Brachytherapy for recurrent nasopharyngeal and naso-ethmoidal tumours

Customized individual applicators for endocavitary brachytherapy in patients with cancers of the nasal cavity, sinonasal region and nasopharynx

Brachytherapy has become an established therapeutic regimen for primary, persistent, recurrent and metastatic tumour disease in the head and neck region. This study presents the authors' preliminary experience with intracavitary brachytherapy by means of an individual silicone applicator in the treatment of patients with nasal, sinonasal, orbital and nasopharyngeal cancer. Between January 2001 and January 2013, twenty patients with cancer of the nasal cavity, the paranasal sinuses and nasopharynx underwent surgery and intracavitary brachytherapy with the aid of an individually manufactured silicone applicator in the Department of Otolaryngology, Head and Neck Surgery and in the Department of Radiotherapy and Radiooncology at the Saarland University Medical Center of Homburg, Germany. The tumour was localized in the nasal cavity/paranasal sinuses (15) affecting the orbit twice and the nasopharynx (5). There were 14 patients with squamous cell carcinoma, 2 patients with mixed tumours and one patient with adenocarcinoma, adenoid cystic carcinoma, mucosal melanoma or plasmocytoma. The majority of the patients presented with advanced disease (T3 or T4 tumours). In 18/20 patients, brachytherapy was performed as a boost technique, in the remaining two solely because of a previous radiation series. All surgical interventions were performed endonasally. Three to six weeks after surgery, a cast of the nasal cavity was created under general anaesthesia. Subsequently, an individual brachytherapy silicon applicator with two to four plastic tubes was manufactured. The radiation therapy was applied using the Ir-192 high-dose-rate-afterloading method (total dose 10-20 Gy) in two to five sessions, additionally in 18/20 patients a percutaneous radiotherapy with a total dose of 30-60 Gy was applied. After a mean duration of follow-up of 2 years, 7/20 patients experienced a local progression, 5/19 a regional recurrence in the neck nodes and 4/19 distant metastases. The 2-year survival was 57.3 %. No serious complications were reported. The silicone applicator was well tolerated by all patients. Because of the complexity of the sinonasal anatomy with the finding of mainly advanced tumours, the presented individual silicone brachytherapy applicator has proven to be useful and meaningful for endocavitary brachytherapy of malignancies of the nasal cavities, paranasal sinuses and nasopharynx.

125I brachytherapy alone for recurrent or locally advanced adenoid cystic carcinoma of the oral and maxillofacial region

BACKGROUND AND PURPOSE

This retrospective study was to evaluate the local control and survival of (125)I brachytherapy for recurrent and/or locally advanced adenoid cystic carcinoma (ACC) of the oral and maxillofacial region.

PATIENTS AND METHODS

A total of 38 patients with recurrent and/or locally advanced ACC of the oral and maxillofacial region received (125)I brachytherapy alone from 2001-2010. Twenty-nine were recurrent cases following previous surgery and radiation therapy. The other 9 cases involved primary tumors. Overall, 12 tumors were located in the major salivary glands, 12 in the minor salivary glands, and 14 in the paranasal region, the nasal cavity or the skull base. The prescribed dose was 100-160 Gy.

RESULTS

Patients were followed for 12-122 months (median 51 months). The 2-, 5-, and 10-year local tumor control rates were 86.3, 59, and 31.5 %, respectively. The 2-, 5-, and 10-year overall survival rates were 92.1, 65 and 34.1 %, respectively. Tumors > 6 cm had significantly lower local control and survival rates. No severe complications were observed during follow-up.

CONCLUSION

(125)I brachytherapy is a feasible and effective modality for the treatment of locally advanced unresectable or recurrent ACC.

