPF (52% vs. 20%, p < 0.001). On multivariate analysis, non-nasopharynx and non-IMRT were associated with an increased risk of loco-regional (LR) failure. Patients with LR progression-free disease had better 2-year overall survival vs. those with LR failure (56% vs. 21%, p < 0.001). Acute and late Grade 3-4 toxicities were reported in 23% and 15% of patients. Severe Grade 3-4 late complications were observed in 12 patients, with a median time to development of 6 months after re-RT.

CONCLUSIONS

Based on our data, achieving LR control is crucial for improved overall survival in this patient population. The use of IMRT predicted better LR tumor control. Future aggressive efforts in maximizing tumor control in the recurrent setting, including dose escalation with IMRT and improved chemotherapy, are warranted.

Sequential External Beam Radiotherapy and High???Dose-Rate Intracavitary Brachytherapy in T1 and T2 Nasopharyngeal Carcinoma: An Evaluation of Long-Term Outcome

OBJECTIVES/HYPOTHESIS

The standard treatment for nonmetastatic nasopharyngeal carcinoma (NPC) is external beam radiotherapy (EBRT), with or without chemotherapy. Because local control in NPC is an independent prognostic factor for distant metastases and survival, various dose-escalation strategies have been used to reduce recurrences at the primary site. The objective of this report was to evaluate the outcome of adjuvant high-dose-rate intracavitary brachytherapy (HDRIB) in patients with T1 and T2 NPC.

STUDY DESIGN AND METHODS

Thirty-three consecutive patients with T1 and T2 NPC were treated prospectively according to a standardized institutional protocol between March 1999 and July 2001. Seventeen patients with stage I/II disease were treated with EBRT to 66 Gy followed by HDRIB (10 Gy in 2 weekly 5 Gy fractions). The remaining 16 patients with Stage III to IVb disease received chemotherapy in addition to radiation. All patients were assessed for treatment response, local control, survival, and toxicity.

RESULTS

Median follow-up for all surviving patients was 67 (range 52-76) months. Local failure occurred in two patients; both subsequently underwent successful salvage treatments. Three patients died of metastatic disease, whereas two died of unrelated causes. Five year local control, overall survival, and disease-free survival rates were 93.8%, 83.9% and 78.4%, respectively. All patients experienced acute or late radiotherapy-related sequelae. However, no grade 4/5 toxicities were reported. Specifically, toxicities that could be attributed to brachytherapy were not seen, except for in one patient who developed severe choanal stenosis.

CONCLUSIONS

EBRT supplemented by HDRIB produced superior local control rates for T1 and T2 NPC at 5 years of follow-up, with acceptable rates of acute and late toxicities.

Salvage high-dose-rate (HDR) brachytherapy for recurrent head-and-neck cancer

BACKGROUND

A significant portion of head-and-neck cancer patients will develop persistent or recurrent disease after definitive treatment. Radiation therapy is often used as definitive therapy or as an adjunct to surgery. Recurrent cancer of the head and neck in the previously irradiated field is, thus, a common occurrence and poses a therapeutic challenge. Some studies have evaluated low-dose-rate (LDR) brachytherapy as a therapeutic option, including a large case series with long-term follow-up by our own institution. High-dose-rate (HDR) brachytherapy offers therapeutic advantages over LDR brachytherapy. This study evaluates the local control and outcomes of patients with previously irradiated recurrent head-and-neck cancer treated with HDR interstitial brachytherapy.

METHODS AND MATERIALS

Between 1997 and 2002, 30 patients who received prior radiation therapy for primary tumors of the head and neck were treated for biopsy-proven recurrent disease. All patients received previous radiation as definitive therapy alone or as adjunct to surgery. All patients were inoperable, refused surgery, or had gross residual disease after salvage surgery for their recurrent disease. Thirty-six sites on the 30 patients were implanted by application of high-dose-rate interstitial brachytherapy techniques with mean tumor dose of 34 Gy (18-48 Gy) in twice daily fractions of 300 to 400 cGy per fraction.

