A case–control study of patients with squamous cell carcinoma of the oral cavity and oropharynx treated with pulsed-dose-rate brachytherapy

Brachytherapy efficacy and safety in the treatment of primitive tongue carcinomas: experience from the Oscar Lambret Center

PURPOSE

The study aim was to evaluate efficacy and safety of brachytherapy for the treatment of early-stage tongue carcinoma and identify factors associated with the risk of local recurrence. The interest is to discuss the contribution of brachytherapy among therapeutics of tongue tumors treatments.

PATIENTS AND METHODS

Between January 2010 and December 2020, 55 patients with T1T2N0 tongue primitive squamous cell carcinomas were treated with interstitial low-dose-rate, pulsed-dose-rate, or high-dose-rate brachytherapy, with or without neck dissection, at the Centre Oscar Lambret of Lille. The primary objective was to evaluate the efficacy of brachytherapy in terms of local recurrence-free survival (LRFS). The secondary objectives were to estimate regional recurrence-free survival (RRFS), overall survival (OS), and to describe toxicities of brachytherapy.

RESULTS

Local recurrence-free survival (LRFS) rates at 1-year, 3-years, and 5-years follow-up were 90.9%, 62.9%, and 49.4%, respectively. The cumulative incidences of local recurrence at 1-year, 3-years, and 5-years follow-up were 1.8%, 10.2%, and 12.3%, respectively; Overall survival (OS) rates at 1-year, 3-years, and 5-years follow-up were 90.9%, 71.2%, and 53.4%, respectively, with a 95% confidence interval (CI). We identified 14 (25.5%) grade 3 complications and 10 (29.1%) grade 2 complications. Age at diagnosis (p<0.001), smoking (p=0.018), and tumor stage (p=0.009) were found to be significant prognostic factors (p<0.05) for LRFS.

CONCLUSION

Brachytherapy is a moderate effective treatment option for early-stage tongue carcinoma. Despite the frequent toxicities generated this approach offers several notable advantages, including preservation of oral anatomy and functions, ultimately leading to an improved quality of life for patients.

Postoperative brachytherapy alone for 217 patients with early-stage oral cavity squamous cell carcinoma

Introduction

Postoperative radiotherapy is generally recommended for pT1/2pN0 squamous cell carcinoma of the oral cavity (OSCC) if risk factors are present. Prospective studies are missing. Interventional radiotherapy offers a precise dose application. In this paper we analyze long-term efficacy and toxicity in a large single-center cohort of patients with early OSCC receiving sole postoperative brachytherapy (BT).

Material and methods

From 1998 to 2023, 217 patients were postoperatively treated with sole BT in our institute. The median follow-up was 110 months (range: 2-316). The primary objective was local control. Secondary outcomes were overall survival, cancer specific survival, and toxicity.

Results

The local recurrence rates for 12, 24, and 60 months were 7.1 %, 9.1 %, and 12.6 %. The disease-free survival was 89.7 %, 86.1 %, and 79.3 %. The overall survival rates at 12, 24, and 60 months were 94.4 %, 89.6 %, and 77.9 %. The cancer-specific survival was 97.1 %, 96.6 %, and 92.9 %, respectively. At two years, the rate of regional recurrence was 8.3 %. Patients without neck dissection had a significantly increased risk for lymph node recurrence (p = 0.025). Side effects ≥ grade 3 were seen in 14 % (30/217). 17 % (37/217) of patients developed a soft tissue necrosis (STN). Osteoradionecrosis (ORN) was seen in 7 % (15/217) of patients. A target volume > 15 cm3 was significantly associated with the occurrence of STN (p = 0.011) and ORN (p = 0.004).

Conclusions

Postoperative interventional radiotherapy for previously not irradiated patients with early-stage OSCC is a safe and efficient treatment. Randomized trials are needed to compare these results to omission of postoperative radiotherapy as well as external beam radiotherapy.