Improved targeting device and computer navigation for accurate placement of brachytherapy needles

Successful treatment of skull base tumors with interstitial brachytherapy requires high targeting accuracy for the brachytherapy needles to avoid harming vital anatomical structures. To enable safe placement of the needles in this area, we developed an image-based planning and navigation system for brachytherapy, which includes a custom-made mechanical positioning arm that allows rough and fine adjustment of the needle position. The fine-adjustment mechanism consists of an XYZ microstage at the base of the arm and a needle holder with two fine-adjustable inclinations. The rotation axes of the inclinations cross at the tip of the needle so that the inclinational adjustments do not interfere with the translational adjustments. A vacuum cushion and a noninvasive fixation frame are used for the head immobilization. To avoid mechanical bending of the needles due to the weight of attached tracking markers, which would be detrimental for targeting accuracy, only a single LED marker on the tail of the needle is used. An experimental phantom-based targeting study with this setup demonstrated that a positioning accuracy of 1.4 mm (rms) can be achieved. The study showed that the proposed setup allows brachytherapy needles to be easily aligned and inserted with high targeting accuracy according to a preliminary plan. The achievable accuracy is higher than if the needles are inserted manually. The proposed system can be linked to a standard afterloader and standard dosimetry planning module. The associated additional effort is reasonable for the clinical practice and therefore the proposed procedure provides a promising tool for the safe treatment of tumors in the skull base area.

Adjuvant fractionated high-dose-rate intracavitary brachytherapy after external beam radiotherapy in Tl and T2 nasopharyngeal carcinoma

BACKGROUND

The value of high-dose-rate intracavitary brachytherapy (HDRIB) for persistent or recurrent nasopharyngeal carcinoma has been well described; however, the benefit of routine adjuvant fractionated HDRIB following external beam radiation therapy (EBRT) has not been completely determined. The objective of this analysis was to evaluate the outcome of two fractions of adjuvant HDRIB treatment in Tl and T2 nasopharyngeal carcinoma.

METHODS

Thirty-three consecutive and nonselected patients who had Tl and T2 non-disseminated nasopharyngeal carcinoma were treated according to an IRB approved institutional research protocol between March 1999 and July 2001. By the 1997 AJCC cancer staging classification, 22 patients (67%) had Tl disease and 11 patients (33%) had T2 disease. Seventeen of these patients who had stage I or stage II disease (i.e., NO or Nl) were treated with EBRT followed by two fractions of adjuvant HDRIB (group 1); 16 patients who had stage III or stage IV disease (i.e., N2 or N3) were treated with concurrent cisplatin, EBRT and adjuvant HDRIB and subsequent adjuvant cisplatin and fluorouracil (5-FU) chemotherapy (group 2). EBRT was delivered by daily conventional fractionation to a total dose of 66 Gy to the primary tumor. Nodal disease received 66 Gy if it was less than 3 cm in maximum diameter and 70 Gy if larger or there was palpable residual disease after 66 Gy. A total of 10 Gy of HDRIB in 2 equal fractions of 5 Gy spaced 1 week apart was delivered starting 1 week after the completion of EBRT. All patients were assessed for treatment response, local control, survival, and toxicity.

RESULTS

The median follow up for all 29 surviving patients is 29 months (range: 17-38 months). One patient died 7 months and one died 18 months after radiation therapy from the effects of distant metastases; two died of unrelated causes. At the time of this analysis, one patient (3%) had persistent local disease and one patient (3%) developed pathologically confirmed local recurrence in the nasopharynx. In addition, one patient (3%) developed recurrence only in a neck node followed by distant metastasis, and two patients (6%) developed distant metastasis without locoregional relapse. The 2-year local control rate at the primary site was 93.6%, and the overall survival and disease-free survival rates were 82% and 74% respectively. All patients experienced some degree of acute and/or late toxicity related to radiation therapy. Ten patients (30%) experienced grade 3 acute and/or late toxicity and six patients (18%) developed grade 4 acute and/or late toxicity. No grade 5 toxicity occurred. No unexpected damage of structures within the HDRIB fields was detected.

