Slide 1

Dr. S. C. Joshi Senior Consultant Oncologist and Radiotherapist D/L : +91 1294253115 Mobile Phone : +919650099151, +919711558463 Email: sanjeev.joshi@aimsindia.co.insanjeev.joshi@aimsindia.co.in scjoshi71@gmail.com Head and Neck Cancers Management Slide 2 Dr. S. C. Joshi Senior Consultant Oncologist and Radiotherapist D/L : +91 1294253115 Mobile Phone : +919650099151, +919711558463 Email: sanjeev.joshi@aimsindia.co.in scjoshi71@gmail.com Slide 3 Epidemiology Head and neck cancers constitute 5% of all cancers worldwide 10 th most common cancer in the world World annual incidence: 643,000 new cases Mortality of about 350,000 cases MC in India 15.4 to 110.6 per 100,000 males 2 to 51.2 per 100,000 females By: Dr.S.C.Joshi Slide 4 Risk Factors Smoking Tobacco (Masala, kaini and others) Viruses - Epstein-Barr Virus, HPV (16, 18) Environmental/occupational Exposures of Asbestos, Chromium, Nickel, Arsenic, Formaldehyde Salted Fish Ionizing Radiation Genetic Immunodeficiency Poor oral hygiene Alcohol Betet nut By: Dr.S.C.Joshi Slide 5 Disease Sites of the Head and Neck Head and neck cancer may occur in diverse structures and sites: Lip Oral cavity Tongue Pharynx Larynx Nasal cavity Sinuses By: Dr.S.C.Joshi Slide 6 Nasal Cavity Nasopharynx Oral Cavity Oropharynx Larynx Hypopharynx Mostly Arise in The Nasopharyngeal Axis By: Dr.S.C.Joshi Slide 7 Head and Neck Cancer Often Spreads to Regional Lymph Nodes Lymph node involvement in up to 30%-50%. By: Dr.S.C.Joshi Slide 8 Slide 9 Diagnosis 70%- 80% are diagnosed having locally advanced disease (Stage III and IV) In the more advanced tumors (stage III and IV) Local recurrence up to 50% Distant metastatic spread (approximately 10%-30%) By: Dr.S.C.Joshi Slide 10 Diagnosis History General physical examination & Local ex Oral cavity Oropharynx (palpation is very important) Nasopharynx (mirror examination) Laryngopharynx (indirect laryngoscopy) Examination of the neck for lymph nodes Direct laryngoscopy Biopsy of any suspected areas By: Dr.S.C.Joshi Slide 11 Laboratory Studies Routine blood counts. Blood chemistry profile Urinalysis Chest radiographs, Plain radiographs of mandible (Panorex view) CT Scan / MRI / PET CT By: Dr.S.C.Joshi Slide 12 No substantial change in survival in 25 yrs. Slide 13 Aims Highest Loco- regional control Anatomical and functional organ preservation Treatment Principles Early Stage Single modality treatment using Surgery or Radiotherapy Late Stage Surgery + Radiotherapy Concurrent Chemoradiotherapy Management Guidelines for H & N Cancers By: Dr.S.C.Joshi Slide 14 Management Guidelines for H & N Cancers When different modalities available, one with maximum chance of cure should be used When different modalities have same results, one offering better quality of life, with organ, function preservation and good cosmetic results should be used By: Dr.S.C.Joshi Slide 15 Surgery v/s Radiotherapy In treatment of head and neck cancers surgery and radiotherapy produce equivalent results in early stages of carcinoma In advanced stages of head and neck cancers surgery combined with pre or postoperative radiotherapy By: Dr.S.C.Joshi Slide 16 Improving Efficacy of Treatment Chemotherapy Radiotherapy Dose escalation schedules Altered Fractionation Schemes Biological Therapy And Molecular Targeting Continuous review during treatment By: Dr.S.C.Joshi Slide 17 Absolute benefit of Chemotherapy > 30% at 5 years Higher For Platinum Based Regimens. Higher doses up to 70 Gy are related with better Loco regional control, however with enhanced acute and long term complications Chemotherapy By: Dr.S.C.Joshi Slide 18 Radiation Therapy Ionizing Radiation High energy electromagnetic waves in the form of X-rays or gamma-rays External beam radiation Utilizes LA to generate X- rays to kill cancer cells Brachytherapy utilizes radioactive substances implanted into tumors. By: Dr.S.C.Joshi Slide 19 X-ray photons interact with matter, knocking electrons from the orbital's of atoms These high energy electrons can either directly damage DNA chemical bonds, or interact with water molecules forming free radicals that then cause DNA damage Damage to DNA may result in single or double strand breaks which can cause cell death DNA repair enzymes are more readily activated in healthy cells than in cancer cells How Radiation Works By: Dr.S.C.Joshi Slide 20 Clinical motivation for high-precision techniques More conformality = Better sparing The Changing Paradigm Conformal radiation IMRT/IGRT/Rapid arc By: Dr.S.C.Joshi Slide 21 Standard Radiation Techniques (old) Conventional external beam radiation usually consists of two opposed lateral fields and a matched anterior field that encompass the cancer and lymph nodes in the neck. Treatment is delivered daily for about 7 