management of head & neck malignancies

Management Of Head & Neck Malignancies

Dr Akhilesh MishraSenior Resident

Radiation OncologyInstitute Rotary Cancer Hospital

AIIMSNew Delhi

UICC (2006) Stage Grouping For Head & Neck CancersExcept Thyroid & Nasopharynx

N0 N1 N2 N3

T is Stage 0 Stage III Stage IV A Stage IV B

T1 Stage I

T2 Stage II

T3 Stage III Stage IV A Stage IV B

T4a Stage IV A Stage IV A Stage IV B

T4b Stage IV B Stage IV B

Stage IV C : Any T , Any N , M1

Goals Of Treatment•Stage I-IV A : Curative•Stage IV B,C : Palliative

Fundamental Modalities

•Radiation•Surgery•Chemo

Head & Neck Cancer Management: Overview

• Overall, in Head & Neck Cancers, Radiation Therapy (RT) is used as a single modality treatment in Stg I & II disease.

• In Stg I & II disease, RT & Surgery have Equal results.

• Resectable Stg III & IV cancers are usually treated with Surgery+ Post-Op.-RT ; with CTRT as an alternative to Surgery+ Post-Op.-RT in selected sites & patients.

Radiation Modalities

• Conventional: Cobalt Or Linear Accelerator.• Brachy -Therapy.• 3DCRT : Three Dimensional Conformal

Radiotherapy – The process by which external beams of radiation are designed and used to selectively and exclusively irradiate only tumour bearing sites.

A Typical Linear-Accelerator (Linac) Set Up

High Dose Rate Brachy-Therapy Unit: “Gammamed-i”

Brachy Therapy for Neck Node

Radiation Modalities

• IMRT : Intensity Modulated Radio Therapy –It is the integration of disciplined 3D target volume & organ at risk volume definition, computerised optimisation of dose distributions allowing treatment fields with various modulated intensities, computer controlled delivery of the optimised plan and the radiologic verification of patient positioning through out the duration of the treatment.

IMRT: Rt. Maxillary Sinus

3D View: Dose Distribution , IMRT

Organs At Risk: Parotids & Spinal Cord ; IMRT

Isodose Curves, IMRT

Radiation Modalities

• IGRT : Image Guided Radio Therapy – It involves targeting gross as well as microscopic disease accurately, to individualise treatments to reduce margins and to allow radiation dose escalation to higher levels with the expectation of improving local control and reducing toxicity.

Dose Distribution: IGRT

Other Radiation Modalities

• Stereo Tactic Radio Therapy / Surgery (SRT / SRS).

• Cyber Knife• X Knife• Tomotherapy• Rapid Arc: A form of IGRT • Gamma Knife

Rapid Arc

Tomotherapy: Schematic

Cyber Knife

Neck Nodes :Anatomical Distribution

Neck Nodes : Levels

Nasopharynx & Oropharynx

Ca. Nasopharynx• Nasopharyngeal Carcinomas are relatively

radiosensitive as well as chemosensitive tumours.

• Radiation Therapy: the mainstay of treatment.• CTRT improves disease free survival compared

to RT alone in advanced Ca. Npx.• Addition of CT to RT improves overall survival

too in Ca. Npx.

Oropharyngeal Cancers• T/t of Oropharyngeal Ca. is aimed at

maximising cure with minimal functional morbidity.

• Radical Radiation Therapy is the treatment of choice in early T1,2 tumours .

• ChemoRadioTherapy (CTRT) is the treatment of choice in advanced T3,4 tumours.

Oropharyngeal Cancers• Surgery is preferred in select early cases

where its associated with reasonable functional outcome.

• Surgery is also preferred with post-op. RT in select advance cases eg. Infiltrative lesions of BoT, tonsil & lesions involving the mandible.

• Surgery is used as a salvage procedure for residual neck nodes following CTRT.

Anatomy Of Larynx, Coronal View

T1 / T2 Glottic Carcinoma• Cure rates are similar in early glottic

cancers with Radiation Therapy and surgical modalities like transoral laser Surgery and open partial laryngectomy.

• There is no conclusive evidence in favour of any particular modality and T/t is based on patient& physician preference.

Advanced Laryngeal Cancers Chemo-Radiotherapy is considered

the standard of care for small volume stage III & IV laryngeal and hypopharyngeal cancers.

Organ preservation now seems a reality.

Anatomy Of Hypopharynx

Larynx Preservation in Pyriform Sinus Cancers.

• Surgery & RT as a single modality have similar results in stg I & II disease.

• However RT is preferred over Surgery due to its low morbidity as well as voice preservation.

• In stg III & IV disease, Surgery+ post-op.-RT as well as CTRT have shown equal results regarding survival.

• Due to higher chance of laryngeal preservation, CTRT should be offered to patients with low volume disease & good follow up.

Post- Cricoid & Posterior Pharyngeal Wall

• T1-2 N0-1 : Radical RT• T3-4 Any N: (I)- Small Volume Disease : (a) Concurrent CTRT (b) Radical RT + Salvage Surgery(Poor Performance Status).• T3-4 Any N: Large Volume Disease : Total Laryngo-

pharyngo-esophagectomy with gastric pull up or free jejunal flap and Adj. RT.

• Surgery is treatment of choice in: Large Volume Disease / Cartilage Erosion /

Bulky Nodes / Extensive Soft Tissue Involvement.

Anatomy Of The Para Nasal Sinuses

Nasal Cavity & Ethmoid Sinus• T1,T2: (I)- Surgery +/- Adjuvant Radiotherapy; (II) Radical RT if surgical resection is morbid.• T3,T4a : Surgery + Adjuvant RT• T4b : (I)-Palliative RT or CT. Concurrent RT-CT may be

considered in good performance status.

