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PORTO, 27-29

JANEIRO 2011
CABEÇA E PESCOÇO - UPDATE.

BRAQUITERAPIA:
PASSADO OU FUTURO

ANGELES ROVIROSA

Oncología Radioterápica
Hospital Clínic Barcelona
España
BRAQUITERAPIA EN EL CÁNCER DE CABEZA Y CUELLO.

PASADO
PRESENTE
FUTURO?
DIFERENTES TÉCNICAS
TRATAMIENTO EFECTIVO
 VENTANA NASAL
 LABIO
 LENGUA
 SUELO DE BOCA
 BASE DE LENGUA
 AMÍGDALA
 MUCOSA YUGAL
 NASOFARINGE
TRATAMIENTO CONSERVADOR

TRATAMIENTO EXCLUSIVO O ASOCIADO A RTE

IGUAL CONTROL LOCAL Y SUPERVIVENCIA

PRESERVACIÓN DE LA ANATOMÍA Y FUNCIÓN DEL


ÓRGANO O ESTRUCTURAS ANATÓMICAS

EVITAR PROBLEMAS ESTÉTICOS

MEJOR CALIDAD DE VIDA


BRAQUITERAPIA EN CÁNCER
DE CABEZA Y CUELLO.

 Una de las técnicamente más difíciles.


 Estructuras sanas vecinas con riesgo de
complicaciones importante.
REQUIERE DE EQUIPOS
Las complicaciones MUY ENTRENADOS
graves, son de difícil
solución y causan gran disconfort en el
paciente; y en ocasiones el médico se siente
impotente ante ellas.
BRAQUITERAPIA EN EL CÁNCER DE
CABEZA Y CUELLO HA OFRECIDO:

 EN ESTADIOS TEMPRANOS:
Iguales resultados en control local y supervivencia que la cirugía.
Tratamiento conservador de órgano y del funcionalismo.

 EN ESTADIOS AVANZADOS:
Permite un incremento de la dosis a nivel del seno del tumor y evitar tratamientos
mutilantes.

 EN POSTOPERATORIOS CON MÁRGENES AFECTOS:


Una solución a exéresis más amplias.

 TRATAMIENTO DE RECIDIVAS DESPUÉS DE OTROS TRATAMIENTOS.


PRESENTE
ESTRO GUIDELINES.
ASTRO GUIDELINES.
PRESENTE
 DESAPARICIÓN PROGRESIVA DEL IRIDIO 192 DE BAJA TASA.

 POCOS BRAQUITERAPÉUTAS FORMADOS EN TÉCNICAS DE ORL.

 IMPLEMENTACIÓN LENTA DE LAS TÉCNICAS DE ALTA TASA.

 EXPERIENCIA DE LA LITERATURA EN ALTA TASA NO SUFICIENTE EN


COMPARACIÓN CON LA BAJA TASA.

 NO SUFICIENTES BRAQUITERAPÉUTAS ENTRENADOS EN LAS TÉCNICAS


DE ALTA TASA.

 FALTA DE DIFUSIÓN DE LA TÉCNICA POR LOS RADIOTERAPÉUTAS.

 TENDENCIA MAYOR DE LOS CIRUJANOS A OPERAR, A SU VEZ


FACILITADA POR LOS RADIOTERAPÉUTAS CON POCA EXPERIENCIA EN
BRAQUITERAPIA.

 PREDOMINIO DE LOS TRATAMIENTOS CON RADIOQUIMIOTERAPIA EN


LOS ESTADIOS AVANZADOS.
TAC: 33% → 61%
RNM: 5% → 16%
GRUPO I: Austria, Bélgica, Dinamarca, Finlandia, Francia, Alemania, Grecia, Islandia, Irlanda italia, Holanda, Noruega, Portugal,
España, Suecia, Suiza y Gran Bretaña.

GRUPO II: Chipre, República Checa, Estonia, Hungaria, Lituania, Malta, Polonia, Eslovaquia y eslovenia.

