Interview with Abrahim Al-Mamgani, co-author

Abrahim Al-Mamgani, Gerda M. Verduijn, Ellen Zwijnenburg, Willem H. Schreuder, Aniel Sewnaik, Willem Weijs, Johhanes A. Rijken, Lisa Tans, Homan Dehnad, Lia Verhoef, Robert van Es, Arash Navran, Luc Karssemakers, Mischa de Ridder; on behalf of the Dutch Head-and-Neck Brachytherapy Group.

 

What was your motivation for initiating this study?

There is no consensus on the optimal treatment for lip carcinoma. This is largely due to the absence of randomised or well-designed prospective studies that directly compare surgical options with brachytherapy in terms of local control rates, complications, and functional and aesthetic outcomes. Brachytherapy is a highly conformal radiation modality compared with other techniques; it offers a steep dose fall-off that minimises damage to surrounding healthy tissue and reduces side effects. However, the primary concern is the fear that this effective treatment may be rendered unavailable, mainly because the implantation into the tissue of the required radioactive source is time-consuming and labour-intensive, and requires specialist skills. Additionally, the limited availability of brachytherapy facilities and experienced brachytherapists worldwide further complicates the issue. This situation underscores the need for greater investment within the radiation oncology and brachytherapy community to recruit and train new radiation oncologists who are skilled in this precise radiation technique.

The primary motivation behind the IR-Lip study, which was conducted by the Dutch Head-and-Neck Brachytherapy Group, was to demonstrate the excellent oncologic and cosmetic outcomes of brachytherapy for lip cancer. The goal was to encourage more radiation oncologists to adopt this modality and to raise awareness about its benefits among healthcare providers involved in the treatment of lip cancer, including dermatologists and head-and-neck, oral and maxillofacial and plastic surgeons.

What were the main challenges during the work?

A key challenge was collecting data from all the patients, who were consecutively treated across the Dutch head-and-neck brachytherapy-dedicated radiotherapy departments. These centres use two different techniques (pulse- and high-dose rates (PDR and HDR)) and four different treatment regimens, making it difficult to draw clear and useful conclusions regarding the best technique and most effective regimen.

What are the most important findings of your study?

The IR-Lip study reported outcomes and toxicity data for 272 patients with lip carcinoma who had been treated with brachytherapy, either as the primary or an adjuvant treatment. The results showed an excellent local control rate of 97%. In the rare case of treatment failure, the study demonstrated a high likelihood of successful salvage treatment, ultimately achieving a local  control rate that approached 100%. Only six patients (2.2%) experienced grade 2 late toxicity related to brachytherapy.

There were no significant differences in local control rates between primary and adjuvant brachytherapy, HDR and PDR treatments, or among the four different HDR regimens. Among patients for whom patient-reported outcome measures were available (all of whom had been treated with HDR), the vast majority reported being highly satisfied with the results. All but one patient said they had no regrets about their decision to undergo brachytherapy. Based on the results of this study, we decided to standardise the use of HDR for the treatment of lip carcinoma, adopting a regimen of nine fractions each of 5Gy as the standard of care across all participating brachytherapy-dedicated radiotherapy departments in the Netherlands.

What are the implications of this research?

The IR-Lip study not only demonstrated excellent oncologic, aesthetic, and functional outcomes, but also led to the standardisation of the entire brachytherapy treatment process for lip cancer across Dutch radiation oncology centres. The use of this precise and effective radiation technique directly improves the quality of care for these patients. However, increased investment is needed to recruit and train radiation oncologists in this highly specialised technique. This can be achieved through the organisation of workshops, practical training courses, bedside teaching in operating rooms, and ongoing training to help brachytherapists to consolidate their skills.

By investing in these areas, we can preserve and enhance the effectiveness of brachytherapy, ensuring its continued success and strengthening its role in the treatment of lip cancer.

 

Figure

 

Upper panel: 32-year-old woman with T1 lower-lip carcinoma. Left: the lip cancer before brachytherapy. Centre: acute dermatitis two weeks after brachytherapy. Right: the excellent aesthetic results achieved just eight weeks after brachytherapy.

Lower panel: 78-year-old woman with large T2 lower-lip cancer. Left: before the implantation. Centre: the three implants in situ. Right: excellent local control and good cosmetic outcome were achieved three months after brachytherapy of a bulky tumour.

 

Abrahim Al-Mamgani, MBChB, MD, PhD

Amsterdam University Medical Centre

Department of Radiotherapy, Location VUmc

Cancer Center Amsterdam 

Amsterdam, The Netherlands

a.al-mamgani@amsterdamumc.nl