Head and neck Head and neck cacancerncer

MUDr. Martin MajirskýMUDr. Martin Majirský5/20145/2014

RRadiotherapy and adiotherapy and OOncology ncology department department UUniversity hospital Královské Vinohradyniversity hospital Královské Vinohrady

&&Third medical faculty Charles University PragueThird medical faculty Charles University Prague

Any tumor that grows in the Any tumor that grows in the mouth, throat, voice box, ear, mouth, throat, voice box, ear, nose, or necknose, or neck

Risk Factors for Risk Factors for Head and Neck CancerHead and Neck Cancer

Tobacco Products:Tobacco Products: Smoking TobaccoSmoking Tobacco CigarettesCigarettes CigarsCigars PipesPipes Chewing TobaccoChewing Tobacco SnuffSnuff

Ethanol ProductsEthanol Products

Chemicals:Chemicals:AsbestosAsbestosChromiumChromiumNickelNickelArsenicArsenicFormaldehydeFormaldehyde

Other FactorsOther Factors:Ionizing RadiationIonizing RadiationPlummer-Vinson Plummer-Vinson SyndromeSyndromeEpstein-Barr VirusEpstein-Barr VirusHuman Papilloma Human Papilloma VirusVirus

HPV associated H&N HPV associated H&N CancersCancers

Increasing incidenceIncreasing incidence Young, Non-SmokersYoung, Non-Smokers Tonsil/Base of TongueTonsil/Base of Tongue High risk strains often sexually High risk strains often sexually

transmitted transmitted (>95% due to HPV 16 (>95% due to HPV 16 )) Very aggressive, Very aggressive, preventionprevention is is

keykey !! Better prognosis than HPV-Better prognosis than HPV-

Other Causes of Head Other Causes of Head and Neck Cancerand Neck Cancer

Gender – Men 2-3x’s > than womenGender – Men 2-3x’s > than women Race – African Americans at greatest riskRace – African Americans at greatest risk Age - > 40 yearsAge - > 40 years Sun ExposureSun Exposure Poor Oral HygienePoor Oral Hygiene Poorly Fitting DenturesPoorly Fitting Dentures Poor Nutrition (low in vitamins A & B)Poor Nutrition (low in vitamins A & B) Environmental/Occupational HazardsEnvironmental/Occupational Hazards Epstein-Barr VirusEpstein-Barr Virus Exposure to Secondhand Smoke!!!!!Exposure to Secondhand Smoke!!!!!

Warning Signs of Head Warning Signs of Head and Neck Cancerand Neck Cancer

HoarsenessHoarseness ErythroplasiaErythroplasia Referred otalgiaReferred otalgia Persistent sore throatPersistent sore throat EpistaxisEpistaxis Nasal obstructionNasal obstruction

Serous otitis Serous otitis mediamedia

Neck massNeck mass Non-healing Non-healing

ulcerulcer DysphagiaDysphagia Submucosal Submucosal

massmassNot all cancers present Not all cancers present with symptoms at early with symptoms at early

stages!stages!

• Non-Healing UlcerNon-Healing Ulcer•Bleeding Bleeding •Loose ToothLoose Tooth•Loose Fitting Loose Fitting DenturesDentures•Difficulty SpeakingDifficulty Speaking•Difficulty Difficulty SwallowingSwallowing•Unexplained PainUnexplained Pain•Weight LossWeight Loss

Signs of Oral CancerSigns of Oral Cancer

Signs of Throat CancerSigns of Throat Cancer

• Ear PainEar Pain• Painful Painful /Difficult /Difficult SwallowingSwallowing• Muffled VoiceMuffled Voice• Difficultly Difficultly Opening MouthOpening Mouth• Weight LossWeight Loss• Lump in NeckLump in Neck

Large tonsil tumor Normal tonsilUvula

Signs of Voice Box Signs of Voice Box CancerCancer

• Hoarseness•Voice Change• Painful/DifficultySwallowing• Ear Pain• Weight Loss• Neck Mass/Lump• Breathing Difficulty

