Management of oropharyngeal tumors
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Transcript of Management of oropharyngeal tumors
BY Dr DEEPAK KUMAR DAS
MOD- Dr AMIT BAHL
PGIMER, CHANDIGARH
ANATOMY
Posterior continuation of oral cavity
which communicates with nasopharynx
above and laryngopharynx below
Extends from plane of hard palate
superiorly to plane of hyoid bone
inferiorly
Subdivided into palatine (faucial
arch) and oropharynx proper
Lateral walls of oropharynx
limited posteriorly by tonsillar
fossa & post tonsillar pillar
With in oropharynx 4 main sites
– soft palate , tonsillar region ,
BOT , post & lateral pharyngeal
wall
EPIDEMIOLOGY Most common site: Tonsil and ant. Tonsillar pillar
M: F- 4: 1
Oropharyngeal cancers account for approximately 10% of annual worldwide incidence of head and neck squamous cell carcinoma.
Relative proportion of pharyngeal cancer
Male FemaleTonsil 37% 33.3%
Other 27.7% 16.1%
Oropharynx
AGE GROUP
MALE FEMALE
0-14 YEAR 0.2% 0
15-34 1.4% 4.6%
35-64 69.3% 72.4%
65 AND ABOVE 29.1% 23%
HBCR, RCC, PGIMER, A 3 YEAR CONSOLIDATED REPORT
Stage at diagnosis: PGIMER
STAGE I 1.7%
STAGE II 10.7%
STAGE III 21.8%
STAGE IV 63.6%
ETIOLOGY 80-90%: Due to tobacco exposure
:Cigarette smoking, cigar and pipe smoking, smokeless tobacco
Alcohol: synetrgistic with alcohol
Viral: HPV usually types 16 and 18
HPV
Double standard DNA virus with >120 strains.
HPV types 6, 11, 16 and 18 are high risk.
HPV 16 is the most common HPV type identified in human tumors.
Etiology cont...HPV 16
>90% of all HPV related oropharyngeal cancers
Confers 14 fold increase in risk for oropharyngealcancer
HPV genome encodes three oncoproteins E5, E6 and E7 in addition to the regulatory genes E1 and E2 as well as capsid proteins L1 and L2.
CRITICAL STEPS OF HPV INDUCED CARCINOGENESIS
PATHOLOGY• Almost exclusively squamous cell carcinoma(95%)
60%- mod diff.
20%- well diff
20%- poorly diff
Variants;
Spindle cell- resembles sacoma
Basaloid- aggressive behaviour and poor clinical outcome
• Lymphoma-10 to 15% tonsil
- 1 to 2% BOT
Pathology cont........• Malignant melanoma
• Lymphoepithelioma
• Minor salivary gland tumors
• Sarcomas
• Plasmacytomas
ROUTES OF SPREAD
Primary routes of spread- direct extension and lymphatic spread
Hematogenous- less common
Submucosal extension- visualised as erythematous regions without distinct borders or ulceration
Lymphatic spread of oropharyngeal tumors
The typical order of metastatic progression is systemic:
Upper jugular chain(level I/II: first echelon)
Mid cervical( level III)
Lower cervical nodes( level IV)
Skip metastasis are rare(0.3%) and level I or V involvement is usually associated with involvement of other nodes.
Most common location of LN metastasis from oropharyngeal cancer is ipsilaterallevel II
Percentage incidence of clinical LN mets and stage
TONSILLARFOSSA
BOT SOFT PALATE
OROPHARY-NGEAL WALL
T1 <10% 70% 10-20% 25%
T2 30% 75% 35% 30%
T3& T4 65-70% 75-85% 60-65% 65-75%
LOCAL SPREADCA TONSIL
Initial lesions
-Tend to be exophytic with central ulceration with infiltratative margins
- some develop submucosally neck nodes with no obvious tonsillar lesion
Advanced lesion
- Penetrate to parapharyngeal space skull base
- May involve mandible, nasopharynx and pyriformsinus
SOFT PALATE
Earliest tumor- red lesion with ill defined border
Spread occurs first to tonsillar pillar and hard palate
Lateral spread may penetrate superior constrictor muscle and skull base and may rarely extend to cranian nerves in parapharyngeal space
Involvement of lateral wall of nasopharynx in advanced cases
BOT Usually remains in tongue unless it begins at
peripheral margin
May invade glossotonsillar sulcus and eventually escape to neck
Advanced lesions- spread to larynx, oral tongue and parapharyngeal space
VALLECULAPosteriorly- to lingual surface of epiglottis
Laterally- to lateral pharyngeal wall and anterior wall PFS along pharyngoepiglotticfold
Inferiorly- to pre-epiglottic space via thin hyoepiglottic ligament
CLINICAL PRESENTATION• Most common symptom- pain either local or reffered,
local pain usually described as sore throat.
