High-dose-rate brachytherapy for primary carcinomas of the oral cavity and oropharynx

Oral Cavity Squamous Cell Carcinoma: Review of Pathology, Diagnosis, and Management

Squamous cell carcinoma of the oral cavity presents a significant global health burden, primarily due to risk factors such as tobacco smoking, smokeless tobacco use, heavy alcohol consumption, and betel quid chewing. Common clinical manifestations of oral cavity cancer include visible lesions and sores, often accompanied by pain in advanced stages. Diagnosis relies on a comprehensive assessment involving detailed history, physical examination, and biopsy. Ancillary imaging studies and functional evaluations aid in accurate staging and facilitate treatment planning. Prognostic information is obtained from histopathological factors, such as tumor grade, depth of invasion, lymphovascular invasion, and perineural invasion. Notably, lymph node metastasis, found in approximately half of the patients, carries significant prognostic implications. Effective management necessitates a multidisciplinary approach to optimize patient outcomes. Surgical resection is the backbone of treatment, aimed at complete tumor removal while preserving functional outcomes. Adjuvant therapies, including radiation and chemotherapy, are tailored according to pathological factors. Further work in risk stratification and treatment is necessary to optimize outcomes in squamous cell carcinoma of the oral cavity.

High-Dose-Rate Brachytherapy for Primary Treatment of Refractory Proliferative Verrucous Leukoplakia of the Hard Palate

Oral proliferative verrucous leukoplakia (PVL) is a rare, progressive form of leukoplakia with a high rate of malignant transformation. No therapies are known to lower the rate of malignant transformation and prevent a recurrence.

An 84-year-old patient with a years-long history of symptomatic PVL of the hard palate refractory to CO2 laser ablation presented to the radiation oncology clinic for consideration of non-surgical management. High dose rate brachytherapy was used to deliver 36 Gy in 12 fractions to the hard palate using an Ir-192 source with a custom-molded applicator.

By three months of follow-up, the patient had complete regression of the PVL and resolution of acute mucositis. With 18 months of follow-up, the patient remains disease- and symptom-free without toxicities of treatment.

High dose rate surface applicator brachytherapy is a feasible and potentially effective treatment for oral PVL, yielding durable control with low long-term toxicity.

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

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

The Effect of High Dose Rate Interstitial Implant on Early and Locally Advanced Oral Cavity Cancers: Update and Long-Term Follow-Up Study

Introduction Brachytherapy, with or without external beam radiation therapy (EBRT), can be an alternative to surgery for organ preservation in early and locally advanced oral cavity cancers. This study aims to evaluate the effect of high dose rate (HDR) interstitial brachytherapy on early and locally advanced squamous cell carcinoma (SCC) of the oral cavity when used alone or as a boost to EBRT. Methods A total of 125 patients with histologically proven stage T1-3/N0-1 SCC of the oral cavity were included in the study. A total of 15 patients with stage I disease received an interstitial implant dose of 3,850 cGy at 350 cGy per fraction, two fractions a day. Another 53 patients had stage II, and 57 patients had stage III disease; these patients received EBRT of 50 Gy in 25 fractions along with an HDR brachytherapy boost of 21 Gy in seven fractions of 3 Gy per fraction twice daily. The stage III patients also received concurrent chemotherapy with injections of cisplatin (70 mg/m2) given every three weeks for three days in divided doses. All node-positive patients received a boost to the node of up to 64 Gy by external beam radiation. Disease response rates, five-year disease-free survival rates, and toxicities were analyzed. Results The median follow-up was 60 months. Among the patients, 103 (82.4%) had a complete response, while 22 (17.6%) had residual disease and were referred for surgical salvage. The five-year disease-free survival was 100% in stage I, 83% in stage II, and 77.2% in stage III; 4% of patients developed grade 3 acute skin toxicity and 23.2% developed acute grade 3 mucositis. Eleven patients died during the follow-up period. Two patients died due to myocardial infarction but had achieved a complete tumor response. One patient had pulmonary tuberculosis and died due to fulminant infection after three years of disease-free survival period. One patient developed a second primary in the brain stem that presented with quadriplegia and expired. Seven patients died due to the progression of the initial disease. Conclusions Proper brachytherapy technique and meticulous planning can minimize the toxicity while providing better tumor control and achieve high local control rates. Brachytherapy, with or without EBRT, can be a surrogate to surgery in early oral cavity cancers as it can achieve organ preservation while providing good functional outcomes.

