11 Lip and buccal mucosa

Lip and buccal mucosa

12

THE GEC ESTROHANDBOOKOF BRACHYTHERAPY | Part II Clinical Practice Version 1 - 10/05/2019

Table 3: Local recurrence rate in buccal mucosa carcinoma with LDR 20. A: brachytherapy alone, B: EBRT + brachytherapy, C: EBRT alone, D Surgery ± EBRT, IBT: interstitial brachytherapy.

Author (reference)

Year

Number

TNM

T

Brachy

Local recurrence

106 T1 210 T2 175 T3 257 T4

A 266 B 80 C 273 D 167

A 19% B 35% C 55% D 22%

LDR Ra, Au, Ir

Gerbaulet (9)

1985

748

23 T1 33 T2 23 T3 6 Tx

1994 2001

A B

A 26% B 48%

Gerbaulet (8)

84

LDR Ir

1995 1996

Parallel tubes Loops

42% 9% loops

Lapeyre (19) Pernot (18)

42

36 T1-3

LDR Ir

LDR Ir IBT Moulds

IBT: 6% Mould 45%

Sakai (42)

1998

55

T1-4

A, B, C, D

T1 8 T2 30 T3 7

Permanent implants Au, Rn

Shibuya (43)

1993

45

A, B

14%

6.3% for 60 - 70 Gy, 7.3% for 70 - 80 Gy, 7.7% for 80 - 100 Gy and in 3/8 patients treated with doses over 100 Gy. Ulceration also is dose rate dependent present in 2.5% at dose rates under 40 cGy/h, in 6% between 40 - 80 cGy/h, 6.9% between 80-120 cGy/h and 15.2% at dose rates over 120 cGy/h. Cosmetic outcome is good to excellent in 80%-95% [27-28-30] with usually only mild depigmentation in 2.5 - 17.3% [27-28-30], teleangiectasia in 15.2%, light oedema 4.4%, dyskeratosis in 4.8% or fibrosis in 8% [30]. In the GEC-ESTRO review good to excellent cosmesis was seen in 94.9% of T1, 84.3% of T2, 72.5% of T3 and 60% of T4 [27]. Poor outcome was noted in 1.3% of T1, 4.1% of T2, 10.1% of T3 and 20% of T4. Lip deformation and retraction is seen in 6% of cases and is seen more frequently after treatment of larger lesions and commissural lesions. Functional loss due to lip deformationwas noted in the GECESTROoverview in 0/126 upper lip, 0.5% of 1199 lower lip, and in 4.2% of 92 commissural cases [27]. Mazeron [12] reported grade 3 cosmetic and functional late effects in 1% of 393 T1, in 5% of 363 T2 and 9 % of 78 T3 lesions. Cosmetic outcome has also been related to dose and dose rate. In the GEC-ESTRO study cosmetic outcome was excellent or good in 96.5% under 50 Gy, 91% between 50 - 70 Gy and 85% for doses over 70 Gy. In T1 cases (when cosmetic damage due to T size is minimal) bad cosmesis was seen in 0%when dose was lower than 60cGy, 1.5% between 60-80 Gy, and 8.6% over 80 Gy. Very few data have been published on complication rates for buccal mucosa LDR- BT. They are estimated to be about 15 to 20% for brachytherapy alone and 25 to 30% for combined irradiation With HDR the adverse side effects are fewer than with LDR [4]. Hair loss, fibrosis, depigmentation, and small telangiectasia on long term follow up are recorded. With LDR it is difficult to maintain a labial protection during the entire time since the irradiation is continuous.The University of Turin published its results with LDR

brachytherapy in 47 T1-2 patients, administering doses between 60 and 80 Gy. They report a 10.6% incidence of mucosal necrosis. In a review of the Valencian Institute of Oncology comparing 99 cases treated with LDR until 1997 (24% treated with plastic tubes) and 104 patients with HDR (all with needles and external fixation with templates), the incidence of long-term complications went down from 16% to 0%. There were no cases of soft tissue or bone necrosis in patients treated with HDR-BT. Moreover, the aesthetic and functional effects were all G1 (normal appearance) or G2 (visible sequelae without functional alteration), with good buccal closure. There were no cases of microstomia, as happens in some cases with surgery.