• Reffered pain: By cranial nerve IX and X
• CN IX involvement referred pain via tympanic nerve of Jacobson localised to inner ear or temperomandibularjoint
• CN X involvement referred pain through auricular nerve of Arnold to external auditory canal
• Asymptomati mass within upper neck
• Odynophagea
Cont........• Dysphagea
• Dysarthria- hot potato voice caused by CN XII involvement or narrowing of pharyngeal air lumen
• Trismus- involvement of pterygoid
• Deep ulceration and necrosis
DIAGNOSTIC WORK UPHistory
General physical examination
LN Examination
Neck should be turned to the side examined to relax sternocleidomastoid muscle
Level, No. ,size, character, skin involvement
INSPECTION
should be done under proper illumination and should be systematic and reproducible
Indirect mirror examination
Allows optimal inspection of BOT, tonsil, vallecula as well as documenting spread to laryngeal and pharyngeal subsites
Cont.......Fibreoptic examination
more informative than IL
Palpation
Palpation of tonsillar fossa and BOT should be performed because these location can harbour occult primary tumors and should be performed at the completion of examination owing to its propensity to trigger gag reflex
Direct laryngoscopy
useful to evaluate large tonsillar or BOT lesions
CONT............
Pan endoscopybecause of risk of second
primaries in upper digestive tractBiopsy of tumor and any
suspicious areasFNAC of LNs
LABOROTORY STUDIES Complete blood count
Radiographic studies• Chest X-ray• Plain radiograph of neck or
mandible• CECT( BOS TO T4)• MRI• PET
RADIOGRAGHIC STUDIES
CECT BOS TO T4 Extent of primary tumor Evaluation of LN status Evaluating involvement of
mandible or base of skull Extracapsular extension- with
irregular nodal margin without clear distinction with surrounding fat or when there is thickening of surrounding fibroadipose tissue or muscle
Subcapsular spread is often difficult to characterise with CT
CONT..........
MRI Superior to CT in specific
situations including delineating orbital or skull base involvement and defining intracranial perineural tumor spread
Better able to identify subtle soft tissue involvement by tumor, deep osseous invasion and marrow replacement
Perineural spread of the disease Extent of anterior spread of BOT
tumors
CONT....... PET
Sensitivity-100%
Specificity-60% for pathologically proven tumour
Ability to detect clinically and radiographicallyoccult pathologic cervical LAP which is useful for delineating radiotherapy volume
TNM staging system for oropharyngeal cancer
Endoscopic, radiographic and physical examination findings should be included while determining staging
PRIMARY TUMOR(T)
Tx: primary tumor cannot be assessed
T0: no evidence of primary tumour
Tis: carcinoma in situ
T1: tumour size 2cm or less
T2: Tumour size > 2 cm but < 4cm in greatest dimension
T3: Tumour >4 cm in greatest dimension
Staging cont.......T4a: Tumour invades larynx, deep/extrinsic muscle of
tongue, medial pterygoid, hard palate or mandible
T4b: Tumour invades lateral pterygoid muscle, pterygoid plate, lateral nasopharynx or skull base or encases carotid artery
REGIONAL LN
Nx: regional LN can not be assessed
N0: no regional LN mets
N1: metastasis in a single ipsilateral LN <3 cm in greatest dimension
Staging cont......N2: metastasis in a single ipsilateral LN> 3cm but not >
6cm in greatest dimension or in multiple ipsilateralLNs none >6 cm in greatest dimension or in bilateral or contralateral LNs , none >6cm in greatest dimension
N2a: metastasis in a single ipsilateral LN > 3cm but not > 6cm in greatest dimension
N2b: multiple ipsilateral LNs, none >6cm in greatest dimension
N2b: bilateral or contralateral LNs, none > 6cm in greatest dimension
N3: LN > 6cm in greatest dimension
Staging cont.......DISTANT METASTASIS
M0: no distant metastasis present
M1: distant metastasis present
Stage groupingStage 0- Tis N0 M0
Stage I- T1 N0 M0
Stage II- T2 N0 M0
Stage III- T3 N0 M0
T1-3 N1 M0
IVA- T4a N0-1 M0
T1-4a N2 M0
IVB- T4b any N M0
any T N3 M0
IVC- any T any N M1
AJCC sixth edition
T4a- resectable
T4b- unresectable
With the advancement of surgical techniques with free flap and other reconstructive options that allow previously unresectable primary lesion now to be resected .
