Int. J. Radiation Oncology Biol. Phys., Vol. -IO. hb. 2. pp. .; I.3 -3 17. 199X Copyright 0 1998 Elaevier Science Inc Printed in the VSA All righls rrserwd 036(1-W If;/UX $19 ix + .(N) PI1 SO360-3016(97)00717-7 l Clinical Investigation CLOSE OR POSITIVE MARGINS AFTER SURGICAL RESECTION FOR THE HEAD AND NECK CANCER PATIENT: THE ADDITION OF BRACHYTHERAPY IMPROVES LOCAL CONTROL JONATHAN J. BEITLER, M.D., MBA,*’ RICHARD V. SMITH, M.D.,’ CARL E. SILVER, M.D.,” ASTRID QUISH, M.D., o SHIVAJI M. DEORE, PH.D., * EDUARD MULLOKANDOV, PH.D.,* DORACY P. FONTENLA, PH.D.,* SCOTT WADLER, M.D.,# MARY KATHERINE HAYES, M.D.,‘t AND BHADRASAIN VIKRAM, M.D.*” *Department of Radiation Oncology.‘Department of Otolaryngology,*Department of Surgery,“Department of Pathology,itDepartment of Medical Oncology,Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY and ‘Beth IsraelMedical Center, NY, NY, +Department of Radiation Oncology,New York Hospital. NY, NY Purpose:Microscopically positive or close margins after surgical resection results in an approximately 21-26% locailfailure rate despite excellentpostoperative external radiation therapy. We sought to demonstrate improved local control in head and neck cancer patients who had a resection with curative intent, and had unexpected, microscopicallypositive or close surgical margins. Methods aud Materials: Twenty-nine patients with microscopically close or positive margins alter curative surgery were gives deilnitive, adjuvant external radiation therapy and “‘1 bracbytherapy. AU 29 pat&& had sqaafilous cell cancer and tonsit was the mostcommonsubsite within the headand neck region. After external radla4ion therapy and thorough discussions with the attending surgeon and speck, amd approprhtte mdiogmphs were reviewedand a target vdume was was the region of the margiu in question and varied in size based on the surgery an target volume was identlfkd the patient was taken back to the opemtig room for iusertionof imp- (range 2.9-21.5 miBicuries)wasdesigned to administer a cumulative lifetime dose of 120~168 Gy. Results: Twenty-nine patientswerefollowed for a median of 26 months(range5-86 months).Two-year actuarial local control was 92%. Conclusion:*251, after external radiation therapy, is an excellent method to improve local control in the subset of patients with unexpectedlyunsatisfactory margins. 0 1998Elsevier Science Inc. Brachytherapy, , “‘1 Positive margins, Close margins,Head and neck, Squamous cell carcinoma. INTRODUCTION The treatment of locally advanced squamous cell head and neck cancer hasevolved from surgery alone to surgery with either pre- or postoperative radiation to surgery plus post- operative radiation therapy (12). Although advanced cancer of the larynx (21) and hypopharynx (15) may best be treated with induction chemotherapy external radiation and salvage surgery, most advanced oropharyngeal and oral cavity can- cer are still treated with surgical resection and postoperative external radiation. Despite the use of intraoperative frozen sections, final pathology reveals an inadequate margin of resection in lo-16% of patients (5, 11). Without adjuvant radiation therapy, the local failure rate for those patients who undergo resection with posi- tive margins is 71-80% (5, 16). With postoperative ex- ternal radiation, local recurrence in the presence of mi- croscopically positive or close margins ranges from 21- 26% (10, 11, 24). We hypothesized that interstitial brachytherapy applied to boost the immediate region of the close or positive margin would further improve local control when compared to postoperative external radiation alone (33). METHODS AND MATERIALS Twenty-nine consecutive patients who underwent cura- tive resection had invasive cancer at or less then one high powered field (HPF) from the margin and went on to ex- -.-^ Presented at 4th International Conference on Head and Neck Cancer, Toronto, Canada 28 July 1996. Reprint requests to: Jonathan J Beitler, M.D., MBA, Associate Professor and Deputy Chairman for Clinical Affairs, Dept. of Radiation Oncology, Montefiore Medical Center, 3335 Steuben Ave.. Bronx. NY 10467. Aclazawledgments-We acknowledge the expert secr&uial assistance of Ana Sanchez. Accepted 3 1 July 1997. 313