RESULTS

At a minimum follow-up of 12 months, local tumor control was achieved in 69% of implanted sites. Disease-specific survival at 1 and 2 years was 54% and 45%, respectively. Overall survival at 1 and 2 years was 56% and 37%, respectively. Grade 3/4 late complications occurred in 16% of the patients. No fatal complications occurred.

CONCLUSION

HDR brachytherapy can play an important role in the salvage treatment of previously irradiated recurrent head-and-neck cancer. This study shows that comparable results are obtained by HDR brachytherapy with fewer late complications than were indicated by previously reported data for LDR brachytherapy.

HDR-192Ir intraluminal brachytherapy in treatment of malignant obstructive jaundice

AIM: To determine the feasibility and safety of intraluminal brachytherapy in treatment of malignant obstructive jaundice (MOJ) and to evaluate the clinical effect of intraluminal brachytherapy on stent patency and patient survival.

METHODS: Thirty-four patients with MOJ were included in this study. Having biliary stent placed, all patients were classified into intraluminal brachytherapy group (group A, n = 14) and control group (group B, n = 20) according to their own choice. Intraluminal brachytherapy regimen included: HDR-¹⁹²Ir was used in the therapy, fractional doses of 4-7 Gy were given every 3-6 d for 3-4 times, and standard points were established at 0.5-1.0 cm. Some patients of both groups received transcatheter arterial chemoembolization (TACE) after stent placement.

RESULTS: In group A, the success rate of intraluminal brachytherapy was 98.0%, RTOG grade 1 acute radiation morbidity occurred in 3 patients, RTOG/EORTC grade 1 late radiation morbidity occurred in 1 patient. Mean stent patency of group A (12.6 mo) was significantly longer than that of group B (8.3 mo) (P < 0.05). There was no significant difference in the mean survival (9.4 mo vs 6.0 mo) between the two groups.

CONCLUSION: HDR-¹⁹²Ir intraluminal brachytherapy is a safe palliative therapy in treating MOJ, and it may prolong stent patency and has the potentiality of extending survival of patients with MOJ.

Adjuvant High-Dose Rate Brachytherapy After Chemoradiation for Treatment of Early T-Stage Nasopharyngeal Carcinoma

The local control of nasopharyngeal carcinoma after conventional radiotherapy has historically been suboptimal. Recently, investigators have reported improved outcomes for this patient population with the use of combined chemoradiotherapy. The purpose of this analysis of our prospective treatment protocol was to evaluate the additional value of high-dose rate intracavitary brachytherapy (HDRIB) on the disease response, local control, and survival. Between March 1999 and January 2001, 16 patients with newly diagnosed locally advanced (stage III and IV) nasopharyngeal carcinoma were treated prospectively at the Radiation Oncology Department of the National University Hospital of Singapore. All patients were staged according to the AJCC (1997) Staging System and had early T stages (T1 and T2). Treatments included concurrent external beam radiotherapy (EBRT) and chemotherapy as follows: 66 Gy to the primary tumor in conventional fractionation with cisplatin based concurrent chemotherapy followed by adjuvant cisplatin and 5-fluorouracil (5-FU) chemotherapy. Ten Gy of HDRIB in 2 weekly fractions were delivered after the completion of EBRT to all 16 patients. All patients were evaluable for treatment response, local control, survival, and toxicity analysis. The median follow-up for the whole group of patients was 18 months (range: 10-34 months). All patients obtained pathologic complete response at the primary site at 4 months after the completion of the treatment. At the time of this analysis, 15 (93.8%) patients are alive with no evidence of disease. One patient (6.2%) developed locoregional recurrence in the neck at 9 months, and distant metastasis at 11 months after the completion of treatment. Our experience has shown adjuvant HDRIB after concurrent chemoradiation offers encouraging disease response, local control, and survival. A prospective study is being planned to further evaluate the role of adjuvant HDRIB after concurrent chemoradiation on treatment outcome.