AJCC seventh edition
T4a- moderately advanced local disease
T4b- very advanced local disease
TREATMENTOBJECTIVES
• Control of primary tumor and regional LNs
• Preservation of anatomy and function of the organ
• Minimal treatment sequelae
MODALITIES
Surgery
- for primary
- for neck disease
Radiotherapy
EBRT
- conventional
-3D CRT and IMRT
Brachytherapy
Chemotherapy
Combined modality
RADIOTHERAPY
Used as definitive treatment in both early as well as late stage
disease as
Cure rate high
Functional outcome better
Lesser morbidity
EBRT Prerequisite
For optimal treatment planning thorough review of
diagnostic films, endoscopic finding and description of the
examination under anaesthesia essential to determine
target volume
Preirradiation dental care hygiene - utmost imp
All patients to be regularly seen by dental or oral surgeons
for dental evaluation and fluoride treatment
Any potential surgical procedure and tooth extractions to be
performed before initiation of radiation therapy
Hard toothbrushes to be avoided
Artificial dentures to be avoided
Techniquesfield technique
Target Volume :
Primary tumor and its local and regional extension with
1cm or 2cm margins.
Nodal volume
Upper , middle and lower deep cervical and
retropharyngeal and parapharyngeal LNS treated
bilaterally in all cases
u
CONVENTIONAL
Two lateral parallel opposed field parallel opposed fields
Three field fieltechn
SIMULATION Supine position
Orfit cast for immobilization
Neck extended, shoulders pulled down to maximize exposure of
head & neck
Tongue to be displaced from the palate by an individually
constructed tongue bite block
Bite block – facilitate immobilization & ↓ amt of normal tissue in
field
Simulation cont........ Field margin :
Superior border
External land mark : zygomatic arch BOT- lower border of zygomatic
arch Tonsil and soft palate- upper border
of zygomatic arch
Anterior border :
Set up by clinical examination (inspection and palpation of buccalmucosa and BOT)
With atleast 2cm margin beyond any clinical evidence of disease
This margin should project 2-3 cmforward of the anterior cortex ofascending ramus ofmandible(depending on tumorextent)
Simulation cont......
