High-Dose Brachytherapy in Chemoradiation Schemes of Patients with Oral Mucosa Cancer

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Cancer of the oral mucosa is a fairly common malignant neoplasm of the oropharyngial zone. The incidence of cancer of the oropharyngeal zone in the world is 1.1%, in the Russian Federation - 5.5%. In 2019, 9287 new cases of oral mucosal cancer were detected in our country, while the average age of the patients was 61.2 years. The incidence rate in 2019 among men was 6.65 cases per 100 thousand population, among women 1.99 per 100 thousand population [1].The main method of treating cancer of the mucous membranes of the oral cavity is surgical. Often, the surgical method is associated with the performance of time-consuming, extended surgical interventions, entailing gross functional and cosmetic defects. A separate category of patients are not subject to surgical treatment, due to concomitant somatic pathology, age, as well as refusal of this type of treatment [4].Brachytherapy (BT) - can be used to treat this type of cancer because it allows dose escalation directly into the tumor. Chemoradiotherapy in combination with brachytherapy has the same cure and survival rates as surgery, but often gives more favorable aesthetic results, especially when the tumor is treated at an early stage [2].Also, the use of brachytherapy in the treatment of cancer of the oropharyngeal zone raises doubts among practitioners due to the proximity to vital structures, including carotid arteries, jugular veins, other major blood vessels and, in some cases, the brain. A limited amount of clinical data is available, but there are several safe and effective ways to use brachytherapy in the treatment of oral mucosal cancer [3, 6]. Brachytherapy in combination with remote irradiation and chemotherapy leads to a local dose increase compared to the capabilities of modern DLT technologies [8]. The main advantages of modern brachytherapy are the use of images to determine the target volume, the implementation of a walking source technology with the possibility of intensity modulation, as well as developments in the field of medical and physical quality assurance [7]. Modern BT plays an important and successful role in the multidisciplinary treatment of head and neck cancer.We present the case of a patient diagnosed with Cancer of the oral mucosa St III T3N1M0, who refused surgical treatment. Instead, chemoradiotherapy with intracranial brachytherapy with high dose rate using 192 Ir was performed. A three-year follow-up after treatment showed that there were no serious complications or cancer recurrence during this period.A clinical case.Patient S., 51 years old, turned to an oncological dispensary with complaints of ulcerative formation in the oral cavity. From anamnesis: smokes for more than 25 years, more than 20 cigarettes a day, abuses alcohol.Objectively, the examination revealed infiltration of the bottom of the oral cavity with an ulcerative surface measuring 2 by 3 cm. enlarged submandibular lymph nodes were palpated. An additional examination was carried out. SCT of the upper and lower jaw, neck from 10.12.15g Conclusion: Cancer of the bottom of the oral cavity (taking into account the data of the histological conclusion). Single enlarged submandibular lymph nodes. Ultrasound of the neck from 03.12.2015 left conglomerate echo + /- oval shape, size 2,3x1,4 cm. (mts in lymph nodes). Small scattered l/nodes up to 6mm on both sides. Cytological examination No. 1364 dated 10.12.15 (l/a neck): c-r cells. Additional research methods did not reveal distant metastasis.Based on the data obtained, the diagnosis was made: Cancer of the oral mucosa St III T3N1M0. PGI no. xxxx: highly differentiated squamous cell carcinoma.At the medical advisory commission, the patient was offered surgical treatment, which he categorically refused. Based on this, the following treatment plan was developed. Stage 1 chemoradiotherapy: 3 courses of intra-arterial chemotherapy (Selective (superselective) embolization (chemoembolization) of tumor vessels in the basin of the left and right facial and left lingual arteries cisplatin 150mg. Against the background of a daily infusion of 5-fluorouracil 4000 mg), with an interval of 21 days. Volumetrically modulated radiation therapy (VMAT) on the primary tumor area (oral mucosa) and regional metastasis pathways (SOD 60 Gy on the zones of regional lymph flow, SOD 50 Gy on the oral cavity), in accordance with international recommendations.He underwent treatment satisfactorily, without the phenomena of hematological toxicity, with the phenomena of radiation epithelitis of the II degree, which were stopped by conservative methods of therapy that did not require interruptions in treatment.After the 1st stage of chemoradiotherapy, according to MRI data, tumor regression of more than 70% was noted. Based on the received result of treatment, the patient is offered to conduct – high-dose brachytherapy for residual tumor of the bottom of the oral mucosa.Brachytherapy provided a high local dose of radiation with a rapid decline and a short overall treatment time and allowed dose escalation directly into the tumor, as well as reducing the risk of radiation damage in "critical" normal tissues and structures, such as salivary glands, lower jaw and masticatory muscles.Under endotracheal anesthesia, plastic catheters were inserted using metal needles into a residual tumor of the oral mucosa with the capture of unchanged tissues. According to the rules of the Paris System, the distance between the applicators was 1.0 - 1.2 cm, and they are located parallel and equidistant (GEC-ESTRO ACROP recommendations for head & neck brachytherapy in squamous cell carcinomas: 1st update - Improvement by cross sectionalimaging based treatment planning and stepping source technology) [5].After that, computer topometry was performed with installed applicators. The obtained anatomical and topographic data were transferred to the BrahyVision planning system, where the target radiation volume, critical structures and tissues were contoured.Individual dosimetric planning. The planning and calculation of the dose was based on 3D images (CT). Parameters used to calculate the dose: ratio α / β = 10 Gy for the tumor and early reactions, α / β = 3 Gy for late reactions in surrounding tissues. The prescribed dose was the minimum dose received by CTV (D90≥95%, V100>90%). Dose inhomogeneities were minimized following the general rules of the Paris system, with additional optimization by geometric and graphical methods. As a result, V150% (the volume of the tumor covered with a dose of 150% of the prescribed dose) was no more than 35%. A single dose for the primary focus was ABOUT 3Gr / per fraction, 2 times a day, with an interval of 6 hours to SOD 21Gr, 7 fractions.From combined radiation therapy, the patient received: conformal remote radiation therapy (VMAT) SOD of the zone of regional metastasis 50 G, SOD of the oral mucosa 50 G; from HDR brachytherapy SOD 21 Gy, EQD2 10.0=73 g, the median follow-up of the patient was 48 months, total and relapse-free survival = 100%.PET/CT scan 48 months after treatment. Conclusion: there was no pathological accumulation of RFP characteristic of the tumor process. Data for pathological formations in the nasal cavity and oral cavity were not revealed. Anatomical spaces of the neck are differentiated. The lymph nodes of the area and neck are not enlarged.Conclusion.It has been shown that intracranial brachytherapy with a high dose rate using 192 Ir can be used to treat cancer of the oropharyngial zone. Chemoradiotherapy in combination with brachytherapy has the same cure and survival rates as surgery, but often gives more favorable aesthetic results, especially when the tumor is treated at an early stage. This clinical case complements the growing evidence of the effectiveness of brachytherapy in patients with cancer of the oral mucosa, who refuse surgical treatment or have concomitant diseases in the decompensation stage.

