Brachytherapy in the Treatment of Head and Neck Cancer

Brachytherapy in the Treatment of Head and Neck Cancer

Drs. Quon and Harrison have
written an excellent review
on the role of brachytherapy in the management of head and neck cancer.
Brachytherapy is a time-honored technique, and the authors have carefully
reviewed the pertinent literature extolling its virtues. However, there are many
papers that fail to document efficacy of brachytherapy over conventional
techniques, demonstrating that, similar to surgery, the technique is both
patient- and operator-dependent.

The ‘Craft of Medicine’

Some radiation oncologists utilizing brachytherapy techniques can do things
that others cannot—they are just better at the craft. As with any surgical
procedure, there is a learning curve for obtaining the best possible results,
and those doing a higher volume of brachytherapy implants will more likely
(although not necessarily) achieve better results than those doing only a few
cases per year. It is not only that the experienced brachytherapist knows better
when and how to place an implant, but also, when not to do so.

These important variables are difficult to quantify but are responsible for
one center obtaining 40% 5-year local control rates while another achieves 75%,
seemingly doing the same thing. Data manipulation is not the cause of these
discrepancies—it is the "craft of medicine" that is operational.

Differences in Technique

One aspect of the authors’ technique that I would question is the need to
wait 5 or more days after placing an intraoperative implant before loading the
catheters and delivering radiation. The authors claim that this allows time for
fibrinogenesis, thereby preventing wound complications. The wound has its
greatest tensile strength immediately after wound closure; the tensile strength
of wounds at 5 to 10 days postoperatively is significantly lower. Also, the risk
of wound infection increases with the length of time that the nylon catheters
are in place.

As a general rule, we load the catheters on the first or second postoperative
day, as soon as the patient is physiologically stable and able to be transported
to our radiation therapy facility. A notable exception to that rule is if the
patient has developed significant postoperative swelling in the implanted area.
Finally, the use of permanent implants (eg, iodine-125 seeds) is associated with
increased hazard both to the radiation oncologist performing the implant and to
the surgeons closing the wound.


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