Post border : to include post cervical l.n at tip of mastoid
Inferior border : extends to thyroid notch (for 3 field technique) or
above clavicle (for 2 lateral fields)
BOT
Upper border kept
from ala of nose to tragus
In simulator planning,
kept at lower border of
zygomatic arch
3 FIELD TECHNIQUE
Isocentrically opposed
lateral fields matched to a
lower anterior neck field
Primary tumor and both
sides of upper neck
irradiated through
opposing lateral field
Both sides of lower neck
is irradiated through a
single AP field with a
midline block at junction
to shield larynx and spinal
cord
MATCHING OF LATERAL AND ANTERIOR FIELD
Collimetrerotation
Beam energy
Optimal energy – CO60 ,4 or 6 MV photon
DOSE Standard daily dose – 200cGy/#
5 fractions a week
Dose to primary tumor & palpable lymph nodes range from 65-
74Gy in 6.5-7.5 wks depending on tumor stage
For elective irradiation of subclinical microscopic lymphatic mets
should be atleast 50Gy
After 40-45 Gy , spinal cord shielded along vertebral body
When indicated post cervical l.n boosted with 9 -12MeV electrons to
spare underlying spinal cord
For lateralised lesions of tonsil
RT given via a wedged pair with anterior and lateral fields
Used for T1-2 and N0-1 diseases
Incorporates primary site and ipsilateral neck
Upper neck treated in same portal as primary site
Lower neck treated with a single AP field with larynx & spinal cord
shielded at field junction
CT scan used to assist in treatment planning for lesions treated
unilaterally
CTV of ipsilateral t/t – primary lesion + I/L jugular vein +
retropharyngeal + supraclav l.ns
Attention given to outline C/L salivary gland
In T1N0 tumor of tonsil not necessary to treat post cervical chain &
mid lower l.n
Only ipsilateral subdigastric l.n included in field
Risk for C/L l.n mets low unless there is tongue invasion , invasion of
soft palate within 1cm of midline or extensive clinically +ve nodes in
ipsilat neck
ATTEMPTS TO IMPROVE THERAPEUTIC RATIO
Altered fractionation Hyper fractionation
Pure
Impure
Accelerated hyperfractionation
Pure
Hybrid
Concurrent chemoradiation
Radiosensitizer
HYPERFRACTIONATION Rationale – use of small dose # allows higher total doses to be
administered within tolerance of late responding tissues
Pure hyperfractionation – same total dose & overall t/t time but
treating twice per day
Impure hyperfractionation - ↑ in total dose & sometimes ↑ OTT & no.
of #
EORTC 22791Non base of tongue cancer patients
T2-3N0-1
arm A arm B
70 Gy(2 Gy/#) 80.5 Gy(1.15 Gy/#,
2#/day)
Locoreg-
Ional control 40% 59%
Trend towards increased overall survival in stage III patients
Accelerated treatment Shortening of overall treatment duration without a comparable
reduction in total dose
Aim – to minimize potential for tumor growth or regeneration
during therapy
Used in head & neck cancers because exhibit accelerate
repopulation
Pure accelerated t/t – same total dose in half overall time by
giving 2 or more #s/day
↑ acute effects
Impure – dose is reduced or rest period interposed in middle of
treatment
Accelerated treatment v/s hyperfractionation
Meta-analysis of radiotherapy in carcinoma of the head and neck(MARCH) collaborative group
Pooled 15 randomised studies
N= 6,515
%Oropharyngeal cancer= 44%
Compared conventionally fractionated radiotherapy to either accelerated radiotherapy or hyperfractionated radiotherapy
Altered fractionation radiotherapy regimens were associated with a 3.4% absolute improvement in 5 year overall survival
Hyperfractionated patients had an absolute 8.2% improvement in overaal survival at 5 yeatrs
2% absolute benefit with accelerated radiotherapy
Heterogeneity in patient inclusion obscure direct comparision between accelerated and hyperfractionated radiotherapy.
RTOG 90-03CONVENTIONAL FRACTIONATION( 70 Gy/ 35#)
Accelerated fractionation with split course(67.2 Gy, 1.6 Gy/#, 2#/ day with 2 week rest after 38.4 Gy)
Accelerated fractionation with concomitant boost( 72 Gy ,1.8Gy/# for 14# followedby 1.8 Gy in the morning and 1.5Gy afternoon boost to the gross disease)
DFS 31.7% 37.6% 39.3%
CONCOMITANT BOOST
Boost dose to a reduced volume given concomitantly with
treatment of initial large volume .
CBRT 54Gy / 30 # / 6 wks & boost dose of 1.5 Gy / # in 12 #
(18Gy) with Inter # interval of 6 hr in last 12#
large field gets 54 Gy & boost field 72 Gy in 6 wks time
In PGI CBRT 45Gy/25#/5wks(1.8Gy/#) , followed by boost of
22.5Gy/15#/3wks (1.5Gy/#)
Boost field gets 67.5Gy/5wks
N=216
Stage III-IVA oropharyngeal cancer
CRT( 66 Gy/33# with cisplatin 100 mg/m2, days 1, 22 and 43)
ART with CB( 67.5 Gy/40 #)
Compliance to RT Better
Grade ¾ mucositis 39% 55%
Grade 3 xerostomia 33% 18%
2 year DFS 56% 61%
Patients with nodal size >2 cm had better DFS with CRT
CONCLUSION- In selected cases of locally advanced oropharyngeal cancer, concomitant boost offers better compliance, toxicity profile and quality of life than chemoradiation.