(II)-Resection in very select group with favourable histology with low biologically aggressive tumours eg. Adenoid Cystic Ca. & BCC.

T/t Neck: N0= Observe , N+=Appropriate Neck Dissection and Post Operative RT to B/L Neck.

Maxillary Sinus• T1,T2 : (I)- Surgery+/- Adjuvant RT. (II)- RT, if margins positive or Peri-neural inv. • T3: Surgery + Adjuvant RT.• T4a : (I)- Combined Craniofacial Resection + Adj. RT. (II)- CT=RT in unresectable tumours• T4b : (I) - Palliative RT or CT; Concurrent CTRT in patients

with good performance status. (II)- Resection in very select group with favourable

histology with low biologically aggressive tumours eg. Adenoid Cystic Ca. & BCC.

T/t Neck: N0= Observe; N+ = Appropriate Neck Dissection and Post Operative RT to B/L Neck.

Oral Mucositis

Radiation / Chemo Induced Oral Mucositis

• Common but Transient adverse effect of RT / CT / CTRT.

• Awareness and knowledge Important.• Radiation therapy must not be discontinued just

because of it.• Only a Radiation Oncologist can decide whether

to stop Radiation therapy owing to oral mucositis.

• Simple care and easy treatment.

National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE) version 3.0

Oral mucositis (clinical exam)• Grade 1 = Erythema of the mucosa• Grade 2 = Patchy ulcerations or pseudomembranes• Grade 3 = Confluent ulcerations or pseudomembranes; bleeding with minor trauma• Grade 4 = Tissue necrosis; significant spontaneous bleeding; life-threatening consequences• Grade 5 = Death

National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE) version 3.0

Oral mucositis (functional/symptomatic)• Grade 1 = Minimal symptoms, normal diet• Grade 2 = Symptomatic but can eat and swallow

modified diet• Grade 3 = Symptomatic and unable to

adequately aliment or hydrate orally• Grade 4 = Symptoms associated with life-

threatening consequences• Grade 5 = Death

World Health Organization (WHO) scale for oral mucositis

• Grade 0 = No oral mucositis• Grade 1 = Erythema and Soreness• Grade 2 = Ulcers, able to eat solids• Grade 3 = Ulcers, requires liquid diet (due to

mucositis)• Grade 4 = Ulcers, alimentation not possible

(due to mucositis)

Managing Radiation/Chemo induced Oral Mucositis.

1. Pain control : Ice chips, Saline, Protective coating- Sucralfate, Local anaesthetic - Lignocaine viscous, 2. Nutritional Support : Soft/Liquid diet, NG-tube, Total Parenteral

Nutrition(TPN), Open Gastrostomy, Percutaneous Endoscopic Gastrostomy (PEG).

Managing Radiation/Chemo induced Oral Mucositis.

3. Oral Decontamination: • brushing with a soft toothbrush, flossing and the use of

non-medicated rinses (e.g. saline or sodium bicarbonate rinses) Nystatin rinse has not been found to be effective

• systemic fluconazole vs. no treatment significantly and dramatically reduced both candidal carriage and incidence of severe mucositis induced by radiation therapy (15% vs. 45%) in patients with head and neck cancer.

• acyclovir and valacycovir have a well-established role in prophylaxis and treatment of lesions caused by HSV in this patient population

Managing Radiation/Chemo induced Oral Mucositis.

4.Palliation of dry mouth:• Sip water as needed to alleviate mouth dryness.

Several supportive products including artificial saliva are available.

• Rinse with a solution of 1/2 tsp baking soda (and/or ¼ or ½ teaspoon of table salt) in 1 cup warm water several times a day to clean and lubricate the oral tissues and to buffer the oral environment

• Chew sugarless gum to stimulate salivary flow.• Use cholinergic agents as necessary

Managing Radiation/Chemo induced Oral Mucositis.

5. Management of bleeding: Local intraoral bleeding can usually be

controlled with the use of topical haemostatic agents such as fibrin glue or gelatin sponge.

Platelet count may fall because of Chemotherapy causing spontaneous bleeding from oral ulcers and platelet counts below 20000/Ml require urgent platelet transfusion .

Managing Radiation/Chemo induced Oral Mucositis.

6. Therapeutic Interventions:• Antioxidants: Topical N-Acetyl Cysteine, Systemic Amifostine. Anti Inflammatory: Benzydamine Hydrochloride Mouthrinse, Oral suspension of L-glutamine (Ph III Trials)• Cryotherapy & Low Level Laser Therapy (Ph II Trials) : may

reduce levels of pro oxidative agents & pro inflammatory cytokines.

• Growth factors (Ph II Trials) : recombinant human keratinocyte growth factor-1,2

Per- Cutaneous Endoscopic Gastrostomy

• PEG is done under light sedation & local anaesthesia.

• Patients can go home same day or next day.

• Feeding is started after 24 hrs of procedure.

Per- Cutaneous Endoscopic Gastrostomy

Indication• PEG is indicated in

patients having an intact function gastro-intestinal tract but are unable to consume sufficient calories to meet metabolic demands.

• Cancers of head & neck are an important set of such patients

Schematic diagram

P E GOut Patient Procedure• Local anesthesia (usually lignocaine

or another spray) is used to anesthetize the throat.

• An endoscope (a flexible tube with a camera and a light on the end) is passed through the mouth, throat and esophagus into the stomach.

• The physician then makes a small incision (cut) in the skin of the abdomen over the stomach and pushes a needle through the skin and into the stomach.

• The tube for feeding then is pushed through the needle and into the stomach. The tube then is sutured (tied) in place to the skin.

PEG Set

A New Dawn……

THANKS!