Adjuvant fractionated high-dose-rate intracavitary brachytherapy after external beam radiotherapy in Tl and T2 nasopharyngeal carcinoma

BACKGROUND

The value of high-dose-rate intracavitary brachytherapy (HDRIB) for persistent or recurrent nasopharyngeal carcinoma has been well described; however, the benefit of routine adjuvant fractionated HDRIB following external beam radiation therapy (EBRT) has not been completely determined. The objective of this analysis was to evaluate the outcome of two fractions of adjuvant HDRIB treatment in Tl and T2 nasopharyngeal carcinoma.

METHODS

Thirty-three consecutive and nonselected patients who had Tl and T2 non-disseminated nasopharyngeal carcinoma were treated according to an IRB approved institutional research protocol between March 1999 and July 2001. By the 1997 AJCC cancer staging classification, 22 patients (67%) had Tl disease and 11 patients (33%) had T2 disease. Seventeen of these patients who had stage I or stage II disease (i.e., NO or Nl) were treated with EBRT followed by two fractions of adjuvant HDRIB (group 1); 16 patients who had stage III or stage IV disease (i.e., N2 or N3) were treated with concurrent cisplatin, EBRT and adjuvant HDRIB and subsequent adjuvant cisplatin and fluorouracil (5-FU) chemotherapy (group 2). EBRT was delivered by daily conventional fractionation to a total dose of 66 Gy to the primary tumor. Nodal disease received 66 Gy if it was less than 3 cm in maximum diameter and 70 Gy if larger or there was palpable residual disease after 66 Gy. A total of 10 Gy of HDRIB in 2 equal fractions of 5 Gy spaced 1 week apart was delivered starting 1 week after the completion of EBRT. All patients were assessed for treatment response, local control, survival, and toxicity.

RESULTS

The median follow up for all 29 surviving patients is 29 months (range: 17-38 months). One patient died 7 months and one died 18 months after radiation therapy from the effects of distant metastases; two died of unrelated causes. At the time of this analysis, one patient (3%) had persistent local disease and one patient (3%) developed pathologically confirmed local recurrence in the nasopharynx. In addition, one patient (3%) developed recurrence only in a neck node followed by distant metastasis, and two patients (6%) developed distant metastasis without locoregional relapse. The 2-year local control rate at the primary site was 93.6%, and the overall survival and disease-free survival rates were 82% and 74% respectively. All patients experienced some degree of acute and/or late toxicity related to radiation therapy. Ten patients (30%) experienced grade 3 acute and/or late toxicity and six patients (18%) developed grade 4 acute and/or late toxicity. No grade 5 toxicity occurred. No unexpected damage of structures within the HDRIB fields was detected.

CONCLUSIONS

EBRT supplemented by two fractions of adjuvant HDRIB produced a 93.6% local control rate for Tl and T2 nasopharyngeal cancer at 2 years of follow up, with acceptable rates of acute and late toxicity. Brief adjuvant HDRIB appears to permit dose escalation safely, even in patients who receive chemotherapy concurrently with conventional radiation therapy. This strategy needs to be optimized and then tested in a prospective randomized phase III trial to learn if it can improve outcome.

Le Fort I osteotomy and low-dose rate Ir192 brachytherapy for treatment of recurrent nasopharyngeal tumours

BACKGROUND

Treatment of recurrent nasopharyngeal carcinoma is a difficult clinical problem. External beam re-irradiation is associated with a long-term cure in a proportion of cases but this may be associated with severe radiation injury.

METHODS

Eighteen patients with post-nasal space tumours were treated between 1986 and 2001 with surgical excision and nasopharyngeal brachytherapy via a Le Fort I osteotomy approach. Low-dose rate (LDR) and high-dose rate (HDR) brachytherapy was used. Data was prospectively collected. Local control and overall survival were measured. Acute and late complications were assessed using the RTOG system.