GRUPO III: Albania, Armenia, Belarus, Bosnia, Herzegovina, Bulgaria, Croacia, Georgia, Israel, Macedonia, Moldova, Rumania,
Montenegro, Servia y Turquia.
PRESENTE

 Jubilación de los grandes referentes en estos


tratamientos.
 Menor número de publicaciones en cabeza y
cuello por los autores referentes previos.
 Autores referentes actuales están centrados
en otras áreas de braquiterapia.
 Aumento de las publicaciones en los Países
del Este, China, India y Japón.
HDR vs LDR
Strahlenther Onkol. 2004 Dec;180(12):776-82.
Late effects of post-high-dose-rate brachytherapy for oropharyngeal carcinoma: are
they severer than post-low-dose-rate?
Nose T, Peiffert D, Lapeyre M, Hoffstetter S, Koizumi M, Nishiyama K.
Department of Radiation Oncology, Osaka Medical Center, Osaka, Japan. fwik3454@mb.infoweb.ne.jp

Abstract
BACKGROUND: . Late effects by high-dose-rate (HDR) brachytherapy have been believed severer than
low-dose-rate (LDR) provided tumor control was constant. Local control of oropharyngeal carcinoma
with HDR at Osaka Medical Center was comparable to LDR series from Centre Alexis Vautrin (82%,
79.5%, respectively). To assess the feasibility of HDR brachytherapy, the late effects were compared.
PATIENTS AND METHODS: . The data of 29 HDR and 24 LDR patients (median follow-up of 27 and 29.5
months, respectively; p = 0.89) were collected. The HDR schedule was 21 Gy/3.5 fractions/2 days
following 46 Gy/23 fractions external beam, while 25 Gy/3 days following 50 Gy/25 fractions external
beam was for LDR. Late changes were evaluated using RTOG/EORTC late morbidity scoring scheme. For
subclinical late changes, mucosa chapter of Dische score was modified for brachytherapy. Scores were
discussed through photos and were agreed on by authors. Late sequelae were estimated, by reviewing
charts, concerning frequency, severity, and duration of mucosal damages (erosion and ulcer).
RESULTS: . Late changes were of no difference (p = 0.12 for EORTC/RTOG, and p = 0.45, 0.47, 1.00, 0.12,
0.16, 0.95, 0.27, 0.21 for erythema, ulceration, edema, thinning, pallor, telangiectasia, mobility impairment
of tongue/faucial pillars, respectively, of the modified Dische score). Late sequelae showed no
differences (p = 0.90, 0.12, 0.40 for frequency, severity, duration, respectively, of mucosal damages).
CONCLUSION: . The late effects by HDR were not severer than by LDR. HDR oropharyngeal
brachytherapy is as safe as LDR.
APLICADORES HDR
NASOFARINGE
Int J Radiat Oncol Biol Phys. 2000 Dec 1;48(5):1331-8.
Salvage radiation therapy for locally recurrent nasopharyngeal carcinoma.
Leung TW, Tung SY, Sze WK, Sze WM, Wong VY, Wong CS, O SK.
Department of Clinical Oncology, Tuen Mun Hospital, Hong Kong, People's Republic of China.

