head & neck cancer horizontal
TRANSCRIPT
HEAD & NECK CANCERHORIZONTAL
Mohamed Abdulla M.D.
Prof. of Clinical Oncology
Kasr Al-Aini School of Medicine
Cairo University
KASO – EXAM & RAP UP COURSE
THURSDAY 16/04/2015
GRAND NILE HOTEL & TOWER
FINDING
SIMILARITIES
IN COMMON
Disclosures:
• Amgen.
• Merck Serono.
• Sanofi.
• Astra Zeneca.
• Astellas.
• Roche.
• Pfizer.
• Novartis
Head & Neck Cancer: Basic Facts:
• 6 – 9% of all cancers.
• Males > Females; (2:1) (4:1).
• 60% advanced at presentation.
• Substantial Geographic Variations Influenced by Risk
Factors:
• Smoking & Alcohol 5 – fold increased incidence.
• HPV Oro-pharyngeal cancer.
• EPV Nasopharyngeal cancer.
83%
59%
36%
0%
50%
100%
5-
ye
ar
Su
rviv
al
Seminars in Oncology, Vol 41, No 6, December 2014, pp 798-806
Head & Neck Cancers:
Molecular & Biological Events:
• HPV-Related Cancers
• Caused by high-risk HPV
• HPV 16
• Driven by viral oncogenes
• Restricted to oropharynx
• Distinct molecular markers
• “Good” prognosis
• Young, good general health
• Environment-Related Cancers
• Caused by environmental
mutagens
• Smoking, alcohol
• Throughout oral mucosa
• Distinct molecular markers
• “Poor” prognosis, comorbidity
• Second cancers
HNC Can Now Be Divided Into 2 Large and Distinct Subtypes
HPV = human papillomavirus.
Goon et al, 2009; Rodriguez et al, 2010.
HPV & Oropharyngeal Cancer:
Changing Incidence Over Time:
Chaturvedi et al, 2011.
Sequential Combined Modality Therapy
A Phase III Study: TAX 324 TPF Vs. PF
Followed by Chemoradiotherapy
R
A
N
D
O
M
I
Z
E
P
P
F
F
Carboplatinum: AUC 1.5 Wkly
Daily Radiotherapy
EUA
T
Surgery
TPF: Docetaxel 75D1 + Cisplatin 100D1 + 5-FU 1,000 CI: D1–4 q3wks x 3
PF: Cisplatin 100 D1 + 5-FU 1,000 CI: D1–5 q3wks x 3
AUC = area under the curve; EUA = examination under anesthesia.
Posner et al, 2007.
TAX 324: Demographics by HPV Status
HPV+
N = 56 (50%)
HPV–
N = 55 (50%) p Value
Treatment
TPF
PF
28 (50%)
28 (50%)
26 (47%)
29 (53%)
.85
Age Yrs
Median (Range) 54 (39–71) 58 (41–78) .02
Nodal Stage
N0–N1
N2–N3
13 (23%)
43 (77%)
18 (33%)
37 (67%)
.30
T stage
T1–T2
T3–T4
28 (50%)
28 (50%)
11 (20%)
44 (80%)
.001
PS WHO
0
1
43 (77%)
13 (23%)
27 (49%)
28 (51%)
.003
PS = performance status; WHO = World Health Organization.
Posner et al, 2011.
TAX 324: Survival and HPV Status
Posner et al, 2011.`
Su
rviv
al
Oro
ph
ary
nx C
an
cer
HPV+
HPV–
p < .0001
TAX 324: Survival, PFS, and Site
of Failure By HPV Status
HPV+
N = 56
HPV–
N = 55
p Value
Median Follow-Up
Months (95% CI) 83 (77–93) 82 (68–86) NS
Survival Status– Alive
– Dead 44 (79%)
12 (21%)
17 (31%)
38 (69%)
< .0001
PFS Status– No Progression/Death
– Progression/Death41 (73%)
15 (27%)
16 (29%)
39 (71%)
< .0001
Local-Regional Failure 7 (13%) 23 (42%) .0006
Distant Metastases 3 (5%) 6 (11%) NS
Both 1 (2%) 2 (4%) NS
Total Disease Failures 9 (16%) 27 (49%) .0002
Died Without Recurrence 5 (9%) 12 (22%) .07
PFS = progression-free survival; NS = not significant.
Posner et al, 2011.
Head & Neck Cancer:
Current Theme of Management:
SurgeryRadiation
TherapyKey
Components
L.R. Distant
Metastases
Systemic
TherapySEER. Stat fact sheets: oral cavity and pharynx cancer. 2003-2009.
Existing Dilemma:
• Different treatment algorithms.
• Many critical structures QoL.
• Organ Preservation.
• Impact of innovations on OAS.
MDTRadiation
Oncologist
Medical Oncologist
Onco-Surgeon
Radiologist
Clinical NutritionistPsychiatrist
Physiotherapist
Speech Aid
Social Worker
Oncology Nurse
Head & Neck Cancer:
Current Theme of Management:
Head & Neck Cancer:
Radiation Therapy Components:1. Patient Preparation.