RESULTS

The overall survival was 67% at 2 years and 33.5% at 5 years. The corresponding local control rates were 42 and 31.5%, respectively. The T stage at relapse was a significant prognostic factor for local control (P=0.004) but not overall survival. Acute toxicity was mild. RTOG grade >/=3 late complications occurred in 40% of patients treated with the HDR, and 0% treated with LDR.

CONCLUSIONS

The results of the Le Fort osteotomy, tumour debulking and post-operative brachytherapy gives local control rates similar to those achieved with wide-field re-irradiation. Complication rates are acceptable and are lower than that reported with other methods of radiation therapy. The surgical technique was well tolerated. HDR brachytherapy with this technique had a high complication rate. This approach is a viable option in the treatment of recurrent nasopharyngeal tumours.

Intensity-modulated radiotherapy in the treatment of nasopharyngeal carcinoma: an update of the UCSF experience

PURPOSE

To update our experience with intensity-modulated radiotherapy (IMRT) in the treatment of nasopharyngeal carcinoma (NPC).

METHODS AND MATERIALS

Between April 1995 and October 2000, 67 patients underwent IMRT for NPC at the University of California-San Francisco (UCSF). There were 20 females and 47 males, with a mean age of 49 (range 17-82). The disease was Stage I in 8 (12%), Stage II in 12 (18%), Stage III in 22 (33%), and Stage IV in 25 (37%). IMRT was delivered using three different techniques: 1) manually cut partial transmission blocks, 2) computer-controlled auto-sequencing segmental multileaf collimator (SMLC), and 3) sequential tomotherapy using a dynamic multivane intensity modulating collimator (MIMiC). Fifty patients received concomitant cisplatinum and adjuvant cisplatinum and 5-FU chemotherapy according to the Intergroup 0099 trial. Twenty-six patients had fractionated high-dose-rate intracavitary brachytherapy boost and 1 patient had gamma knife radiosurgery boost after external beam radiotherapy. The prescribed dose was 65-70 Gy to the gross tumor volume (GTV) and positive neck nodes, 60 Gy to the clinical target volume (CTV), 50-60 Gy to the clinically negative neck, and 5-7 Gy in 2 fractions for the intracavitary brachytherapy boost. Acute and late normal tissue effects were graded according to the Radiation Therapy Oncology Group (RTOG) radiation morbidity scoring criteria. The local progression-free, local-regional progression-free, distant metastasis-free rates, and the overall survival were calculated using the Kaplan-Meier method.

RESULTS

With a median follow-up of 31 months (range 7 to 72 months), there has been one local recurrence at the primary site. One patient failed in the neck. Seventeen patients developed distant metastases; 5 of these patients have died. The 4-year estimates of local progression-free, local-regional progression-free, and distant metastases-free rates were 97%, 98%, and 66% respectively. The 4-year estimate of overall survival was 88%. The worst acute toxicity documented was as follows: Grade 1 or 2 in 51 patients, Grade 3 in 15 patients, and Grade 4 in 1 patient. The worst late toxicity was Grade 1 in 20 patients, Grade 2 in 15 patients, Grade 3 in 7 patients, and Grade 4 in 1 patient. At 3 months after IMRT, 64% of the patients had Grade 2, 28% had Grade 1, and 8% had Grade 0 xerostomia. Xerostomia decreased with time. At 24 months, only one of the 41 evaluable patients had Grade 2, 32% had Grade 1, and 66% had Grade 0 or no xerostomia. Analysis of the dose-volume histograms (DVHs) showed that the average maximum, mean, and minimum dose delivered were 79.3 Gy, 74.5 Gy, and 49.4 Gy to the GTV, and 78.9 Gy, 68.7 Gy, and 36.8 Gy to the CTV. An average of only 3% of the GTV and 3% of the CTV received less than 95% of the prescribed dose.

CONCLUSION

Excellent local-regional control for NPC was achieved with IMRT. IMRT provided excellent tumor target coverage and allowed the delivery of a high dose to the target with significant sparing of the salivary glands and other nearby critical normal tissues.