SPLIT COURSE
Gap in between treatment
For pts with poor general condition, old age
Disadvantages: impaired tumor control due to gap & prolonged
T/T time (Repopulation)
In PGI 35Gy/15#/3wks followed by gap of 2 wks
25Gy/10#/2wks
Study Institution year No of patients
T1 T2 T3 T4 Overall
Perez Washington university 1959-91
154 76%
63%
59%
33% 56%
Jackson Vacouver centre, British columbia
1975-93
271 94%
79%
58%
56% 75%
Mende-nhall
University of Florida 1964-2003
503 88%
84%
78%
61% 79%
Batani Institute Curie 1958-83
465 90%
84%
64%
47% 64%
Wang Massachusetts generalhospital
1970-93
102 91%
91%
80%
ND ND
LOCAL CONTROL RATES FOR TREATMENT OF SQ. CELL CA OF TONSILLAR FOSSA
Study Institution year No. Of patients
T1 T2 T3 T4 overall
Mendenhall
University of florida
1964-2003
333 98% 92% 82% 53% 82%
Harrison MSKCC 1981-95 68 87% 93% 82% 89%
Wang MGH 1970-93 90 85% 85% 54% ND
LOCAL CONTROL RATE FOR TREATMENT OF SQ. CELL CA OF BOT
Local control rate with tumours of soft palate
study Institution year No of patients
T1 T2 T3 T4 Overall
Cheraet al
University of Florida
1963-2004
145 90% 90% 67%
57% 44%
LOCOREGIONAL ADVANCED OROPHARYNGEAL CANCER
Concurrent chemoradiation is the standard treatment and established by:
Meta-Analysis of Chemotherapy on Head and Neck Cancer( MACH-NC)
Published in 2000 and updated in in 2007 , 2009 and 2011
Includes 87 randomised trials
N= 16485
No of patients of oropharynx-5878
Result: 6.2% absolute improvement in overall survival at 5 years from the use of concurrent chemoradiotherapy compared to radiotherapy alone
Oropharynx- 8.1%
SEQUENTIAL CHEMORADIATION Administration of induction chemotherapy followed by concurrent
chemoradiation
Randomised trials comparing triplet( taxane, platin, 5 FU) v/s doublet( platin, 5 FU) induction chemotherapy followed by concurrent chemoradiation
Both Madrid trial and TAX 324 trial demonstrated that triplet therapy was associated with higher rates of complete response, improve-
ment in time to failure, PFS and OS compared with doublet therapy
To date there is no comparative data between sequential chemoradiationand concurrent chemoradiation
INDICATION OF POST OPERATIVE RADIATION
Close , inadequate or (+) margins
Larger lesions (T3-4)
Poorly differentiated lesions
Perineural spread
Lymphovascular invasion
Soft tissue extension
Desmoplastic stromal invasion
Multiple LNS involvement
ADJUVANT RADIATION OR CHEMORADIATION
Two trials: EORTC 22931 and RTOG 9501
EBRT: 60-66 Gy in 30- 33# concomitantly on days 1, 22 and 43 with cisplatin
RTOG 9501 EORTC 22931
SAMPLE SIZE 416 334
Oropharynx 43% 30%
Hypopharynx 10% 20%
Inclusion criteria Positive margin2 or more LN involvedExtracapsular extension
Positve margin, extra capsular extension, perineuralinvolvement, LVE, oral cavity or oropharyngeal tumours with involvement of level IV OR V
HIGH RISKPositive resection margin
6% 13%
Cont......Extracapsularextension
49% 41%
Both 4% 16%
Total 59% 70%
Outcome endpointCRT v/s RT
3 yr estimate 5 yr estimate
Locoregional recurrence 22% v/s 33% 18% v/s 31%
DFS 47% v/s 36% 47% v/s 36%
OS 56%v/s 47% 53 v/s 40%
Median follow up 45.9 month 60 month
Patients with involved resection margin and extracapsular spread of the disease appear to gain the most benefit from concurrent chemoradiation
BRACHYRHERAPY
Used in ca BOT, soft palate, tonsil
INDICATION Used as a boost after EBRT
Used alone in purely exophytic early tumors( T1 or T2)
Recurrent carcinoma
C/I Large tumour > 5 cm
Associated with bulky cervical nodes
Extends to RMT, nasopharynx, larynx, hypopharynx