TUMORTUMOR

DiagnosisDiagnosis

AnamnesisAnamnesis Physical examination Physical examination

((mouth, throat, voice box, and neckmouth, throat, voice box, and neck)) LaboratoryLaboratory Endoscopy + biopsyEndoscopy + biopsy Imaging CTImaging CT

MRIMRI

PETPET

RoleRole of radiotherapy of radiotherapy CurativeCurative

• initially trinitially treeatment of small laryngeal tumours stage atment of small laryngeal tumours stage T1,T2N0 (voice preservation tT1,T2N0 (voice preservation thherapy)erapy)

• radiotherapy combined with chemotherapy by radiotherapy combined with chemotherapy by inoperabile cases, inoperabile cases,

• or for patient whose decline radical operationor for patient whose decline radical operation Postoperative (adjuvant)

• operative field and regional lymphnodes of large tumours pT3,4N+

Preo-perative (neoadjuvant)• reduce a tumour mass and convert an inoperble case to

operable Paliative

• reduce a tumour mass, analgetic treatment• haemostatic therapy

Radiation requirementsRadiation requirements TargetTarget volume volume

• Primary target volume – PTV 1 is clinical target volume - CTV +internal margin IM + setup margin SM and regional lymphnodes

• target dose 40 - 45 Gy• PTV 2 PTV 2 - target dose 15-20 Gy /postoperative radiotherapy- target dose 15-20 Gy /postoperative radiotherapy• PTV 2 - target dose 30-34 Gy / radical radiotherapy

Fractionation schedules Fractionation schedules • standard fractionation schedule - 5 per week 1,8 – 2 Gy• hyperfractionation: 5 per week/tvice per day 1,2 Gy• accelerated radiotherapy : 5 per week/tvice per day 1,7 Gy• hypofractionation radiotherapy: once or twice per week 4-

8Gy

Critical organs, tolerance Critical organs, tolerance dosedose

Spinal cord• 45 – 50 Gy45 – 50 Gy

LensLens• 4-5 Gy4-5 Gy

Optic chiasm, optic nerve (II)Optic chiasm, optic nerve (II)• 55 Gy55 Gy

Hearing and Taste impairment is usually Hearing and Taste impairment is usually observed observed

after doses of around 30 Gy.after doses of around 30 Gy.

Technology and planning of Technology and planning of radiotherapyradiotherapy

Source of radiationSource of radiation• linear accelerator (X-ray – 6MV, electron beam

energy 6,9,12 MeV• Co 60• High Dose Rate, Low Dose Rate brachytherapy

CT scanCT scan SimulatorSimulator Planning systemPlanning system Intensity-Modulated Radiation Therapy - Intensity-Modulated Radiation Therapy -

IMRTIMRT

Ways of irradiationWays of irradiation

2 parallel opposed fields2 parallel opposed fields lateral parallel opposed fields and lateral parallel opposed fields and

anterior fieldsanterior fields matching photon and electron matching photon and electron

fieldsfields direct fieldsdirect fields Individual plan (many fields), Individual plan (many fields),

IMRTIMRT

Aids for irradiationAids for irradiation

Accuracy of immobilizationAccuracy of immobilization• stereotactic frame, individual plastic

face mask /ORFIT/ Beam shapingBeam shaping custom-made alloy blocks, multileaf

collimator Beam modificationBeam modification

• wedges, compensators, inhomogeneity corrections

Oral cavityOral cavity C00 carcinoma of lipC00 carcinoma of lip C01 carcinoma of base of tongue C01 carcinoma of base of tongue C02 carcinoma of tongueC02 carcinoma of tongue C03 carcinoma of lower alveolusC03 carcinoma of lower alveolus C04 carcinoma of base of oral C04 carcinoma of base of oral

cavitycavity C05 carcinoma of palateC05 carcinoma of palate C06 carcinoma of buccal mocosaC06 carcinoma of buccal mocosa Strategy of therapyStrategy of therapy

• Stage T1, T2:• Surgery or radiotherapy

• Stage T3, T4, N+• Surgery and postoperative

radiotherapy

Tongue

Submentalnodes

Submandibularnodes

Jugulo-digastric node

Upper

Mid

Lower

Cervical nodes

Tongue-tumor accros the middle line , with metastatic lymphnodes T4N1-2.Radiotherapy technique:lateral and anterior fields with or without wedges, Dose: 74 Gy in 7-8 weeks with reducinng fields after 44Gy on spilnal cord.

