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A technique for interstitial nasopharyngeal brachytherapy
0360-3016/87
Im. J. Radiation Oncology Biol. Phys., Vol. 13, pp. 451-453 F’rintedin the U.S.A. All rights reserved.
Copyright
0 I987 Peqwnon
$3.00 + .OO Journals
Ltd.
??Technical Innovations and Notes
A TECHNIQUE FOR INTERSTITIAL NASOPHARYNGEAL LOUIS B. HARRISON,
M.D.
AND JOSEPH B. WEISSBERG,
BRACHYTHERAPY M.D.
Department of Therapeutic Radiology, Yale University School of Medicine, 333 Cedar St., New Haven, CT 065 10 Two patients have recently been seen with recurrent epidermoid carcinoma in the nasopharynx. Both have
achieved local control and are disease-free after a brachytherapy procedure. Here we describe our technique for interstitial nasopharyngeal brachytherapy. Nasopharyngeal, Brachytherapy, Iodine-l 25.
gether and pulled caudad, thereby accomplishing adequate retraction of the soft palate. A large dental mirror was placed in the oropharynx to give visualization of the nasopharynx and the tumor mass. The physician held the mirror in one hand, and used the other hand to insert introduction trochars into the desired location in the nasopharynx, thereby implanting Iodine-125 seeds under mirror guidance (Fig. 2). The appropriate number of seeds were placed with only minimal bleeding.
INTRODUCTION One of the major problems in the management of nasopharyngeal cancer is the treatment of locally recurrent disease after high dose external beam radiotherapy. Various groups have approached this problem either with further external beam therapy4 or with brachytherapy.3,5-g External beam therapy is hindered by the radiation tolerance of important surrounding structures. Brachytherapy entails difficulties both in exposing the nasopharynx and in performing an acceptable implant. Recently, we have had the experience of treating two patients with brachytherapy for recurrent carcinoma of the nasopharynx. Both patients were approached with the same technique, in which local control has been achieved by implant. The procedure has been performed without complication and with relative simplicity. We will describe our interstitial implant technique and briefly discuss the topic of nasopharyngeal brachytherapy.
METHODS
RESULTS We have used the described technique on two patients with recurrent squamous cell cancer of the nasopharynx. Their brief case histories serve to summarize our results. Case 1: A 65-year old white male presented in June 1982, complaining of right neck swelling. He had massive bilateral cervical lymphadenopathy and a large right nasopharyngeal tumor mass extending down to the right posterolateral pharyngeal wall. Biopsy revealed squamous cell carcinoma. Soft tissue films and CT scan revealed no bony erosion. He was staged T3N3b (left neck NZb, right neck NZb) MO, Stage IV (AJC).’ The patient received radical external beam radiation therapy with the primary site receiving 7000 rads, involved neck sites receiving 6600 rads, and uninvolved neck sites receiving 4500 rads. There was complete tumor regression. The patient did well until May 1983 when a local recurrence in the nasopharynx was found. There was a 3 cm mass at the primary site, protruding into the posterior nasopharynx. Biopsy revealed recurrent tumor. The
AND MATERIALS
Our patients were prepared for the procedure in the operating room under general orotracheal anesthesia. The mouth was held widely opened either with Weitlander retractors or a Davis mouth clamp; both provide good exposure. Red rubber catheters were inserted through each nostril, and were retreived in the oropharynx and brought out through the oral cavity (see Fig. 1). The two ends of the catheters were then clamped to-
Accepted for publication 30 September 1986.
Reprint requests to: Louis B. Harrison, M.D., Department of Radiation Oncology/Brachytherapy Service, Memorial SloanKettering Cancer Center, 1275 York Ave., New York, NY 10021. 451
452
I. J. Radiation Oncology 0 Biology 0 Physics
March 1987, Volume 13, Number 3
Fig. 1. General patient set-up, including an enlarged view of what is seen on the dental mirror (insert).
neck was controlled. The patient received six cycles of chemotherapy with bleomycin/methotrexate/cisplatinum with some regression. However, there was clearly residual local disease. In September 1983 a radioactive Iodine implant was performed using our described technique. Films and dosimetry of the implant are presented in Figures 3 and 4. A total of 23 seeds, each with 0.525 r&i activity, were placed for a total activity of 12.07 mCi. The patient had complete regression of tumor, and
Fig. 2. The radiation oncologist stands or sits above the patient’s head, thereby gaining adequate exposure.
Fig. 3. Lateral projection showing the 125 Iodine seeds in the nasopharynx.
Fig. 4. Lateral projection showing 125 I seeds in the nasopharynx. The isodose curves are superimposed. Using a specific gamma factor for 125 I of 1.1 rads/mCi/hr at 1 cm. These curves represent the dose at total decay. Beginning with the innermost isodose curve, the doses are 50,000 rads, 40,000 rads, 30,000 rads, 20,000 rads, 10,000 mds, 8,000 rads, and 5,000 rads, respectively.
