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HEAD and NECK CANCERS

HEAD and NECK CANCERS. Elshami Elamin, MD. Head and neck surgery Radiation oncology Medical oncology Plastic and reconstructive surgery Specialized nursing care Dentistry/prosthodontics Physical medicine and rehabilitation Speech and swallowing therapy. Clinical Social work

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HEAD and NECK CANCERS

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  1. HEAD and NECK CANCERS Elshami Elamin, MD

  2. Head and neck surgery Radiation oncology Medical oncology Plastic and reconstructive surgery Specialized nursing care Dentistry/prosthodontics Physical medicine and rehabilitation Speech and swallowing therapy Clinical Social work Nutrition support Pathology Diagnostic radiology Adjunctive services Neurosurgery Ophthalmology Psychiatry Addiction Services MULTIDISCIPLINARY TEAM

  3. SUPPORT AND SERVICES • Pain and symptom management • Nutritional support: • Enteral feeding • Dental care for RT effects • Oral supplements • Xerostomia management • Smoking cessation • Tracheotomy care • Social work and Case management • Supportive Care

  4. Lymphatic drainage of the head and neckand associated sites of primary tumorsLymphatic drainage • Level I • Submental: Lower lip, chin, anterior oral cavity (including anterior one-third of the tongue and floor of the mouth) • Submandibular: Upper and lower lips, oral tongue, floor of the mouth, facial skin • Level II • Oral cavity and pharynx (including soft palate, base of the tongue, and piriform sinus) • Level III • Larynx, hypopharynx, and thyroid • Level IV • Larynx, hypopharynx, thyroid, cervical esophagus, and trachea • Level V • Nasopharynx, thyroid, paranasal sinuses, and posterior scalp • Supraclavicular: Infraclavicular sites (including lungs, esophagus, breasts, pancreas, GI tract, GU and gynecologic sources)

  5. Ethmoid Sinus Tumors • Squamous cell carcinoma • Undifferentiated carcinoma • Adenocarcinoma • Salivary gland tumor • Esthesioneuroblastomas • Sarcoma (nonrhabdomyosarcoma)

  6. Ethmoid Sinus TumorsTreatment • T1, T2: • Complete surgical resection (preferred) or • Adj RT or Chemo/RT if adverse characteristics (positive margins and perineural invasion) • Definitive RT • T3, T4 resectable: • Complete surgical resection • Postoperative RT • Unresectable: • Chemo/RT or • RT or • Clinical trial (preferred)

  7. Ethmoid Sinus TumorsTreatment • Incomplete excision (eg, polypectomy, endoscopic procedure) • Gross residual disease: • Surgery (preferred), if feasible • Adj RT • RT or • Chemo/RT • No disease on physical exam, imaging, and/or endoscopy: • RT or • Surgery, if feasible • Adj RT

  8. Maxillary Sinus Tumors • Squamous cell carcinoma • Undifferentiated carcinoma • Adenocarcinoma • Salivary gland tumor • Esthesioneuroblastoma • Sarcoma (nonrhabdomyosarcoma)

  9. Maxillary Sinus TumorsTreatment • T1, N0 (all histologies): Complete surgical resection: • Margin –ve: • Observe • Perineural invasion: • Consider RT or • chemo/RT • Margin +ve: • reresection • Margin –ve  RT • Margin +ve  chemo/RT • T2, N0 (SCC, Undifferentiated): • Complete surgical resection: • Margin -ve  Consider RT • Perineural invasion  Consider RT or chemo/RT • Margin +ve  reresection • Margin –ve  RT • Margin +ve  chemo/RT • T2, N0 (Adenoidcystic, other histologies) • Complete surgical resection  RT

  10. Maxillary Sinus Tumors • T3, N0, Operable T4 (all histologies): • Complete surgical resection: • Adverse characteristics: • Chemo/RT to primary and neck • No adverse characteristics: • RT to primary and neck (SCC and undifferentiated) • T4, inoperable (all histologies): • Clinical trial or • Definitive RT or • Chemo/RT • Any T, N+, resectable: • Surgical excision + neck dissection: • Adverse characteristics: • Chemo/RT to primary and neck • No adverse characteristics: • RT to primary and neck

