Escolar Documentos
Profissional Documentos
Cultura Documentos
BRACHYTHERAPY
in HEAD and NECK
CANCERS
Dr. Sayan
Brachytherapy - Placement of sealed radioactive
sources into or immediately adjacent to the target
tissue is called as brachytherapy.
CLINICAL:
– Feasibility for Brachytherapy: Mouth opening, dental status,
proximity of bones to implant site and requirement of dental
shields/spacers
– Requirement of tracheostomy
– Fitness for anesthesia
Important Facts to be Noted in H&N
Brachytherapy
PHYSICAL:
– Dose distribution even in a good implant is likely to be non-
homogenous (due to complex geometry)
– Even minor displacement may produce significant hot/cold
spots; increased morbidity/recurrence
– Peripheral fall off- may cause under-dosage of a site
– Under-dosage at borders where placement of additional
radio-active line may not be possible (dorsum and lateral
border tongue)
Important Facts to be Noted in H&N
Brachytherapy
• PHYSICAL:
– Interstitial edema may produce alteration in dose distribution
calculated to an extent of 10-15%.
– Narrow loops may prevent Rx with after-loading technique.
– Dose prescription volume and dose points should be clearly
specified.
– Method of optimization should be noted.
– Optimization is not to be used as a substitute for good
catheter placement
Important Facts to be Noted in H&N
Brachytherapy
BIOLOGICAL:
– Type of lesion: proliferative/infiltrative
– Ulcerative/proliferative lesions respond better
• Sensitivity
• Well defined and hence better delineation
• Minimal potential margin
– Infiltrative lesions are less preferred
– Larger lesion to be avoided for same reasons
Important Facts to be Noted in H&N
Brachytherapy
BIOLOGICAL:
– Total duration of EBRT + Brachytherapy should be kept as short
as possible (<8 weeks) to minimize tumor cell repopulation
– Interval between EBRT and Brachytherapy should be as short as
possible (<1–2 weeks) depending on degree of recovery from
mucositis
– Interval between twice daily HDR fractions should be as long as
possible (minimum of 6 hours)
– Previous irradiation history for dose calculation
Important Facts to be Noted in H&N
Brachytherapy
• BIOLOGICAL:
– In case of brachytherapy boost, placement of radio-opaque
markers before starting EBRT can help delineate the target
volume, before any shrinkage occurs
– No definite evidence on use of concomitant chemotherapy; risk
of increased mucosal toxicity compromising treatment –
however, appears to be useful for the treatment of recurrences
Mazeron JJ, Richaud P. Lip cancer, report of the 18th annual meeting of the
European Curietherapy Group, May 1981. J Eur Radiother 1984;5:50–6.
Hypodermic Needles
• Catheters are looped through the oral tongue via entry sites in
the submental and submandibular areas.
• However, as the oral tongue is situated away from the mandible, the
risk of osteonecrosis is small.
FLOOR OF MOUTH IMPLANT
• Radical Implant: recommended for T1N0 and T2N0 tumors <30 mm and
>5 mm from the mandible
• Tumors >30 mm and <40 mm and >5 mm from the mandible may be
treated either with brachytherapy or by surgery.
• Postop brachytherapy may be used in case of close or positive margins or
lymphatic invasion or tumour infiltration > 5 mm in the absence of positive
lymph nodes.
• Involvement of the mandible is an absolute contraindication to
brachytherapy.
• Both guide-gutter and plastic tube techniques are applicable. In order to
decrease the dose to the mandible, contact between the mandible and
high dose areas should be minimized (no more than two lines).
Buccal Mucosa
• Indication: lesions <4 cm in diameter and <1.5 cm in thickness
involving the anterior and central part of the buccal mucosa.
1) needles are implanted through the skin: first parallel to each other,
parallel to the oral mucosa and parallel to the horizontal branch of the
mandible.
• The lines are placed 3-5 mm deep, under the buccal mucosa.
• They should cover 10 mm of normal mucosa behind or in front of the
lesion with a recommended spacing of 12 to 15 mm.
• 2-3 plastic tubes are usually required to cover the target volume if
the thickness of the tumour does not exceed 5 mm
• If the lesion is thicker than 5 mm, a
second plane of tubes is implanted
between the first one and the skin, with an
interplane spacing equal to the
intersource spacing in each plane.
• For all these different implants, the position of the lines must be checked not
only when the mouth is open but also closed, with the shielding device in
place inside the oral cavity.