GEC-ESTRO recommendations for head & neck cancer brachytherapy (interventional radiotherapy): 2nd update with focus on HDR and PDR

Modern brachytherapy (BT) is playing an important role in the multidisciplinary treatment of Head and Neck (H&N) cancer, as an organ- and function-preserving therapy. Low-dose-rate (LDR) technology has been replaced by modern remote afterloading and stepping source equipment using pulsed dose rate (PDR) or high dose rate (HDR) sources, improved image guidance and 3D treatment planning systems. This is an update of the previous GEC-ESTRO recommendations for H&N tumors, mainly applied to squamous carcinomas. Indications, results and recommended doses for different tumor sites are presented according to the published studies.

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.

Dose volume histogram constraints in patients with head and neck cancer treated with surgery and adjuvant HDR brachytherapy: A proposal of the head and neck and skin GEC ESTRO Working group

BACKGROUND

The Head and Neck and Skin (HNS) Working group of the GEC-ESTRO acknowledges the lack of widely accepted Dose Volume Histogram (DVH) constraints in adjuvant head and neck brachytherapy and issues recommendations to minimize mandibular Osteoradionecrosis (ORN) and Soft Tissue Necrosis (STN).

METHODS

A total of 227 patients with the diagnosis of head and neck cancer treated with surgery and adjuvant HDR brachytherapy alone or combined with other treatment modalities during the period 2000-2018 were analyzed.

RESULTS

STN was observed in 28 out of 227 cases (12.3%) with an average time to appearance of 4.0 months. In previously unirradiated cases, there was a positive correlation between CTV size and STN (p = 0.017) and a trend towards significance between Total EQD2-DVH TV₁₀₀ dose and STN (p = 0.06). The risk of STN in the absence of both factors (i.e, CTV < 15 cm³ and Total EQD2-DVH TV₁₀₀ dose < 87 Gy) was 2%, with one factor present 15.7% and with both factors 66.7% (p = 0.001). ORN was observed in 13 out of 227 cases (5.7%) with an average time to appearance of 26.2 months. In unirradiated cases, ORN correlated with Total Physical Dose to Mandible_2cm3 (p = 0.027). Patients receiving Total Physical Doses greater than 61 Gy had a 20-fold increased risk of ORN.

CONCLUSIONS

In Unirradiated patients the panel recommends to avoid implantation of postoperative CTVs exceeding 15 cm³ at Total EQD2-DVH TV₁₀₀ doses in excess of 87 Gy as well as to limit the irradiation of the Mandible_2cm3 to 61 Gy. In previously irradiated patients the panel cannot make a recommendation based on the available results.

[Brachytherapy for head and neck cancers]

The main indications of the brachytherapy of head and neck cancers are the limited tumours of the lip, the nose, the oral cavity and the oropharynx. Nasopharynx tumours are nowadays treated by intensity-modulated radiotherapy. This technique can be exclusive, associated with external radiotherapy or postoperative. It can also be a salvage treatment for the second primaries in previously irradiated areas. If the low dose rate brachytherapy rules remain the reference, the pulse dose rate technique allows the prescription of the dose rate and the optimisation of the dose distribution. Results of high dose rate brachytherapy are now published. This paper reports the recommendations of the Gec-ESTRO, published in 2017, and takes into account the data of the historical low dose rate series, and is upgraded with the pulsed-dose rate and high dose rate series.

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.

A review of the clinical experience in pulsed dose rate brachytherapy

Pulsed dose rate (PDR) brachytherapy is a treatment modality that combines physical advantages of high dose rate (HDR) brachytherapy with the radiobiological advantages of low dose rate brachytherapy. The aim of this review was to describe the effective clinical use of PDR brachytherapy worldwide in different tumour locations. We found 66 articles reporting on clinical PDR brachytherapy including the treatment procedure and outcome. Moreover, PDR brachytherapy has been applied in almost all tumour sites for which brachytherapy is indicated and with good local control and low toxicity. The main advantage of PDR is, because of the small pulse sizes used, the ability to spare normal tissue. In certain cases, HDR resembles PDR brachytherapy by the use of multifractionated low-fraction dose.

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.