  11. Maxillary Sinus TumorsPRINCIPLES OF RT • Definitive RT: • Primary and gross adenopathy: • > 66 Gy • Neck: • Low-risk nodal stations: • > 50 Gy • Postoperative RT: • Primary: • > 60 Gy • Neck • High-risk nodal stations: • > 60 Gy • Low-risk nodal stations: • > 50 Gy

  12. Salivary Gland Tumors(Parotid, Submaxillary, Minor salivary) • Characteristics of benign tumor: • Mobile superficial lobe • Slow growth • Painless • VII intact • No neck nodes.

  13. Salivary Gland Tumors(Parotid, Submaxillary, Minor salivary) • Untreated resectable: clinically benign (< 4 cm: T1, T2): • Complete surgical excision: • Benign or low G  Observe • Adenoid cystic  RT to tumor bed and skull base • Intermediate or high G  RT to tumor bed and ips neck • Untreated resectable, clinically Suspicious (> 4 cm or deep lobe): • CT/MRI base of skull to clavicle  FNA (salivary tumor): • Surgical resection: • Benign  Observe • Cancer see treatment

  14. PAROTID GLAND • Superficial lobe: • Node –ve: • Parotidectomy • Node +ve: • Parotidectomy + neck dissection • Deep lobe: • Node –ve: • Total parotidectomy • Node +ve: • Total parotidectomy + neck dissection

  15. PAROTID GLAND • Completely excised: • No adverse characteristics • Observe • Adverse characteristics (Intermediate or high G, adenoid cystic, Close or +ve margins, neural/perineural invasion, Lymphatic/ vascular invasion, LN mets) • Adj RT or Consider Chemo/RT • Incompletely excised, gross residual disease (No further surgical resection possible): • Definitive RT or Chemo/RT

  16. Other salivary gland tumors • Complete excision +/- LN dissection: • No adverse characteristics: • Observe • Adverse characteristics (Intermediate or high G, adenoid cystic, Close or +ve margins, neural/perineural invasion, Lymphatic/ vascular invasion, LN mets) • Adj RT or Consider Chemo/RT

  17. Salivary Gland Tumors (Parotid, Submaxillary, Minor salivary) • Previously treated incompletely resected: • Negative P/E and imaging: • Adj RT • Gross residual disease: • Surgical resection, if possible: • Adj RT • No surgical resection possible: • Definitive RT or Chemo/RT • Not resectable: • FNA or open biopsy • Definitive RT or Chemo/RT

  18. F/U • Physical exam: • Year 1 q 1–3 m • Year 2, q 2–4 m • Years 3–5 q 4–6 m • > 5 years q 6–12 m • Chest imaging as clinically indicated • TSH every 6-12 m if neck irradiated • CT scan/MRI- baseline

  19. Salivary Gland TumorsRecurrence • Locoregional or distant, Resectable: • Surgery + selected metastasectomy RT • Locoregional, Not resectable: • RT or • Chemo/RT or • Chemotherapy or • Best supportive care

  20. Salivary Gland TumorsPRINCIPLES OF RADIATION THERAPY • Definitive RT: • Unresectable or gross residual disease: • Photon/electron therapy or neutron therapy • Primary and gross adenopathy: • > 70 Gy or • 19.2 nGy • Low-risk nodal stations: • 45-54 Gy or • 13.2 nGy • Postoperative RT: • Photon/electron therapy or neutron therapy • Primary: • > 60 Gy or • 18 nGy • Neck: • 45-54 Gy or • 13.2 nGy

  21. Cancer of the Lip • T1–2, N0: • Surgery or RT • Resectable T3, T4, N0 and any T, N1-3: • Surgery  Adj RT +/- Chemo if high risk or • RT or Chemo/RT if not surgical candidate • Unresectable: • RT or Chemo/RT or best supportive care

