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.

THANK YOU