HEAD AND NECK CANCER

DR :OMER HASHIM

head &neck cancer Diagnosis

Other1%

Leukemias5%Lymphomas

9%

Salivary gland tumours

7%

Squamous cell carcinomas

78%

Treatment planning bases

Staging of disease using TNM classification T = Tumor size N = Nodal status M = Metastasis

Eg. T3N2M0 laryngeal carcinoma

Age of the patient

co-morbid conditions :- Medical Dental Speech Nutritional Psychosocial Socioeconomic

Preparing patients

Full history &examination :- concurring symptoms analysis :- presenting symptoms – compression – LNs & metastasis .

Fully head & neck examination –cranial nerves examination

Work up :- CBC _RFT LFTImage CT

CT scan: Accurate information about pneumatization, integrity of bony structures.MRI: soft tissue extension, Perineural, perivascular infiltration, intracranial extension.Base of skull CT? MRI?.Imaging before or after Biopsy? Larynx?

MR of choice in: Parotid, facial area, skull base (intracranial extension), Any tumor with potential perineural affection, oral cavity and oropharynx.T2 WI excellent tumor to muscle enhancement.T2 allows differentiation between secretions and mucosal thickening together with tumor which have low signal (Low water content).In T1 look at the tumor invading Fat.(Fat shows high signal in T1).

STOP SMOKING

Dental Consultation

CONSENT

Dental Treatment

• Must be done immediately

– no delay in radiotherapy– cancer is progressing!!

Dental Treatment

• Extractions– abscesses, gross caries– advanced periodontal disease– heavily restored teeth w/ poor OH

Must have 2 weeks healing prior to start of radiotherapy!!!

CleaningRestorations

Complete these during healing phase post-extraction

Dental Treatment

• Dentate?– daily topical application– 1.23% APF gel– 2% Neutral NaF gel

Treatment of the early stage

Primary surgery Primary radiotherapy

XRTCCH+XRT

Salvage surgery

Locally advanced stage

Usually treated with concurrent CH &XRT with Salvage surgery if not in CR

Types of radiotherapy

XRT

Radical XRT

Post operative

XRT

Treatment Techniques

Basic treatment technique: for the majority:- Two lateral and one lower anterior fields.- First including the spinal cord in phase I and

then off cord for phase II.

Overlapping RegionProblem

WHY IT’S A PROBLEM?

Ways To Solve this Overlap

Gap between two fields calculated by :

½ field1 length x depth/SSD + ½ field2 length x depth/SSD

Block the spinal cord in the anterior field

Use Collimator and Couch angle.Disadvantage :-Time consummating ,table movement from

inside

Field boarders

Superior border according to the site of the disease

Whenever possible avoid : Optic pathways, part of the TMJ and auditory canal from the portals.

1- At the base of skull when we want to include the retropharyngeal node, e.g. Hypopharynx.

Above base when the site is already in the base, e.g. nasopharynx

• Superior border:NasopharynxHypopharynxOropharynxOral cavity:Larynx

Above skull base. because the primary at skull base.

Skull base? Retropharyngeal nodes

Skull base? Primary at skull base.

Do you want lymph node? So skull base/If not take only a margin (1 to 2 cm).

Glottic? Above the glottis.

Supraglottic? Lymph nodes so skull base.

Subgltic (very rare) only margin above the larynx.

Glottic with extensive supra? Skull base.

Lower border :-

above the arytenoids

put it as low as possible

If you can I protect the larynx

If you cant not the larynx

Dot cut in lymph nodes

Anterior border :-Covering skin over the larynx

A strip of the anterior midline skin is usually spared whenever possible to minimize lymph-drainage impairment after irradiation.

tumor extend to anterior s/c tissue, large submandibular,Ns jugular LNs are present, Surgical scar? Extracapsular extension

Lymph nodes covered

• Group I: Low risk: 20%.T1 Floor of mouth, oral tongue, retromolar trigone,

gingiva, hard palate, buccal m

• Group II Intermediate risk 20–30%T1: Soft palate, pharyngeal wall, supraglottic larynx,

tonsil T2: Floor of mouth, oral tongue, retromolar trigone,

gingiva, hard palate, buccal mucosa

• Goup: III High risk>30% T1–T4Nasopharynx, pyriform sinus, base of tongue.

T2–T4: Soft palate, pharyngeal wall, supraglottic larynx, tonsil .

T3–T4: Floor of mouth, oral tongue, retromolar

trigone, gingiva, hard palate, buccal mucosa.

Posterior border:If N0 with low risk of subclinical spread to the

posterior cervical nodes, the posterior border is placed behind the insertion of the sternomastoid.

If N+ cases or primary tumors with substantial spread to the posterior cervical nodes, posterior border placed behind the spinous process or with good safety margin to the

No evidance that shower increase skin dose

Nasopharynx, oropharynx, or Oral Cavity the junction should be made above the thyroid notch (thus the anterior spinal cord shield protect the larynx as well).

In the hypopharynx and the larynx we avoid midline shield.

Tumor site +ve LNS clinical or pathological Surgical role LNs dissected or not

Acute complication

General

Nausea vomiting Fatigue Wt loss

Extra-Oral

Cuteneous burns Alopecia Xeroderma

intraoral

erythema Mucositis ulceration

Dysphagia

CANDIDIASIS

TREATMENT:

1. Nystatin 100,000 u/ml oral suspension

5 mL (1 tsp.) P.O. qid

Swish for 1 min. and swallow

**If another organism or systemic infection is

suspected, alert the medical oncologist immediately**

ORAL MUCOSITIS

TREATMENT:

2. Diphenhydramine (Benadryl) elixir

Mixed with Kaopectate or Maalox 1:1

by pharmacist

15 mL (1 Tbsp.) P.O. prn pain

Swish for 30 sec. then spit out

Chronic complication

Xerostomia

Usually began I week after treatment .• Problems with xerostomia

–increased caries risk• daily topical fluoride application• frequent recalls - every 3 months• increased cost to patient

Problems with xerostomia

increased trauma risk soft tissues very dry easily injured

Problems with xerostomia thick secretions

change in mucous:serous ratio increased “gag” difficulty wearing dentures

Problems with xerostomia difficulty swallowing

H2O with/between meals chronic Candidiasis

Trismus

2o to fibrosis of musclesexacerbated by pre-XRT trauma (ie. Surgery)

Problems with trismusimpaired nutrition if severevery limited access for dental treatment

restorationscleaninginability to make/wear dentures

Treatment for trismus

Physiotherapy for trismus

Edema

2o to decreased lymphatic drainage from fibrosisnot usually a functional problem but cosmetic

Soft tissue necrosis

2o to trauma 2o

to ischemia

Areas most susceptible hard/soft palate FOM, ventral surface of tongue mucosa overlying internal oblique ridge

Treatment

Refer to the surgery

steoradionecrosis

“death of bone following radiation”

hypoxic injurydevitalized bone will often not be painful!patient may not be aware of it - LOOK!radiographic changes may/may not be present

Problems with Osteoradionecrosissuperinfection with bacteria/fungussharp spicules will traumatize other soft tissues - more problemscan be progressive, potential “en bloc” resection

Hyperbaric Oxygen Therapy