Yonsei Med J.  2010 Jul;51(4):557-561. 10.3349/ymj.2010.51.4.557.

Cesium Implant for Tongue Carcinoma with a Thickness of 1.5 cm or More: Cases Successfully Treated with a Modified Manchester System

• Nishioka T
• Fujino M
• Homma A
• Yamashita
• Sato A
• Ohmori K
• Obinata K
• Shirato H
• Notani K
• Nishio M

• KMID: 1805194
• DOI: http://doi.org/10.3349/ymj.2010.51.4.557

Abstract

PURPOSE
Deciding on treatment carcinoma of the tongue when the tumor has a thickness of 1.5 cm or more is difficult. Surgery often requires wide resection and re-construction, leading to considerable functional impairment. A cesium implant is an attractive option, but according to the Manchester System, a two plane implant is needed.
MATERIALS AND METHODS
According to the textbook, a tumor is sandwiched between the needles, which are implanted at the edge of the tumor. This may cause an unnecessarily high dose to the outer surface of the tongue, which sometimes leads to a persistent ulcer. To avoid this complication, we invented a modified implantation method, and applied the method to five consecutive patients.
RESULTS
With a minimum follow-up of 2 years, all primary tumors in 5 consecutive patients have been controlled. No complications occurred in soft tissue of the tongue or in the mandible.
CONCLUSION
Our modified Manchester System was feasible and effective for tumors that has a thickness of 1.5 cm or more.

Keyword

Carcinoma of the tongue; brachytherapy; cesium; neck dissection

Figure

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  Fig. 1 Original Manchester System for T2N0 with a thickness of 1.5 cm. The tumor is shown sandwiched between full length needles. Dose is prescribed at the 0.5 cm plane B from the lateral border of the tongue. Overdose is a concern at plane A.

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  Fig. 2 Modified Manchester System at Hokkaido University. Insert full intensity needles 5 mm from the lateral border of the tongue. Half intensity needles were implanted at the medial border of the tumor. Dose is prescribed at plane A. Dose at plane D, which is 1.1 - 1.2 time higher than that at the plane A, is a concern.

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  Fig. 3 (A) Gadolinium-enhanced MR image clearly revealed the tumor. The thickness was 15.3 mm and the height was 27.5 mm. (B) Operating room X-ray image. A total of 15 Cs needles were implanted. Their alignment was satisfactory. (C) CT image immediately after implant. The lateral needles were implanted 0.5 cm from the mucosal surface. The inner needles were placed 1.0 cm from the lateral needles. This alignment was the same as in the simulation. The dose prescription plane is highlighted in yellow (1,198 rad/day) and the inner plane 5 mm away from the outer needle plane is highlighted in red (1,437 rad/day). The dose at the red plane will end up with 20% higher than that of the lateral portion of the tongue. (D) Appearance of the tongue mucosa 2.5 years after the implant. The mucosa appears slightly white, there is no sign of tissue necrosis. (E) Slight atrophy is seen in the area of the implant. When the tongue protrudes, a slight deviation to the left is observed.

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