2. Positioning.
3. Fixation.
4. Volume to be Treated, Volumes to be Avoided.
5. Portal Arrangement.
6. Energy Used.
7. Dose, Fractionation & OAP
8. Acceptance and Quality Control.
9. Adding Systemic Therapy.
10. Management of Anticipated Complications & Follow Up
Radiation Therapy Components:
1. Patient Preparation: Compliance: • Detailed history including previous HNSCC & radiation treatment.
• All investigations (Imaging, laboratory, pathologic, endoscopic) Accurate Staging Clear Intention & Therapeutic Strategy.
• General Examination:• Performance Status.
• Complexion: PALOR ANEMIA., Depression.
• Nutritional Assessment.
• Co-morbid illness DM
• Neurological Assessment.
• Pulmonary Assessment.
• Locoregional Examination:• Palpable primary & lymph nodes.
• Oral Hygiene Correction before treatment.
• Stoma Care.
• Understanding, Instructions, Interventions.
• Discuss with family.
• MDCT
• MRI
• PET/CT
• Others
• Hematological
• Organ Function
• Others
Poor Radiation Results From Non-compliance
in Radiation TechniqueCritical Impact of Radiotherapy Protocol
Compliance and Quality in the Treatment of
Advanced Head and Neck Cancer: Results
From TROG 02.02
CO June 20, 2010 vol. 28 no. 18 2996-3001
Noncompliance, more relapses
Radiation Therapy Components:
2. Positioning: Comfortable & Reproducible
SUPINESTRECHED
SHOULDERS
Snehal et al..Medical Dosimetry, Vol. 34, No. 3, pp. 225-227, 2009
• Acanthiomeatal Line is
perpendicular to table.
• Chin in neutral position.
Radiation Therapy Components:
3. Fixation:
• Thermoplastic Mask.
• Placement of Markings;
“Lead & Laser).
• Tongue Bite
(Depressor): In or Out.
Radiation Therapy Components:
4. Volume:
ICRU Reports 50 & 62:
• GTV: Gross Tumor Volume.
• CTV: Clinical Target Volume:
Extension of Subclinical
Disease.
• PTV: GTV + CTV + (3 – 5 mm).
• OAR or ORV.
ICRU Report 50 (1993) Prescribing, recording and
reporting photon beam therapy. International
Commission on Radiation Units and Measurements,
Bethesda, MD
• No Place for limited volumes except in Early glottic
cancers (T1-2).
• Neck nodes are usually included except in Early Glottic
Cancers and PNS.
• Bilaterality of neck nodes is mostly required.
Radiation Therapy Components:
4. Volume:
3D Techniques (Conformal, IMRT, IGRT)
Spare Normal Tissues as much as we can
Accurate radiation dose delivery
No treatment volume Reduction.
Radiation Therapy Components:
4. Volume:
Radiation Therapy Components:
4. Volume: Larynx: Glottic:
Early Glottic Cancer T3-4 Glottic Cancer
Radiation Therapy Components:
4. Volume: Larynx: Supraglottic:
Nasopharynx Basic Considerations:
Anatomical Data:Skull Base: Sphenoid
and Occipital Bones
Pre-
Vertebral
Fascia
Nasal
Cavity
Oropharynx
Basic Considerations:
Anatomical Data:
Basic Considerations:
Anatomical Data:
Basic Considerations:
Anatomical Data:
Basic Considerations:
Anatomical Data:U
pw
ard
exte
nsio
n
Basic Considerations:
Anatomical Data:The Most
Common Site
Bounded by:
Atlas vertebra
Axis vertebra
Sup. Constrictor ms
Buccopharyngeal
fascia
Retropharyngeal
space
Prevertebral fascia
Basic Considerations:
Anatomical Data:
Basic Considerations:
Anatomical Data:
Pharyngo-Basilar Fascia
Basic Considerations:
Anatomical Data:
Superior
Pharyngeal
Constrictor
Muscle
Skull Base
Pharyngobasilar fascia Muscle Deficiency Area
=
Sinus of Morgagni
Potential Route
for Intracranial
Spread
Radiation Therapy Components:
4. Volume: Nasopharynx:
Radiation Therapy Components:
4. Volume: Paranasal Sinuses:
Ipsilateral Tumor Bed + Ethmoid + Frontal + Openings on the
contralateral side. Nodes will be included if locally advanced or
high grade lesion.
Radiation Therapy Components:
4. Volume: Oropharynx:
Radiation Therapy Components:
4. Volume: Hypopharynx:
Radiation Therapy Components:
4. Volume: Oral Tongue and Floor of
Mouth:
• The best obtained is parallel opposed.
• Supplementations.
• IMRT.
• High Energy photon beams: 6-10 MV.
• Electron Beam: Energy according to desired depth as a
supplementation or sometimes for re-irradiation.
• Others.
Radiation Therapy Components:
5-6: Portal Arrangement & Energies:
Radiation Therapy Components:
7. Dose & Fractionation:
Radiation Therapy Components:
7. Dose & Fractionation:
Radiation Therapy Components:
8. Plan Acceptance:
Radiation Therapy Components:
9. Adding Systemic Therapy:
Seminars in Oncology, Vol 41, No 6, December 2014, pp 798-806
MACH-NC: 2009 Update:
93 Trials – 17346 Patients:
J.-P. Pignon et al. / Radiotherapy and Oncology 92 (2009) 4–14
CISPLATIN 100 mg/m2 (D1+22+43) +
RTH
• Early Reactions.
• Late Reactions.
• Follow up Strategy.
Radiation Therapy Components:
10. Management of Anticipated Complications:
Thank You