High-Dose-Rate Interstitial Brachytherapy in Early Stage Buccal Mucosa and Lip Cancer: Report on the Consecutive 12 Patients and Review of the Literature

Aims and background

To evaluate clinical outcome and toxicity using high-dose-rate brachytherapy as monotherapy in head and neck carcinomas.

Methods

Between September 2004 and April 2010, a series of 12 patients with lip (7 patients) or buccal mucosa (5 patients) cancers were treated by exclusive interstitial high-dose-rate brachytherapy. The median age of the patients was 71.5 years (range, 47–87). Stages were T1N0M0 and T2N0M0 in 6 and 6 patients, respectively. A dose of 27 to 54 Gy in 9 to 16 fractions, 3 to 4.5 Gy per fraction, 2 fractions per day with a minimal gap of 6 h in between was delivered.

Results

After a median follow-up of 46 months (range, 10–85), the disease-free and overall survival was 83% (10 of 12 patients) and 50% (6 of 12 patients), respectively. The crude local control in the lip cancer patients was 100% and in the buccal mucosa cancer patients was 60%. No severe toxicity was registered.

Conclusions

High-dose-rate brachytherapy is feasible and safe and offers the possibility to treat patients in an outpatient regimen.

GEC-ESTRO ACROP recommendations for head & neck brachytherapy in squamous cell carcinomas: 1st update - Improvement by cross sectional imaging based treatment planning and stepping source technology

The Head and Neck Working Group of the GEC-ESTRO (Groupe Européen de Curiethérapie - European Society for Therapeutic Radiology and Oncology) published in 2009 the consensus recommendations for low-dose rate, pulsed-dose rate and high-dose rate brachytherapy in head & neck cancers. The use of brachytherapy in combination with external beam radiotherapy and/or surgery was also covered as well as the use of brachytherapy in previously irradiated patients. Given the developments in the field, these recommendations needed to be updated to reflect up-to-date knowledge. The present update does not repeat basic knowledge which was published in the first recommendation but covers in a general part developments in (1) dose and fractionation, (2) aspects of treatment selection for brachytherapy alone versus combined BT+EBRT and (3) quality assurance issues. Detailed expert committee opinion intends to help the clinical practice in lip-, oral cavity-, oropharynx-, nasopharynx-, and superficial cancers. Different aspects of adjuvant treatment techniques and their results are discussed, as well the possibilities of salvage brachytherapy applications.

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.

Clinical outcome of high-dose-rate interstitial brachytherapy in patients with oral cavity cancer

Purpose

To evaluate the clinical outcome of high-dose-rate (HDR) interstitial brachytherapy (IBT) in patients with oral cavity cancer.

Materials and Methods

Sixteen patients with oral cavity cancer treated with HDR remote-control afterloading brachytherapy using ¹⁹²Ir between 2001 and 2013 were analyzed retrospectively. Brachytherapy was administered in 11 patients as the primary treatment and in five patients as salvage treatment for recurrence after the initial surgery. In 12 patients, external beam radiotherapy (50-55 Gy/25 fractions) was combined with IBT of 21 Gy/7 fractions. In addition, IBT was administered as the sole treatment in three patients with a total dose of 50 Gy/10 fractions and as postoperative adjuvant treatment in one patient with a total of 35 Gy/7 fractions.

Results

The 5-year overall survival of the entire group was 70%. The actuarial local control rate after 3 years was 84%. All five recurrent cases after initial surgery were successfully salvaged using IBT ± external beam radiotherapy. Two patients developed local recurrence at 3 and 5 months, respectively, after IBT. The acute complications were acceptable (≤grade 2). Three patients developed major late complications, such as radio-osteonecrosis, in which one patient was treated by conservative therapy and two required surgical intervention.

Conclusion

HDR IBT for oral cavity cancer was effective and acceptable in diverse clinical settings, such as in the cases of primary or salvage treatment.

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.

Intensity-modulated radiation therapy for head and neck cancer

In head and neck cancer, intensity-modulated radiation therapy (IMRT) makes the use of electron beams for irradiation of the posterior neck obsolete, inherently performs missing tissue compensation, and allows concave and intentionally nonhomogeneous dose distributions. By clinical use of these physical characteristics, salivary or lacrimal glands, optic pathway and auditory structures can be selectively underdosed and good evidence of decreased radiation toxicity is available. Evidence for increased local control is still lacking. Recurrences are mainly located in the high-dose-prescription regions, suggesting the need for even higher doses in these areas. Image-aided design of IMRT dose distribution is an area of intense research. New positron emission tomography and magnetic resonance imaging developments might allow definition of volumes inside the tumor where treatment failure is most likely to occur. If these volumes are small, focused dose escalation of large magnitude can be attempted and the hypothesis of improved local control by IMRT can be tested.