[Treatment of nasopharyngeal cancer: literature review]

The conventional radiotherapy and the associated treatments improved the prognostic of nasopharyngeal cancer. A better selection of the patients who must have a more aggressive treatment also probably contributed to this improvement. Even if a relation could be found between the locoregional relapse rate and the distant relapse rate, these two events remain often independent. It results from it that the improvement of local control rate necessarily does not result in a better control of the disease. The patients with a locally advanced tumor, with or not an invasion of the base of the skull and/or neurological symptoms, must have an aggressive locally treatment. This probably includes the increase in dose delivered to the tumor via a more conformational radiotherapy, a brachytherapy, radiotherapy in stereotaxic conditions or other techniques. Dose within the tumor must be at least 70 Gy and the prophylactic nodal dose, at least 50 Gy. CT scan and MRI are essential for delineating the volumes of interest. The protocols of hyperfractionated radiotherapy did not give convincing results. Association with chemotherapy allowed, on the other hand, an improvement of the prognostic locally advanced cancers. Neoadjuvant or adjuvant chemotherapy was largely used to attempt to limit the risks of systemic dissemination, but an improvement of results was not clearly demonstrated. An improvement of the rates of survival and control of the disease, on the other hand, was observed in a certain number of studies with the chemoradiotherapy. In the event of locoregional relapse, an aggressive attitude can allow the control of the disease in the absence of systemic dissemination. Salvage treatments are, however, disappointing for when distant relapse occurs which suggests a difference in chemosensitivity between primary tumor and metastasis.

High-dose, high-precision treatment options for boosting cancer of the nasopharynx

PURPOSE

The aim of the study is to define the role and type of high-dose, high-precision radiation therapy for boosting early staged T1,2a, but in particular locally advanced, T2b-4, nasopharyngeal cancer (NPC).

MATERIALS AND METHODS

Ninety-one patients with primary stage I-IVB NPC, were treated between 1991 and 2000 with 60-70Gy external beam radiation therapy (ERT) followed by 11-18Gy endocavitary brachytherapy (ECBT) boost. In 1996, for stage III-IVB disease, cisplatinum (CDDP)-based neoadjuvant chemotherapy (CHT) was introduced per protocol. Patients were analyzed for local control and overall survival. For a subset of 18 patients, a magnetic resonance imaging (MRI) scan at 46Gy was obtained. After matching with pre-treatment computed tomogram, patients (response) were graded into four categories; i.e. LD (T1,2a, with limited disease, i.e. disease confined to nasopharynx), LRD (T2b, with limited residual disease), ERD (T2b, with extensive residual disease), or patients initially diagnosed with T3,4 tumors. Dose distributions for ECBT (Plato-BPS v. 13.3, Nucletron) were compared to parallel-opposed three-dimensional conformal radiation therapy (Cadplan, Varian Dosetek v. 3.1), intensity modulated radiation therapy (IMRT) (Helios, Varian) and stereotactic radiotherapy (SRT) (X-plan, Radionics v. 2.02).

RESULTS

For stage T1,2N0,1 tumors, at 2 years local control of 96% and overall survival of 80% were observed. For the poorest subset of patients, well/moderate/poorly differentiated T3,4 tumors, local control and overall survival at 2 years with CHT were 67 and 67%, respectively, vs. local control of 20% and overall survival of 12% without CHT. For LD and LRD, conformal target coverage and optimal sparing can be obtained with brachytherapy. For T2b-ERD and T3,4 tumors, these planning goals are better achieved with SRT and/or IMRT.

CONCLUSIONS

The dosimetric findings, ease of application of the brachytherapy procedure, and the clinical results in early staged NPC, necessitates ERT combined with brachytherapy boost to be the therapy of preference for LD and LRD. For locally advanced T3,4 tumors, our current protocol indicates neoadjuvant chemotherapy in conjunction with high cumulative doses of radiotherapy (81Gy); IMRT and/or SRT to be the preferred technique for boosting the primary tumor.

