RADIO- AND RADIOCHEMOTHERAPY OF HEAD AND NECK TUMORS. Zoltán Takácsi-Nagy PhD Department of Radiotherapy National Institute of Oncology, Budapest 1.
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1 RADIO- AND RADIOCHEMOTHERAPY OF HEAD AND NECK TUMORS Zoltán Takácsi-Nagy PhD Department of Radiotherapy National Institute of Oncology, Budapest 1.
2 NEW PATIENTS/YEAR WITH HEAD AND NECK CANCER ALL OVER THE WORLD (3-7 %) THE SIXTH MOST COMMON HUMAN CANCER ETIOLOGY: TOBACCO, ALCOHOL, BETEL NUTS, POOR DENTAL HYGIENE, NUTRITIONAL DEFICIENCY, VIRAL (HPV), GENETIC 60 % ARE STAGE III-IV. AT THE TIME OF THE DIAGNOSIS 2.
3 INCIDENCE OF ORAL CAVITY AND PHARYNGEAL TUMORS IN CENTRAL EUROPE (cases/ inhabitants) Years Male Female 3.
4 TUMORS OF THE HEAD AND NECK REGION CAN CAUSE A HIGH VARIETY OF SYMPTOMS BECAUSE OF THEIR LOCATION WHICH ARE OFTEN NOT SPECIFIC OPERATION OF A NECK DISEASE (LYMPH NODE) WITHOUT DETAILED HEAD AND NECK EXAMINATION IS FORBIDDEN 4.
5 SYMPTOMS ULCERATIVE OR EXOPHYTIC LESIONS PAIN HOARSENESS NASAL SOUND SWALLOING DIFFICULTIES SPEACH DIFFICULTIES BLEEDING MASS ON THE NECK 5.
6 6.
7 LOCALIZATION OF HEAD AND NECK CANCERS LIP, ORAL CAVITY PHARYNX (Epipharynx, Mesopharynx, Hypopharynx) ~ 40 % LARYNX ~ 40 % NASAL, PARANASAL SINUSES SALIVARY GLANDS EYE, ORBIT THYROID GLAND HISTOLOGY 90% planocellular carcinoma 10% others: lymphoepithelial-, adenocarcinoma, lymphoma, sarcoma, melanoma OCCULT METASTASIS IS FREQUENT! 7.
8 UICC TNM CANCER STAGING 8.
9 9.
10 10.
11 EXAMINATION HISTORY PHYSICAL EXAMINATION INSPECTION WITH HEADLIGHT OR HEADMIRROR ENDOSCOPE PALPITATION CT, MRI, PET-CT, PANOREX HISTOLOGY, ASPIRATION CYTOLOGY CHEST X-RAY ETC. (HPV) 11.
12 12.
13 T3N0 BASE OF TONGUE TUMOR 13.
14 14.
15 15.
16 POSITRON EMISSION TOMOGRAPHY (PET) PALATE TUMOR WITH SUPRACLAVICULAR LYMPH NODES ON BOTH SIDES (N2c) 16.
17 17.
18 EXTERNAL RADIOTHERAPY MEGAVOLTAGE EQUIPMENT: LINEAR ACCELERATOR MV PHOTONS or ELECTRONS LINAC 18.
19 TREATMENT PLANNING CT-based 3D treatment planning Conformal 3D radiotherapy Irregular, individually shaped fields using multi-leaf collimator 19.
20 BRACHYTHERAPY (BT) 20.
21 CARCINOMA OF THE BASE OF TONGUE - BRACHYTHERAPY
22 22.
23 23.
24 24.
25 IN THE TREATMENT OF HEAD AND NECK TUMORS LOCOREGIONAL TREATMENT IS A BASIC REQUIREMENT 25.
26 Stage III-IV. base of tongue cancer. Histological results of N0 neck after dissection. 26.
27 27.
28 28.
29 MULTIMODAL TREATMENT OF HEAD AND NECK TUMORS SURGERY RADIOTHERAPY CHEMOTHERAPY 29.
30 ADVANTAGES OF RADIOTHERAPY IN THE TREATMENT OF HEAD AND NECK TUMORS AVOIDING OF RADICAL SURGICAL METHODS PRACTICALLY NO MORTALITY GOOD COSMETIC AND FUNCTIONAL RESULTS ELECTIVE TREATMENT OF THE LYMPH NODES IN CASE OF FAILURE OF RADIOTHERAPY THE EFFECTIVENESS OF SALVAGE SURGERY IS SATISFACTORY IN SOME CASES IT IS AN EXCLUSIVE TREATMENT THERE ARE NO SIGNIFICANT CONTRAINDICATIONS 30.
31 AIM OF RADIATION THERAPY CURATIVE PALLIATIVE (total dose Gy) (total dose Gy) Curative treatment DEFINITIVE (exclusive) RADIOTHERAPY RADIOCHEMOTHERAPY POSTOPERATIVE (total dose: Gy) (eradiacation of microscopical residualis tumor cell) 31.