Interstitial nasopharyngeal brachytherapy 0 L. B. HARRISON
remains without disease in January 1986. There has been no complication. Case 2: A 67-year old white female presented in July 1982 with a left neck mass, found to be poorly differentiated squamous cell carcinoma, consistent with lymphoepithelioma. Extensive work-up including multiple nasopharyngeal biopsies revealed no obvious primary site. She received 6000 rads to the nasopharynx, 6300 rads to involved sites in the left neck, and 4600 rads to uninvolved neck sites. She had no tumor identifiable at the conclusion of radiation therapy in September 1982. The patient developed a tumor in the left side of the nasopharynx in June 1985. This was felt to be a recurrence of what was initially an occult primary tumor. Pathology revealed anaplastic invasive squamous cell carcinoma, consistent with the original lymph node biopsies of 1982. The tumor extended to the midline. On June 25, 1985 we performed a radioactive Iodine implant using our described technique. A total of 22 seeds, each with 0.56 mCi activity, were placed. The total implant activity was 12.32 mCi. There was minimal bleeding during the procedure, but no other complications. As of January 1986, the patient is without evidence of disease and without any treatment-related complications. DISCUSSION Using radioactive implants for cancers of the nasopharynx is not a new idea. In 1956 Sooy’ described a technique of intranasal septectomy, electrodessication of
AND J. B. WEISSBERG
453
tumor, followed by radioactive cobalt application to the nasopharyngeal mucosa. The cobalt was placed into the nasopharynx via a Foley catheter, with the balloon distended to hold the catheter in good position. This intracavitary technique salvaged three of six patients with recurrent tumor who were otherwise felt to have incurable disease. Another intracavitary approach is advocated by Wang et al.’ They irradiated the nasopharynx with a pair of cuffed pediatric endotracheal tubes which entered the tumor bed via the nares. Suit et ~1.~has described the use of a radium mold strategically placed in the tumor bed. There has also been emerging interest in interstitial brachytherapy. Hilaris et al3 implanted radioactive seeds (gold, radon) into the nasopharynx via a surgically fashioned defect in the hard palate. The disadvantage of this approach was the requirement that the patient wear a permanent obturator to close the defect. Vikram et a17s8has described a technique for implanting Iodine-125 seeds that is similar to our own. He uses transnasal trochar introduction with visualization of the nasopharynx via a fiberoptic nasopharyngoseope. We feel that our technique is simple, easy to apply, and should be considered as an option for the radiotherapist who desires to implant the nasopharynx. We are recommending nasopharyngeal brachytherapy, and we are using our technique, as part of the overall management of patients with local recurrence. In addition, we join other groups* who are looking at brachytherapy as part of the primary management of patients with larger nasopharyngeal tumors.
REFERENCES 1. American Joint Committee on Cancer: Manual for Staging Cancer, 2nd edition. Philadelphia, J.B. Lippincott.
1983, pp 31-36. 2. Amommam, R., Prempree, T., Sewchand, W., Jaiwatana, J.: Radiation management of advanced nospharyngeal cancer. Cancer 52: 802-807,1983. 3. Hilaris, B., Lewis, J., Henscke, U.: Therapy of recurrent cancer of the nasopharynx. Arch. Otolaryngol.87: 80-84,
1968. 4. McNeese, M.D., Fletcher, G.H.: Retreatment of recurrent nasopharyngeal carcinoma. Radiol. 138: 19 1- 193, 198 1. 5. Sooy, F.A.: Experimental treatment of recurrent carci-
noma of the nasopharynx with electroclesication, radioactive cobalt and x-ray radiation. Am. J. Otol.Rhinol. Laryn-
gol. 65: 723-735, 1956.
6. Suit, H.D., Lloyd, R.S., Andrews, R., Scheider, S.E.: Tech-
nique for intracavitary irradiation of the nasopharynx. Am. J. Roentgenol. 84: 629-63 1,196O.
7. Vikram, B.: Brachytherapy
in nasopharynx cancer. In Brachytherapy Oncology-1983, Hilaris, B. and Bat&a M.
(Eds.): Memorial Sloan-Kettering Cancer Center New York, Dept. ofRadiation Therapy. 1983, pp. 125-128. 8. Vikram, B., Hilaris, B.: Transnasal permanent interstitial implantation of carcinoma of the nasopharynx. Int. J. Radiat. Oncol. Biol. Phys. 10: 153-155, 1984. 9. Wang, C.C., Busse,J., Gitterman, M.: A single afterloading application for intracavitary irradiation of carcinoma of the nasopharynx. Radiol. 115:737-738, 1975.