About the authors

Ivan Petrovich Moshurov

FSBE HE «N.N. Burdenko Voronezh State Medical University» of the Ministry of Healthcare of the Russian Federation, Voronezh. Russia.

Email: moshurov@vokod.vrn.ru
ORCID iD: 0000-0003-1333-5638
SPIN-code: 3883-6042

M.D., prof., Head of Department of Oncology N.N. Burdenko Voronezh State Medical University

Russian Federation, г. Voronezh, 4 Vaitsekhovsky St.

Natalia Viktorovna Korotkikh

FSBE HE «N.N. Burdenko Voronezh State Medical University» of the Ministry of Healthcare of the Russian Federation, Voronezh. Russia.

Email: kornat78@mail.ru
ORCID iD: 0000-0002-0308-513X
SPIN-code: 2212-6667

Candidate of Medical Sciences, Assistant, Department of Oncology

Russian Federation, г. Voronezh, 4 Vaitsekhovsky St.

Dmitry Yurievich Kamenev

1. N.N. Burdenko Voronezh State Medical University, Voronezh. Russia.
2 Voronezh Regional Clinical Oncological Dispensary, Voronezh, Russia.

Author for correspondence.
Email: kamenev_dmitrii@mail.ru
ORCID iD: 0000-0001-9774-9496
SPIN-code: 2478-7289

Candidate of Medical Sciences, Assistant, Department of Oncology

Russian Federation, 4 Vaitsekhovsky str., Voronezh, 394036, Russia

Anastasia Vladimirovna Tsurikova

BUZ VO VOKOD

Email: anastasiyacurikova@yandex.ru
ORCID iD: 0000-0002-3504-9301
SPIN-code: 8339-8868

Head of Radiotherapy Department №1

Russian Federation, Voronezh, 4 Vaitsekhovsky St.

Irina Nikolaevna Kulikova

BUZ VO VOKOD

Email: irakulikova68@mail.ru
ORCID iD: 0000-0003-0991-9374
SPIN-code: 2500-0526

Radiotherapist, Radiotherapy Department No. 5

Russian Federation, г. Voronezh, 4 Vaitsekhovsky St.

References

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