Afterloading interstitial radiation therapy

LI. J. Radiation Oncology Bid. Phys.,

1976,

mERLOADING

Vol. 1, pp. 365-368.

Pergamon Press.

INTERSTITIAL

Printed in the U.S.A.

RADIATION

THERAPY

C. C. WANG, M.D.,? ARTHUR BOYER, Ph.D.S and OSCAR MENDIONDO, M.D.5 Department of Radiation Medicine, Massachusetts General Hospital, Boston, MA 02114 and the Department of Radiation Therapy, Harvard Medical School, Boston, MA 02115, U.S.A. A technique for afterloading interstitial radiation therapy employing Angiocatb-“% is hereby described. Its flexfbflity and applhbility to various lesions arising from the skin, breast, lymph nodes and oral cavity is discussed. Four Caseyare p-ted to ffhtrate varhs points. Afte&Ah

devfces. InterstiM radfation therapy, Skin, Breast, Lymph nodes, Oral cavity,

Raadwn&lants.’

The benefiqial effects of low dose rate radiation therapy are well known. Interstitial radiation therapy for tumors arising from various sites accessible for implantation, such as carcinoma of the skin, oral cavity, breast, vagina, anus, etc. at least as a portion of the total treatment, is highly desirable. Because of this, “low intensity” radium needles have been used for decades and in expert hands have resulted in excellent cosmetic and functional radiotherapeutic results. Unfortunately, due to the inherent nature of rigidity of the radium needles and preloading, its use has been primariky limited to a small implant. For a large implant, interstitial radium therapy has been found ,impractical due to the lack of sufficient number of suitable needles and the unavoidable radiation exposure to the operator. Cdnsequently, interstitial radiation therapy had been largely neglected in daily radiotherapeutic practice. There is, therefore, a dire need for a search for a radium substitute for afterloading interstitial work. In this country, credit must be given to Henschke’,2 who in 1958 proposed the use of ‘?r seeds in plastic tubing for afterloading and removable implants. In 1971, Roach et aL3 adopted the

use of Intracath and 13’Cs for interstitial implantation with 6 cases reported. During the past 2 years, a technique employing Angiocath and ‘?r seeds has been used at the Department of Radiation Medicine at the Massachusetts General Hospital. Fiftyseven patients with various lesions have been treated with remarkable short term results. The lesions were grouped together as shown in Table 1. This technique, similar to that of Roach et al.,’ has been found to be highly flexible and applicable to most lesions arising from various sites accessible for implantation and deserves a brief communication. Angiocaths are used because they are commercially available and totally disposable. Several lengths are useful, 2 in. and 5.25 in. 14 gauge, 2 in. and 2.5 in. 16 gauge. These Angiocaths are supplied sterilized and sealed in plastic tubes and have inner needles inserted into their hollow cores. The agiocaths can be removed from their packages and inserted directly into the lesions using the needles provided as a stiffening and guiding stilletto. The ‘%, supplied by RAD/IRD Inc.,

TRadiotherapist and Head, Division of Clinical Services, Department of Radiation Medicine, Massachusetts General Hospital, and Professor of Radiation Therapy, Harvard Medical School, Boston, Massachusetts, U.S.A. *Asst. Physicist in Radiation Medicine, Mas-

sachusetts General Hospital, Asst. Professor of Radiation Therapy, Harvard Medical School, Boston, Massachusetts, U.S.A. OResident in Radiation Medicine, Massachusetts General Hospital, Boston, Massachusetts, U.S.A. 365

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Radiation Oncology ??Biology 0 Physics

Table 1. Lesions treated by Angiocath-‘?r afterloading implants at the Massachusetts General Hospital as of 3 1 October 1974 Skin: preauricular lip

nose ear other areas Nasal septum Metastatic nodes Floor of mouth Tongue Buccal mucosa Breast: post segmental mastectomy post simple mastectomy inoperable Anus and rectum Total

18 6t 3 3 1 5 2 3t 6 3 4 I9

Vol. 1. No. 3-4

consists of cylindrical seeds, 2.5 mm in length and O-5 mm in diameter. These seeds are encapsulated in tubing on 1 cm centers. The tubing has an outer diameter equivalent to a 21 gauge needle and fits easily into 14 gauge or 16 gauge Angiocaths. The iridium-filled tubings can be attached to plastic caps which fit snugly into the plastic openings of the Angiocaths (Fig. 1A). After. proper arrangement of the Angiocaths, the inner needles are removed. The Angiocaths,are held in place by lead shots crimped over their free ends (Fig. 1B). The depth of each Angiocath is plumbed and the

16 t

2 2 57

tone patient underwent three implants, one for a preauricular squamous cell carcinoma of the skin, and two for midjugular and metastatic nodes.

Fig. 1B. Photograph shows assembled Angiocathiridium-cap-lead shot in one unit.

Fig. 1A. Photograph shows Angiocath, iridiumfilled tubing attached to a plastic cap and lead shot.

iridium-filled tubing is cut to fit the implant area appropriately, and is then inserted to the Angiocath at a convenient time and place and held in place securely by the cap mentioned above. Any iridium-filled tubing can be removed at any time without disturbing the entire plane.

Afterloading interstitial radiation therapy 0 C. C. WANGet al.

