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Page 2 of 15 Tropiano et al. Mini-invasive Surg 2024;8:17 https://dx.doi.org/10.20517/2574-1225.2024.41

2023 with IRT on the primary lesion at Azienda Ospedaliera Universitaria di Sassari and Mater Olbia Hospital were
included.

Results: A total of 15 patients were treated with IRT following the principles of anatomical implantation. The only
treatment-related toxicity observed has been the mechanical damage to the skin from the buttons used to stabilize
the plastic tubes.

Conclusion: IRT with anatomical implantation allows a high nose preservation rate and very good cosmetic results,
which appear to be decisive advantages in comparison with traditional surgery, while confirming comparable
effectiveness from an oncological point of view. However, in the present series, we describe typical skin toxicity
that may have a negative impact on cosmetic results. We propose a new strategy involving the use of a soft
medium such as a sponge to protect the skin from damage.

Keywords: Nose vestibule cancer, brachytherapy, interstitial implantation, endocavitary, cosmetic preservation,
skin toxicity

INTRODUCTION
Nasal vestibule squamous cell carcinoma (NV-SCC) is classically considered a rare type of cancer. It has
been reported to account for less than 1% of all head and neck malignancies, with an incidence of 0.3-0.4/
[1]
100,000 person per year . However, data on the incidence is unreliable because the nasal vestibule (NV) is
not a clearly defined anatomic area and a specific WHO International Classification of Diseases (ICD) code
has not been assigned. The current Union for International Cancer Control (UICC)/American Joint
Committee on Cancer (AJCC) staging system classifies primary lesions of the NV with the same criteria as
ethmoid and nasal cavity proper.

The recent interest on these issues and the systematic description of the peculiar clinical features of NV-
SCC has brought to propose new standards for classification and staging of these malignancies . These
[2-4]
[3-6]
include the definition of clear anatomical boundaries for the NV itself, a specific WHO code for the site and
the adoption of a specific separate T classification, making NV the third subsite within nasal cavity and
paranasal sinuses .
[7]

Surgery (mostly consisting of partial or total rhinectomy) has been the traditional, predominant treatment
for NV-SCC [8-16] . Interventional radiotherapy (IRT) has demonstrated non-inferiority to upfront surgery in
terms of local-recurrence free survival (LRFS) and disease-specific survival (DSS) [6,8,9,17-27] , while providing
superior local control compared to external beam radiation therapy (EBRT) [6,20,28-32] . However, when surgery is
selected, in view of the specific spread pattern of NV-SCC among cartilages, with early skin invasion, a
through resection of the ala/nasal wall is most often indicated, requiring complex and unpredictable
multiple reconstructive surgeries or the creation and fitting of a bone-anchored prosthesis (epithesis) for
cosmetic restoration [33-39] . On the contrary, IRT allows the preservation of the cartilaginous framework,
leading to much more favorable functional [3,40] and cosmetic outcomes [6,21] . Based on these findings, the
Italian Society of Otolaryngology defined IRT as the therapeutic standard for the primary lesions in NV-
SCC without bone involvement.
[41]
To achieve optimal cosmetic and functional results through IRT, the necessity to preserve the perichondral
layer feeding the cartilage has been outlined, and novel criteria for the implantation of the applicators have
[17]
been described, thus defining the concept of “anatomic implantation” .