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Dr. S. C. JoshiSenior Consultant Oncologist and RadiotherapistD/L : +91 1294253115Mobile Phone : +919650099151, +919711558463Email: sanjeev.joshi@aimsindia.co.inscjoshi71@gmail.comHead and Neck Cancers Management

Head and Neck Cancers Management Dr. S. C. JoshiSenior Consultant Oncologist and RadiotherapistD/L : +91 1294253115Mobile Phone : +919650099151, +919711558463Email: sanjeev.joshi@aimsindia.co.inscjoshi71@gmail.com

Epidemiology

Head and neck cancers constitute 5% of all cancers worldwide10th most common cancer in the worldWorld annual incidence:643,000 new cases Mortality of about 350,000 casesMC in India15.4 to 110.6 per 100,000 males 2 to 51.2 per 100,000 females

By: Dr.S.C.JoshiRisk Factors

SmokingTobacco (Masala, kaini and others)Viruses - Epstein-Barr Virus, HPV (16, 18)Environmental/occupational Exposures of Asbestos, Chromium, Nickel, Arsenic, FormaldehydeSalted FishIonizing RadiationGenetic ImmunodeficiencyPoor oral hygieneAlcoholBetet nut

By: Dr.S.C.JoshiDisease Sites of the Head and Neck

Head and neck cancer may occur in diverse structures and sites:Lip Oral cavityTonguePharynx LarynxNasal cavitySinuses By: Dr.S.C.JoshiNasal CavityNasopharynxOral CavityOropharynxLarynxHypopharynx

Mostly Arise in The Nasopharyngeal Axis

By: Dr.S.C.Joshi

Head and Neck Cancer Often Spreads to Regional Lymph NodesLymph node involvement in up to 30%-50%. By: Dr.S.C.Joshi> 75 % present with advanced disease in developing countries due to the lack of awareness, early intervention and treatment facilities By: Dr.S.C.JoshiDiagnosis

70%- 80% are diagnosed having locally advanced disease (Stage III and IV)In the more advanced tumors (stage III and IV)Local recurrence up to 50%Distant metastatic spread (approximately 10%-30%)

By: Dr.S.C.Joshi9Diagnosis

History General physical examination & Local ex Oral cavityOropharynx (palpation is very important)Nasopharynx (mirror examination) Laryngopharynx (indirect laryngoscopy)Examination of the neck for lymph nodes Direct laryngoscopy Biopsy of any suspected areas

By: Dr.S.C.JoshiLaboratory Studies

Routine blood counts. Blood chemistry profile Urinalysis Chest radiographs, Plain radiographs of mandible (Panorex view)CT Scan / MRI / PET CT By: Dr.S.C.JoshiSurgeryRadiotherapyChemotherapyNo substantial change in survival in 25 yrs.AimsHighest Loco- regional control Anatomical and functional organ preservationTreatment PrinciplesEarly StageSingle modality treatment usingSurgery or RadiotherapyLate StageSurgery + RadiotherapyConcurrent Chemoradiotherapy

Management Guidelines for H & N Cancers By: Dr.S.C.JoshiManagement Guidelines for H & N Cancers When different modalities available, one with maximum chance of cure should be used

When different modalities have same results, one offering better quality of life, with organ, function preservation and good cosmetic results should be used

By: Dr.S.C.JoshiSurgery v/s Radiotherapy

In treatment of head and neck cancers surgery and radiotherapy produce equivalent results in early stages of carcinomaIn advanced stages of head and neck cancers surgery combined with pre or postoperative radiotherapy

By: Dr.S.C.JoshiImproving Efficacy of Treatment

Chemotherapy RadiotherapyDose escalation schedules Altered Fractionation SchemesBiological Therapy And Molecular TargetingContinuous review during treatment

By: Dr.S.C.JoshiAbsolute benefit of Chemotherapy > 30% at 5 yearsHigher For Platinum Based Regimens.Higher doses up to 70 Gy are related with better Loco regional control, however with enhanced acute and long term complications

Chemotherapy

By: Dr.S.C.Joshi

Radiation Therapy

Ionizing RadiationHigh energy electromagnetic waves in the form of X-rays or gamma-raysExternal beam radiation Utilizes LA to generate X-rays to kill cancer cellsBrachytherapy utilizes radioactive substances implanted into tumors.By: Dr.S.C.JoshiX-ray photons interact with matter, knocking electrons from the orbital's of atomsThese high energy electrons can either directly damage DNA chemical bonds, or interact with water molecules forming free radicals that then cause DNA damageDamage to DNA may result in single or double strand breaks which can cause cell deathDNA repair enzymes are more readily activated in healthy cells than in cancer cells

How Radiation Works

By: Dr.S.C.Joshi

Clinical motivation for high-precision techniquesMore conformality = Better sparing

The Changing Paradigm

Conformal radiation

IMRT/IGRT/Rapid arc

By: Dr.S.C.Joshi

Standard Radiation Techniques (old)

Conventional external beam radiation usually consists of two opposed lateral fields and a matched anterior field that encompass the cancer and lymph nodes in the neck.Treatment is delivered daily for about 7 weeks.When this technique developed, physicians used regular X-rays or fluoroscopy to setup these fields.