Im. J. Radiation Oncology Biol. Phys., Vol. 13, pp. 451-453 F’rintedin the U.S.A. All rights reserved.
Copyright
0 I987 Peqwnon
$3.00 + .OO Journals
Ltd.
??Technical Innovations and Notes
A TECHNIQUE FOR INTERSTITIAL NASOPHARYNGEAL LOUIS B. HARRISON,
M.D.
AND JOSEPH B. WEISSBERG,
BRACHYTHERAPY M.D.
Department of Therapeutic Radiology, Yale University School of Medicine, 333 Cedar St., New Haven, CT 065 10 Two patients have recently been seen with recurrent epidermoid carcinoma in the nasopharynx. Both have
achieved local control and are disease-free after a brachytherapy procedure. Here we describe our technique for interstitial nasopharyngeal brachytherapy. Nasopharyngeal, Brachytherapy, Iodine-l 25.
gether and pulled caudad, thereby accomplishing adequate retraction of the soft palate. A large dental mirror was placed in the oropharynx to give visualization of the nasopharynx and the tumor mass. The physician held the mirror in one hand, and used the other hand to insert introduction trochars into the desired location in the nasopharynx, thereby implanting Iodine-125 seeds under mirror guidance (Fig. 2). The appropriate number of seeds were placed with only minimal bleeding.
INTRODUCTION One of the major problems in the management of nasopharyngeal cancer is the treatment of locally recurrent disease after high dose external beam radiotherapy. Various groups have approached this problem either with further external beam therapy4 or with brachytherapy.3,5-g External beam therapy is hindered by the radiation tolerance of important surrounding structures. Brachytherapy entails difficulties both in exposing the nasopharynx and in performing an acceptable implant. Recently, we have had the experience of treating two patients with brachytherapy for recurrent carcinoma of the nasopharynx. Both patients were approached with the same technique, in which local control has been achieved by implant. The procedure has been performed without complication and with relative simplicity. We will describe our interstitial implant technique and briefly discuss the topic of nasopharyngeal brachytherapy.
METHODS
RESULTS We have used the described technique on two patients with recurrent squamous cell cancer of the nasopharynx. Their brief case histories serve to summarize our results. Case 1: A 65-year old white male presented in June 1982, complaining of right neck swelling. He had massive bilateral cervical lymphadenopathy and a large right nasopharyngeal tumor mass extending down to the right posterolateral pharyngeal wall. Biopsy revealed squamous cell carcinoma. Soft tissue films and CT scan revealed no bony erosion. He was staged T3N3b (left neck NZb, right neck NZb) MO, Stage IV (AJC).’ The patient received radical external beam radiation therapy with the primary site receiving 7000 rads, involved neck sites receiving 6600 rads, and uninvolved neck sites receiving 4500 rads. There was complete tumor regression. The patient did well until May 1983 when a local recurrence in the nasopharynx was found. There was a 3 cm mass at the primary site, protruding into the posterior nasopharynx. Biopsy revealed recurrent tumor. The
AND MATERIALS
Our patients were prepared for the procedure in the operating room under general orotracheal anesthesia. The mouth was held widely opened either with Weitlander retractors or a Davis mouth clamp; both provide good exposure. Red rubber catheters were inserted through each nostril, and were retreived in the oropharynx and brought out through the oral cavity (see Fig. 1). The two ends of the catheters were then clamped to-
Accepted for publication 30 September 1986.
Reprint requests to: Louis B. Harrison, M.D., Department of Radiation Oncology/Brachytherapy Service, Memorial SloanKettering Cancer Center, 1275 York Ave., New York, NY 10021. 451
452
I. J. Radiation Oncology 0 Biology 0 Physics
March 1987, Volume 13, Number 3
Fig. 1. General patient set-up, including an enlarged view of what is seen on the dental mirror (insert).
neck was controlled. The patient received six cycles of chemotherapy with bleomycin/methotrexate/cisplatinum with some regression. However, there was clearly residual local disease. In September 1983 a radioactive Iodine implant was performed using our described technique. Films and dosimetry of the implant are presented in Figures 3 and 4. A total of 23 seeds, each with 0.525 r&i activity, were placed for a total activity of 12.07 mCi. The patient had complete regression of tumor, and
Fig. 2. The radiation oncologist stands or sits above the patient’s head, thereby gaining adequate exposure.
Fig. 3. Lateral projection showing the 125 Iodine seeds in the nasopharynx.
Fig. 4. Lateral projection showing 125 I seeds in the nasopharynx. The isodose curves are superimposed. Using a specific gamma factor for 125 I of 1.1 rads/mCi/hr at 1 cm. These curves represent the dose at total decay. Beginning with the innermost isodose curve, the doses are 50,000 rads, 40,000 rads, 30,000 rads, 20,000 rads, 10,000 mds, 8,000 rads, and 5,000 rads, respectively.