Abstract
PURPOSE: To study the treatment outcome in patients with locally recurrent nasopharyngeal carcinoma (NPC) and to explore whether
a combination of high-dose-rate (HDR) intracavitary brachytherapy and external beam radiation therapy (ERT) could improve the
therapeutic ratio.
METHODS AND MATERIALS: Ninety-one patients with nonmetastatic locally recurrent NPC who were treated with curative intent
during the years 1990-1999 were retrospectively analyzed. Eighty-two patients had histologically proven carcinoma. The remaining 9
had clinical and imaging features suggestive of local recurrence. The Ho's T-stage distribution at recurrence (rT) was as follows: rT1-
37, rT2-14, rT3-40. Total equivalent dose (TED) was calculated by the linear-quadratic formula without a time factor correction. For
those treated by combined-modality treatment (CMT), the TED was taken as the summation of the equivalent dose by ERT and the
absolute dose delivered to floor of the sphenoid by brachytherapy. Eight patients were treated solely with brachytherapy, all receiving
24-45 Gy in 3-10 sessions. Forty-one patients were treated with ERT alone receiving a median TED of 57.3 Gy (range, 49.8-62.5 Gy).
Forty-two patients were treated by CMT with a median equivalent dose of 50 Gy (range, 40-60 Gy) given by ERT and 14.8 Gy by
brachytherapy (range, 3-29.6 Gy). Multivariate analyses were performed using the Cox regression proportional hazards model.
RESULTS: The 5-year actuarial overall survival rate, disease specific survival rate and local failure-free survival (LFFS) rate for the
whole group were 30%, 33. 3% and 37.8%, respectively. The 3-year LFFS rates of rT1, rT2, and rT3 diseases were 64%, 61.5%, and
18.4%, respectively (p = 0.001). Of the 8 patients treated with brachytherapy alone, 4 failed locally. Further analyses were concentrated
on the ERT (41 patients) and CMT (42 patients) groups. The 3-year LFFS rates of rT1, rT2, and rT3 diseases were 66.7%, 66.7%, and
18.4%, respectively (p = 0.0008). Better local control for patients who received a TED of 60 Gy or greater was shown. The
corresponding 3-year LFFS rates were 29% and 60% (p = 0.0004). Subgroup analysis on the ERT and CMT groups showed a 3-year
LFFS rate of 33.5% and 57% (p = 0.003). ERT group had an excess of patients with rT3 disease. Further analysis was performed on the
rT1-2 patients showing a trend toward improvement in local control in favor of the CMT group (3-year LFFS rates: CMT, 71.7%; ERT,
54%; p = 0.13). Multivariate analyses showed that rT stage (p = 0.002) and TED (p = 0.01; HR, 0.93; 95% confidence interval, 0.88-0. 98)
remained significant. The 5-year major and central nervous system (CNS) complication-free rates were 26.7% and 47.8%. The following
factors were found to be significant on univariate analyses for both complications in the ERT and CMT groups: (1) Modality of
treatment: more complications with ERT group; and (2) rT stage. Multivariate analyses showed that the rT stage was significant for
predicting the occurrence of major (p = 0.004) and CNS complications (p = 0.04).
CONCLUSION: For rT1-2 local recurrences, CMT with at least 60 Gy TED is recommended. The high incidence of major late
complications is of serious concern. Ways of improving the local control of Ho's rT3 disease and reducing the risk of late
complications should be explored
LABIO
LENGUA
Int J Radiat Oncol Biol Phys. 2001 Sep 1;51(1):171-5.
Phase III trial of high- vs. low-dose-rate interstitial radiotherapy for early mobile
tongue cancer.
Inoue T, Inoue T, Yoshida K, Yoshioka Y, Shimamoto S, Tanaka E, Yamazaki H, Shimizutani
K, Teshima T, Furukawa S.
Division of Multidisciplinary Radiotherapy, Biomedical Research Center, Osaka University
Graduate School of Medicine, Suita, Osaka, Japan.

Abstract
PURPOSE: Early mobile tongue cancer can be controlled with interstitial radiotherapy
(ISRT). We carried out a Phase III trial to compare the treatment results of low-dose-rate
(LDR) ISRT and high-dose-rate (HDR) ISRT for early mobile tongue cancer.
METHODS AND MATERIALS: From April 1992 through October 1996, 59 patients with
cancer of the early mobile tongue were registered in this Phase III study. Eight patients were
excluded from the evaluation because of violations of the requirements for this study. Of 51
eligible patients, 26 patients were treated with LDR-ISRT (70 Gy/4-9 days) and 25 patients
with HDR-ISRT (60 Gy/10 fractions/1 week). For the hyperfractionated HDR-ISRT, the time
interval between 2 fractions was more than 6 h.
RESULTS: Five-year local control rates of the LDR and HDR groups were 84% and 87%
respectively. Nodal metastasis occurred in 6 patients in each group. Five-year nodal control
rates of the LDR and HDR groups were 77% and 76%, respectively.
CONCLUSION: Hyperfractionated HDR-ISRT for early mobile tongue cancer has the same
local control compared with continuous LDR-ISRT. Hyperfractionated HDR-ISRT is an
alternative treatment for continuous LDR-ISRT.
LENGUA
Brachytherapy. 2010 Jul-Sep;9(3):227-34. Epub 2010 Jan 29.
Efficacy of high-dose-rate interstitial brachytherapy in patients with oral tongue
carcinoma.
Guinot JL, Santos M, Tortajada MI, Carrascosa M, Estellés E, Vendrell JB, Muelas R, Chust ML, Mengual JL,
Arribas L.
Department of Radiation Oncology, Fundación Instituto Valenciano de Oncología (IVO), Valencia, Spain.
jguinot@fivo.org

