Treatment of 'inoperable' neck nodes using surgical clearance and postoperative interstitial irradiation

The inability to remove all disease at the time of a radical neck dissection, or inoperable recurrent disease after a neck dissection, are both familiar problems for the head and neck surgeon. All too frequently the conventional treatment options have already been used, the patient having received external beam radiotherapy and possibly cytotoxic chemotherapy. In such circumstances, and provided that the primary tumour remains under control, a positive approach to the further management of the neck metastases should be adopted, given that the patient is in otherwise reasonable health and does not have gross distant metastatic disease. We describe our experience with postoperative interstitial irradiation (brachytherapy) using after-loaded iridium-192 (192Ir) wires positioned at the site of the tumour after its surgical exposure and debulking or clearance. All the treated patients had previously received external beam irradiation to the neck and in the first three cases local skin necrosis occurred as a sequel to interstitial implantation. Therefore, in the other five patients, cutaneous or myocutaneous flaps were used to resurface the area at the time of implant placement. This combination of techniques, which has not been described previously, provided local tumour control in four out of the five cases without irradiation necrosis occurring in any of them.