High dose rate brachytherapy for oral cancer

Brachytherapy results in better dose distribution compared with other treatments because of steep dose reduction in the surrounding normal tissues. Excellent local control rates and acceptable side effects have been demonstrated with brachytherapy as a sole treatment modality, a postoperative method, and a method of reirradiation. Low-dose-rate (LDR) brachytherapy has been employed worldwide for its superior outcome. With the advent of technology, high-dose-rate (HDR) brachytherapy has enabled health care providers to avoid radiation exposure. This therapy has been used for treating many types of cancer such as gynecological cancer, breast cancer, and prostate cancer. However, LDR and pulsed-dose-rate interstitial brachytherapies have been mainstays for head and neck cancer. HDR brachytherapy has not become widely used in the radiotherapy community for treating head and neck cancer because of lack of experience and biological concerns. On the other hand, because HDR brachytherapy is less time-consuming, treatment can occasionally be administered on an outpatient basis. For the convenience and safety of patients and medical staff, HDR brachytherapy should be explored. To enhance the role of this therapy in treatment of head and neck lesions, we have reviewed its outcomes with oral cancer, including Phase I/II to Phase III studies, evaluating this technique in terms of safety and efficacy. In particular, our studies have shown that superficial tumors can be treated using a non-invasive mold technique on an outpatient basis without adverse reactions. The next generation of image-guided brachytherapy using HDR has been discussed. In conclusion, although concrete evidence is yet to be produced with a sophisticated study in a reproducible manner, HDR brachytherapy remains an important option for treatment of oral cancer.

Dose reduction trial from 60 Gy in 10 fractions to 54 Gy in 9 fractions schedule in high-dose-rate interstitial brachytherapy for early oral tongue cancer

To compare the effects of 60 Gy/10 fractions (twice a day) with those of 54 Gy/9 fractions in high-dose-rate interstitial brachytherapy (HDR-ISBT) for early tongue cancer, we performed a matched-pair analysis of patients with early tongue cancer (T1-2N0M0), who were treated with 60 or 54 Gy of radiation between 1996 and 2004. Seventeen patients treated with 54 Gy and 34 matched-pair patients treated with 60 Gy were extracted and analyzed. Local recurrence occurred in two patients in the 54-Gy arm and five patients in the 60-Gy arm. The 2-year local control rates were 88% for both the 54-Gy arm and 60-Gy arm (not significant). The 2-year overall survival rates were 88% in the 60-Gy arm and 82% in the 54-Gy arm. Two-year actuarial complication-free rates were 91% in the 60-Gy arm and 83% in the 54-Gy arm (not significant), respectively. There was no significant association between the total dose and local control rate and late complications. The outcome of 54 Gy/ 9 fractions was similar to that of 60 Gy/ 10 fractions in patients with early tongue cancer.

Adaptive biological image-guided IMRT with anatomic and functional imaging in pharyngo-laryngeal tumors: impact on target volume delineation and dose distribution using helical tomotherapy

BACKGROUND AND PURPOSE

Adaptive image-guided IMRT appears to be a promising approach for dose escalation in pharyngo-laryngeal tumors. In this framework, we assessed in a proof of concept study the impact of anatomic and functional imaging modalities acquired prior and during radiotherapy on the target volume delineation and the dose distribution using helical tomotherapy.

MATERIALS AND METHODS

Ten patients with pharyngo-laryngeal squamous cell carcinoma were treated by concomitant chemo-radiation delivered in 7 weeks. CT, T2-MRI, fat suppressed T2-MRI, and static and dynamic FDG-PET were acquired for each patient before the start of treatment and during radiotherapy, after mean prescribed doses of 14, 25, 35 and 45 Gy. GTVs were manually delineated on CT and MRI images while PET images were automatically segmented by means of a gradient-based method. From these volumes, CTVs and PTVs were derived using consistent guidelines. Simultaneous integrated boost IMRT planning was performed using helical tomotherapy.

