Endoscopy-guided brachytherapy for sinonasal and nasopharyngeal recurrences
Introduction
Locoregional recurrence and progression is the main pattern of failure and the most common cause of death in head and neck oncology [1], [2]. The incidence of recurrence after radical treatment may be as high as 30–50% [3], [4], and the typical median survival rate with the use of only platinum-based chemotherapy is about 6 months (5). The outcomes, in terms of disease-free survival (DFS) and overall survival (OS), specifically for sinonasal and rhinopharyngeal recurrences are, on average, better: the data available in the literature report a 1-year survival rate of 54.9%, a value that drops however to 22.1% and 12.4% for 3- and 5-year survival rates, respectively (6); the survival rates of rhinopharyngeal recurrences are influenced by several prognostic factors such as Karnofsky Performance Scale and age at recurrence (7). Regarding sinonasal recurrence, the 5-year survival rate reported in the literature is 52.3% (8). Generally, the approach in the case of recurrent disease is salvage surgery followed by a reirradiation [9], [10], [11], [12]. In reirradiation, the risk of toxicity is greater, and with external beam irradiation alone, it is difficult to spare adjacent normal tissues. For this reason, brachytherapy (BT) is often used for its peculiar characteristics. In fact, BT provides a series of favorable features, which need to be taken into account when considering a second course of radiation therapy. First, it allows delivery of a high and localized dose of radiation to the target. Second, another extremely important aspect to consider is the rapid falloff, which allows the reduction of the dose to the surrounding tissues. It is noteworthy to stress the shortness of overall treatment time, which is undoubtedly a key factor in head and neck cancers and especially in recurrences [13], [14]. In particular, customized mold-based high-dose-rate (HDR) BT can be used to treat tumors arising in unusual positions, such as the maxillary antrum, with favorable dosimetric profile [15], [16]. Furthermore, an innovative approach involving perioperative image-adapted BT is currently receiving great interest in the multidisciplinary management of head and neck cancers (17). For this reason, perioperative BT can be taken into account in sinonasal and nasopharyngeal recurrences after a full course of radiotherapy. However, despite this, the data concerning toxicities about patients reirradiated with BT available in the literature in the different studies vary greatly with a range up to 35.5% of reported overall toxicity (18). However, it is still not fully validated, especially for recurrences. In this situation, endoscopic surgery followed by perioperative HDR BT could offer important advantages. In fact, it could be useful to perform a debulking to reduce the volume to treat and then to position catheters on the high-risk areas of the surgical bed under direct endoscopic vision. Such approach compared with those currently used in clinical practice and reported in the literature allows to accurately identify the area to irradiate and at the same time to spare the surrounding tissues. Noteworthy, the endoscopic procedure is minimally invasive. Toxicity rates regarding perioperative HDR BT available in the literature are encouraging, both in the adjuvant setting (19) and most importantly in previously irradiated recurrent patients (20).
In the present work, we evaluated the preliminary outcomes of perioperative endoscopic-guided BT performed in our institution of sinonasal and nasopharyngeal recurrences after a full course of radiotherapy; the primary endpoint was to determine the rate of perioperative complications as well as acute and late toxicities. Another evaluated point was the percentage of target coverage, this because we wanted to know if this catheter positioning technique could help to improve the implant.
Section snippets
Patient selection
Patients with diagnosed sinonasal and nasopharyngeal recurrence who underwent BT from December 2010 to January 2014 were considered for this work. All the data were selected from the intranet hospital multidivisional electronic database Spider's Net (21). Inclusion criteria were histologically proven diagnosis of sinonasal and nasopharyngeal recurrences, previous treatment with full course of radiotherapy >65 Gy, and informed consent. All patients had a disease clinically detected with MRI
Results
From the data stored in Spider's Net, we identified 9 patients. In fact, we performed the endoscopic procedure to place the catheters for BT 11 times in 9 patients with recurrent disease; in two of the cases (a sinonasal recurrence of melanoma and an adenoid cystic carcinoma), no previous radiation therapy had been performed; therefore, they were not included in the statistical analysis; 1 patient was not included in the statistical analysis on account of his followup being too short. A total
Discussion
In the treatment of ear, nose, and throat (ENT) cancers to achieve LC, it is necessary to deliver a high dose. Unfortunately with external beam irradiation alone, it is difficult to spare the adjacent healthy tissue and thus avoid unwanted late effects. BT allows us to deliver higher dose intensity and a reduction of the dose to surrounding OARs (rapid falloff). It could be combined in different ways as curative, adjuvant, perioperative as a boost with EBRT, or as a palliative treatment (24).
Conclusion
Our experience shows that modern BT may have an important role in the treatment of head and neck cancer. The combination of endoscopy and BT seems to be an effective and elegant option for treating sinonasal and nasopharyngeal recurrences after a full course of EBRT because of the optimal conformation of the dose of BT and the high precision in catheter positioning made possible by an endoscopic approach.