CONCLUSIONS

EBRT supplemented by two fractions of adjuvant HDRIB produced a 93.6% local control rate for Tl and T2 nasopharyngeal cancer at 2 years of follow up, with acceptable rates of acute and late toxicity. Brief adjuvant HDRIB appears to permit dose escalation safely, even in patients who receive chemotherapy concurrently with conventional radiation therapy. This strategy needs to be optimized and then tested in a prospective randomized phase III trial to learn if it can improve outcome.

Reirradiation of nasopharyngeal carcinoma with intracavitary mold brachytherapy: an effective means of local salvage

PURPOSE

To assess the role of intracavitary mold brachytherapy in salvaging local failure of nasopharyngeal carcinoma (NPC).

METHODS AND MATERIALS

The outcomes of 118 consecutive NPC patients with local failure treated with mold brachytherapy between 1989 and 1996 were retrospectively reviewed. Eleven patients received additional external radiotherapy.

RESULTS

All molds were tailor-made, and the whole procedure was performed under local anesthesia. Pharyngeal recess dissection was routinely performed to allow direct contact of the radioactive source with the pharyngeal recess, a common site of local failure. Initially, the molds were preloaded with 192Ir wires, but since 1992, the sources have been manually afterloaded; the mold has also been redesigned for better conformity, ease of insertion, and radiation safety. Using brachytherapy alone, 50-55 Gy was given for recurrence in 4-7 days; for persistence, 40 Gy was administered. The overall complete remission rate was 97%. The rates of 5-year local control, relapse-free survival, disease-specific survival, overall survival, and major complication were 85%, 68.3%, 74.8%, 61.3%, and 46.9%, respectively. Major complications included nasopharyngeal necrosis with headache, necrosis of cervical vertebrae with atlantoaxial instability, temporal lobe necrosis, and palsy of the cranial nerves. The afterloaded mold was as effective as the preloaded version, but with fewer complications.

CONCLUSIONS

Intracavitary mold brachytherapy was effective in salvaging NPC with early-stage local persistence or first recurrence.

Association between high initial tissue levels of cyclin d1 and recurrence of nasopharyngeal carcinoma

OBJECTIVES/HYPOTHESIS

Cyclin D1 expression and the rate of apoptosis have been reported to serve as important prognostic indicators in human cancers. The purpose of the present study was to determine the prognostic significance of both initial cyclin D1 expression and the apoptotic index in nasopharyngeal carcinoma.

STUDY DESIGN

Cohort study.

METHODS

Cyclin D1 protein levels and apoptosis in tumors and their corresponding adjacent, histologically normal tissues were determined at the time of initial diagnosis using immunohistochemical staining, Western blot analysis, and in situ end labeling, respectively, in 64 patients with T1-T4/N0-N2, poorly differentiated squamous cell carcinoma of the nasopharynx. All cases were treated by routine radiation therapy with a total median dose of 70 Gy and followed up for 10 years.

RESULTS

High levels of cyclin D1 were found in 35 of 64 tumor specimens (54.7%); no cyclin D1--positive cells were determinable in normal epithelium of the nasopharynx. Rates of early local recurrence (within 5 y) were significantly higher (P <.01) for patients with high levels of cyclin D1 before radiation therapy (24 of 35 patients [68.6%]) as compared with patients with low or no expression (3 of 29 [10.3%]). Furthermore, patients bearing high levels of cyclin D1 had a poorer prognosis concerning 10-year survival than the others (P <.001), whereas overexpression of cyclin D1 did not correlate with the initial TMN classification (P >.05). According to the rate of spontaneous apoptosis in tumors below or above the median, patients were divided into two groups. There was no statistically significant difference for the overall survival between the two groups (P >.05).

CONCLUSIONS

The present study demonstrates that cyclin D1 can be used as an indicator of recurrence and subsequent prognosis in nasopharyngeal carcinoma after radiation therapy. At the same time, the apoptotic state before radiation therapy is of no value in predicting the prognosis of patients with nasopharyngeal carcinoma.