  22. Cancer of the Oral Cavity(Buccal mucosa, floor of mouth, anterior tongue, alveolar ridge, retromolar trigone, hard palate) • H&P • Biopsy • Chest x-ray or Chest CT • As indicated for evaluation: • Panorex • CT/MRI • Examination under anesthesia • Preanesthesia studies • Dental evaluation • Multidisciplinary consultation as indicated

  23. Cancer of the Oral Cavity • T1–2, N0:- • RT  salvage surgery for residual dz OR • excision of primary ± unilateral or bilateral selective neck dissection  adj RT +/-chemo (high risk pts); • High Risk:- Extracapsular nodal dz, +ve margins, multiple +ve LN or perineural/lymphatic/vascular invasion. • Resectable T3, N0: • Excision of primary and reconstruction + unilateral or bilateral selective neck dissection; • Adj RT (optional) • High Risk: Adj RT +/- chemo

  24. Cancer of the Oral Cavity (Resectable T1-3, N1-3) • N1, N2a-b, N3: • Excision of primary, ipsi comprehensive neck dissection ± contra selective neck dissection • N2c (bilateral): • Excision of primary and bilateral comprehensive neck dissection • Adj Therapy: • RT (optional) • High Risk; RT +/- chemo

  25. Cancer of the Oral Cavity • Resectable T4, Any N: • Surgery (preferred for bone invasion)Chemo/RT or • Chemo/RT  Surgery for residual dz (primary or LN)

  26. Cancer of the Oropharynx(Base of tongue/tonsil/posterior pharyngeal wall/soft palate) • H&P • Biopsy • Chest x-ray or Chest CT • CT with contrast or MRI recommended for primary and neck • Panorex as indicated • Dental evaluation as indicated • Speech & swallowing evaluation as indicated • Examination under anesthesia with laryngoscopy • Preanesthesia studies • Multidisciplinary consultation as indicated

  27. Cancer of the OropharynxT1-2, N0-1 • Definitive RT (preferred): • surgery for residual dz • Concurrent chemo/RT (T1-T2, N1 only): • surgery for residual dz • Excision of primary ± unilateral or bilateral neck dissection: • One +ve node without adverse features: • Consider RT • Adverse features: • RT or Chemo/RT (multiple +ve nodes only)

  28. Cancer of the OropharynxT3-4, N0 • Concurrent chemo/RT (preferred): • Salvage surgery if residual dz • Surgery + RT: • RT +/- Chemo if high risk or adverse features • Induction chemo followed by chemo/RT off protocol: • Salvage surgery if residual dz • Multimodality clinical trial

  29. Cancer of the Oropharynxany T3-4, N+ or any T, N2-3 • Concurrent chemo/RT (preferred): or • Induction chemo followed by chemo/RT off protocol: • Residual Primary tumor: • Salvage surgery + neck dissection as indicated • Residual neck mass Neck dissection • CR but initial N2-3; • Observe or Neck dissection • OR --- 

  30. Cancer of the Oropharynxany T3-4, N+ or any T, N2-3 • Surgery: primary and neck: • N1, N2a–b, N3; • Excision of primary, ipsi neck dissection • N2c; • Excision of primary and bilateral neck dissection • Adj RT or Chemo/RT • Multimodality clinical trial

  31. PRINCIPLES OF RT • Conventional fractionation: 70 Gy (2 Gy/d) in 7 wks • Altered fractionation: 72 Gy/6 weeks (1.8 Gy/d, 1.5 Gy/d boost daily during last 12 treatment days) • Hyperfractionation: 81.6 Gy/7 weeks (1.2 Gy bid) • Primary and gross adenopathy • > 70 Gy (2 Gy/d) • Neck • Low risk: 44-50 Gy (2 Gy/d) • Postoperative RT: • Primary: 60 Gy (2 Gy/d) • Neck • High-risk: 60 Gy (2 Gy/d) • Low-risk:50 Gy (2 Gy/d) • Concurrent Therapy: Conventional RT + Cisplatin 100 mg/m q 3 wk • Use of other fraction sizes and multiagent chemotherapy, has been evaluated with no consensus on the optimal approach.