By: Dr.S.C.JoshiWith the advent of CT guided planning, a new era in RTP has emerged.We are now better able to customize our treatment plans to fit the individual patient anatomy

CT Based Radiation Planning

By: Dr.S.C.JoshiIMRT Intensity Modulated Radiation TherapyIn this intensity of the radiation beam in a given treatment field is varied via multiple multi leaf blocking arrangements called segments

Intensity modulation combined with multiple fields (radiation beam angles) or arcs allows for conformal radiotherapy (ie high radiation iso dose lines conform to the target volume and spare normal tissues).

By: Dr.S.C.JoshiIntensity Modulated Radiation Therapy (IMRT)IMRT is an advanced form of 3D-CRT technique in which a computer aided optimisation process is used to determine customised non-uniform intensity distribution through inverse planning to attain certain specified dosimetric and clinical objectives

By: Dr.S.C.JoshiMultiple beam angles or arcsMulti-leaf collimatorAccurate patient positioning and immobilizationPhysics quality assurance measuresWell trained radiation therapy staff

Intensity Modulated Radiation Therapy (IMRT)By: Dr.S.C.Joshi

Multi-leaf Collimator

The multi-leaf collimator is inside the linear accelerator. It is comprised of multiple 1 cm thick metal radiation blocks each driven by an independent motor and controlled by a central computer. The multi-leaf collimator allows for multiple blocking patterns in each radiation field which in turn allows for intensity modulation of the radiation dose.

By: Dr.S.C.Joshi

Immobilization

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3 Clamp4 Clamp5 Clamp

Random Errors with different Fixation devicesRadiotherapy Oncology,2001Head and Neck Immobilization Devices

28By: Dr.S.C.JoshiTime Interval

Importance of the time interval between surgery and postoperative RT in the combined management of head and neck cancers

PORT within 6-7 weeks / laterLRC : 70% (PORT within 7 weeks) >27% (PORT more than 7 weeks)

Therefore patient must be seen by oncologist immediately after surgery and HPE report.

Bhadrasain V,IJROBP,1979By: Dr.S.C.Joshi

Isodose Distribution of an IMRT Plan

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IMRT - Hypopharynx

By: Dr.S.C.JoshiDaily X-rays or CT scansAre done and overlaidwith the planning CTMillimeter adjustments are made with automatic couch position shiftsTreatment becomes more accurate and consequently smaller target volumes will result in less side effects

IGRT Image Guided Radiation Therapy

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IGRT MV X-rays

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IGRT kV X-rays

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IGRT Cone Beam CT (CBCT)

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IGRT - CBCT

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Rapid arc cases

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Rapid arc cases

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Rapid arc cases

In Developing World

Infectious diseases are the main killersPatients present in an advanced stageFund allocation to health is less than that of developed countriesNo or poor social health security systemGeographic clustering of facilities to urban areasLinear accelerators are expensive, with high operational costs.High precision facilities available in only selected centers.

By: Dr.S.C.JoshiHow to Optimize Treatment for Developing Countries?Optimization of Treatment

Prompt treatment in a good referral centreOptimal Infrastructure support required for implementation of CTRT/AFRT schedulesAvoidance of Treatment BreaksIntegration of Chemotherapy Integration of high-precision techniqueGood Nutritional Support.Affordable cost

By: Dr.S.C.JoshiOur Oncology Facilities

Linear accelerator from Varian trilogy with rapid arcBrachytherapy ChemotherapyDaycare facilities for out patients and isolation wards Complete nuclear medicine with Radionuclide TherapyPalliative care Cancer screening Cancer awareness programBy: Dr.S.C.JoshiRadiotherapy Team

Consultant Oncologist

Medical Physicist

Radiation Therapist

Radiation Therapist AideBy: Dr.S.C.Joshi

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Linac RoomBy: Dr.S.C.Joshi

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By: Dr.S.C.JoshiHead and neck cancer is a serious illness that affects thousands of Indians each yearSmoking cessation and tobacco chewing is critical in the prevention of the diseaseMultimodality treatment interventions have a proven track record against the disease, but come with significant morbidityTargeted chemotherapy regimens are being developed to reduce side effectsIMRT/IGRT and rapid arc have also significantly reduced the incidence of side effects from treatment.

Summary

By: Dr.S.C.JoshiThank You For Your Kind AttentionDr. Sanjeev Chandra Joshiscjoshi71@gmail.com