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New Approach to Cancer of the Lip Yields Excellent Results
Abstract & Commentary
Synopsis: Controversy exists regarding the best approach to early epidermoid cancers of the lip. Various approaches have been advocated, including surgery with or without postoperative radiotherapy, and low- dose rate (LDR) brachytherapy. In 1999, after almost 15 years of using LDR, Guinot and colleagues in Valencia, Spain, switched to high-dose rate (HDR) brachytherapy exclusively for their patients with early lip tumors, and they found that the outcomes were equivalent. In addition, the HDR technique is quick and easy to perform.
Source: Guinot J-L, et al. Radiother Oncol. 2003;69: 113-115.
Based on their earlier success with LDR brachytherapy for patients with early stage lip cancers, Guinot et al applied similar principles with an HDR system and reported their results for those patients treated from 1999 to 2002. Their all-male cohort of 39 patients with a mean age of 73 years (range, 38-90 yrs) included 38 squamous cell cancers and 1 basal cell tumor. Thirty-six lesions involved the lower lip and 3 were on the upper lip. There were 21 T1, 6 T2, and 12 T4 tumors. Four patients had clinically positive neck nodes at presentation.
Triangular plastic templates were used as needle guides for the insertion of 3-9 needles per case. The needles were inserted under local anesthesia parallel to the longitudinal dimension of the affected lip. Any air gaps were filled in with bolus material. No simulation was done. Rather, optimized dosimetry calculations were made based on an assessment of the required active length for the sources, which always encompassed the whole lip. The median active length was 6 cm (range, 4.5-7 cm). Treatment was prescribed to the 90% isodose line. Total dose was 40.5-45 Gy in 8-10 fractions b.i.d., with 45 Gy in nine 5 Gy fractions for 5 days being the most commonly used schedule. Three millimeter lead shielding was always used behind the lip to protect the underlying structures such as the gingiva.
Actuarial local control at 3 years was 88%, and actuarial disease-free survival at 3 years was 91%. Local control was statistically significantly worse in T4 lesions (74%) compared with T1-2 tumors (95%; P < .05). Three of 4 patients with persistent or recurrent disease were salvaged with surgery, resulting in an ultimate local control rate of 97% (38/39). All 3 patients who received postoperative radiotherapy to the neck following dissection for positive nodes remained free of disease, while one who had RT alone to the neck recurred. Acute toxicity, primarily transient mucositis and ulceration, was similar to that seen with LDR brachytherapy, and resolved by 2 months. Chronic toxicity was limited to low-grade atrophy and minimal pain, with no long-term complications seen. Cosmesis and functional outcome were very good.
Guinot et al concluded that HDR brachytherapy yields 90-95% local control in small and intermediate lesions with very satisfying cosmesis. Implant dose homogeneity was better than with LDR brachytherapy, and there was no exposure to the staff by virtue of the remote control nature of the HDR system. Follow-up is still short, but HDR and LDR brachytherapy appear to confer equivalent results for carcinomas of the lip.
Comment by Edward J. Kaplan, MD
Lip cancers are typically treated either surgically or with RT. Cerezo and associates from Princess Margaret Hospital analyzed outcomes in 117 lip cancer patients treated with surgery (n = 28), external beam radiation therapy alone (n = 61), or postoperatively (n = 28), and found no significant difference in local control or survival.1 Similarly, de Visscher and colleagues from The Netherlands compared results for 90 RT patients to 166 patients who underwent surgery, and found similar results for both groups.2 LDR brachytherapy has also been used successfully for many years to treat lip cancers. Local control rates range from 90-95%.3-5 To my knowledge, the paper by Guinot et al is the first report focusing solely on an HDR technique for the treatment of lip cancer.
Advantages offered by the HDR approach are quick administration of therapy for 5 weekdays, no requirement for general anesthesia, excellent dose coverage, preservation of structure and function, and lack of radiation exposure to the staff. Although follow-up is relatively short, the toxicity profile and outcomes appear to be comparable to LDR brachytherapy. Larger tumors may require additional treatment, reserving HDR brachytherapy as a boost. The potential benefits of sentinel node biopsy are being explored.6
Dr. Kaplan is Acting Chairman, Department of Radiation Oncology, Cleveland Clinic Florida, Ft. Lauderdale, FL; Medical Director, Boca Raton Radiation Therapy Regional Center, Deerfield Beach, FL.
1. Cerezo L, et al. Radiother Oncol. 1993;28:142-147.
2. de Visscher L, et al. Head Neck. 1999;21:526-530.
3. Pigneux J, et al. Cancer. 1979;43:1073-1077.
4. Beauvois S, et al. Radiother Oncol. 1994;33:195-203.
5. Tombolini V, et al. Tumori. 1998;84:478-482.
6. Altinyollar H, et al. Eur J Surg Oncol. 2002;28:72-74.