Interstitial nasopharyngeal brachytherapy 0 L. B. HARRISON
remains without disease in January 1986. There has been no complication. Case 2: A 67-year old white female presented in July 1982 with a left neck mass, found to be poorly differentiated squamous cell carcinoma, consistent with lymphoepithelioma. Extensive work-up including multiple nasopharyngeal biopsies revealed no obvious primary site. She received 6000 rads to the nasopharynx, 6300 rads to involved sites in the left neck, and 4600 rads to uninvolved neck sites. She had no tumor identifiable at the conclusion of radiation therapy in September 1982. The patient developed a tumor in the left side of the nasopharynx in June 1985. This was felt to be a recurrence of what was initially an occult primary tumor. Pathology revealed anaplastic invasive squamous cell carcinoma, consistent with the original lymph node biopsies of 1982. The tumor extended to the midline. On June 25, 1985 we performed a radioactive Iodine implant using our described technique. A total of 22 seeds, each with 0.56 mCi activity, were placed. The total implant activity was 12.32 mCi. There was minimal bleeding during the procedure, but no other complications. As of January 1986, the patient is without evidence of disease and without any treatment-related complications. DISCUSSION Using radioactive implants for cancers of the nasopharynx is not a new idea. In 1956 Sooy’ described a technique of intranasal septectomy, electrodessication of
AND J. B. WEISSBERG
453
tumor, followed by radioactive cobalt application to the nasopharyngeal mucosa. The cobalt was placed into the nasopharynx via a Foley catheter, with the balloon distended to hold the catheter in good position. This intracavitary technique salvaged three of six patients with recurrent tumor who were otherwise felt to have incurable disease. Another intracavitary approach is advocated by Wang et al.’ They irradiated the nasopharynx with a pair of cuffed pediatric endotracheal tubes which entered the tumor bed via the nares. Suit et ~1.~has described the use of a radium mold strategically placed in the tumor bed. There has also been emerging interest in interstitial brachytherapy. Hilaris et al3 implanted radioactive seeds (gold, radon) into the nasopharynx via a surgically fashioned defect in the hard palate. The disadvantage of this approach was the requirement that the patient wear a permanent obturator to close the defect. Vikram et a17s8has described a technique for implanting Iodine-125 seeds that is similar to our own. He uses transnasal trochar introduction with visualization of the nasopharynx via a fiberoptic nasopharyngoseope. We feel that our technique is simple, easy to apply, and should be considered as an option for the radiotherapist who desires to implant the nasopharynx. We are recommending nasopharyngeal brachytherapy, and we are using our technique, as part of the overall management of patients with local recurrence. In addition, we join other groups* who are looking at brachytherapy as part of the primary management of patients with larger nasopharyngeal tumors.
REFERENCES 1. American Joint Committee on Cancer: Manual for Staging Cancer, 2nd edition. Philadelphia, J.B. Lippincott.
1983, pp 31-36. 2. Amommam, R., Prempree, T., Sewchand, W., Jaiwatana, J.: Radiation management of advanced nospharyngeal cancer. Cancer 52: 802-807,1983. 3. Hilaris, B., Lewis, J., Henscke, U.: Therapy of recurrent cancer of the nasopharynx. Arch. Otolaryngol.87: 80-84,
1968. 4. McNeese, M.D., Fletcher, G.H.: Retreatment of recurrent nasopharyngeal carcinoma. Radiol. 138: 19 1- 193, 198 1. 5. Sooy, F.A.: Experimental treatment of recurrent carci-
noma of the nasopharynx with electroclesication, radioactive cobalt and x-ray radiation. Am. J. Otol.Rhinol. Laryn-
gol. 65: 723-735, 1956.
6. Suit, H.D., Lloyd, R.S., Andrews, R., Scheider, S.E.: Tech-
nique for intracavitary irradiation of the nasopharynx. Am. J. Roentgenol. 84: 629-63 1,196O.
7. Vikram, B.: Brachytherapy
in nasopharynx cancer. In Brachytherapy Oncology-1983, Hilaris, B. and Bat&a M.
(Eds.): Memorial Sloan-Kettering Cancer Center New York, Dept. ofRadiation Therapy. 1983, pp. 125-128. 8. Vikram, B., Hilaris, B.: Transnasal permanent interstitial implantation of carcinoma of the nasopharynx. Int. J. Radiat. Oncol. Biol. Phys. 10: 153-155, 1984. 9. Wang, C.C., Busse,J., Gitterman, M.: A single afterloading application for intracavitary irradiation of carcinoma of the nasopharynx. Radiol. 115:737-738, 1975.