In terms of toxicity, our results indeed show that the use of this procedure seems to be
References (37)
- et al.
Patterns of failure, prognostic factors and survival in locoregionally advanced head and neck cancer treated with concomitant chemoradiotherapy: A 9-year, 337-patient, multi-institutional experience
Ann Oncol
(2004) - et al.
Meta-analysis of chemotherapy in head and neck cancer (MACH-NC): An update on 93 randomised trials and 17,346 patients
Radiother Oncol
(2009) Medical treatment in head and neck cancer
Ann Oncol
(2005)- et al.
Locally recurrent nasopharyngeal carcinoma
Radiother Oncol
(2000) - et al.
Salvage high-dose rate (HDR) brachytherapy for recurrent head-and-neck cancer
Int J Radiat Oncol Biol Phys
(2005) - et al.
Re-irradiation in the management of isolated neck recurrences: Current status and recommendations
Radiother Oncol
(2006) - et al.
GEC-ESTRO recommendations for brachytherapy for head and neck squamous cell carcinomas
Radiother Oncol
(2009) - et al.
Use of customized-mold brachytherapy in the management of malignancies arising in the maxillary antrum after maxillectomy: A dosimetric analysis
Brachytherapy
(2011) - et al.
Treatment of upper gum carcinoma with high-dose-rate customized-mold brachytherapy
Brachytherapy
(2008) - et al.
Perioperative image-adapted brachytherapy for the treatment of paranasal sinus and nasal cavity malignancies
Brachytherapy
(2014)
Phase I-II trial of perioperative high-dose-rate brachytherapy in oral cavity and oropharyngeal cancer
Brachytherapy
Perioperative high-dose-rate brachytherapy (PHDRB) in previously irradiated head and neck cancer: Initial results of a Phase I/II reirradiation study
Brachytherapy
Practical considerations in the re-irradiation of recurrent and second primary head-and-neck cancer: Who, why, how, and how much?
Int J Radiat Oncol Biol Phys
ACR appropriateness criteria retreatment of recurrent head and neck cancer after prior definitive radiation expert panel on radiation oncology-head and neck cancer
Int J Radiat Oncol Biol Phys
A proposal for the stratification of the risk of locoregional failure after surgical resection, perioperative high dose rate brachytherapy, and external beam irradiation: The University of Navarre predictive model
Brachytherapy
Combination of surgical resection and HDR-brachytherapy in patients with recurrent or advanced head and neck carcinomas
J Craniomaxillofac Surg
High-dose-rate interstitial brachytherapy in recurrent and previously irradiated head and neck cancers—Preliminary results
Brachytherapy
Salvage radiation therapy for locally recurrent nasopharyngeal carcinoma
Int J Radiat Oncol Biol Phys
Cited by (24)
Function Preservation in Head and Neck Cancers
2023, Clinical OncologyFunctional results of exclusive interventional radiotherapy (brachytherapy) in the treatment of nasal vestibule carcinomas
2021, BrachytherapyCitation Excerpt :On the contrary, in patients treated with IRT, nasal function and cytological findings are substantially preserved when compared to healthy non-irradiated subjects. The rapid dose fall off of the IRT, exploited also in the adjuvant/perioperative setting [36, 37], with a drastic reduction of the irradiated mucosal surface inside the nasal/paranasal cavities, may be decisive factors for the functional preservation. Such original evidence, together with the confirmation of oncological effectiveness, which remains of course the most relevant argument, and the very favourable eshtetic results, supports the establishment of interstitial IRT as the new standard for the treatment of the primary lesion in cT1 and cT2 (according to the Wang staging) NV SCCs.
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
2017, Radiotherapy and OncologyCitation Excerpt :The Rotterdam group reported significant differences in local control between patients treated with or without a brachytherapy boost in the pooled analysis for T1–T2 N+ cases, thus confirming the results of other investigators with early local disease [46,47]. Larger tumors are nowadays better suited with high-precision external techniques although the development of endoscopically-guided intracavitary-interstitial devices may extend the brachytherapy indications for this location [48,49]. Shallow (less than 0.5 cm thick) head and neck tumors arising in certain sites such as scalp, face, pinna, lip, buccal mucosa, maxillary antrum, hard palate, oral cavity external auditory canal, and the orbital cavity after exenteration can be treated with brachytherapy with surface molds or prosthesis.
Current radiotherapy for recurrent head and neck cancer in the modern era: a state-of-the-art review
2022, Journal of Translational MedicineHigh-Dose-Rate Interstitial Brachytherapy (Interventional Radiotherapy) for Conjunctival Melanoma with Orbital Extension
2021, Ocular Oncology and Pathology