Abstract
PURPOSE: To evaluate the results of high-dose-rate (HDR)-interstitial brachytherapy (ISBT) in oral tongue
carcinomas.
METHODS AND MATERIALS: Between September 1999 and August 2007, 50 patients were treated for oral
tongue carcinoma with HDR-ISBT. The patient's mean age was 58 years. Forty-two patients were in T1-2 stage
and 8 patients were in T3 stage; 16 patients were in N+ stage and 34 patients in N0 stage. Exclusive ISBT was
given to 17 patients (34%) in T1-2 N0 stage and complementary to external beam radiotherapy (EBRT) to 33
patients (66%). A perioperative technique was performed on 14 patients. The median total dose was 44 Gy when
HDR was used alone (4 Gy per fraction) and 18 Gy when complementary to 50 Gy EBRT (3 Gy per fraction).
RESULTS: The median followup was 44 months. Actuarial disease-free survival rates at 3 and 5 years were 81%
and 74%, respectively. Local failure developed in 7 patients. Actuarial local control (LC) rates were 87% and 79%
at 3 and 5 years in T1-2 stage 94.5% and 91% and T3 stage 43% and 43% (with salvage surgery). Exclusive HDR
cases showed LC in 100% of the cases, and the combined group (EBRT+HDR) showed LC in 80% and 69% of
the cases at 3 and 5 years (p=0.044). Soft-tissue necrosis developed in 16% and bone necrosis in 4% of the
cases.
CONCLUSIONS: HDR brachytherapy is an effective method for the treatment of oral tongue carcinoma in low-
risk cases. Doses per fraction between 3 and 4 Gy yield LC and complication rates similar to low-dose rate. The
perioperative technique promises encouraging results
SUELO DE BOCA
Int J Radiat Oncol Biol Phys. 1998 Apr 1;41(1):53-8.
High dose rate versus low dose rate interstitial radiotherapy for carcinoma of the
floor of mouth.
Inoue T, Inoue T, Yamazaki H, Koizumi M, Kagawa K, Yoshida K, Shiomi H, Imai A, Shimizutani K, Tanaka E,
Nose T, Teshima T, Furukawa S, Fuchihata H.
Department of Radiation Oncology, Biomedical Research Center, Osaka University Medical School, Suita, Japan.

Abstract
PURPOSE: Patients with cancer of the floor of mouth are treated with radiation because of functional and
cosmetic reasons. We evaluate the treatment results of high dose rate (HDR) and low dose rate (LDR)
interstitial radiation for cancer of the floor of mouth.
METHODS AND MATERIALS: From January 1980 through March 1996, 41 patients with cancer of the floor of
mouth were treated with LDR interstitial radiation using 198Au grains, and from April 1992 through March
1996 16 patients with HDR interstitial radiation. There were 26 T1 tumors, 30 T2 tumors, and 1 T3 tumor. For
21 patients treated with interstitial radiation alone, a total radiation dose of interstitial therapy was 60 Gy/10
fractions/6-7 days in HDR and 85 Gy within 1 week in LDR. For 36 patients treated with a combination therapy,
a total dose of 30 to 40 Gy of external radiation and a total dose of 48 Gy/8 fractions/5-6 days in HDR or 65 Gy
within 1 week in LDR were delivered.
RESULTS: Two- and 5-year local control rates of patients treated with HDR interstitial radiation were 94% and
94%, and those with LDR were 75% and 69%, respectively. Local control rate of patients treated with HDR
brachytherapy was slightly higher than that with 198Au grains (p = 0.113). For late complication, bone
exposure or ulcer occurred in 6 of 16 (38%) patients treated with HDR and 13 of 41 (32%) patients treated with
LDR.
CONCLUSION: HDR fractionated interstitial brachytherapy can be an alternative to LDR brachytherapy for
cancer of the floor of mouth and eliminate radiation exposure for the medical staff
BASE DE LENGUA
Strahlenther Onkol. 2004 Dec;180(12):768-75.
Interstitial high-dose-rate brachytherapy in the treatment of base of tongue
carcinoma.
Takácsi-Nagy Z, Polgár C, Oberna F, Somogyi A, Major T, Remenár E, Fodor J, Kásler M, Németh G.
Department of Radiotherapy, National Institute of Oncology, Budapest, Hungary. Takacsi@oncol.hu