RESULTS

GTVs significantly decreased throughout the course of RT for all imaging modalities (p<0.001). Clinically non-significant differences and high correlations were found between GTVs delineated on CT and MRI, irrespective of the sequence used. By contrast, FDG-PET-based GTVs segmented from pre- and per-treatment images were significantly smaller compared to anatomical imaging modalities, without any difference existing between static and dynamic acquisition. These differences in GTVs translated into parallel reductions of both prophylactic and therapeutic CTVs and PTVs. Resulting FDG-PET-based and adaptive IMRT planning reduced the irradiated volumes by 15-40% compared to pre-treatment CT planning (V(90), V(95) and V(100)), but did marginally impact on doses to the OAR such as the spinal cord and the parotid glands.

CONCLUSIONS

Adaptive IMRT with FDG-PET images has a significant impact on the delineation of TVs and on the dose distribution in pharyngo-laryngeal tumors. Such an approach might thus be considered for dose escalation strategies.

Positron emission tomography-guided, focal-dose escalation using intensity-modulated radiotherapy for head and neck cancer

PURPOSE

To assess the feasibility of intensity-modulated radiotherapy (IMRT) using positron emission tomography (PET)-guided dose escalation, and to determine the maximum tolerated dose in head and neck cancer.

METHODS AND MATERIALS

A Phase I clinical trial was designed to escalate the dose limited to the [(18)-F]fluoro-2-deoxy-D-glucose positron emission tomography ((18)F-FDG-PET)-delineated subvolume within the gross tumor volume. Positron emission tomography scanning was performed in the treatment position. Intensity-modulated radiotherapy with an upfront simultaneously integrated boost was employed. Two dose levels were planned: 25 Gy (level I) and 30 Gy (level II), delivered in 10 fractions. Standard IMRT was applied for the remaining 22 fractions of 2.16 Gy.

RESULTS

Between 2003 and 2005, 41 patients were enrolled, with 23 at dose level I, and 18 at dose level II; 39 patients completed the planned therapy. The median follow-up for surviving patients was 14 months. Two cases of dose-limiting toxicity occurred at dose level I (Grade 4 dermitis and Grade 4 dysphagia). One treatment-related death at dose level II halted the study. Complete response was observed in 18 of 21 (86%) and 13 of 16 (81%) evaluated patients at dose levels I and II (p < 0.7), respectively, with actuarial 1-year local control at 85% and 87% (p = n.s.), and 1-year overall survival at 82% and 54% (p = 0.06), at dose levels I and II, respectively. In 4 of 9 patients, the site of relapse was in the boosted (18)F-FDG-PET-delineated region.

CONCLUSIONS

For head and neck cancer, PET-guided dose escalation appears to be well-tolerated. The maximum tolerated dose was not reached at the investigated dose levels.

[18F]fluoro-deoxy-glucose positron emission tomography ([18F]FDG-PET) voxel intensity-based intensity-modulated radiation therapy (IMRT) for head and neck cancer

BACKGROUND AND PURPOSE

Focused dose escalation may improve local control in head and neck cancer. Planning results of [(18)F]fluoro-deoxy-glucose positron emission tomography ([(18)F]FDG-PET) voxel intensity-based intensity-modulated radiation therapy (IMRT) were compared with those of PET contour-based IMRT.

PATIENTS AND METHODS

PET contour-based IMRT aims to deliver a homogeneous boost dose to a PET-based subvolume of the planning target volume (PTV), called PTV(PET). The present PET voxel intensity-based planning study aims to prescribe the boost dose directly as a function of PET voxel intensity values, while leaving the dose distribution outside the PTV unchanged. Two escalation steps (2.5 and 3 Gy/fraction) were performed for 15 patients.

RESULTS

PTV(PET) was irradiated with a homogeneous dose in the contour-based approach. In the voxel intensity-based approach, one or more sharp dose peaks were created inside the PTV, following the distribution of PET voxel intensity values.

CONCLUSIONS

While PET voxel intensity-based IMRT had a large effect on the dose distribution within the PTV, only small effects were observed on the dose distribution outside this PTV and on the dose delivered to the organs at risk. Therefore both methods are alternatives for boosting subvolumes inside a selected PTV.

