Principles and Practice of Radiation Therapy Chapter 33 Head and Neck Cancers Copyright © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

Head and Neck Cancers Nasopharynx Oral Hypopharynx and larynx Lip Oral cavity Oral tongue Floor of mouth Oropharynx Hypopharynx and larynx Paranasal sinuses Salivary glands Orbit Epidemiology Etiology Clinical presentation Detection and diagnosis Patterns of spread Disease classification Treatment Survival

Nasopharynx Epidemiology Incidence 2000 new cases Age Gender Race Worldwide Asia Chinese immigrants

Nasopharynx Etiology Causes Risk factors Unknown Diet Epstein-Barr virus (EBV) Tissue type Heredity

Nasopharynx Clinical Presentation Symptoms Neck mass Hearing loss Nasal blockage Others

Nasopharynx Detection and Diagnosis Types Keratinizing squamous cell carcinoma Nonkeratinizing carcinoma Undifferentiated carcinoma Lymphoepithelioma

Nasopharynx Detection and Diagnosis Imaging Magnetic resonance imaging (MRI) Positron emission tomography (PET)

Nasopharynx Patterns of Spread Lymphatics 80% of patients are node positive at diagnosis Metastases Bone Lung Liver

Nasopharynx Disease Classification Tumor Node Metastasis (TNM) T1 T2a T2b T3 T4 N0 N1 N2 N3

Nasopharynx Treatment Surgery Rarely used Neck dissection Selective Modified radical Radical

Nasopharynx Treatment Chemotherapy Timing Agents Cisplatin 5-fluorouracil (5-FU) Doxorubicin Epirubicin Bleomycin Mitoxantrone Methotrexate Vinca alkaloids

Nasopharynx Treatment Radiation therapy Treatment of choice Radiosensitive Standard head and neck (H&N) treatment

Nasopharynx Treatment Radiation therapy Three-field technique Opposed laterals Supraclavicular (SCV) Off cord Posterior triangles

Nasopharynx Treatment Radiation therapy Borders Lateral Superior Inferior Anterior Posterior

Nasopharynx Treatment Radiation therapy Borders SCV Superior Inferior Lateral

Nasopharynx Treatment Radiation therapy Borders Off cord Posterior Posterior triangle Blocking

Nasopharynx Treatment Radiation therapy Beam energy Photons 6 MV Electrons Depth dependent Dose Laterals 4500 cGy SCV 5040 cGy Total dose 6500 to 7500 cGy

Nasopharynx Treatment Radiation therapy Side effects Xerostomia Effect of intensity-modulated radiation therapy (IMRT)

Nasopharynx Survival Recurrence rate 5-year survival Local failure Regional failure 5-year survival

Oral General Information Leukoplakia Erythroplakia Dysplasia Determination of cancer Biopsy Toluidine Laser Acetic acid

Oral Epidemiology Incidence Deaths Race Age Worldwide 35,000 new cases 7500 annually Race Age Worldwide

Oral Etiology Causes Risk factors Unknown Tobacco Cigarettes Pipes Smokeless Secondhand smoke

Oral Etiology Risk factors Alcohol Ultraviolet (UV) rays Irritation Dentures Nutrition Plummer-Vinson syndrome

Oral Etiology Risk factors Mouthwash Human papillomavirus (HPV) Immunosuppression Lichen planus Gender

Oral Clinical Presentation Location Oral tongue Lips Floor of mouth Minor salivary gland Gums

Oral Clinical Presentation Symptoms Sore Pain Lump White or red patch Sore throat

Oral Detection and Diagnosis Types Squamous cell carcinoma Verrucous carcinoma Minor salivary glands

Oral Patterns of Spread Lip 5% to 10% present with positive nodes Floor of mouth and oral tongue 35% to 40% present with positive nodes Oropharynx Additional cancers 15% present with an additional cancer

Oral Disease Classification N2a N2b N2c N3

Oral Treatment Surgery Primary tumor resection Mandibular resection Maxillectomy Mohs microsurgery

Oral Treatment Surgery Neck dissection Pedicle or free flap reconstruction Dental extraction

Oral Treatment Chemotherapy Neoadjuvant Palliation Agents Cisplatin 5-FU

Oral Treatment Radiation therapy Lip cancers Indications Treatment parameters Single-field electron Internal shielding Dose 6000 to 7000 cGy