Abstract
BACKGROUND AND PURPOSE: . To date none of the studies examined the feasibility and efficacy of interstitial
high-dose-rate (HDR) brachytherapy in the treatment of carcinoma of the tongue base. Therefore the aim of this
study was to contribute to this issue.
PATIENTS AND METHODS: . Between 1992 and 2000 37 patients (mean age 55 years) with T1-4 and N0-3
carcinoma of the base of tongue were presented. Neck dissection was carried out in twelve cases (32%). 30
patients with advanced stage received brachytherapy boost after 50-66.5 Gy (mean, 60 Gy) locoregional external
beam irradiation (EBI) and 7 patients with early stage (T1-2, N0) were managed locally with wide tumor excision
and sole brachytherapy. 4 of them underwent neck dissection and the others were subjected to 50 Gy regional
EBI. The mean dose of boost and sole brachytherapy was 18 Gy and 28 Gy, respectively.
RESULTS: . The median follow-up time for surviving patients was 51 months. The 7 sole brachytherapy patients
are living with no evidence of disease. For patients treated with EBI and brachytherapy boost, the 5-year
actuarial rate of local, locoregional recurrence-free and overall survival was 60%, 52% and 46%, respectively. For
all patients in univariate analysis larger tumor size (T4 vs. T1-3) was significant negative predictor of local (RR:
7.23) and locoregional control (RR: 3.87), but nodal involvement was not. Delayed soft tissue ulceration and
osteoradionecrosis occurred in 4 (13%) EBI and brachytherapy treated patients. None of the sole brachytherapy
patients experienced severe late radiation toxicity.
CONCLUSION: . EBI combined with interstitial HDR brachytherapy boost result in acceptable local tumor control
with low incidence of late side effects in patients with advanced disease. Fractionated sole HDR brachytherapy
following tumor excision is a feasible treatment option for patients with early stage cancer and gives excellent
local results
BASE DE LENGUA
Magy Onkol. 2004;48(4):297-301. Epub 2005 Jan 17.
Teletherapy versus teletherapy and "boost" brachytherapy in the treatment of base
of tongue tumors: 5-year results.
[Article in Hungarian]
Takácsi Nagy Z, Oberna F, Somogyi A, Polgár C, Major T, Pólus K, Fodor J, Németh G.
Országos Onkológiai Intézet, Budapest, 1122, Hungary. takacsi@oncol.hu

Abstract
AIM: To study the importance of high-dose-rate (HDR) boost brachytherapy (BT) after
percutaneous irradiation of base of tongue tumors.
METHODS: Between 1992 and 2000 seventy patients with biopsy proven carcinoma of the base
of tongue were treated with primary radiation therapy. Fourty patients received a mean dose of
61 Gy (range, 50-72 Gy) external beam irradiation, and afterwards 30 patients were treated with
a mean dose of 18 Gy (range, 12-30 Gy) boost HDR BT. Prognostic factors were analyzed in uni-
and multivariate model.
RESULTS: At a median follow-up of 56 (16-108) months, boost BT increased the incidence of
local tumor control (LTC) from 38% to 67% (p=0.0145). The 5-year probability of LTC was 60%
vs. 36% (p=0.0188), the locoregional tumor control 52% vs. 34% (p=0.0753) and the overall
survival (OS) 46% vs. 26% (p=0.0545), respectively, in favor of the boost group. Serious, grade
4 radiation toxicity occurred in 5% (2/40) and 13% (4/30) without or with boost treatment,
respectively (p=0.2110). In multivariate analyses for LTC, tumor size (p=0.0042) and boost
(p=0.0444), and for OS tumor size (p=0.0047) and nodal status (p=0.0163) had a significant
effect.
CONCLUSION: Boost BT after teletherapy improves LTC significantly without considerable
increase in the risk of side-effects.
RECIDIVAS
Int J Radiat Oncol Biol Phys. 2005 Aug 1;62(5):1444-50.
Salvage high-dose-rate (HDR) brachytherapy for recurrent head-and-neck
cancer.
Hepel JT, Syed AM, Puthawala A, Sharma A, Frankel P.
Department of Internal Medicine, University of California at Irvine, Orange, CA 90806, USA. bvigil@memnet.org