• The shielding system may reduce the thickness of the target volume by
stretching the cheek and squeezing the tumour so irradiation is better
adapted
Oropharynx
Indications
Tumors less than 5 cm as combination modality
Brachytherapy alone: 1) purely exophytic tumours ≤ 10 mm in
diameter
2) recurrent cancers
3) new tumour arising in previously
irradiated territory
Contra-indications
Tumour extends to the RMT, NPX, larynx, HPX
If the lesion is fixed to the underlying structures or invades bone.
Tumour is associated with bulky cervical lymph nodes
Base of tongue
• Patients who do not have palpable LN
metastasis receive elective irradiation to the
neck along with EBRT to the primary site.
• Treatment is completed with an implant to the
base-of-tongue, performed approximately 2-3
wks after the completion of EBRT.
• This type of implant usually consists of
three sagittal planes, each containing a
'looping' catheter running over the dorsum
of the base of tongue and two or three
blind ending catheters with buttons sutured to
the looping catheter.
• The implants are done under GA with nasal intubation.
• A temporary tracheostomy might be necessary if the vallecular region is invaded
by a large tumor.
• Supine position with the neck in hyperextension
• 3 or 4 sagitally oriented parallel loops, spaced 15 - 20 mm, are implanted.
• The posterior branch of the central loop is first implanted. A guide needle is
inserted perpendicularly to the skin above the hyoid bone. The needle is guided
into the pharynx, in most cases into the vallecula, with the index fingertip. A nylon
filament is introduced into the needle. Then the needle is removed. A nylon tube is
advanced along the nylon filament, and the two are clamped together. Then the
tube is pulled into oropharyngeal cavity. The filament is removed.
• A second needle is implanted anteriorly into the base of tongue, and a filament is
advanced into the needle. The needle is removed and the filament inserted into
the first plastic tube. The two are clamped together and pulled through tongue and
skin, so completing the loop. The filament is removed.
RAYNAL LOOP SUBSTITUTION TECHNIQUE
Vallecular region
• The loop technique can be modified for
implanting vallecular tumours.
• The posterior inferior branches of the loops are
implanted between the hyoid bone and the
thyroid cartilage through the epiglottis, and the
superior branches into the base of tongue.
• When the loops are formed, the free portion of
the epiglottis is pulled forward and held against
the base of tongue
• Straight, blind-ended plastic tubes may replace
loops if a stepping source afterloader is used.
Soft Palate
Classical Plastic Loop Technique
The procedure is carried out under general anaesthesia
with nasal intubation
Two parallel frontal loops 15 -20 mm apart are
implanted to cover the whole or two thirds of the faucial
arch
Poseidon Technique
• This technique permits to treat lesions of
the uvula and small central tumours of
the soft palate
• Three curved needles are implanted in a
sagittal direction into the soft palate.
• They are inserted into the mucosa at the
junction of the hard and soft palate and
sort at the free border laterally and
through the uvula for the central line.
Then a loop is made joining the two
lateral lines.
Tonsil
• For tumours of the tonsillar region, the implant
covers only the ipsilateral tonsillar region and a part
of the soft palate.
• The two pillars and the soft palate are implanted
using Pernot technique, but the tubes exit in the
oropharyngeal cavity at the opposite side of the soft
palate.
• A plastic spacer secures spacing between the
oropharyngeal extremities of the tubes. These
extremities are fixed with buttons.
• For tumours limited to the lower half of the tonsillar
region, the two tubes can be replaced by a loop
covering only the tonsillar region (Baillet technique)
•For tumours involving the tonsillar region as
well as the adjacent tongue, an additional
loop may be implanted into the tongue, in
order to irradiate the glosso-tonsilar sulcus
and the adjacent tongue
Nag S, Cano ER, Demanes DJ, et al. The ABS recommendations for HDR brachytherapy for
head and neck carcinoma. Int J Radiat Oncol Biol Phys 2001;50:1190–8
Mazeron JJ, Simon JM, Le Péchoux C, et al. Effect of dose rate on local control and
complications in definitive irradiation of T1-2 squamous cell carcinoma of mobile tongue
and floor of mouth with interstitial iridium 192. Radiother Oncol 1991;21:39–47.
Dose for Brachytherapy– here in TMH
• Radical Brachytherapy:
T1-2 N0 tumors - low dose rate 60-70Gy
high dose rate 49 Gy/14# (2#/day)
Catheter Removal
• Implant catheters should be removed in the operating room,
where management of haemorrhage and airway protection are
achieved more effectively.
• An intravenous access is recommended and the presence of
two persons is mandatory.
• In case of bleeding, bimanual compression for ten minutes is
usually effective for stopping arterial bleeding.
Post-treatment Patient Care and Follow-up
• GEC-ESTRO recommends that patients should be seen 1 month
after treatment, every 3 months during years 1 to 3, then every 6
months during years 4 and 5, then yearly.