Select a specific interstitial brachytherapy procedure (other than prostate) and discuss the

specifics of the procedure (everything from how the implant is inserted to patient
simulation, HDR/LDR for treatment, the applicator used, etc.). Use text and internet
resources to get information on the specific procedure you choose to discuss.
In general, oral tongue cancers arise from the lateral aspect of the tongue. They are more
challenging to control than base of tongue tumors, likely because they are less radiosensitive.
For patients treated with definitive radiation therapy, compression of the overall treatment time is
crucial, thus brachytherapy is an essential component of the treatment. A common dosefractionation schedule is 30 Gy in 10 q.d. fractions to the primary tumor with a brachytherapy
boost.1
Treatment of the oral tongue includes both external-beam radiation therapy for the lymphatic
disease and primary tumor, as well as, a boost to the primary tumor via brachytherapy. Prior to
treatment, patients who are planned to receive brachytherapy meet with the prosthodontist. The
prosthodontist takes impressions of the patients mouth to construct a wax-covered, lead
mandibular shield. The patient wears a lead shield to protect the contiguous gingiva, teeth, as
well as, the mandible. Without the lead shielding, a 10% incidence of osteradionecrosis is
correlated with high dose rate (HDR), namely greater than 50cGy/h using the Paris System and a
large reference volume, greater than 25,0000 mm3.1 Usually, the patient, under patientcontrolled anesthesia, has an elective tracheostomy, as well as, a feeding tube inserted before the
physician inserts the catheters.
In preparation to perform brachytherapy, cross-section images are obtained using CT, ultrasound,
or magnetic resonance imaging (MRI).2 The tongue cancer is carefully measured with the patient
under anesthesia. Clinical understaging is common. The physician plans for the implantation to
cover a planning target volume (PTV) created from a 1-cm expansion of the gross tumor volume
(GTV). Before treatment, permanent metal markers are inserted to radiographically delineate the
original borders of tongue tumor and to draw detailed diagrams of the tumor. Often times,
photographs are also taken of the treatment area.1
A heavy silk suture is utilized to move the tongue in such a way that the target volume does not
overlie the mandible. The physician then inserts the catheters submentally in parallel rows.
Frequently, a number 15 surgical scalpel is helpful in penetrating the skin before inserting the
catheter. Depending on the situation, the lead shield is sutured in place either directly before or
after the catheter insertions. The distance between the catheters ranges from 1.0 1.5 cm. The
preferred method is to extend the catheter 1 cm above the dorsum of the tongue. Two halfmoon spacers and a metal button are utilized to protect the palate from mechanical trauma, as
well as, to guarantee the implant covers any exophytic disease above the surface of the tongue.
Metal buttons are inserted with the top button situated with its flat side abutting the palate. Both
buttons and spacers are secured using long 00 silk sutures and are brought out through the
mouth. The implant is planned to treat the area 1 cm superior to the surface of the tongue. The
inferior part of the catheter is secured utilizing metal buttons crimped around the catheter then
sutured to the patients skin. Next, methylmethacrylate or bone cement is used to glue the
catheters and metal buttons together. This technique prevents the catheter from slipping. Once
the prescribed dose is delivered, the physician removes the catheters using gentle traction on the
submental aspect of the catheter. Next, the exposed catheter is cut to be flush with the submental

skin. Then the catheters are completely removed from the patients mouth. Lastly, the dental
shield is taken out and the mouth is irrigated.
The 2 most common techniques for brachytherapy of the oral tongue are Paris system guidegutter technique and plastic-tube technique. Here I will explain the guide-gutter technique. The
iridium-192 (192Ir) gutter guide hairpin technique is used most often in small tumors of the oral
cavity.2 The guide-gutter technique uses iridium wire hairpins with fixed separation of 12 mm.
This technique is used for smaller tumors measuring 30 mm or less in length. Commonly the
patient will sit upright and be under local anesthesia and sedation. The objective of the guidegutter technique is for the sources to be of equal distant apart, parallel and straight, and to cover
the entire target volume. The first part of the implant uses inactive guide gutters. The physician
with the assistance of fluoroscopy, inserts guide gutters parallel with equal distant apart into the
tongue. The guide gutter is initially inserted at an angle toward the midline of the tongue. When
guide gutter is within the muscle, the physician straightens it out. Thus, the lateral limb of the
hairpin runs between 3 4 mm inferior to the mucosa of the lateral border of the tongue as seen
in figure 1. The separation between the hairpin guides should range between 10 -15 mm. After
the physician confirms via fluoroscopy the hairpin guides positions, he or she runs a silk suture
under the bridge of one another (see figure 2). At this time, the radioactive hairpins are cut to the
desired length, which typically is between 4 5 cm for implants of the lateral border of the
tongue. Now, starting with the most posterior guide gutter, the active hairpin is inserted into the
guide gutter. See figure 3. Once the hairpin is in position, it is held in place via a Reverdin
needle and the inactive stainless steel guide is removed from the tongue as seen in figure 4. At
this time, the pre-prepared suture is tied over the bridge of the hairpin securing it within the
tongue. Starting at the posterior aspect moving toward the anterior aspect, this procedure is
repeated for all of the needles. Figure 5 demonstrates the completion of the implant with the 3
hairpins implanted and sutured in place. Figures 6 7 demonstrate radiographs of a tumor
implanted with 4 hairpins.3

Figure 1.

Figure 2.

Figure 3.

Figure 4.

Figure 5.

Figure 6.

Figure 7.
1. Kahn F, Gerbi B. Treatment Planning in Radiation Oncology. 3rd ed. Philadelphia, PA:
Lippincott, Williams & Wilkins; 2012.
2. Levitt S, Purdy J, Perez C, et al. Technical Basis of Radiation Therapy. 4th ed. New York, NY:
Springer Heidelberg Dordrecht; 2008.
3. Ash D., Gerbaulet. Oral tongue cancer. European Society for Radiation Oncology Web site.
http://www.estro.org/binaries/content/assets/estro/about/gec-estro/handbook-ofbrachytherapy/hc-9-23072002-oral-tongue-print_proc.pdf. Accessed May 2, 2016.