Abstract
BACKGROUND: A significant portion of head-and-neck cancer patients will develop persistent or recurrent disease
after definitive treatment. Radiation therapy is often used as definitive therapy or as an adjunct to surgery.
Recurrent cancer of the head and neck in the previously irradiated field is, thus, a common occurrence and poses
a therapeutic challenge. Some studies have evaluated low-dose-rate (LDR) brachytherapy as a therapeutic option,
including a large case series with long-term follow-up by our own institution. High-dose-rate (HDR) brachytherapy
offers therapeutic advantages over LDR brachytherapy. This study evaluates the local control and outcomes of
patients with previously irradiated recurrent head-and-neck cancer treated with HDR interstitial brachytherapy.
METHODS AND MATERIALS: Between 1997 and 2002, 30 patients who received prior radiation therapy for
primary tumors of the head and neck were treated for biopsy-proven recurrent disease. All patients received
previous radiation as definitive therapy alone or as adjunct to surgery. All patients were inoperable, refused
surgery, or had gross residual disease after salvage surgery for their recurrent disease. Thirty-six sites on the 30
patients were implanted by application of high-dose-rate interstitial brachytherapy techniques with mean tumor
dose of 34 Gy (18-48 Gy) in twice daily fractions of 300 to 400 cGy per fraction.
RESULTS: At a minimum follow-up of 12 months, local tumor control was achieved in 69% of implanted sites.
Disease-specific survival at 1 and 2 years was 54% and 45%, respectively. Overall survival at 1 and 2 years was
56% and 37%, respectively. Grade 3/4 late complications occurred in 16% of the patients. No fatal complications
occurred.
CONCLUSION: HDR brachytherapy can play an important role in the salvage treatment of previously irradiated
recurrent head-and-neck cancer. This study shows that comparable results are obtained by HDR brachytherapy
with fewer late complications than were indicated by previously reported data for LDR brachytherapy.
PDR
Int J Radiat Oncol Biol Phys. 2000 Jan 1;46(1):27-30.
Early results of pulsed-dose-rate interstitial brachytherapy for head and neck
malignancies after limited surgery.
Strnad V, Lotter M, Grabenbauer G, Sauer R.
Department of Radiation Therapy, University Erlangen-Nürnberg, Erlangen, Germany.
vratislav.strnad@strahlen.med.uni-erlangen.de

Abstract
PURPOSE: The aim of this study was to evaluate the relative incidence of toxicity and local control in patients
with head and neck malignancies who underwent interstitial pulsed-dose-rate (PDR) brachytherapy (iBT).
PATIENTS AND METHODS: From October 1997 to December 1998, 61 patients underwent interstitial PDR
brachytherapy procedures in our department; 47 were patients with head and neck cancer. Forty patients
received brachytherapy as part of their curative treatment regimen, and 7 patients were implanted for palliative
purposes and excluded from the analysis of therapy efficacy. Twenty-four patients had interstitial
brachytherapy procedures alone with D(REF) = 50 Gy; in 23 patients, iBT procedures were performed with
D(REF) = 24 Gy in combination with external radiation. A dose per pulse (dp) of 0.5 Gy was prescribed for 38/47
patients, and a dp = 0.7 Gy for 9/47 patients. The pulses were delivered 24 h a day, with a time interval of 1 h
between two pulses, resulting in an effective dose rate of 0.5 Gy/h or 0.7 Gy/h. A follow-up of the patients was
done to analyze acute and delayed toxicity, local control, and survival. The analysis was performed after
median follow-up of 12 months (5-18 months).
RESULTS: After a median follow-up of 12 months, soft tissue necrosis was seen in one patient and bone
necrosis in another. No other serious side effects were observed. Permanent locoregional tumor control was
achieved in 37 of 40 patients. No distant metastases were observed.
CONCLUSIONS: PDR interstitial brachytherapy with 0.5-0.7 Gy/h is a safe therapy. These preliminary results
suggest that PDR interstitial brachytherapy of head and neck cancer is comparable with low-dose-rate (LDR)
brachytherapy.
PDR

