Head & neck cancer horizontal

HEAD & NECK CANCERHORIZONTAL

Mohamed Abdulla M.D.

Prof. of Clinical Oncology

Kasr Al-Aini School of Medicine

Cairo University

KASO – EXAM & RAP UP COURSE

THURSDAY 16/04/2015

GRAND NILE HOTEL & TOWER

FINDING

SIMILARITIES

IN COMMON

Disclosures:

• Amgen.

• Merck Serono.

• Sanofi.

• Astra Zeneca.

• Astellas.

• Roche.

• Pfizer.

• Novartis

Head & Neck Cancer: Basic Facts:

• 6 – 9% of all cancers.

• Males > Females; (2:1) (4:1).

• 60% advanced at presentation.

• Substantial Geographic Variations Influenced by Risk

Factors:

• Smoking & Alcohol 5 – fold increased incidence.

• HPV Oro-pharyngeal cancer.

• EPV Nasopharyngeal cancer.

83%

59%

36%

0%

50%

100%

5-

ye

ar

Su

rviv

al

Seminars in Oncology, Vol 41, No 6, December 2014, pp 798-806

Head & Neck Cancers:

Molecular & Biological Events:

• HPV-Related Cancers

• Caused by high-risk HPV

• HPV 16

• Driven by viral oncogenes

• Restricted to oropharynx

• Distinct molecular markers

• “Good” prognosis

• Young, good general health

• Environment-Related Cancers

• Caused by environmental

mutagens

• Smoking, alcohol

• Throughout oral mucosa

• Distinct molecular markers

• “Poor” prognosis, comorbidity

• Second cancers

HNC Can Now Be Divided Into 2 Large and Distinct Subtypes

HPV = human papillomavirus.

Goon et al, 2009; Rodriguez et al, 2010.

HPV & Oropharyngeal Cancer:

Changing Incidence Over Time:

Chaturvedi et al, 2011.

Sequential Combined Modality Therapy

A Phase III Study: TAX 324 TPF Vs. PF

Followed by Chemoradiotherapy

R

A

N

D

O

M

I

Z

E

P

P

F

F

Carboplatinum: AUC 1.5 Wkly

Daily Radiotherapy

EUA

T

Surgery

TPF: Docetaxel 75D1 + Cisplatin 100D1 + 5-FU 1,000 CI: D1–4 q3wks x 3

PF: Cisplatin 100 D1 + 5-FU 1,000 CI: D1–5 q3wks x 3

AUC = area under the curve; EUA = examination under anesthesia.

Posner et al, 2007.

TAX 324: Demographics by HPV Status

HPV+

N = 56 (50%)

HPV–

N = 55 (50%) p Value

Treatment

TPF

PF

28 (50%)

28 (50%)

26 (47%)

29 (53%)

.85

Age Yrs

Median (Range) 54 (39–71) 58 (41–78) .02

Nodal Stage

N0–N1

N2–N3

13 (23%)

43 (77%)

18 (33%)

37 (67%)

.30

T stage

T1–T2

T3–T4

28 (50%)

28 (50%)

11 (20%)

44 (80%)

.001

PS WHO

0

1

43 (77%)

13 (23%)

27 (49%)

28 (51%)

.003

PS = performance status; WHO = World Health Organization.

Posner et al, 2011.

TAX 324: Survival and HPV Status

Posner et al, 2011.`

Su

rviv

al

Oro

ph

ary

nx C

an

cer

HPV+

HPV–

p < .0001

TAX 324: Survival, PFS, and Site

of Failure By HPV Status

HPV+

N = 56

HPV–

N = 55

p Value

Median Follow-Up

Months (95% CI) 83 (77–93) 82 (68–86) NS

Survival Status– Alive

– Dead 44 (79%)

12 (21%)

17 (31%)

38 (69%)

< .0001

PFS Status– No Progression/Death

– Progression/Death41 (73%)

15 (27%)

16 (29%)

39 (71%)

< .0001

Local-Regional Failure 7 (13%) 23 (42%) .0006

Distant Metastases 3 (5%) 6 (11%) NS

Both 1 (2%) 2 (4%) NS

Total Disease Failures 9 (16%) 27 (49%) .0002

Died Without Recurrence 5 (9%) 12 (22%) .07

PFS = progression-free survival; NS = not significant.

Posner et al, 2011.

Head & Neck Cancer:

Current Theme of Management:

SurgeryRadiation

TherapyKey

Components

L.R. Distant

Metastases

Systemic

TherapySEER. Stat fact sheets: oral cavity and pharynx cancer. 2003-2009.

Existing Dilemma:

• Different treatment algorithms.

• Many critical structures QoL.

• Organ Preservation.

• Impact of innovations on OAS.

MDTRadiation

Oncologist

Medical Oncologist

Onco-Surgeon

Radiologist

Clinical NutritionistPsychiatrist

Physiotherapist

Speech Aid

Social Worker

Oncology Nurse

Head & Neck Cancer:

Current Theme of Management:

Head & Neck Cancer:

Radiation Therapy Components:1. Patient Preparation.