  32. Cancer of the Oral CavityOropharynxF/U • Physical exam: • Year 1, every 1-3 m • Year 2, every 2-4 m • Years 3-5, every 4-6 m • > 5 yr, every 6-12 m • Chest imaging as clinically indicated • TSH every 6-12 m, if neck irradiated • Speech and swallowing evaluation and rehabilitation as indicated

  33. Hypopharynx (laryngopharynx)entrance to the esophagusWork-up • H&P • Biopsy • Chest x-ray or Chest CT • CT with contrast or MRI of primary and neck • Examination under anesthesia with laryngoscopy and esophagoscopy • Preanesthesia studies • Dental evaluation • Multidisciplinary consultation as indicated

  34. Cancer of the Hypopharynx • Early T stage not requiring total laryngectomy: • Most T1, N0-1 • Small T2, N0 • Resectable advanced cancer requiring total laryngectomy: • T1, N2-3 • T2-4, Any N • Participation in clinical is preferred • Unresectable

  35. Early T stage (not requiring total laryngectomy) Most T1, N0-1, small T2, N0 • Definitive RT: • Neck dissection (selective vs comprehensive) if residual dz • Surgery: Partial laryngopharyngectomy + • Ipsi or bilateral selective neck dissection (N0) • Comprehensive neck dissection levels 1-5 (N1) • Adj RT or Chemo/RT if adverse features: • Extracapsular nodal spread • +ve margins • Multiple +ve nodes • Perineural/lymphatic/vascular invasion

  36. T1, N2-3; T2-3, any N (if total laryngectomy required) • Induction chemotherapy x 2 cycles: • CR of primary site: • Definitive RT: • Residual neck mass  Neck dissection • CR of neck  if initial N2-3Observe or neck dissection • PR of primary site: • Chemo x 1 cycle: • CR of primary  definitive RT • Residual neck mass  Neck dissection • CR of neck  if initial N2-3Observe or neck dissection • Residual primary  savage surgery; • RT or chemoRT depending on adverse features • Less than PR of primary: • Surgery: • RT or chemoRT depending on adverse features

  37. T1, N2-3; T2-3, any N (if total laryngectomy required) • Laryngopharyngectomy + selective (N0) or comprehensive (N+) neck dissection • Adj RT or ChemoRT depends on adverse features • Concurrent chemoRT: • CR of primary; • Residual neck mass  Neck dissection • CR of neck  if initial N2-3 observe or neck dissection • PR of primary; • Salvage surgery + neck dissection as indicated • Multimodality clinical trial

  38. Hypopharynx T4, any N • Surgery + comprehensive neck dissection • Chemo/RT • Concurrent chemo/RT: • CR of primary: • Residual neck mass  Neck dissection • CR of neck; N1  observe • if initial N2-3  observe or neck dissection • PR of primary: • Salvage surgery + neck dissection as indicated • Multimodality clinical trial

  39. HypopharynxPRINCIPLES OF RADIATION THERAPY • Definitive RT • Primary and gross adenopathy: • > 70 Gy (2 Gy/d) • Neck; low risk > 50 Gy (2 Gy/d) • Postoperative RT: • Primary: > 60 Gy (2 Gy/d) • Neck; • high-risk > 60 Gy (2 Gy/d) • Low-risk > 50 Gy (2 Gy/d) • Postoperative chemoRT for high risk: • Concurrent Cisplatin 100 mg/m q 3 wks

  40. Occult Primary • Neck mass  FNA • SCC • Adenocarcinoma • Anaplastic Epithelial tumors WORK-up • Complete head and neck exam with attention to skin, including nasopharyngoscopy • Chest x-ray • CT or MRI (skull base through thoracic inlet) • PET scan • Examination under anesthesia • Direct laryngoscopy and nasopharynx survey • If level IV, lower V nodes: • Bronchoscopy, EGD • Chest/abdominal/pelvic CT