PDR
PDR
Brachytherapy. 2003;2(3):158-63.
The role of pulsed-dose-rate brachytherapy in previously irradiated head-and-
neck cancer.
Strnad V, Geiger M, Lotter M, Sauer R.
Department of Radiation Oncology, University Erlangen-Nürnberg, Erlangen, Germany. vstrnad@strahlen.med.uni-erlangen.de

Abstract
PURPOSE: The purpose of this prospective study was to analyze the value of interstitial pulsed-dose-rate (PDR)
brachytherapy (iBT) with regard to local control and the incidence of side effects in patients with head-and-neck cancer
in a previously irradiated area.
METHODS AND MATERIALS: From October 1997 to September 2001, 43 patients with head-and-neck cancer in a
previously irradiated area (31 patients with recurrent cancer) were treated with iBT alone or in combination with
external beam radiation. Thirty-four of 43 patients received interstitial PDR brachytherapy (DREF=20-60 Gy) as part of
their curative treatment regimen alone or in combination with external radiation. Nine patients were implanted for
palliative purposes. The pulses were delivered 24 h/day with a time interval of 1 h between two pulses. The dose per
pulse (dp) ranged from 0.4-0.7 Gy. Sixteen of 43 (37%) patients also received cisplatin or carboplatin with 5-fluorouracil
during the time of the iBT. Additionally 20/43 (47%) patients were treated with interstitial hyperthermia. Thirteen of 43
(30%) patients received external beam radiation in a dose range from 20-67 Gy. A follow-up of all patients was done to
analyze local control and survival, and acute and delayed toxicity. This analysis was performed after a median follow-
up of 24 months (6-48 months).
RESULTS: Local tumor control was achieved in 34 of a total of 43 patients (79%) and in 30/34 patients (88%) treated for
curative intention. Distant metastases were observed in 5/43 (12%) patients. The 2-year local recurrence-free survival
rates, disease-free survival rates, and overall survival rates according to the Kaplan-Meier method for all patients were
68%, 62%, and 49%, respectively, and for patients treated with curative intention they were 80%, 77% and 66%,
respectively. There was no statistical difference in the probability of local recurrence in patients subgrouped by
recurrent tumor vs. secondary primary, tumor size, grading and lymphangiosis. The application of chemotherapy or
hyperthermia did not have significant influence on the therapy results. Soft tissue necrosis was the only serious side
effect seen in 2/43 patients (4.7%). No other serious side effects were observed.
CONCLUSIONS: Interstitial pulsed-dose-rate brachytherapy for patients with previously irradiated head-and-neck
cancer is an effective therapy with minimal toxicity. The role of chemotherapy and hyperthermia in these patients
remains unclear. Further randomized studies with larger patient numbers are necessary to draw a definite conclusion
PDR
Strahlenther Onkol. 2005 Dec;181(12):762-7.
Role of interstitial PDR brachytherapy in the treatment of oral and oropharyngeal
cancer. A single-institute experience of 236 patients.
Strnad V, Melzner W, Geiger M, Zenk J, Waldfahrer F, Lotter M, Ott O, Seeger A, Iro H, Sauer R.
Department of Radiation Oncology, University Erlangen-Nuremberg, Erlangen, Germany. vstrnad@strahlen.imed.uni-
erlangen.de