2. Positioning.

3. Fixation.

4. Volume to be Treated, Volumes to be Avoided.

5. Portal Arrangement.

6. Energy Used.

7. Dose, Fractionation & OAP

8. Acceptance and Quality Control.

9. Adding Systemic Therapy.

10. Management of Anticipated Complications & Follow Up

Radiation Therapy Components:

1. Patient Preparation: Compliance: • Detailed history including previous HNSCC & radiation treatment.

• All investigations (Imaging, laboratory, pathologic, endoscopic) Accurate Staging Clear Intention & Therapeutic Strategy.

• General Examination:• Performance Status.

• Complexion: PALOR ANEMIA., Depression.

• Nutritional Assessment.

• Co-morbid illness DM

• Neurological Assessment.

• Pulmonary Assessment.

• Locoregional Examination:• Palpable primary & lymph nodes.

• Oral Hygiene Correction before treatment.

• Stoma Care.

• Understanding, Instructions, Interventions.

• Discuss with family.

• MDCT

• MRI

• PET/CT

• Others

• Hematological

• Organ Function

• Others

Poor Radiation Results From Non-compliance

in Radiation TechniqueCritical Impact of Radiotherapy Protocol

Compliance and Quality in the Treatment of

Advanced Head and Neck Cancer: Results

From TROG 02.02

CO June 20, 2010 vol. 28 no. 18 2996-3001

Noncompliance, more relapses


2. Positioning: Comfortable & Reproducible

SUPINESTRECHED

SHOULDERS

Snehal et al..Medical Dosimetry, Vol. 34, No. 3, pp. 225-227, 2009

• Acanthiomeatal Line is

perpendicular to table.

• Chin in neutral position.


3. Fixation:

• Thermoplastic Mask.

• Placement of Markings;

“Lead & Laser).

• Tongue Bite

(Depressor): In or Out.


4. Volume:

ICRU Reports 50 & 62:

• GTV: Gross Tumor Volume.

• CTV: Clinical Target Volume:

Extension of Subclinical

Disease.

• PTV: GTV + CTV + (3 – 5 mm).

• OAR or ORV.

ICRU Report 50 (1993) Prescribing, recording and

reporting photon beam therapy. International

Commission on Radiation Units and Measurements,

Bethesda, MD

• No Place for limited volumes except in Early glottic

cancers (T1-2).

• Neck nodes are usually included except in Early Glottic

Cancers and PNS.

• Bilaterality of neck nodes is mostly required.


4. Volume:

3D Techniques (Conformal, IMRT, IGRT)

Spare Normal Tissues as much as we can

Accurate radiation dose delivery

No treatment volume Reduction.


4. Volume:


4. Volume: Larynx: Glottic:

Early Glottic Cancer T3-4 Glottic Cancer


4. Volume: Larynx: Supraglottic:

Nasopharynx Basic Considerations:

Anatomical Data:Skull Base: Sphenoid

and Occipital Bones

Pre-

Vertebral

Fascia

Nasal

Cavity

Oropharynx

Basic Considerations:

Anatomical Data:


Anatomical Data:U

pw

ard

exte

nsio

n


Anatomical Data:The Most

Common Site

Bounded by:

Atlas vertebra

Axis vertebra

Sup. Constrictor ms

Buccopharyngeal

fascia

Retropharyngeal

space

Prevertebral fascia


Anatomical Data:


Anatomical Data:

Pharyngo-Basilar Fascia


Anatomical Data:

Superior

Pharyngeal

Constrictor

Muscle

Skull Base

Pharyngobasilar fascia Muscle Deficiency Area

=

Sinus of Morgagni

Potential Route

for Intracranial

Spread


4. Volume: Nasopharynx:


4. Volume: Paranasal Sinuses:

Ipsilateral Tumor Bed + Ethmoid + Frontal + Openings on the

contralateral side. Nodes will be included if locally advanced or

high grade lesion.


4. Volume: Oropharynx:


4. Volume: Hypopharynx:


4. Volume: Oral Tongue and Floor of

Mouth:

• The best obtained is parallel opposed.

• Supplementations.

• IMRT.

• High Energy photon beams: 6-10 MV.

• Electron Beam: Energy according to desired depth as a

supplementation or sometimes for re-irradiation.

• Others.


5-6: Portal Arrangement & Energies:


7. Dose & Fractionation:


8. Plan Acceptance:


9. Adding Systemic Therapy:

Seminars in Oncology, Vol 41, No 6, December 2014, pp 798-806

MACH-NC: 2009 Update:

93 Trials – 17346 Patients:

J.-P. Pignon et al. / Radiotherapy and Oncology 92 (2009) 4–14

CISPLATIN 100 mg/m2 (D1+22+43) +

RTH

• Early Reactions.

• Late Reactions.

• Follow up Strategy.


10. Management of Anticipated Complications:

Thank You

Head & neck cancer horizontal

Health & Medicine

Transcript of Head & neck cancer horizontal