  41. Occult Primary (NO primary found) • Adenocarcinoma (levels I–III): • Comprehensive neck dissection + parotidectomy, if indicated • RT to neck ± parotid bed • SCC: • Comprehensive neck dissection • N1  Adj RT • Extracapsular spread or N2, N3  RT or ChemoRT • Poorly diff or nonkeratinizing SCC or NOS or Anaplastic (Not thyroid) : • Comprehensive neck dissect  Adj RT +/- chemo or • RT or Chemo RT • Residual dz  Comprehensive neck dissect

  42. Cancer of the Glottic Larynxwork-up • H&P • Biopsy • Chest x-ray or Chest CT • CT with contrast and thin cuts through larynx, or • MRI of primary and neck • Examination under anesthesia with laryngoscopy • Preanesthesia studies • Dental evaluation as indicated • Speech & swallowing evaluation as indicated • Multidisciplinary consultation as indicated

  43. Glottic Larynx Severe dysplasia/CIS • Clinical trial or • Endoscopic removal (stripping/laser) or • RT

  44. Glottic LarynxTotal laryngectomy not required(Most T1-2, any N) • RT to primary > 66 Gy or • Partial laryngectomy/endoscopic resection (selected superficial lesions) or • Open partial laryngectomy • N-ve  observe • N+ve  Neck dissection and/or RT

  45. Glottic LarynxResectable requiring total laryngectomyMost T3, any N • Concurrent chemoradiation: • Primary and neck CR observe • if initial N2-3Observe or neck dissection • Primary CR, neck PR  Neck dissection • Primary PR  Salvage surgery + neck dissection as indicated

  46. Glottic LarynxResectable requiring total laryngectomyMost T3, any N • Surgery: • N0:- • Laryngectomy with ipsi thyroidectomy +/- unilat or bilateral selective neck dissection • N1:- • Laryngectomy with ipsi thyroidectomy, ipsi comprehensive neck dissection ± contral selective neck dissection • N2-3:- • Laryngectomy with ipsi thyroidectomy, ipsi or bilateral comprehensive neck dissection • Adj Therapy: • If adverse features: (Extracapsular nodal spread +ve margins, multiple +ve LN or perineural/lymphovascular invasion) • Adj RT +/- chemo

  47. Glottic LarynxT4 • Selected T4: • Consider concurrent chemoRT or • Clinical trial for function preserving • Primary and neck CR observe • if initial N2-3Observe or neck dissection • Primary CR, neck PR  Neck dissection • Primary PR  Salvage surgery + neck dissection as indicated

  48. Glottic Larynx T4, Any N • N0:- • Laryngectomy with ipsi thyroidectomy +/- unilat or bilateral selective neck dissection • N1:- • Laryngectomy with ipsi thyroidectomy, ipsi comprehensive neck dissection ± contral selective neck dissection • N2-3:- • Laryngectomy with ipsi thyroidectomy, ipsi or bilateral comprehensive neck dissection • Adj chemo/RT

  49. Glottic LarynxPRINCIPLES OF RADIATION THERAPY • Definitive RT • Primary and gross adenopathy: • > 70 Gy (2 Gy/d) • For early cancer of the glottic larynx, preferred dose is 2 Gy/d with total dose modification accordingly • Neck • Low-risk: > 50 Gy (2 Gy/d) • Postoperative RT • Primary: > 60 Gy (2 Gy/d) • Neck • High-risk: > 60 Gy (2 Gy/d) • Low-risk > 50 Gy (2.0 Gy/day) • Postoperative chemoradiation for high pathologic risk features: • Concurrent Cisplatin at 100 mg/m q 3 wks

  50. Glottic LarynxF/U • Physical exam: • Year 1, every 1-3 m • Year 2, every 2-4 m • Years 3-5, every 4-6 m • > 5 years, every 6-12 m • Chest imaging as clinically indicated • TSH every 6-12 m, if neck irradiated • Speech and swallowing evaluation and rehabilitation as indicated

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