Fixed to underlying structures or bone
Clinical target volumePalpable and visible tumor including extension visible on CT or MRI with a safety margin of
at least 1 cm
ABS RECOMMENDATION
The dose by EBRT ranges from 50-60 Gy depending on the stage of the disease and the dose of brachytherapy ranges from 16-30 Gy
HDR brachytherapy fraction size should not exceed 4.5 Gy
RESULTS
RESULTS
IMRTIncreased dose gradient between target volumes and
surrounding normal tissue
Decreased acute and late side effects
DISADVANTAGE
- Potential for marginal misses and local failure from overly restrictive radiation deposition in regions that received comprehensive radiation with conventional techniques.
Benefits from IMRT requires:
- Appropriate patient selection
- Accurate delineation of organ at risk and treatment volumes
- Meticulous quality control in radiation planning and delivery
- Limiting interfraction and intrafraction variability
Target Volumes
Cont.....
CTV 59.4
GTV
CTV 54
CTV 59.4GTV
CTV 59.4GTV
IMRT PLANNING AVOIDANCE STRUCTURES
HIGH PRIORITY COMPLICATION
SPINAL CORD TRANSVERSE MYELITIS
BRAIN STEM NEURAL DEFICIT
INTERMEDIATE PRIORITYPAROTID GLAND( contralateral)
XEROSTOMIA
ADD. STRUCTURES
ORAL CAVITY ACUTE MUCOSITIS
LARYNX VOICE CHANGE
MANDIBLE OSTEORADIONECROSIS
CONSTRAINTS
PAROTID GLAND (RTOG 0022)
Mean dose of either gland < 26 Gy
At least 50% of either parotid gland receieves less than 30 Gy
At least 20 ml of combined volume of both the parotid gland receives < 20 Gy
SUBMANDIBULAR GLAND
Mean dose < 39 Gy
CONSTRICTORS
Mean dose < 60 Gy
LARYNX
Mean dose < 45 Gy
RESULTS
Chao et al. Radiother Oncol 2001;61:275-80
RESULTS OF IMRT
BIOLOGIC THERAPY
EGFR inhibitors – cetuximab
IgG1 chimeric monoclonal Ab
MOA
Abrogation of radiation induced
phosphorylation of EGFR
receptors ( mechanism underlying
accelerated repopulation)
Enhanced radiation induced
apoptosis.
Attenuate radiation induced
expression of DNA repair proteins
CETUXIMAB Specifically targets EGFR with high affinity & blocks ligand binding
Enhances antitumor activity of cisplatin
Enhances antitumor activity of radiotherapy
Showed activity in pts with SCCHN & documented platinum
resistance
EGFR inhibition is a promising new approach for radiosensitization
Need to drive predictive biomarkers to assess response to molecular
therapies
Optimize radiotherapy fractionation schemes to complement targeted
agents
DOSE, SCHEDULE AND TOXICITY
Intravenous cetuximab given one week before radiotherapy
Loading dose of 400 mg per square meter of BSA over a period of
120 minutes, followed by weekly 60-minute infusions of 250 mg per
square meter for the duration of radiotherapy
Premedication to be given
Before the initial dose , a test dose of 20 mg should be infused over
a 10-minute period, followed by a 30-minute observation period
Side effects
Infusion reaction -angioedema, urticaria, hypotension
,bronchospasm
Hypersenstivity reactions, acniform rash
BONNER STUDYEBRT( SFX: 70 Gy/ 35#, HFX:72-76.8 Gy/ 60-64#, AFX with CB: 72 Gy/ 42#)
EBRT PLUS CETUXIMAB
Median duration of locoregionalcontrol
14.9 month 24.4 month
2 year PFS 37% 46%
5 year OS 36.4% 45.6%
Median survival
29.3 month 49 month
Cont.....When compared by disease site, oropharyngeal tumors
derived most benefit with the addition of Cetuximab with radiotherapy than the tumors of larynx and hypopharynx
Possible explanation may be
The addition of anti EFGR antibody preferentially benefits locally advanced squamous cell carcinoma of head and neck based on tumors primary anatomic location favouring oropharyngeal tumors.