Nasopharyngeal carcinoma: treatments and outcomes in the 20th century

Nasopharyngeal carcinoma (NPC), although rare in Europe and North America, is not uncommon in parts of Asia such as southern China and Hong Kong. Consequently, very few oncologists in the Western world have extensive experience in treating this neoplasm. Treatment using external beam therapy and/or brachytherapy evolved greatly during the 20th century and is still evolving, particularly with the use of adjunctive chemotherapy regimes. Diagnosis of NPC has also improved with the availability of CT and MRI. This worldwide review is divided into historical, transitional and modern eras, with the latter concerning 1971-2000. Currently, the most controversial aspects of NPC are recommendations for treatment of recurrent disease and the role of chemotherapy in the overall framework of treatment. Comparison of results from different centres is not possible without an understanding of the various staging systems that are, and have been, used; a comparison is given in this review. In the future, early diagnosis, adequate radiation dose to the primary with boost to bulky disease, and regular follow-up with biopsy of any suspicious residual or recurrent disease, are likely to become key issues to improve outcome. Also, apart from direct/indirect nasopharyngoscopy, the role of follow-up CT needs to be studied for early detection of residual or recurrent disease. More clinical trials on chemo-radiation are also required, in order to study optimum doses and agents.

Role of endocavitary brachytherapy with or without chemotherapy in cancer of the nasopharynx

PURPOSE

We previously reported our preliminary experience with nasopharyngeal cancer boosted after 60-70 Gy external beam radiotherapy (EBRT) by fractionated endocavitary brachytherapy (ECBT) to cumulative doses of 78-82 Gy. As for Stage III-IVB disease, cisplatin (CDDP)-based neoadjuvant chemotherapy (CHT) was given. The aim of the present study was to define the role of ECBT more accurately.

METHODS AND MATERIALS

Ninety-one patients with primary nasopharyngeal cancer, staged according to the 1997 UICC/AJCC classification system, were treated between 1991 and 2000 with 60-70 Gy external beam radiotherapy and 11-18 Gy ECBT. Of the 91 patients, 21 were treated in conjunction with CHT and 70 without CHT. Tumors were subdivided into undifferentiated (UD) and well, moderately, and poorly differentiated (WMP-D) subtypes. Treatment results were analyzed for local control (LC), disease-free survival (DFS), freedom from distant metastasis, and overall survival (OS).

RESULTS

A univariate and multivariate Cox regression analysis found stage, treatment period, age, and grade significant for LC, DFS, and OS. At 2 years, for Stage I-IIB (1st period, 1991-1996), the LC, DFS, and OS were 96%, 88%, and 80%, respectively, vs. 65%, 46%, and 52% for Stage III-IVB. For the 2nd treatment period (1996-2000; CHT for Stage III-IVB), the LC, DFS, and OS at 2 years was 100%, 90%, and 61% (Stage I-IIB), respectively, vs. 86%, 74%, and 66% (Stage III-IVB). Three prognostic groups (PGs) were constructed. For the 1991-1996 period, at 2 years, patients in the good PG (UD Stage I-IIB disease) had 100% LC and 92% OS; those in the intermediate PG (UD Stage III-IVB or WMP-D Stage I-IIB), had 94% LC and 71% OS; and those in the poor PG (WMP-D Stage III-IVB) had 47% LC and 40% OS. For the 1996-2000 period, at 2 years, the good PG had 100% LC and 88% OS; the intermediate PG had 100% LC and 64% OS; and the poor PG had 71% LC and 60% OS.

CONCLUSION

For Stage I-IIB disease treated between 1991 and 2000, at 3 years, the LC and OS was 97% and 67%, respectively. The results with 77-81 Gy without CHT warrant EBRT combined with ECBT to remain our standard of care for Stage I-IIB disease. For N2-3 and/or T3-4 tumors, in addition to high doses of RT, neoadjuvant CHT was administered as of 1996. For the 1991-2000 period, at 3 years, the LC was 86% and the OS was 72% with CHT, with little extra morbidity; they were 68% and 35% without CHT. Because of better target coverage and sparing, T3-4 tumors are currently boosted by stereotactic RT to 81.2 Gy.