Oropharygeal carcinoma Oropharygeal carcinoma C05.1 carconoma of palate velum C05.1 carconoma of palate velum C05.2 carcinoma of uvula C05.2 carcinoma of uvula

palatinapalatina C09 carcinoma of tonsilaC09 carcinoma of tonsila C01 base of tongue C01 base of tongue Regional lymfonodesRegional lymfonodes

• jugulo-digastric nodes,,mid cervical lymphnodes, retropharyngeal and upper deep cervical lymphnodes

• Strategy of the treatmentStrategy of the treatment• T1, T2

• Surgery or radiotherapy • T3, T4

• Surgery and postoperative radiotherapy, or palliative radiotherapy

Base of

tongue

Vallecula

Aryepiglotic fold

Free portion of epiglotis

Tonsil

Anterior pillar of soft palate

Field margines for small tumours of the tonsillar fossa.Schielding is used as indicated for opposing lateral fields.

b

Pacientka r. 1949, dlaždicobuněčný karcinom kořene jazyka s prorůstáním do čelisti vlevo, T4N1M0, G3, st.p. 3 cyklech indukční chemoterapie, RT do LD 70 Gy/35 fr., kompletní remise.

Pacientka r.1945, dlaždicob.Ca G2 baze ústní a arcus palatoglossus, T4N1M0.

Léčba:- 1 cycle chemoterapie cDDP/5FU-Radik. RT IMRT 66 Gy (BED 70 Gy)

-Kompletní remise. Bez recidivy po 3 letech.

NasopharynxNasopharynx C11.0 – 9C11.0 – 9 Strategy of the Strategy of the

treatmenttreatment• radical radiotherapyradical radiotherapy• radiochemotherapyradiochemotherapy• PTV 1

• 42Gy in 4 weeks42Gy in 4 weeks• PTV 2

• 74 Gy in 8 weeks74 Gy in 8 weeks

Adjuvant chemotherapyAdjuvant chemotherapy

5-FU and cis platin5-FU and cis platin

Pterigoid fossa

Mandibular nerve (Vc)

Foramen ovale

Cranial nerves

Internal carotid artery

Foramen lacerum

Pituitary gland

Sphenoid sinus

Nasopharynx

Hard palate

Internal carotid artery

Cavernous sinus

Isocentrically nasopharyngeal lateral fields

Dose distribution from a two lateral fields

Dose distribution from a two lateral fields

Pacient r.1943, nasopharyngeeal Ca, cT2NXM0, G3

After 1 cycle of chemo

RT 74 Gy

LarynxLarynx

C 32.1 supraglottic tumoursC 32.1 supraglottic tumours C32. Glottic tumoursC32. Glottic tumours C32.2 subglotis tumoursC32.2 subglotis tumours Strategy of the treatmentStrategy of the treatment

• T1, T2, N0• surgery or radiotherapy

• T3, 4, N+• surgery and radiotherapy

2 lateral fields ,linear accelarator X6MeV

a

a

Thyroid glandThyroid gland C73C73 papillary and follicular carcinoma papillary and follicular carcinoma medullary carcinoma medullary carcinoma anaplastic anaplastic ccarcinomaarcinoma NON-Hodgkins lympNON-Hodgkins lymphhoma oma metastatic dimetastatic dissseasesease Strategy of the treatmentStrategy of the treatment

• surgery• postoperative radiotherapy by Iodine-131 non-

concentrated tumours, and tumours stage T4 N+• palliative radiotherapy by inoperable cases • radiotherapy combinated with chemotherapy

Thank you for attention.Thank you for attention.