weeks. When this technique developed, physicians used regular X-rays or fluoroscopy to setup these fields. By: Dr.S.C.Joshi Slide 22 With the advent of CT guided planning, a new era in RTP has emerged. We are now better able to customize our treatment plans to fit the individual patient anatomy CT Based Radiation Planning By: Dr.S.C.Joshi Slide 23 IMRT Intensity Modulated Radiation Therapy In this intensity of the radiation beam in a given treatment field is varied via multiple multi leaf blocking arrangements called segments Intensity modulation combined with multiple fields (radiation beam angles) or arcs allows for conformal radiotherapy (ie high radiation iso dose lines conform to the target volume and spare normal tissues). By: Dr.S.C.Joshi Slide 24 Intensity Modulated Radiation Therapy (IMRT) IMRT is an advanced form of 3D-CRT technique in which a computer aided optimisation process is used to determine customised non-uniform intensity distribution through inverse planning to attain certain specified dosimetric and clinical objectives By: Dr.S.C.Joshi Slide 25 Multiple beam angles or arcs Multi-leaf collimator Accurate patient positioning and immobilization Physics quality assurance measures Well trained radiation therapy staff Intensity Modulated Radiation Therapy (IMRT) By: Dr.S.C.Joshi Slide 26 Multi-leaf Collimator The multi-leaf collimator is inside the linear accelerator. It is comprised of multiple 1 cm thick metal radiation blocks each driven by an independent motor and controlled by a central computer. The multi-leaf collimator allows for multiple blocking patterns in each radiation field which in turn allows for intensity modulation of the radiation dose. By: Dr.S.C.Joshi Slide 27 Immobilization By: Dr.S.C.Joshi Slide 28 3 Clamp 4 Clamp 5 Clamp Random Errors with different Fixation devices Radiotherapy Oncology,2001 Head and Neck Immobilization Devices 28By: Dr.S.C.Joshi Slide 29 Time Interval Importance of the time interval between surgery and postoperative RT in the combined management of head and neck cancers PORT within 6-7 weeks / later LRC : 70% (PORT within 7 weeks) >27% (PORT more than 7 weeks) Therefore patient must be seen by oncologist immediately after surgery and HPE report. Bhadrasain V,IJROBP,1979 By: Dr.S.C.Joshi Slide 30 Isodose Distribution of an IMRT Plan 30By: Dr.S.C.Joshi Slide 31 IMRT - Hypopharynx By: Dr.S.C.Joshi Slide 32 Daily X-rays or CT scansAre done and overlaidwith the planning CT Millimeter adjustments are made with automatic couch position shifts Treatment becomes more accurate and consequently smaller target volumes will result in less side effects IGRT Image Guided Radiation Therapy By: Dr.S.C.Joshi Slide 33 IGRT MV X-rays By: Dr.S.C.Joshi Slide 34 IGRT kV X-rays By: Dr.S.C.Joshi Slide 35 IGRT Cone Beam CT (CBCT) By: Dr.S.C.Joshi Slide 36 IGRT - CBCT By: Dr.S.C.Joshi Slide 37 Rapid arc cases By: Dr.S.C.Joshi Slide 38 Slide 39 Rapid arc cases By: Dr.S.C.Joshi Slide 40 Rapid arc cases Slide 41 In Developing World Infectious diseases are the main killers Patients present in an advanced stage Fund allocation to health is less than that of developed countries No or poor social health security system Geographic clustering of facilities to urban areas Linear accelerators are expensive, with high operational costs. High precision facilities available in only selected centers. By: Dr.S.C.Joshi Slide 42 Slide 43 Optimization of Treatment Prompt treatment in a good referral centre Optimal Infrastructure support required for implementation of CTRT/AFRT schedules Avoidance of Treatment Breaks Integration of Chemotherapy Integration of high-precision technique Good Nutritional Support. Affordable cost By: Dr.S.C.Joshi Slide 44 Our Oncology Facilities Linear accelerator from Varian trilogy with rapid arc Brachytherapy Chemotherapy Daycare facilities for out patients and isolation wards Complete nuclear medicine with Radionuclide Therapy Palliative care Cancer screening Cancer awareness program By: Dr.S.C.Joshi Slide 45 Radiotherapy Team Consultant Oncologist Medical Physicist Radiation Therapist Radiation Therapist Aide By: Dr.S.C.Joshi Slide 46 Slide 47 Slide 48 Linac Room By: Dr.S.C.Joshi Slide 49 Slide 50 Slide 51 Head and neck cancer is a serious illness that affects thousands of Indians each year Smoking cessation and tobacco chewing is critical in the prevention of the disease Multimodality treatment interventions have a proven track record against the disease, but come with significant morbidity Targeted chemotherapy regimens are being developed to reduce side effects IMRT/IGRT and rapid arc have also significantly reduced the incidence of side effects from treatment. Summary By: Dr.S.C.Joshi Slide 52 Dr. Sanjeev Chandra Joshi scjoshi71@gmail.com