Adjuvant high-dose-rate brachytherapy after external beam radiotherapy in nasopharyngeal carcinoma

PURPOSE

To compare the local control and survival rates obtained with either external beam radiation therapy (ERT) and adjuvant high-dose-rate (HDR) brachytherapy (BRT) or ERT alone in patients with nasopharyngeal cancer.

METHODS AND MATERIALS

Between December 1993 and December 1999, 144 patients (106 male, 38 female) with the diagnosis of nasopharyngeal cancer were treated with either ERT and adjuvant HDR BRT (Group A) or ERT alone (Group B) at our department. BRT was not applied in 38 patients for the following reasons: (1) Unit was unavailable (n = 13), (2) Patient was younger than 18 years (n = 17), (3) Patient received accelerated hyperfractionated ERT (n = 6), and (4) Patient refused BRT (n = 2). The median age for whole group was 43 (range: 9-82 years). According to the AJCC-1997 staging system, there were 11 (7.6%), 35 (24.3%), 38 (26.4%), and 60 (41.7%) patients in Stage I, II, III, and IV, respectively. There were 57 (39.6%) patients with T1, 41 (28.5%) with T2, 20 (13.9%) with T3, and 26 (18.1%) with T4 tumors. Histopathologic diagnosis was WHO 2-3 in 137 (95.2%) patients. ERT doses ranged between 58.8 and 74 Gy (median: 66 Gy). There were significantly more patients with young age, N2 status, and Stage III disease in Group B and with Stage II disease in Group A. Significantly more patients received chemotherapy in Group B. BRT with an HDR 192Ir microSelectron afterloading unit was delivered in 106 patients at the conclusion of ERT using a single-channel nasal applicator. Dose was prescribed at 1 cm from the source, and total dose of 12 Gy in 3 fractions on 3 consecutive days was given immediately after ERT. Besides radiotherapy, 82 (56.9%) patients received cisplatin-based chemotherapy, as well. Follow-up time ranged between 12 and 80 months (median: 32 months).

RESULTS

The two groups were comparable in terms of local recurrence, locoregional failure, regional failure, and rate of distant metastasis. Local failure was observed in 11 (10.3%) out of 106 patients in Group A and in 2 (5.2%) out of 38 patients in Group B (p > 0.05). Three-year disease-free survival rate was 67% and 80% (p = 0.07), respectively, and 3-year local recurrence-free survival rate was 86% and 94% (p = 0.23) for Group A and B, respectively. Multivariate analysis showed that advanced nodal status and male gender were significantly unfavorable factors for disease-free survival, and Stage II disease was unfavorable for local recurrence-free survival. The administration of adjuvant HDR BRT was not an independent prognostic factor in multivariate analysis. Out of 106 patients, 42 (39.7%) experienced nasal congestion, transient nasal obstruction, and/or fibrinous exudate in response to antihistaminic treatment. Only three (2.8%) patients experienced nasal synechy related, most probably, to the BRT. Five patients developed severe neural complications; only one out of five was observed in Group A. No severe complication attributed directly to BRT was detected.

CONCLUSION

The acute and late morbidity of adjuvant HDR BRT is acceptable with our treatment scheme, but we did not find any local control difference between our patients treated with adjuvant BRT after ERT and ERT alone. We believe that the exact role of adjuvant HDR BRT can be elucidated only by prospective randomized studies.

Chemotherapy and high–dose-rate brachytherapy in the management of advanced cancers of the nasopharynx

PURPOSE

The aim of this study was to calculate the costs of chemotherapy and high-dose-rate brachytherapy in advanced-stage nasopharyngeal cancer. It is argued whether the effect of chemotherapy and this type of high-dose, high-precision radiation therapy is worth the costs.

