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

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

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

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

Purpose

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

Material and methods

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

Results

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

Conclusions

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

Brachytherapy for radiotherapy-resistant head and neck cancer: A review of a single center experience

OBJECTIVES/HYPOTHESIS

Despite advances in radiotherapy and chemotherapy treatments for head and neck cancers, the local failure rate is high. In most radiotherapy-resistant cases, surgery is performed; however, some cases are considered unresectable. No standard treatment for these situations has been established. In this study, we review our experience with brachytherapy (BT), which has a different biological mechanism than standard radiotherapy.

METHODS

All patients received prior radiation to the recurrence area. Median high-dose radiation BT dose was 50 Gy, administered in 5 to 10 Gy fractions twice daily for 5 days. High-dose radiation was given via four to 10 catheters inserted under local anesthesia (3 patients) or general anesthesia with preventive tracheostomy (10 patients).

RESULTS

Thirteen patients received BT from 2010 to 2014. Male:female ratio was 1.6:1, and median age was 66 years (range 23-89). Of those 13 patients, 10 patients were diagnosed with squamous cell carcinoma (SCC) of the oral cavity, two patients with SCC of the nasal mucosa, and one patient with eccrine duct carcinoma. Prior radiation dose ranged from 60 to 70 Gy. Local control was achieved in 11 of 13 patients; only 15.3% (2 of 13) had in-field recurrence. Five patients developed local out-of-field recurrence, and two developed distant metastases. Five patients are alive with no evidence of disease. No major toxicities were encountered. Two patients had severe mucositis and recovered within several weeks.

CONCLUSION

Brachytherapy for radiotherapy-resistant head and neck cancers is feasible with minor adverse events, which enables good local control. However, many advanced head and neck cancers develop regional or distant metastases; therefore, additional treatment should be suggested.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:2246-2251, 2016.

[Brachytherapy in combination with function-preserving surgery. An interdisciplinary challenge]

A multimodal, interdisciplinary approach known as intensity-modified brachytherapy is a promising alternative for patients with advanced head and neck cancer infiltrating the orbita and skull base. An 87-year-old man presented with a recurrence of squamous cell carcinoma of the medial corner of the left eye that had been locally resected and irradiated by external beam radiotherapy multiple times. The cancer was resected with preservation of the eye with close margins, implantation of afterloading catheters, and reconstruction of the defect with a median forehead flap. The patient was irradiated with a total radiation dose of 30 Gy IMBT. After 1 year, there was no evidence of locoregional recurrence. The background of this therapeutic process and analysis of the current literature regarding this interdisciplinary treatment of head and neck cancer infiltrating the orbita and skull base are discussed based on this case report.

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

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

The role of pulsed-dose-rate brachytherapy in previously irradiated head-and-neck cancer

PURPOSE

The purpose of this prospective study was to analyze the value of interstitial pulsed-dose-rate (PDR) brachytherapy (iBT) with regard to local control and the incidence of side effects in patients with head-and-neck cancer in a previously irradiated area.

METHODS AND MATERIALS

From October 1997 to September 2001, 43 patients with head-and-neck cancer in a previously irradiated area (31 patients with recurrent cancer) were treated with iBT alone or in combination with external beam radiation. Thirty-four of 43 patients received interstitial PDR brachytherapy (DREF=20-60 Gy) as part of their curative treatment regimen alone or in combination with external radiation. Nine patients were implanted for palliative purposes. The pulses were delivered 24 h/day with a time interval of 1 h between two pulses. The dose per pulse (dp) ranged from 0.4-0.7 Gy. Sixteen of 43 (37%) patients also received cisplatin or carboplatin with 5-fluorouracil during the time of the iBT. Additionally 20/43 (47%) patients were treated with interstitial hyperthermia. Thirteen of 43 (30%) patients received external beam radiation in a dose range from 20-67 Gy. A follow-up of all patients was done to analyze local control and survival, and acute and delayed toxicity. This analysis was performed after a median follow-up of 24 months (6-48 months).

RESULTS

Local tumor control was achieved in 34 of a total of 43 patients (79%) and in 30/34 patients (88%) treated for curative intention. Distant metastases were observed in 5/43 (12%) patients. The 2-year local recurrence-free survival rates, disease-free survival rates, and overall survival rates according to the Kaplan-Meier method for all patients were 68%, 62%, and 49%, respectively, and for patients treated with curative intention they were 80%, 77% and 66%, respectively. There was no statistical difference in the probability of local recurrence in patients subgrouped by recurrent tumor vs. secondary primary, tumor size, grading and lymphangiosis. The application of chemotherapy or hyperthermia did not have significant influence on the therapy results. Soft tissue necrosis was the only serious side effect seen in 2/43 patients (4.7%). No other serious side effects were observed.

CONCLUSIONS

Interstitial pulsed-dose-rate brachytherapy for patients with previously irradiated head-and-neck cancer is an effective therapy with minimal toxicity. The role of chemotherapy and hyperthermia in these patients remains unclear. Further randomized studies with larger patient numbers are necessary to draw a definite conclusion.

Early wound complications in advanced head and neck cancer treated with surgery and Ir 192 brachytherapy

OBJECTIVES

Brachytherapy, either as primary or adjuvant therapy, is increasingly used to treat head and neck cancer. Reports of complications from the use of brachytherapy as adjuvant therapy to surgical excision have been limited and primarily follow Iodine 125 (I125) therapy. Early complications include wound breakdown, infection, flap failure, and sepsis, and late complications may include osteoradionecrosis, bone marrow suppression, or carotid injuries. The authors sought to identify the early wound complications that follow adjuvant interstitial brachytherapy with iridium 192 (IrS92).

STUDY DESIGN

A retrospective chart review of all patients receiving adjuvant brachytherapy at a tertiary medical center over a 4-year period.

METHODS

Nine patients receiving Ir192 brachytherapy via afterloading catheters placed during surgical resection for close or microscopically positive margin control were evaluated. It was used during primary therapy in six patients and at salvage surgery in three. Early complications were defined as those occurring within 6 weeks of surgical therapy.

RESULTS

The overall complication rate was 55% (5/9), and included significant wound breakdown in two patients, minor wound dehiscence in three, and wound infection, bacteremia, and local tissue erosion in one patient each. All complications occurred in patients receiving flap reconstruction and one patient required further surgery to manage the complication. Complication rates were not associated with patient age, site, prior radiotherapy, timing of therapy, number of catheters, or dosimetry.

CONCLUSIONS

The relatively high complication rate is acceptable, given the minor nature of most and the potential benefit of radiotherapy. Further study should be undertaken to identify those patients who will achieve maximum therapeutic benefit without prohibitive local complications.