Post on 10-Jun-2020
London Dec 2013
Patient selection for adjuvant treatments in salivary gland tumors
Vincent GREGOIRE, MD, PhD, Hon. FRCR Radiation Oncology Dept. Head and Neck Oncology
Program & Center for Molecular Imaging, Radiotherapy and Oncology, Université Catholique de Louvain, St-Luc University Hospital, Brussels,
Belgium
London Dec 2013
Epidemiology
Salivary Gland Tumors •0.3-3% of all malignant tumors •4-6% of all Head & Neck malignancies •80% of salivary gland tumors arise in the parotid gland
Malignant salivary gland tumors •0.6 - 1.0 new cases/100,000 inhabitants per year •1-3% of Head & neck tumors •≈ 25% of parotid tumors are malignant •≈ 50% of submandibular gland tumors are malignant •≈ 80% of minor salivary gland tumors are malignant
High grade mucoepidermoid C
London Dec 2013
Histological subtypes: malignant T
Shah et al., 2012
London Dec 2013
TNM staging (major salivary glands)
AJCC staging, 7th edition
Primary tumor (T) Tx: primary tumor cannot be assessed T0: no evidence of primary tumor T1: tumor 2 cm or less without extraparenchymal extension T2: tumor more than 2 cm but no more than 4 cm without
extraparenchymal extension T3: tumor more than 4 cm and/or tumor having extraparenchymal
extension T4a: tumor invades skin, mandible, ear canal, and/or facial nerve T4b: tumor invade skull base and/or pterygoid plates and/or encases
carotid artery Extraparenchymal extension is clinical or macroscopic evidence of invasion of soft
tissue; microscopic extension alone does not constitute extraparenchymal extension for classification purposes
London Dec 2013
TNM staging (major salivary glands)
AJCC staging, 7th edition
Regional lymph nodes (N) NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Metastasis in a single ipsilateral lymph node, ≤ 3 cm in greatest dimension N2a Metastasis in a single ipsilateral lymph node, > 3 cm but not > 6 cm in greatest dimension N2b Metastasis in multiple ipsilateral lymph nodes, none > 6 cm in greatest dimension N2c Metastasis in bilateral or contralateral lymph nodes, none > 6 cm in greatest dimension N3 Metastasis in a lymph node, > 6 cm in greatest dimension Distant Metastasis (M) MX Distant metastasis cannot be assessed M0 No distant metastasis M1 Distant metastasis
London Dec 2013
Treatment options
• Surgery • Radiotherapy
London Dec 2013
Surgery: primary tumor
Parotid gland • Superficial parotidectomy • Total parotidectomy • Extended total parotidectomy • Radical parotidectomy • Extended radical parotidectomy Submandibular gland • Submandibulectomy
London Dec 2013
Post-operative radiotherapy for malignant tumors
Shah et al., 2012
Memorial Sloan Kettering Institute (n=2807): tumor grade
London Dec 2013
Post-operative radiotherapy for malignant tumors
Memorial Sloan Kettering Institute (n=2807): tumor site
Shah et al., 2012
London Dec 2013
Post-operative radiotherapy for malignant tumors
Shah et al., 2012
Memorial Sloan Kettering Institute (n=2807): tumor histology
London Dec 2013
Post-operative radiotherapy for malignant tumors
Shah et al., 2012
Memorial Sloan Kettering Institute (n=2807): tumor stage
London Dec 2013
Post-operative radiotherapy for malignant tumors
Dutch Head and Neck Oncology Cooperative Group (n=666)
Terhaard et al., 2009
London Dec 2013
Post-operative radiotherapy for malignant tumors
Dutch Head and Neck Oncology Cooperative Group 1984-1985 (n=538)
Terhaard et al., 2005
R2 surgery R1 surgery
R2 surgery + RxTh R0 surgery R1 surgery + RxTh R0 surgery + RxTh
London Dec 2013
Neck management
Risk factor for nodal metastasis
• Histology and grading, e.g. high grade vs low grade, SCC, salivary duct carcinoma, undifferentiated carcinoma
• T-stage • Extraparenchymal extension • VII nerve palsy
London Dec 2013
Neck management
High risk of occult metastasis
Low risk of occult metastasis / unknown
Node-positive Node-negative
MRND ± RxTh* SND ± RxTh* ± RxTh?
Pre-operative assessment
* Multiple nodes and/or extracapsular rupture
London Dec 2013
Post-operative radiotherapy for malignant tumors
Dutch Head and Neck Oncology Cooperative Group 1984-1985 (n=538)
Terhaard et al., 2005
10-y
ear a
ctua
rial r
egio
nal c
ontro
l (%
)
Surgery Surgery ± RxTh Surgery Surgery
± RxTh
London Dec 2013
Post-operative radiotherapy for malignant tumors
• T3-T4 tumors • Close surgical margins (e.g. deep lobe, facial nerve) • Microscopically positive margin (R1) • High grade tumors • Node positive neck (>pN1 and/or extracapsular
extension) • Perineural infiltration • Recurrent tumor (including pleomorphic adenoma)
London Dec 2013
IMRT for parotid gland tumors
Left parotid ADC Dose: 30 x 2.0 Gy
PTV
Right parotid
Spinal cord
Inner ear
London Dec 2013
VIIa
Xb
VIII
IX
II
Ib
London Dec 2013
Normal tissue dose constraints IMRT for parotid gland tumors
DAHANCA, 2013
London Dec 2013
Post-operative radiotherapy for malignant tumors
Dutch Head and Neck Oncology Cooperative Group 1984-1985 (n=538)
Terhaard et al., 2005
5-ye
ar lo
cal c
ontro
l
London Dec 2013
Primary radiotherapy for malignant tumors
Dutch Head and Neck Oncology Cooperative Group 1984-1985 (n=538)
Terhaard et al., 2005
London Dec 2013
Primary radiotherapy for malignant tumors
± 1985
London Dec 2013
Primary radiotherapy for malignant tumors
Jensen et al., 2012
Hadron Therapy (Carbon ions) for adenoid cystic carcinoma
50 Gy photon IMRT + 24 GyE Carbon
London Dec 2013
Primary radiotherapy for malignant tumors
Schulz-Ertner et al., 2005
Hadron Therapy (Carbon ions) for adenoid cystic carcinoma: retrospective comparison with photon IMRT
IMRT + C-boost (n=29)
IMRT (n=34)
Loco
-reg
iona
l con
trol (
%)
London Dec 2013
Summary – key points
• Primary management is surgery • Postoperative radiotherapy (IMRT, ≈ 60 Gy) is
recommended for high risk patients • Isolated neck recurrences are rare and nodal
irradiation is indicated in pN+ patients • Radical RT (66-70 Gy) can be used in inoperable
cases • Carbon ions may be recommended for inoperable
adenoid cystic carcinoma