METHODS AND MATERIALS

Clinical results of Stage III-IVB nasopharyngeal cancer in patients treated between 1991 and 2000 are reported. Treatment was broken down into five categories: workup, chemotherapy, preparation of radiation therapy, and application of radiation. For each category, costs were computed. Nasopharyngeal cancer treatment costs were compared with costs previously reported on patients treated for cancers of the oral cavity, larynx, and oropharynx.

RESULTS

With the addition of neoadjuvant chemotherapy and high cumulative doses of radiation (77-81 Gy) with brachytherapy, disease-free survival increased from 48% to 74% (p=0.002), and overall survival increased from 35% to 72% (p=0.005). The Rotterdam protocol has been implemented stepwise: as of 1991, costs per patient increased from 4521 Euros (US$5023; 2001 exchange rate [December]: 1 Euro approximately 0.88 US$) for conventional external beam radiation therapy to 13,728 Euros (US$15,253) in 2000 for combinations of chemotherapy, conventional external beam radiation therapy, and brachytherapy. In case of stereotactic radiotherapy, the cost was 14,516 Euros (US$16,495).

CONCLUSIONS

Costs for cancer in the nasopharynx vary from 14,528 Euros (US$16,509) to 15,316 Euros (US$17,405) in case of brachytherapy and stereotactic radiotherapy, respectively, if follow-up costs are added. The treatment cost for other head and neck sites was 21,858 Euros (US$24,126). Given the improvement in survival, the sparing capabilities of current high-dose, high-precision radiotherapy techniques, and the favorable cost profile compared with other sites, it is argued that costs should not be considered prohibitive for the introduction of chemotherapy and high-technology-based radiotherapy in advanced nasopharyngeal cancer.

Managing nasopharyngeal carcinoma with intracavitary brachytherapy

PURPOSE

At our institution, we have been using intracavitary brachytherapy as a boost in selected cases of both primary and recurrent nasopharyngeal carcinoma. The local control, distant metastasis-free rate, overall survival, and morbidity are presented.

METHODS AND MATERIALS

Between January 1, 1955, and August 2000, 576 patients with a diagnosis of nasopharyngeal carcinoma were seen at the department of radiation oncology, University of California-San Francisco, and 55 patients received intracavitary brachytherapy as one part of their treatment. All patients were treated with megavoltage external beam radiation, including 43 patients treated for initial disease and 12 for recurrence. Brachytherapy was routinely used for early cases of T1 and T2 lesions and selected cases of more advanced lesions, as well as recurrent lesions. The median age was 48 years (range 22-85 years); there were 17 women and 38 men, and 39 patients were ethnic Chinese, 13 were white, and 3 were other races. Stage at treatment (primary and recurrent) was I (n=13), II (n=18), III (n=19), and IV (n=5); 18 patients had concurrent chemotherapy. The brachytherapy applicators used were Rotterdam (n=24), balloon (n=16), ovoid (n=14), and ribbon (n=1). The dose rate was high (n=24), low (n=29), or pulsed (n=2). External beam doses ranged from 54 to 72 Gy for primary disease and 30 to 42 Gy for recurrent disease. Brachytherapy doses ranged from 5 to 7 Gy for high dose rate and 10 to 54 Gy for low dose rate.

RESULTS

With a median follow-up of 36 months in those who were treated for primary carcinoma, the 5-year estimate of local control was 89%, the distant metastasis-free rate was 75%, and the overall survival estimate was 86%. Recurrent patients had a median follow-up of 50 months; the 5-year estimate of local control was 64%, the distant metastasis-free rate was 100%, and the overall survival estimate was 91%. Patients with Stage I or II disease had a longer overall survival compared with those with Stage III or IV (p=0.05). There was a significant difference in the rate of distant metastases due to nodal status (N0 vs. N1-N3, p=0.02) or to overall stage (I/II vs. III/IV, p=0.005).

CONCLUSIONS

Intracavitary boost brachytherapy was found to be effective and well tolerated in selected cases of both primary and recurrent nasopharyngeal carcinoma.

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.