Cancerele ORL
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![Page 1: Cancerele ORL](https://reader036.fdocuments.us/reader036/viewer/2022081420/56812a42550346895d8d6903/html5/thumbnails/1.jpg)
Cancerele ORL
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Localizari principale
• Cavitatea nasala si sinusurile fetei• Rinofaringele (nasofaringele)• Cavitatea bucala• Orofaringele • Laringele• Hipofaringele (laringo-faringele)
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Anatomia si histologia nasofaringelui (NF)
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Anatomie
• NF=spatiu cuboidal• Baza craniului->palatul moale• Anterior comunica cu cavitatile nasale prin coane si
imferior se continua cu orofaringele
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Epidemiologie• <1/100 000 in Europa si America• >20/100 000 (la rasa asiatica) din Asia de Sud-
Est
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Epidemiologia tumorilor cauzate de EBV
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Epidemiologie• In populatiile “low-risk” se observa o distributie
bimodala: la 15-25 ani si la 50-59 ani. • La populatiile “high-risk” incidenta creste dupa 30 de
ani, este maxima la 40-60 si descreste apoi treptat • Aceasta distributie este similara la amandoua sexe.• B/F=3/1• Indivizii din populatiile high-risk daca se muta in alte
zone, riscul scade progresiv la generatiile urmatoare, dar ramane mai mare (persistenta infectiei cu EBV sau predispozitie genetica)
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Histologie
• Populatiile high-risk: carcinom epidermoid necheratinizant (cauza: EBV)
• Populatiile low-risk: carcinom epidermoid necheratinizant, cheratinizant si carcinomul nediferentiat
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Etiologia cancerului de rinofaringe
I. Factori de mediu-virusul Ebstein-Barr (EBV)-in mai mica masura: HPV-carcinogeni chimici: nitrosamine volatile (in
special din pestele sarat-afumat, fumul de tigara, praf (tamplari), fum, chimicale
-radioterapie craniana
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Etiologia cancerului de rinofaringe
II. Factori genetici-asociere cu unele variante HLA-variante cu functionaliate redusa a enzimelor de
detoxifiere CYP2E1 (care metabolizeaza nitrosoaminele)
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Cai de extensie
• Locala• Limfatica• Hematogena
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Extensia localaANTE: Cavitatea nasalaLAT: spatiu parafaringeal, sinusurile maxilare, spatiul infratemporalSUP: sin. sfenoidale, baza craniuluiinclusiv sinusurile cavernoase
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Extensia locala
INF: orofaringe -> hipofaringe
POST: baza craniului, meninge, emisfere cerebrale, cerebel
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Extensia limfatica-70% din pacienti prezinta metastaze
ganglionare la diagnostic
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Clasificarea ganglionilor regiunii cervicale si cefalice
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Simptomatologia• Hemoptizie• Obstructie nasala• Otita medie seroasa (prin obstrutia canalului
Eustachio)=otalgie• Pareza de nervi cranieni (cel mai frecvent VI)
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Diagnosticul• Examen ORL• Biopsie• CT/RMN/PET-CT cap si gat• Radioscopie toracica• Ecografie hepatica
• In caz de metastaze ganglionare cervicale cu punct de plecare neprecizat:
a) endoscopie tripla: faringo-laringoscopie, bronhoscopie, endoscopie digestiva superioara
b)PET-CT
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Tratamentul cancerului de NF (1)
• T1 (tumora limitata la NF sau maxim invazie la nivelul cavitatilor nasale sau orofaringelui)
=>RT (singura) la nivelul NF (66-70 Gy) si la nivelul ganglionilor (44-64 Gy)
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Tratamentul cancerului de NF (2)
• T1 + N1-3 sau T2-4 +N0-3=>radiochimioterapie concomitenta[-RT la nivelul NF (66-70 Gy) si la nivelul
ganglionilor (44-64 Gy)-chimioterapie cu cisplatin]Optional: supraimpresiune prin brahiterapie la
nivelul rinofaringelui
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Tratamentul cancerului de NF (3)
• M1=>chimioterapie-daca raspuns complet clinic la nivelul
metastazelor-> radiochimioterapie concomitenta cu scop curativ
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Tehnici de radioterapieIn ordinea crescatoare a preferintei:• 2D-RT (radioterapie bidimensionala, clasica)• 3D-RT (radioterapie conformationala)-mai
buna incadrare tumorala si limitarea dozei la tesuturile normale decat 2D-RT
• IMRT (radioterapie cu intensitate modulata) –o si mai buna protectie a tesuturilor normale decat 3D-RT si prin aceasta, uneori, o incadrare mai buna a tumorii
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RT-2D in cancerul de RF• 2 campuri laterale• 1 camp anterior
Ortovoltaj-abandonat
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RT-3D in cancerul de RF
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IMRT
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• A dosimetry comparison between (a) a 3-beam conventional 2D treatment, (b) a 6-beam conventional 3D conformal RT treatment, and (c) a 7-beam IMRT treatment. The PTV is represented by the solid red line. The 100% and 70% of the prescription dose are shown by the green and red colour-washed areas. A better dose conformity to the PTV can be achieved in the IMRT treatment.