Brachytherapy for primary and recurrent nasopharyngeal carcinoma: 20 years' experience at Long Beach Memorial

PURPOSE

We evaluated treatment outcomes of patients with mostly locally advanced primary and recurrent cancer of the nasopharynx managed with interstitial and intraluminal brachytherapy.

METHODS AND MATERIALS

This is a retrospective analysis of 56 patients with cancer arising from the nasopharynx treated with interstitial and intracavitary afterloading brachytherapy from 1978 to 1997. Patients were divided into three treatment groups: 15 patients with primary cancer (Group 1), 34 patients with recurrent or persistent disease (Group 2), and 7 patients with cancer in the nasopharynx who had history of previous definitive radiation therapy to the nasopharynx for head and neck cancer (Group 3). Fifty-three percent of patients in Group 1 had 1992 AJCC Stage IV disease, and 49% of patients in Groups 2 and 3 had extensive disease (defined as T3, T4, or parapharyngeal extension). Group 1 received megavoltage radiation to 50-60 Gy followed by a boost to the primary site and neck (in cases of persistent neck disease) with a combination of interstitial and intracavitary brachytherapy (mean dose 33-37 Gy). Five patients received chemotherapy, and 6 patients received hyperthermia. Groups 2 and 3 patients were treated with brachytherapy implants (mean dose 50-58 Gy) without external beam radiation. Twenty-five patients received chemotherapy either before or during radiation, and 21 patients received hyperthermia.

RESULTS

The overall survival at 2, 5, and 10 years for patients in Group 1 was 79%, 61%, and 61%, respectively, and for patients in Groups 2 and 3 combined was 48%, 30%, and 20%, respectively. Cause-specific survival at 2, 5, and 10 years was 87%, 74%, and 74%, respectively, for patients in Group 1; and 82%, 60%, and 60%, respectively, for patients in Groups 2 and 3. Local control at 2, 5, and 10 years was 93%, 93%, and 77%, respectively, for patients in Group 1; and 81%, 59%, and 49%, respectively, for patients in Groups 2 and 3. Control in the neck at 2, 5, and 10 years was achieved in 93%, 93%, and 93% of patients, respectively, in Group 1; and 88%, 81%, and 81%, respectively, for patients in Groups 2 and 3. Disease-free survival was 87%, 74%, and 62%, respectively, for patients in Group 1, and 56%, 41%, and 34%, respectively, for patients in Groups 2 and 3. There were 4 peri-operative deaths. One death (2%) was attributable to the development of late complications. Forty-five percent of patients experienced some form of late complications.

CONCLUSION

Interstitial afterloading brachytherapy can provide effective treatment for nasopharyngeal cancers, especially for locally persistent/recurrent and locally extensive lesions.

Results of hypofractionated stereotactic re-irradiation on 13 locally recurrent nasopharyngeal carcinomas

Thirteen patients with locally recurrent, previously-irradiated nasopharyngeal carcinoma were treated with linac-based hypofractionated stereotactic radiotherapy (24 Gy in two or four fractions). One- and 3-year overall survival were 54 and 31%. Three patients were free of disease at 30, 34 and 65 months. No severe acute or late complications were seen.

Iodine seeds in the treatment of slowly proliferating tumours in the head and neck region

Locally recurrent/persistent disease is a major cause of morbidity and mortality in patients suffering from tumours arising in the head and neck region. Iodine-125, with its long half-life of 60 days, is particularly suited for the treatment of slowly proliferating tumours (e.g. adenoidcystic carcinomas) of this site. We report our experience with 18 patients using iodine-125 seeds, placed at the time of surgery in patients with such tumours. Eleven of the patients were treated for recurrent disease following previous radical treatment. Disease free survival was 89% at 2 years and 53% at 5 years after treatment. These results are encouraging in a group of patients in whom achieving and maintaining local control can be extremely difficult.