Findings is related to the fact that HPV is associated primarily with oropharyngeal tumors
Current study RTOG 1016 is comparing concurrent chemoradiation to the same radiotherapy with cetuximabin HPV associated oropharyngeal cancer
SURGERY Limited role in carcinoma oropharynx as because
Surgically inaccessible
Increased post operative and functional morbidities
INDICATION
As definitive treatment for small lesion ( T1/T2)
As a part of combined approach for advanced stage tumors (with RT)
For residual ds in neck after RT
As salvage for persistent or recurrent ds
ADVANTAGE One time procedure - But most pts will require postop RT
Limited amount of tissue exposed to treatment
Late sequelae minimal
RT reserved for subsequent tumor which may be unsuitable for surgery
Cosmetic defects
Functional defects
Greater amount of disability
Complex reconstructive procedures
Expertise required – not available everywhere
DISADVANTAGES
Surgical proceduresBOT Midline mandibulotomy-splitting the lip,mandible, oral tongue
midline
Lateral mandibulotomy-dividing the mandible near the angle and approaching the BOT from the side
Floor drop procedure
TONSIL
Tumour < 1 cm- wide local excision
Tumour involving palatine tonsil- radical tonsillectomy
SOFT PALATE
Surgery is rarely recommended as initial therapy because of significant nasopharyngeal reflux during swallowing
RESULTSParsons et el reviewed the radiation oncology and
surgical literature from 1970 to 2000 and compared outcome between surgery with and without radiation and definitive radiation with or without LN dissection
Surgery with or without RT
RT with or without LN dissection
Local control 79% 76%
5 year OS 49% 52%
5 year CSS 62% 63%
Severe complication 32% 3.8%
Fatal complication 3.5% o.4%
LOCOREGIONAL RECURRENT DISEASE
Locoregional failure patients udergo salvage surgery if feasible.
Re-irradiation is performed in
- surgically unresectable
- high performance status
- patient understands the high potential of significant treatment related morbidity and modest likelihood of long term survival.
These patients usually have limited volume well circumscribed recurrent disease and a prolonged time from initial treatment.
All attempts are made to limit the volume of retreatment with the use of IMRT.
Stage I & II: Surgery or RT( EBRT or brachytherapy) gives similar locoregional control
Stage III & IV: Concurrent chemoradiation
OBJECTIVE: To review NCCN and ESMO clinical practice guidelines and to suggest revisions to account for potential difference in demographic and resources, to better reflect current clinical management of head and neck cancer within Asean region
GUIDELINES
Stage I & II: only RT
Stage III, IVA & IVB: Concurrent chemoradiation
Sequential chemoradiation is preferred in N2-3 tumours in patients having good performance status
SEQUELAE OF TREATMENTACUTE TOXICITY LATE TOXICITY
- mucositis - xerostomia
-dermatitis - dental caries
- Dysphagea - osteoradionecrosis
-Sore throat - prolonged dysphagea
- Odynophagea - trismus
- In field alopecia - hypothyroidism
- Xerostomia - cervical fibrosis
- Taste distrubance - neck lymphedema
- Dehydration - hearing loss
-Compromised nutrition
CONCLUSION Primary radiotherapy is preferred treatment in early stage tumors
Altered fractionation schedules produce better results but with increased toxicity
No improvement in LRC or survival for pts treated with surgery +RT as compared
to RT alone
Surgery preferred in case of residual or recurrent disease.
Brachytherapy plays a limited role because of technical difficulty due to
anatomical location
Concurrent chemoradiation is the treatment of choice for locoregionally
advanced tumors.
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