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Conturajul ganglionilor
• Sistemul Rotterdam si Brussel
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Brachiterapia in cancerul de rinofaringe
• Aplicatorul Rotterdam
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Carcinoame epidermoide chreatinizante ORL
• Cavitatea bucala• Orofaringele • Laringele• Hipofaringele (laringo-faringele)
![Page 31: Cancerele ORL](https://reader036.fdocuments.us/reader036/viewer/2022081420/56812a42550346895d8d6903/html5/thumbnails/31.jpg)
Etiologie
I. Factori de mediu-fumatul-mestecatul de tutun-HPV-iritatie mecanica cronica (dantura)
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Etiologie
II. Factori genetici-identificabili doar in 10% din cazuri-rudele de grad 1. a pacientilor cu cancere ORL
au un risc de 2-4x mai mare
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Carcinomul de cavitate bucala
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Carcinomul de orofaringe
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Tratament• T1-2 (tumora mai mica de 4 cm) + N1-2Optiuni:a) RT exclusiva-tumora restanta=> chirurgie de salvareb) Rezectie tumorala +/- limfadenectomie
cervicala uni- sau bilaterala+/- radioterapie adjuvanta
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Tratament• T3-4a (tumora mai mare de 4 cm cu invazia
altor organe) +/- N1-3Optiuni:a) RCT exclusiva-de preferat-tumora restanta=> chirurgie de salvareb) Rezectie tumorala + limfadenectomie cervicala uni- sau
bilaterala+/- radioterapie adjuvanta
![Page 37: Cancerele ORL](https://reader036.fdocuments.us/reader036/viewer/2022081420/56812a42550346895d8d6903/html5/thumbnails/37.jpg)
Carcinomul de laringe
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Carcinom laringian-tratament
• Carcinom in situa)Rezectie endoscopicab)RT
• T1-2a)Laringectomie partialab)RT
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Carcinom laringian-tratament• T3, N0-2a) Radiochimioterapie concomitentab) Laringectomie totala plus limfadenectomie
• T4a (invazia cartilajului tiroid)a) De preferat Laringectomie totala plus limfadenectomie +/-
RCTb) RCT la pacientii, care refuza laringetomie
• T4b (invazia spatiului paravertebral, inglobarea art. carotide, invazie mediastinala)
-RCT concomitenta
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Carcinomul de hipofaringe
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Tratament• T1, N0Optiuni:a) RT exclusiva-tumora restanta=> chirurgie de salvareb) Hemi-faringo-laringectomie plus
limfadenectomie
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Tratament• T2-3, N0-N2Optiuni:a) RCT exclusiva-tumora restanta=> chirurgie de salvareb) Faringo-laringectomie (sau hemi-… in T2N0)
plus limfadenectomie +/- RCT• T4aa)De preferat faringo-laringectomie plus
limfadenectomie +/- RCTb)RCT exclusiva