Oral Treatment Radiation therapy Floor of mouth and oral tongue Treatment parameters Standard H&N Tongue immobilization Dose Upper neck – 6500 to 7500 cGy SCV – 5040 cGy

Oral Treatment Radiation therapy Oropharynx Indications Treatment parameters Standard H&N Dose Upper neck – 6500 to 7500 cGy SCV – 5040 cGy

Hypopharynx and Larynx General Information Divisions of the larynx Glottis Supraglottis Subglottis

Hypopharynx and Larynx Epidemiology Incidence 11,300 new cases Decreasing by 2% to 3% per year Deaths 3660 per year

Hypopharynx and Larynx Etiology Causes Unknown Risk factors Tobacco Alcohol Nutritional deficits HPV Immunosuppression

Hypopharynx and Larynx Etiology Risk factors Occupational exposure Gender Age Race Gastroesophageal reflux disease (GERD)

Hypopharynx and Larynx Clinical Presentation Location Symptoms Laryngeal cancers Hoarseness Hypopharyngeal cancers Sore throat Cough Pain Mass

Hypopharynx and Larynx Detection and Diagnosis Types Squamous cell carcinomas Adenocarcinomas Chondrosarcomas

Hypopharynx and Larynx Patterns of Spread Vocal cords lack lymphatics Anatomically resistant to spread by direct extension Metastasizes to lung

Hypopharynx and Larynx Disease Classification Supraglottic T1 T2 T3 T4a T4b

Hypopharynx and Larynx Disease Classification Glottic T1 T1a T1b T2 T3 T4a T4b

Hypopharynx and Larynx Disease Classification Glottis T1: Tumor limited to vocal cord(s) (may involve anterior or posterior commissure) with normal mobility T1a: Tumor limited to one vocal cord T1b: Tumor involves both vocal cords T2: Tumor extends to supraglottis and/or subglottis, and/or with impaired vocal cord mobility T3: Tumor limited to the larynx with vocal cord fixation T4: Tumor invades through the thyroid cartilage and/or to other tissues beyond the larynx (e.g., trachea, soft tissues of neck, including thyroid, and pharynx)

Hypopharynx and Larynx Disease Classification Subglottic T1 T2 T3 T4a T4b

Hypopharynx and Larynx Disease Classification Hypopharyngeal T1 T2 T3 T4a T4b

Hypopharynx and Larynx Disease Classification N stages NX N0 N1 N2a N2b N2c N3

Hypopharynx and Larynx Treatment Surgery Vocal cord stripping Cordectomy Laser surgery

Hypopharynx and Larynx Treatment Surgery Partial laryngectomy Total laryngectomy Standard treatment for advanced disease Pharyngectomy Neck dissection Tracheotomy G-tube

Hypopharynx and Larynx Treatment Chemotherapy Agents 5-FU Cisplatin Chemoradiation

Hypopharynx and Larynx Treatment Radiation therapy Indications Primary treatment for early-stage glottic cancers Regional vs. local irradiation

Hypopharynx and Larynx Treatment Radiation therapy Parallel-opposed laterals Borders Anterior Posterior Superior Inferior

Hypopharynx and Larynx Treatment Radiation therapy Wedges Bolus Dose 6500 to 7000 cGy Hyperfractionation 7440 to 7680 cGy 120 cGy per fraction bid

Hypopharynx and Larynx Survival 5-year survival Glottic cancer Overall – 85% to 95% Node negative T3 – 65% Node positive T3 – 50% Node negative T4 – 40% Node positive T4 – 10%

Hypopharynx and Larynx Survival 5-year survival Supraglottic Stage I – 83% Stage II – 70% Stage III – 57% Stage IV – 43%

Hypopharynx and Larynx Survival 5-year survival Subglottis Stage I – 54% Stage II – 68% Stage III – 53% Stage IV – 36% 5-year survival Hypopharynx Stage I – 41% Stage II – 36% Stage III – 36% Stage IV – 10%

Paranasal Sinus Epidemiology Incidence 2000 new cases Gender Age More common in Asia and Africa

Paranasal Sinus Etiology Causes Unknown Risk factors Occupational exposures EBV Smoking

Paranasal Sinus Clinical Presentations Location Maxillary sinus Nasal cavity Ethmoid sinus Frontal sinus Sphenoid sinus

Paranasal Sinus Clinical Presentations Symptoms Asymptomatic in early stages Epistaxis Congestion Pain Drainage Loss of function

