Elsevier

Brachytherapy

Volume 14, Issue 3, May–June 2015, Pages 419-425
Brachytherapy

Endoscopy-guided brachytherapy for sinonasal and nasopharyngeal recurrences

https://doi.org/10.1016/j.brachy.2014.11.012Get rights and content

Abstract

Objective/Purpose

To evaluate the preliminary results of perioperative endoscopy-guided brachytherapy (BT) in recurrent sinonasal and nasopharyngeal tumors already treated for their primary tumor with a full course of radiotherapy.

Methods and Materials

Patients with recurrence and already treated with a previous full course of radiotherapy >65 Gy who underwent BT from December 2010 to January 2014 were taken into account for this work. Macroscopic disease was resected by an endoscopic approach, and catheters for BT were endoscopically positioned and fixed at the same time on the surgical bed. Surgery was performed under electromagnetic navigation guidance. The irradiation dose was 30 Gy in 12 fractions, 2.5 Gy each, twice a day, in 6 days.

Results

We performed the endoscopy-guided BT 11 times in 9 patients; in two cases, no previous radiation therapy had been performed; and in one case, followup was too short to be considered. A total of 6 patients were eligible for the analysis. One patient underwent BT three times because of previous target margin recurrences. There were no immediate complications. The median and mean followups were 21 and 19 months, respectively. The median V90 and V85% were 93% and 95%, respectively. In one case, we had a transient deficit of the VI cranial nerve (G3), and in another case, we diagnosed a noncomplicated osteonecrosis (G2). The median disease-free survival is 12 months, and the median overall survival is 23 months.

Conclusions

The combination of endoscopy and BT seems to be a safe option for treating recurrent sinonasal and nasopharyngeal tumors.

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

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