30. Paediatric malignancies - The GEC-ESTRO Handbook of Brachytherapy

Paediatric malignancies

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THE GEC ESTRO HANDBOOK OF BRACHYTHERAPY | Part II Clinical Practice Version 1 - 01/09/2023

Figure 4. Example of treatment of the forearm alveolar rhabdomyosarcoma in a 10 months old girl. She was treated with second look surgery and perioperative placement of catheters within the surgical bed. Dose was 60 Gy in pulses of 0.42 Gy per pulse.

Figure 5. Silicone mould with brachytherapy catheters placed at the medioinferior part of the orbita.

Figure 6. Exenterated orbita filled with a thermoplastic mould and catheters in a conal arrangement.

Head and neck tumours A large experience in treatment of head and neck sarcoma comes from Amsterdam, with the AMORE protocol (‘‘Ablative surgery, MOuld technique with afterloading brachytherapy, and RE constructive surgery’’). The AMORE protocol is a treatment for non-para-meningeal and selected para-meningeal tumours that includes two surgical sessions within 1 week, with brachytherapy in between. It consists of ablative surgery, brachytherapy, and surgical reconstruction in three steps [4, 65]: The first step is complete macroscopic surgical tumour ablation, preserving vessels, muscles and nerves. An individual mould made of thermoplastic material in

the shape of the surgical defect is placed in the operative bed in the same operative procedure. Catheters are imbedded in the mould, with a distance to the surface of the mould of approximately 4 mm. Then, subcutaneous tissues and skin are closed over the mould, and the catheters protrude through the surgical incision (Figure 7); The second step is irradiation of the operative bed to treat microscopic tumour residuum, with 3D treatment planning; The third step is reconstructive surgery, directly after removal of the mould with a free-vascularised or pedicled muscle or musculocutaneous flap (Figure 8). One objective of reconstruction is to supply an adequate and well-oxygenated tissue volume in the irradiated defect. If osseous