Head and Neck Cancer Flashcards
Aetiology
Male more common than female
Smoking
Alcohol
Marijuana
Primary aim in management of primary HN site
Optimise tumour control
Preserve function (e.g., can treat larynx with XRT and preserve voice)
high local control for early stage
improve survival for advanced
improve therapeutic ratio
Are other primaries are common?
Yes
Generally other primaries will be present (HN cancer will most likely not be the initial primary)
Patients typically have mortality due to other diseases/primaries rather than HN cancer
Diagnosis of HN Cancer
Core Biopsy
Incisional Biopsy (removal of portion of tumour)
Excisional Biopsy (removal of the full tumour volume) (can commit patient to XRT, therefore preferred to be avoided)
Histology
PET Scan
Head and Chest CT Radiograph
Pan-endoscopy (can locate if other primaries are located in GI/GU tract)
Histology of HN Cancer
SCC most common
Other: Adeno-carcinoma, Adenoid cyst, Muco-epidermoid, Plasmacytoma, Lymphoma, Melanoma
Staging of HN Cancer
TNM
Treatment Options for HN Cancer
Sole Modality:
IMRT (dose is localised to HN, smaller margins, spare normal tissue)
Brachytherapy
Surgery
Combined Modality:
Chemoradiation (Can provide good local control, remove microscopic residual disease) (Increase toxicity needs to be considered)
Chemoradiation for HN
Increased morbidity, therefore not appropriate for all patients
8% survival advantage at 5 years
Agents used: Cisplatin, 5FU
Given concurrently with RT
Indications for Post Op RT
Locally advanced disease
Close/positive margins
3 or more nodes involved
Extracapsular spread
Lymph vascular or peri neural spread
Indications for Post op CT/RT
Positive margins
Extracapsular spread
Sites RT can be used to treat
Primary lesion and gross nodal disease
Site of resected gross disease
Operative bed (require higher RT dose)
Treat nodes at risk of microscopic involvement
Acute Side Effects of Head and Neck RT
Lethargy
Nausea/Vomiting
Skin changes
Alteration in taste
Dysphagia
Odynophagia
Alteration in saliva consistency
Late Side Effects of HN RT
Xerostomia (dry mouth due to reduced saliva)
Radiation caries (tooth decay from radiation-induced dry mouth)
Mucosal fragility
Alopecia
Loss of sweating
Trismus
Atrophy of SC tissues
Right Parotid Nodes Dose Fractionation
T1-2 (nodes < 1cm) -> 3DCRT = 60Gy/30 / IMRT = 63Gy in 35
T3-4 (nodes > 1 cm) -> 3DCRT & IMRT = 70 Gy in 35
Site of resected disease = 3DCRT & IMRT 60 Gy in 30
Operative Bed = 3DCRT & IMRT = 54Gy in 27
Patient Management of HN Patients
Daily review (RT, nurses)
Weekly review by medical staff
Allied health review (dietician, speech pathology, social work, OT, physio)
Oral Cavity Anatomy
Comprised of Buccal Cavity, alveolus, hard palate, tongue, floor of mouth
Oral Cavity Treatment
Surgery mainstay of treatment (to preserve saliva)
Possibility of more than one tumour is high (avoid RT where possible)
Aim to cure, but optimise speech, eating
Function of Larynx
Protect airway
Vocalisation
Clinical Presentation of Larynx Cancer
Hoarse/husky voice
Local pain
Mass in neck
Airway compromise
Aspiration
Early Glottic Cancer Classification
Characterised with low incidence of nodes
T
Early Glottic Cancer Treatment Options
RT
Surgery (conservative)
Laser (currently under investigation)
RT Treatment position for Glottis Cancer
Supine, head first
Shell
Hands on chest/by side
Knee bolster
Head rest
RT Planning for EGC
3DCRT:
- centre on glottis
- typically 5x5 or 6x6 field is used
- overshoot ant
IMRT:
- GTV + 1cm = CTV +0.5 cm = PTV
Dose fractionation for EGC (T1 and T2)
T1 = 60 Gy in 28-30
T2 = 66 Gy in 30-33
T3 Glottic Cancer
Local control better with surgery
RT Planning for T3 Glottis
IMRT: entire larynx = CTV