32 BEFORE RADIOTHERAPY DENTAL CARE IS REQUIRED! 32.
33 T1-2 N0-1 MULTIMODAL TREATMENT OF HEAD AND NECK TUMORS RADIOTHERAPY or SURGERY (except epipharyngeal cancer ) T3-4 N0-3 or T1-4 N2-3 RADIO/CHEMO/THERAPY SURGERY +/- POSTOPERATIVE IRRADIATION or POSTOPERATIVE RADIOCHEMOTHERAPY INDUCTION CHEMOTHERAPY + RADIOCHEMOTHERAPY OR SURGERY CETUXIMAB + RADIOTHERAPY 33.
34 RADIOCHEMOTHERAPY (RCT) IN THE THERAPY OF LOCOREGIONAL ADVANCED PHARYNGEAL AND LARYNGEAL TUMOR CONCOMITANT RCT: STANDARD TERATMENT 100 mg/m 2 Cisplatin (days: 1, 22 & 43) LOCAL TUMORCONTROLL: 18-26% OVERALL SURVIVAL: 6,5 % Pignon J.P., et al. Radiother Oncol 92:4-14, Meta-Analysis of Chemotherapy in head and neck cancer (MACH-NC): An update on 93 randomised trials and patients 34.
35 RADIOSENSITIVITY OF PHARYNGEAL TUMORS NASOPHARYNX OROPHARYNX tonsilla, tonsillar arch, palatum molle, uvula, lateral and posterior paharyngeal wall, base of tongue HYPOPHARYNX sinus pyriformis, posterior pharyngeal wall, postcricoid region + - Radiosensitivity 35.
36 RT OF NASOPHARYNGEAL TUMOR 90% poorly differentiated nasopharyngeal cc. (lymphoepitelioma) Radiosensitive tumor! PRIMARY TREATMENT = RADIO/CHEMO/THERAPY Gy EBI 60 Gy EBI + 4 x 4 Gy BT EBI: external beam irradiation; BT: brachytherapy 36.
37 RT OF NASOPHARYNGEAL TUMOR Lateral field Epipharynx + upper neck Anterior field Lower neck 37.
38 BT OF NASOPHARYNGEAL TUMOR 38.
39 RT OF OROPHARYNGEAL TUMOR PRIMARY TERATMENT: RT * or CONCOMITANT RCT ** T1-2 N0-1 uvula, tonsilla, base of tongue: SURGERY T3-4, N2-3: RADICAL SURGERY + POSTOP. RT QUALITY OF LIFE!!! (After surgery) * Radiotherapy ** Radiochemotherapy 39.
40 RT OF OROPHARYNGEAL TUMOR POSTOPERATIVE RT: Gy PRIMARY RT: Gy 40.
41 BT BASE OF TONGUE 41.
42 3-DIMENSIONAL (CONFORMAL) RADIOTHERAPY OF THE OROPHARYNGEAL TUMOR 42.
43 3-DIMENSIONAL (CONFORMAL) RADIOTHERAPY OF THE OROPHARYNGEAL TUMOR 43.
44 44.
45 3-DIMENSIONAL (CONFORMAL) RADIOTHERAPY OF THE OROPHARYNGEAL TUMOR 45.
46 RT OF HYPOPHARYNGEAL TUMOR PRIMARY TREATMENT: T1-2N0 SURGERY +/- POSTOP. RT or RT N+ or T2-4 SURGERY +/- POSTOP. RT/RCT or RCT or INDUCTION CHEMOTHERAPY 46.
47 RT OF GLOTTIC TUMOR GLOTTIC-SUPRAGLOTTIC TUMOR: T1-2 N0: RT ALONE or SURGERY (QUALITY OF LIFE!!!) T1-2 N+, T3 N0/+, EARLY T4 : CONCOMITANT RCT or TOTAL LARYNGECTOMY (QOL!!!) ADVANCED T4 (SOFT TISSUE - BESE TONGUE): TOTAL LARYNGECTOMY + POSTOP. RT SUBGLOTTIC TUMOR: STANDARD TREATMENT: TOTAL LARYNGECTOMY + POSTOP. RT 47.
48 TREATMENT ALGORYTHM OF EARLY STAGE VOCAL CORD CANCER T1-2N0 vocal cord carcinoma high differentiated T1N0 others transoral laeser or RT RT local recurrence previously no RT previously RT RT operation recovery local recurrence inapposite for PO unadapted for PO-re controll PL TL recovery local recurrence controll RT: radiotherapy, PO: partial operation, PL: partial laryngectomy, TL: total laryngectomy 48. TL
49 CUTAN LYMPHOMA RT before RT after RT 49.
50 SKIN CANCER - RT before RT after RT 50.
51 5-YEAR RESULTS OF PHARYNGEAL AND LARYNGEAL TUMORS TREATED WITH RADIOTHERAPY ALONE (%) NASOPHARYNX HYPOPHARYNX MESOPHARYNX LARYNX 51.
52 SIDE EFFECTS OF RADIOTHERAPY MUCOSITIS/EPITHELITIS XEROSTOMY (IMRT) DECREASED Ig-A LEVEL (CARIES) DETERIORATION OF SENSE OF TASTE SOFT TISSUE/OSTEORADIONECROSIS INJURY OF THE SPINAL CORD 52.
53 53.
54 54.
55 55.
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