Head and Neck Cancer Flashcards by Amrita Nag

Aetiology

Male more common than female
Smoking
Alcohol
Marijuana

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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

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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

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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)

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Histology of HN Cancer

SCC most common

Other: Adeno-carcinoma, Adenoid cyst, Muco-epidermoid, Plasmacytoma, Lymphoma, Melanoma

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Staging of HN Cancer

TNM

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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)

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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

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Indications for Post Op RT

Locally advanced disease
Close/positive margins
3 or more nodes involved
Extracapsular spread
Lymph vascular or peri neural spread

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Indications for Post op CT/RT

Positive margins

Extracapsular spread

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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

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Acute Side Effects of Head and Neck RT

Lethargy
Nausea/Vomiting
Skin changes
Alteration in taste
Dysphagia
Odynophagia
Alteration in saliva consistency

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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

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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

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Patient Management of HN Patients

Daily review (RT, nurses)

Weekly review by medical staff

Allied health review (dietician, speech pathology, social work, OT, physio)

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Oral Cavity Anatomy

Comprised of Buccal Cavity, alveolus, hard palate, tongue, floor of mouth

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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

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Function of Larynx

Protect airway

Vocalisation

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Clinical Presentation of Larynx Cancer

Hoarse/husky voice

Local pain

Mass in neck

Airway compromise

Aspiration

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Early Glottic Cancer Classification

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Characterised with low incidence of nodes
T

Early Glottic Cancer Treatment Options

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RT
Surgery (conservative)
Laser (currently under investigation)

RT Treatment position for Glottis Cancer

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Supine, head first
Shell
Hands on chest/by side
Knee bolster
Head rest

RT Planning for EGC

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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)

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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

Head and Neck Cancer Flashcards

(49 cards)