Paranasal Sinus Detection and Diagnosis Types Papillomas Benign Squamous cell Most common Adenocarcinoma and mucoepidermoid carcinoma Lymphomas

Paranasal Sinus Detection and Diagnosis Types Esthesioneuroblastoma Verrucous carcinoma Small cell neuroendocrine Teratomas Sarcomas Metastatic disease

Paranasal Sinus Patterns of Spread Metastatic disease is uncommon Lung Liver Bone Nodal disease

Paranasal Sinus Disease Classification TNM T1 T2 T3 T4 NX N0 N1 N2 N3

Paranasal Sinus Treatment Surgery Site specific Chemotherapy Historical treatment Gaining clinical support

Paranasal Sinus Treatment Radiation therapy Preoperative Treatment details are site specific Wedged-pair vs. single-field electron Dose 6000 cGy

Paranasal Sinus Survival Maxillary sinus Early stage – 80% Unresectable tumors – less than 20% Ethmoid sinus Low grade – 90% High grade – less than 20%

Salivary Gland Epidemiology Incidence Rare Age Gender Deaths 700 annually

Salivary Gland Etiology Cause Unknown Risk factor Radiation Occupational exposure Diet Tobacco Family history

Salivary Gland Clinical Presentation Location Parotid Submandibular Sublingual Minor 25/50/75 rule

Salivary Gland Clinical Presentation Symptoms Mass Pain Facial asymmetry Numbness

Salivary Gland Detection and Diagnosis Types Named according to tissue type Grading Mucoepidermoid Adenoid cystic

Salivary Gland Detection and Diagnosis Types Acinic cell Polymorphous low-grade adenocarcinoma

Salivary Gland Detection and Diagnosis Types Rare adenocarcinomas Basal cell Clear cell Cystadenocarcinoma Sebaceous Oncocytic Mucinous

Salivary Gland Detection and Diagnosis Types Malignant mixed tumors Carcinoma ex pleomorphic adenoma Squamous cell Undifferentiated Metastatic disease

Salivary Gland Detection and Diagnosis Imaging CT and MRI Ultrasound Nuclear medicine

Salivary Gland Patterns of Spread Increasing number of patients with advanced disease at diagnosis Nodular disease Metastatic disease Lung Bone

Salivary Gland Disease Classification TNM T1 T2 T3 T4 N1 N2a N2b N2c N3

Salivary Gland Treatment Surgery Parotidectomy Submandibular and sublingual gland surgery Frey’s syndrome

Salivary Gland Treatment Chemotherapy Poor response to chemotherapy Does not improve survival

Salivary Gland Treatment Radiation therapy Patient position Lateral oblique “Chicken wing” Immobilization Lateral uniframe Treatment includes tumor plus margin and unilateral cervical nodes

Salivary Gland Treatment Radiation therapy Dual energy 4:1 ratio of electrons to photons Alternative treatment techniques Dose Complete resection 6000 to 6500 cGy Incomplete resection 7000 to 7500 cGy

Salivary Gland Treatment Radiation therapy Neutron therapy Experimental

Salivary Gland Survival 5-year survival Overall – 68% 10-year survival Stage I – 83% Stage III – 32% Survival by grade Low grade High grade

Orbit General Information Primary cancers Melanoma Lymphoma Medulloepithelioma Retinoblastoma Secondary cancers

Orbit Epidemiology Incidence Age Deaths Approximately 2400 new cases 1300 melanomas Age Deaths Approximately 250 annually

Orbit Etiology Causes Risk factors Unknown Melanoma Lymphoma Eye color Inherited melanoma Oculodermal melanocytosis Sun exposure Welding Lymphoma Immunosuppression

Orbit Clinical Presentation Symptoms Changes in sight “Floaters” Dark spots Bulging Pain

Orbit Patterns of Spread Regional lymphatics Direct extension

Orbit Treatment Surgery Iridectomy Iridotrabeculectomy Iridocyclectomy Resection Enucleation

Orbit Treatment Chemotherapy Laser therapy Lymphoma Melanoma Rituxan Melanoma Laser therapy Transpupillary thermotherapy

Orbit Treatment Radiation therapy Brachytherapy Episcleral plaque therapy Technique Dose

Orbit Treatment Radiation therapy External beam radiation therapy (EBRT) Proton beam Spelled out EBRT

Orbit Survival Melanoma Stages I and II Stage III Stage IV Lymphoma