Abstract
PURPOSE: To evaluate the role of pulsed-dose-rate interstitial brachytherapy (PDR IBT) in patients with head-
and-neck malignancies.
PATIENTS AND METHODS: From October 1997 to December 2003, 236 patients underwent PDR IBT for head-
and-neck cancer at the authors' department. 192 patients received brachytherapy as part of their curative
treatment regimen after minimal non-mutilating surgery, 44 patients were treated with irradiation alone. 144
patients had sole IBT (median D(REF) = 56 Gy), in 92 patients IBT procedures (median D(REF) = 24 Gy) were
performed in combination with external irradiation. The pulses (0.4-0.7 Gy/h) were delivered 24 h a day with a
time interval of 1 h between two pulses. The analysis of tumor control, survival and treatment-related toxicity
was performed after a median follow-up of 26 months (6-75 months).
RESULTS: At the time of analysis permanent local tumor control was registered in 208 of 236 patients (88%).
At 5 years overall survival and local recurrence-free survival of the entire group were 82-73% and 93-83% for
T1/2, and 56% and 83% for T3/4, respectively. Soft-tissue necrosis was seen in 23/236 patients (9.7%) and
bone necrosis in 17/236 patients (7.2%). No other serious side effects were observed.
CONCLUSION: PDR IBT with 0.4-0.7 Gy/h and 1 h between pulses is safe and effective. These results confirm
that PDR IBT of head-and-neck cancer is comparable with low-dose-rate (LDR) brachytherapy - equally
effective and less toxic
PDR
Strahlenther Onkol. 2007 Sep;183(9):512-6.
Preliminary report of pulsed dose rate brachytherapy in head-and-neck cancer.
Ziemlewski A, Zienkiewicz J, Serkies K, Badzio A.
Department of Oral and Maxillofacial Surgery, Medical University of Gdańsk, Poland. adam@ziemlewski.pl

Abstract
PURPOSE: To assess the feasibility and acute/delayed toxicity of pulsed-dose-rate brachytherapy
(PDR BT) in head-and-neck tumors.
PATIENTS AND METHODS: 45 head and neck cancer patients underwent interstitial or contact PDR BT
at a dose of 10.2-70 Gy (median, 70 Gy) and 0.6 or 1.0 Gy/pulse/h. 42 patients were administered BT as
part of their curative treatment; 32 of them had sole BT. Three reirradiated patients with recurrent
tumor had palliative BT.
RESULTS: PDR BT was well tolerated. Intense bleeding was the only complication associated with
catheter removal from the tongue and bucca. 44 patients who completed BT experienced acute
mucositis. Grade 3 toxicity of skin and oral mucosa occurred in three (6.8%) and six patients (13.6%),
respectively. At a median follow-up of 22 months (range, 2-67 months), late serious toxicity (grade 4,
for soft tissue and bone) was seen in seven patients (15.9%). Among the parameters analyzed, only
dental care performed before BT had a significant impact on mucosal side effects. Acute severe
mucositis was observed in 23% of patients without dental care compared to 0% of those with dental
care (p=0.044). Late severe mucositis occurred in 17.7% and 26.9% of the respective patients (p=0.035),
overall in 23%. The larger the volume encompassed by the reference isodose, the more late (p=0.004)
mucosal reactions were observed.
CONCLUSION: PDR BT continued over a few days is a feasible and safe approach in head-and-neck
tumors; however, it is accompanied by some toxicity. Dental care should precede isotope application.
PDR
PLANIFICACIÓN 3D.
Hungarian Oncology 2000; 44:109-15
10 Pacientes

Hungarian Oncology 2000; 44:117-21


FUTURO
FUTURO
 TÉCNICA EFECTIVA.

 IMPLEMENTACIÓN DE LAS TÉCNICAS EN LOS


SERVICIOS.

 FORMACIÓN DE RESIDENTES Y ESPECIALISTAS

 DIFUSIÓN DE LAS TÉCNICAS Y RESULTADOS.


CONCLUSIONES
 TUVO PASADO.

 TIENE PRESENTE.

 PUEDE Y DEBE TENER FUTURO.


Muito obrigada !!!