Dose 60-70Gy in 33-35#
Advanced Glottic Cancer (T3-4/N1-3/M0) Treatment Options
RT (rarely)
Chemoradiation
Laryngectomy +/- PORT +/- CT `
Supraglottis node involvement
High incidence of nodes at presentation, subclinical nodal involvement
As it is midline structure, requires bilateral necks treated
Treatment options for Supraglottis T1N0M0
- Radical RT (requires good airways)
- Supraglottic laryngectomy (requires good airway reserve, need to learn to swallow again, increased risk of aspiration)
Treatment options for Supra glottis (advanced disease)
Surgery +/- post op RT +/- CT
Chemoradiation
Radiation alone (refused surgery or comorbidities)
5 field technique
Hypopharynx Anatomy
Lies laterally to larynx
communicates superiorly with oesophagus an inferiorly with cervical oesophagus
Three parts:
- posterior pharyngeal wall
- piriform fossae
- post-cricoid space
Clinical presentation of hypo phrayngeal lesions
Sore throat
Dysphagia
Weight loss
Stridor
Hypophrayngeal Treatment Options
Early Stage
- Partial Pharyngo-laryngectomy
- Few treated with RT or surgery alone
If advanced (with Piriform fossa involvement)
- Pharyngo-laryngectomy + post op RT+/- CT
- CT/RT
- RT alone (rarely)
Treatment options for Pharyngeal Wall
Early disease
- Surgically (due to large submucosal spread)
Locally advanced disease -
- Majority Surgery + Post Op RT+/- CT
- RT or CT/RT (if not fit for S)
Post Cricoid Tumours treatment
Rare tumour
Generally locally advanced at presentation
Associated with iron deficiency
RT volume includes upper mediastinum
Treatment:
Majority = pharyngo-laryngectomy + RT +/- CT
Differing Salivary Glands
Parotid gland
Submandibular gland
Sublingual
Histology of Salivary gland tumour
Benign
- Pleomorphic adenoma
- Oncocytoma
- Warthins Tumour
Malignant
- Adenocarcinoma
- SCC
- Muco-epidermoid
- Adenoid Cyst
Treatment options for Salivary Gland Tumour
Surgery +/- post op RT
Conserve facial nerve
Volume: parotid bed +/- ipsi-lateral neck nodes
Nasal Cavity Aetiology, Pathology, Clinical Presentation
Aetiology:
- Wood workers
Pathology
- SCC, NHL, Plasmacytoma, Melanoma, Inverting Papilloma
Clinical Presentation
- Epistaxis, Nasal Obs
Treatment Options for Nasal Cavity
Surgery +/- RT
RT Volume - primary plus margin (nodes not included)
Nasopharyngeal Cancer Epidemiology
Chinese Origin
Males more common than females
Nasopharyngeal Cancer Clinical Presentation
- Painless neck lump
- Nasal obstruction
- Sore throat
- Facial pain
- Proptosis
- Cranial nerve defects
Nasopharyngeal Treatment options
RT is standard
Chemo/RT (synchronus improves survival in advanced disease - more chemo sensitive)
RT Volume = Nasopharyngeal + bilateral neck nodes
Dose = 63-70 Gy to primary lesion
Treatment options for the Neck
Observation with delayed neck dissection for recurrence
Surgery (elective +/- post op RT +/- CT) (therapeutic +/- post op RT +/- CT)
RT +/- neck dissection for persisting disease
Choice of therapy for neck is dependent on:
Nodal involvement
Extracapsular spread (increased risk of LR -> requires Post Op RT, requires higher dose)
Different types of neck dissection
Radical neck dissection
Modified radical neck dissection
Functional neck dissection
Supra-omohyoid neck dissection
Complications of Neck Dissection
Death
Lymphodaema
Infection
Affects nervous, vascular, lymphatic, pulmonary system
Which glottic patients are offered RT
Good airway
– Compliant with follow-up
– Easy to examine
– Cords fixed because of bulk of tumour
– Understand they have a higher risk of recurrence
– Understand that laryngectomy may be recommended n
suspicion recurrence and may not be confirmed
histologically
Complications of surgery
death
flap necrosis
carotid rupture