367

CASE REPORTS Case 1. J. S. 40 year old female with a tumor

showed basal cell carcinoma. The lesion was treated with 3000 rad in 12 elapsed days mass in the upper quadrant of the left breast divided in 10 fractions with 280 kVp beam. Twelve days after the last fraction, the tumor measuring 4 x 5 cm in diameter underwent lumpectomy and left axillary lymph node site was implanted using 10 Angiocaths, 6 of biopsy. The pathologic report showed infiltrat- them vertical, l-2 cm apart, and 2 crossing ing ductal carcinoma, signet cell type, with each end (Fig. 3). These Angiocaths were metastases to axillary nodes. Patient refused afterloaded with ‘=Ir seeds delivering an mastectomy. Postoperative radiation therapy additional 2350 rad in 52 hr. Patient was NED was given. From 30 January 1973 to 9 March in December 1975, with excellent cosmetic 1973, the left breast received 4000 rad in 31 results. Case 3. C. W. 70 year old male with five elapsed days through medial and lateral tangential portals with bolus, divided into 22 month history of progressive swelling of the nose. In May 1974, he had massive swelling of fractions. The left axillary, supraclavicular and infraclavicular areas received an equival- the nose, which was tender and red, with its ent of approximately 5000 rad on the 2 MV tip measuring 4 x 4 cm. A crusted and ulcerVan de Graaff machine. On 27 March 1973, ated lesion, apparently arising in the nasal she underwent afterloading interstitial im- septum, filled the nostrils. Biopsy showed plant. The lumpectomy site was treated with 2 invasive, keratinizing squamous cell carinterstitial planes (Fig. 2). The superficial cinoma. No regional nodes were palpable. The plane contained 7 Angiocaths and the deeper lesion was initially treated with 3300 rad in 16 plane 6 Angiocaths. The distance between the days divided in 11 fractions with 280 kV Angiocaths was l-2 cm and between the X-ray beam. On 2 July 1974,25 days after the planes 1.5 cm ‘?r seeds were inserted into the last fraction, afterloading interstitial implant tubings for interstitial irradiation. A total of was done. Three Angiocaths were inserted 2200 rad was delivered to the point midway into the midline of the nose and both nasal between the planes in 72 hr. Patient was seen alae, 2 into the nasal septum and an additional on 21 November 1974,and showed no evidence one horizontally into the base of the upper lip of recurrence locally in the left breast or in the (Fig. 4). A dose of 300 rad at 0.5 cm from the nodal drainage areas. Unfortunately, the pa- plane was given in 75 hr. In November 1975, tient developed bilateral pleural effusion with patient was NED with a most remarkable positive bone scans suspicious of distant cosmetic result. metastases. She is undergoing chemotherapy. Case 4. J. S. 66 year old male with multiple Case 2. .T. W. 54 year old male who superficial squamous cell carcinomas in the presented in April 1973 with a 4-Ox 5.0 cm right buccal mucosa from the right retromolar area of indurative skin with poorly defined borders in the lower lip and right chin. Biopsy

Fig. 2. Photograph shows two plane implant to the lumpectomy site of the breast.

Fig. 3. Photograph shows afterloading implant to a large basal cell carcinoma in the lower lip and right chin.

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Fig. 5. Photograph shows large curved plane implant for multiple squamous cell carcinomas of the entire right buccal mucosa. no evidence of residual disease. Cosmetic result was excellent.

Fig. 4. Photograph shows implant of the nasal vestibule for squamous cell carcinoma of the nasal septum.

trigone region to the lower lip across the midline. The lesion was treated with a pair of oblique wedged fields on an isocentric Cobalt 60 machine for 4OOOrad in 26 elapsed days divided into 20 fractions. One week later, two-thirds of the lower lip and the entire right buccal mucosa were treated with 13 vertical Angiocath-iridium implant forming a curved single plane delivering an additional dose of 2835~4 in 40.5 hr (Fig. 5). Sixteen months later, on his follow-up visit, the patient showed

DISCUSSlON The cases reported herein illustrate the applicability and flexibility of the Angiocathiridium technique. No attempt is made to evaluate the therapeutic results of the patients treated in this fashion, or to claim the entire originality of this method. We feel that this technique is relatively simple and useful for afterloading interstitial radiation therapy. It has been found suitabk for lesions of the skin breast, lymph nodes, anal and vaginal lesions, and various oral lesions such as lip, buccal mucosa and floor of the mouth. For lesions of the tongue, this technique appears to be less satisfactory and requires further investigation. Perhaps the “steel guide-double pin’* technique by Pierquin, Ch‘ksagne and Cox would be a superior method.4

REFERENCES technique: In AjIe?io&ng in Radbthempy ed. U.K.: Interstitial implantation in by Simon N. Proceedings of a Conference held treatment of primary bronchogenic carcinoma. Am. J. Roentgen. 79: 981-987, 1958. in New York City, 68 May 1971, Washington, 2. Henschke, U.K., Hilaris, B.S., Mahan, G.D.: US Dtpt of Health, Education and Welfare, Afterloading in interstitial and intracavitary Publication FDA 72-8024, pp 388-403. radiation therapy. Am. J. Roentgen. 99: 386-395, 4. Pitrquin, B., Chassagne, D., Cox, J.D.: Consis1%3. tent local control of certaiu ma&nant tuamrs. 3. Roach, L.C. et al.: A simple afterloading needle Radiology 99: 661-667, 1971. 1. Htnschkt,