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Both high-dose and low-dose brachytherapy can be safely combined with flap reconstruction in salvage treatment of recurrent head and neck cancer
Peter W. Henderson, MD MBA, David I. Kutler, MD, Bhupesh Parashar, MD, David M. Otterburn, MD, Marc A. Cohen, MD, Jason A. Spector, MD FACS.
Weill Cornell Medical College, New York, NY, USA.

BACKGROUND: Brachytherapy for treatment of recurrent head and neck cancer (RH&NC) previously treated by external beam radiation can be delivered as high-dose radiation (HDR) via removable catheters, or low-dose radiation (LDR) via permanently implanted seeds. Soft tissue coverage with either pedicled or free flap reconstruction is an important adjunct in salvage procedures for RH&NC, but it is unclear whether the localized radiation increases morbidity of the transferred tissue in these especially high-risk patients.
METHODS: A retrospective chart review evaluated patients with RH&NC who underwent flap coverage after surgical re-resection and concomitant brachytherapy. HDR was delivered via temporary catheters using Ir-192 for 4-6 days, and LDR via permanent implantation of Cs-131 radioactive seeds. The primary endpoint of this study was flap viability, defined as survival of the flap sufficient to maintain wound coverage and obviate the need for future procedures in order to obtain wound coverage. Secondary endpoints included wound healing complications (classified as minor, which resolved with wound care, and major, which required return to the operating room), seroma, bleeding complications, and surgical site infections. Statistical analysis was performed and significance was set at p<0.05.
RESULTS: Nineteen patients (mean age: 64 years) were included in the series; 6 received HDR, and 13 received LDR. Patients were reconstructed with either pedicled pectoralis flap (n=17), free VRAM (n=1), or free ALT and pectoralis flap (n=1). Mean radiation dose was 21.0 +/- 2.4 Gy in HDR, and 81.7 +/- 5.5 Gy in LDR. Follow-up was 8.9 +/- 6.5 months. Flap viability was 100% (19 of 19) (Figure 5). There were complications in 50% of the HDR group (3 occurrences of minor wound breakdown that healed with dressings and local wound care), and in 23.1% of the LDR group (1 hematoma that required evacuation, 1 flap infection, and 1 major wound breakdown that resulted in the development of an orocutaneous fistula that resolved with non-operative management). Pectoralis major donor site complications occurred in 3 of 19 subjects; 2 subjects in the HDR group (1 incisional dehiscence requiring negative pressure dressing, and 1 hematoma requiring evacuation), and 1 subject in the LDR group (incisional eschar that resolved with local wound care). There was no statistically significant difference between the HDR and LDR groups in terms of either flap viability or complications (p >0.05).
CONCLUSIONS: In patients who have flap reconstruction and immediate brachytherapy following salvage procedures for recurrent head and neck cancer, neither HDR nor LDR impacted long term flap viability or skin graft survival. Flap coverage of defects (with or without skin grafting) in combination with brachytherapy is a safe and effective means of providing soft tissue coverage in these challenging patients.

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