Current Radiation Therapy Management Issues in Oral Cavity Cancer

Oral cavity cancer presents a therapeutic challenge to the treating surgeons,radiation oncologists, and medical oncologists. In early-stage disease, surgery or radiation alone often achieves excellent local control. Patients who have risk factors for recurrence after surgery should undergo adjuvant radiotherapy or chemoradiotherapy. In locally advanced disease, recurrence rates and deaths caused by disease progression continue to be unacceptably high. During the past decade, multiple randomized studies have shown a benefit in the addition of chemotherapy to radiation in the definitive or postoperative setting. Also, hyperfractionated and concomitant boost radiotherapy has shown superior results when compared with conventional once-daily radiotherapy. The addition of chemotherapy to hyperfractionated or concomitant boost radiotherapy also seems to improve outcomes at the cost of increased toxicities. In addition to traditional therapeutic modalities, new targeted agents seem promising to improve outcomes and possibly allow use of decreased doses of chemotherapy or radiotherapy, thus decreasing the toxicity of treatment.Overall, the management of cancer of the oral cavity is evolving rapidly,and a multidisciplinary approach to the patient who has oral cavity cancer is important to ensure the highest quality of patient care.

High-dose-rate interstitial brachytherapy for oropharyngeal carcinoma: results of 83 lesions in 82 patients

PURPOSE

Low-dose-rate interstitial brachytherapy (LDRIB) represents an effective modality for treatment of oropharyngeal carcinoma. The drawback is radioexposure of medical personnel. To eliminate this concern, we initiated high-dose-rate interstitial brachytherapy (HDRIB) in 1993. The present study evaluated the efficacy and complications associated with this approach.

METHODS AND MATERIALS

Between 1993 and 2003, HDRIB +/- external radiotherapy was used to treat 83 oropharyngeal squamous cell carcinomas. Median duration of follow-up was 26 months (range, 1-108 months). Of the 82 patients, 76 were previously untreated and 6 displayed previous history of head and neck cancer. T distribution comprised T1 (n = 7), T2 (n = 47), T3 (n = 24), and T4a (n = 5). External radiotherapy of 46 Gy was combined with 21 Gy/3.5 fractions/2 days HDRIB for 68 lesions, and 48 Gy/8 fractions/5 days HDRIB alone was used for 15 lesions. Involved nodes were either boosted by external radiotherapy or resected.

RESULTS

Five-year local control, regional control, cause-specific and overall survival rates were 82%, 84%, 88%, and 64%, respectively. Local control rates for early (T1/T2) and advanced (T3/T4) tumors were 89% and 66%, respectively (p = 0.02). Transient soft tissue necrosis was experienced in 29% of patients. No bone sequelae were observed in previously untreated patients.

CONCLUSIONS

High-dose-rate interstitial brachytherapy could achieve excellent local control and acceptable rates of complication, equivalent to reported results for LDRIB series. Given the advantage of radioprotection, HDRIB may replace LDRIB in the treatment of oropharyngeal carcinoma.

Tumour thickness predicts cervical nodal metastases and survival in early oral tongue cancer

Squamous cell carcinoma (SCC) of the oral tongue is characterized by a high propensity for cervical nodal metastasis, which affects the probability of regional control and survival. Until now, elective treatment of the clinically negative neck in early lesions (T(1-2)) of the oral tongue cancer remains controversial. This study attempted to identify predictive factor(s) for cervical nodal metastasis and treatment outcomes in patients with early stage SCC of the oral tongue treated primarily by surgery. Fifty patients with previously untreated Stage I/II primary tongue carcinomas with available archival specimens treated at the Royal Marsden Hospital between 1981 and 1998 were reviewed. Clinico-pathological features including age, gender, alcohol and tobacco consumption, tumour location, histological grade, tumour-stromal border, growth pattern, tumour thickness, and clinical stage were evaluated and the correlations with cervical metastases and outcome analysis were determined. The overall occult nodal metastatic rate was 40% (20/50). Tumour thickness exceeding 5 mm was statistically significantly correlated with cervical metastases (P = 0.003; relative risk = 2.429). No statistical correlation was observed between other clinico-pathological parameters and nodal metastasis. With a median follow-up of 98 months, 5-year actuarial overall, disease-specific (DSS), and relapse-free survival were 65.71, 67.77, and 68.18%, respectively. Univariate analysis for DSS showed poorer outcomes for patients with age > 60 years (P = 0.0423) and tumour thickness > 5 mm (P = 0.0067). The effect of tumour thickness was maintained (P = 0.005) on multivariate analysis. The present study indicates that the thickness of primary tumour has a strong predictive value for occult cervical metastasis and poor outcomes in patients with Stage I/II oral tongue SCC. Thus, elective neck treatment (surgery or irradiation) is indicated for tumours exceeding 5 mm thickness.

