The role of salvage surgery with interstitial brachytherapy for the Management of Regionally Recurrent Head and Neck Cancers

Abstract

Background: The optimal treatment for regional lymphatic recurrences from head and neck cancer has not been fully established. In order to explore the therapeutic benefit of surgical resection and adjuvant brachytherapy, the authors reviewed their experience utilizing interstitial brachytherapy (IBT) at the M. D. Anderson Cancer Center.

Methods: A retrospective chart review of the 51 patients who received salvage surgical resection of lymphatic recurrences and adjuvant IBT between 1993 and 2012 at the M. D. Anderson Cancer Center was undertaken. All patients underwent neck dissection with complete resection and intraoperative placement of afterloading brachytherapy catheters. Soft tissue reconstruction was performed as necessary. The technical aspects of IBT were reviewed, and the overall and disease free survival rates and the recurrence rates were determined.

Results: All patients had received external beam radiation (EBRT) as part of their initial treatment to a median dose of 66 Gy; 40 and 68% of the patients also had a neck dissection or chemotherapy, respectively. The cumulative regional recurrence probability is 28 and 38% at 5 years and 10 years. All of the patients underwent salvage neck dissection and IBT, with 81% also undergoing soft tissue reconstruction. The median dose delivered to the tumor bed was 60 Gy over a median duration of 4.5 days. There were 21 early adverse events, 8 of which were severe, and 19 late adverse events, 6 of which were severe. The most common early and late adverse events due to surgery and brachytherapy were dysphagia (7.1%) and true vocal cord paralysis (17.9%), respectively. There were no perioperative deaths or carotid hemorrhages. Nineteen patients developed recurrence including regional recurrence and distinct metastasis. The median time to recurrence is 130 months using Kaplan-Meier product limit method. The 2-year disease-free survival rate was 58%. The 2-year, 5-year, and 10-year overall survival rates were 69, 56, and 46%, respectively.

Conclusions: Regional recurrences in previously irradiated tissues after the definitive treatment of primary head and neck cancers represent a challenging problem. We demonstrated that salvage neck dissection with IBT provided encouraging regional control and survival rates, while maintaining relatively low acute and long-term toxicity rates.

Keywords: Brachytherapy; Neck dissection; Recurrence; Squamous cell carcinoma.

Fig. 1

Patterns of failure after salvage neck dissection and IBT. DM indicates distant metastases. Numbers represent the number of affected patients

Fig. 2

Kaplan-Meier curve of (a) disease-free survival, (b) overall survival for patients who underwent salvage neck dissection and IBT for cervical lymphatic recurrences and (c) probability of regional recurrence free after salvage IBT, including neck recurrences both inside and out of the brachytherapy treatment volume

Fig. 3

(a): Photograph of a brachytherapy implant after neck dissection for cervical recurrence. The catheters are placed in parallel array one cm apart. (b): Brachytherapy Dosimetry: The patient was treated to the 61 cGy/hr. line, which is 1 cm wide. The dose declines rapidly with distance, so only a limited volume of the neck is treated