Management of advanced cervical metastasis using intraoperative radiotherapy

Abstract

Seventy-five patients who had advanced cervical metastasis with possible invasion of the deep muscles or carotid artery were approached with aggressive resection and intraoperative radiotherapy (IORT). All metastatic nodes were greater than 3 cm, 65% were fixed on clinical examination, and 35% involved the carotid artery. Forty-six (61%) of the patients had previously received irradiation. Fifteen of the patients required extended neck dissections with carotid resections and grafting. After the resection an average single dose of 2000 cGy of electron beam IORT was delivered. At 2 years, the local control rate within the IORT port was 68% and the absolute survival rate was 45%. Local control rates for close and microscopic margins (76% and 73%, respectively) were significantly better than the control rate for gross residual disease (25%, P < .05). The combination of extended neck dissection, including carotid artery resection if necessary, and IORT appears to offer improved control.

Positive surgical margins in neck dissection specimens in patients with head and neck squamous cell carcinoma and the effect of radiotherapy

“…[7][8][9][10] In this analysis, we evaluated the effects of surgery and postoperative radiotherapy. Most patients died of disease after a median diseasefree interval of 9 months.…”

Intraoperative Radiation Therapy: A Promising Treatment Modality in Head and Neck Cancer

“…Scala et al reported that 1-year in-field control for patients with negative margins was 82% compared to 56% in those with a positive margin (9). At least five other studies also showed that positive margins (more so for gross residual than microscopic residual) at the time of IORT significantly predicted for in-field failure when compared to close or clear margins (2, 11, 13, 18, 19). In addition, doses of IORT of more than 15 Gy were shown to be associated with better LC (10, 12).…”

“…A third paper by Freeman et al, mentioned in the above section on neck recurrences, that studied 75 patients with advanced cervical lymph node metastases with 2-year LC and OS of 68 and 45%, respectively, included 22 patients with primary advanced untreated disease. This study did not report on the percent of patients also receiving adjuvant EBRT (18). These three studies with promising results paved the way for more single-institution studies.…”

“…Another study on neck IORT included 52 patients with recurrent tumors who received a median dose of 20 Gy of IOERT. With a median follow up of 2 years, 2-year local control (LC) and OS were 68 and 45%, respectively, for all 75 patients (18). Most of the other series on IORT for neck recurrences, listed in Table 1, included between 17 and 84 patients (10, 14, 15, 19).…”

“…Intraoperative radiation therapy-related complications rate reported in the literature (Table 1) ranges between 22 and 52% in both the primary and recurrent setting (11–13, 18, 19, 27). Early studies by Toita et al reported a significant increase in the rate of toxicities with doses exceeding 20 Gy (19), whereas other studies failed to show significant changes in toxicity rates with different doses (10, 12).…”