High-dose-rate brachytherapy in the treatment of recurrent and residual head and neck cancer

OBJECTIVES/HYPOTHESIS

Interstitial and endocavitary brachytherapy are well-accepted kinds of radiotherapy that are commonly used in recurrent head and neck cancer. Most reports about brachytherapy in the successful treatment of head and neck tumors used low-dose-rate brachytherapy. There are only a few reports about high-dose-rate brachytherapy (HDRBT) in head and neck cancer patients.

METHODS

After 10 years of experience with HDRBT with Ir 192, we have analyzed the results regarding response rates, survival time, and side effects. Between 1991 and 2000, 90 consecutive patients (68 men, 22 women) were treated with interstitial (68 patients) or intracavitary (22 patients) HDRBT in the head and neck area. Primary tumor locations were as follows: oropharynx (n = 26), tongue/floor of mouth (n = 22), nasopharynx (n = 10), nose/paranasal sinuses (n = 9), salivary glands (n = 5), hypopharynx (n = 5), CUP syndrome (n = 5), and others (n = 8). High-dose-rate brachytherapy was administered in 51 patients with recurrent disease and in 32 patients with residual tumor after primary radiochemotherapy. Seven patients were given exclusive HDRBT in a primary palliative situation. The single dose per fraction ranged from 1.5 to 7.5 Gy (median value, 5 Gy), and the total HDRBT dose ranged from 4.0 to 42.0 Gy (median value, 17.5 Gy).

RESULTS

The overall remission rate was 81% with a 46% rate of complete remissions. We observed no change in or progression of tumor in 17 cases (19%). The rate of complete remissions (and median overall survival time) was different in the three therapy groups: in case of recurrent disease, 28% (6 mo); in case of residual tumor, 84% (25 mo); and in primary palliative brachytherapy, 0% (1 mo). Late toxicities III and IV (radiation treatment oncology group score) occurred in 6 of 90 (6.7%) patients.

CONCLUSIONS

High-dose-rate brachytherapy proved to be an effective treatment modality in locoregional recurrent head and neck cancer. In cases with persistent or residual tumor after primary radiochemotherapy a local boost with brachytherapy can improve the chance of cure of tumor disease.

Phase III trial of high- vs. low-dose-rate interstitial radiotherapy for early mobile tongue cancer

PURPOSE

Early mobile tongue cancer can be controlled with interstitial radiotherapy (ISRT). We carried out a Phase III trial to compare the treatment results of low-dose-rate (LDR) ISRT and high-dose-rate (HDR) ISRT for early mobile tongue cancer.

METHODS AND MATERIALS

From April 1992 through October 1996, 59 patients with cancer of the early mobile tongue were registered in this Phase III study. Eight patients were excluded from the evaluation because of violations of the requirements for this study. Of 51 eligible patients, 26 patients were treated with LDR-ISRT (70 Gy/4-9 days) and 25 patients with HDR-ISRT (60 Gy/10 fractions/1 week). For the hyperfractionated HDR-ISRT, the time interval between 2 fractions was more than 6 h.

RESULTS

Five-year local control rates of the LDR and HDR groups were 84% and 87% respectively. Nodal metastasis occurred in 6 patients in each group. Five-year nodal control rates of the LDR and HDR groups were 77% and 76%, respectively.

CONCLUSION

Hyperfractionated HDR-ISRT for early mobile tongue cancer has the same local control compared with continuous LDR-ISRT. Hyperfractionated HDR-ISRT is an alternative treatment for continuous LDR-ISRT.

Influence of age on the results of brachytherapy for early tongue cancer

PURPOSE

To determine the influence of elder age on the results of brachytherapy for early (T1-2 N0 M0) oral tongue cancer and examine the compatibility of low-dose rate (LDR) with high-dose rate (HDR) brachytherapy.

METHODS AND MATERIALS

We analyzed 591 patients treated at Osaka University Hospital between 1967 and 1999. We compared the results of radiotherapy for 156 elderly patients (137 LDR and 19 HDR) 65 years of age or older and 435 patients (383 LDR and 52 HDR) less than 65 years of age.

RESULTS

HDR brachytherapy showed the same local control rate as LDR brachytherapy (81% at 3 years). Elderly patients showed a poorer local control rate (75% at 3 years) than the younger group (83% at 3 years)(p = 0.002). Multivariate analysis identified age as the only prognostic factor for local control (p = 0.002).

CONCLUSIONS

HDR brachytherapy achieved the same result as LDR brachytherapy. However, the elderly patient showed a higher rate of local recurrence after brachytherapy.