Manually after-loaded 192Ir low-dose rate brachytherapy after subtotal excision and flap reconstruction of recurrent cervical lymphadenopathy from head and neck cancer

Background: Treatment of extensive recurrent cervical lymph node metastases from previously irradiated head and neck cancer represents a difficult clinical challenge. We report the results of an approach of maximal surgical debulking and manually after-loaded intra-operative brachytherapy. Patients and methods: Seventy-four procedures were carried out at the Royal Marsden Hospital between 1979 and 2003. All patients had previously been treated with radical radiotherapy or chemoradiation. Patients underwent maximal surgical debulking, followed by brachytherapy to the tumour bed with low-dose rate Ir-192 to a dose of 60 Gy to the reference isodose using the Paris system. Results: Overall and disease specific survival rates were 31 % and 28% at two years and 23% and 17% at five years. Corresponding Loco-regional control rates were 37 % and 23%, respectively. Fifty per cent of patients developed metastatic disease within 5 years of treatment. Best results were obtained with surgical excision, brachytherapy and reconstruction of the skin defect using a vascularised myo-cutaneous flap with in-field control rates of 72 % at two years and 66% at 5 years. Nine per cent of patients developed fistulae, 4 % had haemorrhage and 8% wound breakdown/infection. Conclusions: Maximal surgical debulking, including removal of overlying skin, and brachytherapy to the surgical tumour bed provides high levels of local control, and can be achieved with acceptable morbidity. Only a minority of patients achieve long-term survival because of the high risk of systemic relapse. (c) 2006 Elsevier Ireland Ltd. All rights reserved.