HEAD and NECK CANCERS Elshami Elamin, MD

MULTIDISCIPLINARY TEAM 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

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

Lymphatic drainage of the head and neck and associated sites of primary tumors Lymphatic 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)

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

Ethmoid Sinus Tumors Treatment 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)

Ethmoid Sinus Tumors Treatment 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: Surgery, if feasible

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

Maxillary Sinus Tumors Treatment 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 T2, N0 (Adenoidcystic, other histologies) Complete surgical resection  RT

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: RT to primary and neck

Maxillary Sinus Tumors PRINCIPLES 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:

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

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

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

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

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

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: No surgical resection possible: Definitive RT or Chemo/RT Not resectable: FNA or open biopsy

F/U Physical exam: Chest imaging as clinically indicated 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

Salivary Gland Tumors Recurrence Locoregional or distant, Resectable: Surgery + selected metastasectomy  RT Locoregional, Not resectable: RT or Chemo/RT or Chemotherapy or Best supportive care

Salivary Gland Tumors PRINCIPLES 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: Primary: > 60 Gy or 18 nGy Neck:

Cancer of the Lip T1–2, N0: Resectable T3, T4, N0 and any T, N1-3: 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

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

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

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

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)

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

Cancer of the Oropharynx T1-2, N0-1 Definitive RT (preferred) : surgery for residual dz Concurrent chemo/RT (T1-T2, N1 only): 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)

Cancer of the Oropharynx T3-4, 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: Multimodality clinical trial

Cancer of the Oropharynx any 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 --- 

Cancer of the Oropharynx any 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

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) 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.

Cancer of the Oral Cavity Oropharynx F/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

Hypopharynx (laryngopharynx) entrance to the esophagus Work-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

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

Surgery: Partial laryngopharyngectomy + 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

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 N2-3 Observe or neck dissection PR of primary site: Chemo x 1 cycle: CR of primary  definitive RT Residual primary  savage surgery; RT or chemoRT depending on adverse features Less than PR of primary: Surgery:

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

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

Hypopharynx PRINCIPLES 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

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

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

Cancer of the Glottic Larynx work-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

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

Glottic Larynx Total 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

Glottic Larynx Resectable requiring total laryngectomy Most T3, any N Concurrent chemoradiation: Primary and neck CR observe if initial N2-3 Observe or neck dissection Primary CR, neck PR  Neck dissection Primary PR  Salvage surgery + neck dissection as indicated

Glottic Larynx Resectable requiring total laryngectomy Most 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

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

Glottic Larynx T4, Any N N0:- N1:- N2-3:- Adj chemo/RT 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

Glottic Larynx PRINCIPLES 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) 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

Glottic Larynx F/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

Supraglottic Larynx Resectable not requiring total laryngectomy Most T1–2, N0 Endoscopic resection ± selective neck dissection or Open partial supraglottic laryngectomy ± selective neck dissection or Definitive RT Adj Therapy:- One +ve LN without other adverse features Consider RT Adverse features: (+ve margins or extracapsular nodal) ChemoRT

Supraglottic Larynx Resectable requiring laryngectomy (T3, N0; T4, N0) (No cartilage destruction, low-volume base-of tongue involvement) Laryngectomy, ipsi thyroidectomy + ipsi or bilateral selective neck dissection N0 or one +ve LN without adverse features RT optional Adverse features RT or chemoRT Concurrent chemoRT: Primary site PR: Salvage surgery + neck dissection as indicated

Supraglottic Larynx Resectable T4, N0 Skin involvement, high-volume invasion of base of tongue; cartilage destruction Laryngectomy, ipsi thyroidectomy + ipsi or bilateral selective neck dissection Adj RT or chemoRT Or Cclinical trial

Supraglottic Larynx Node positive disease H&P Biopsy Chest x-ray or Chest CT CT with contrast and thin cuts through larynx or MRI of primary and neck recommended Examination under anesthesia with laryngoscopy Dental evaluation as indicated Speech & swallowing evaluation as indicated Multidisciplinary consultation as indicated

Supraglottic Larynx (N+ve) CLINICAL STAGING 1- Resectable; Not requiring total laryngectomy (T1–2, N+ and selected T3–4) 2- Resectable; Requiring total laryngectomy (Most T3–4, N+): Low-volume base-oftongue involvement No cartilage destruction 3- High-volume T4, N+: Cartilage destruction Skin involvement High-volume invasion of base of tongue 4- Unresectable

Supraglottic Larynx Resectable; Not requiring total laryngectomy (T1–2, N+ and selected T3–4) Definitive RT or Concurrent chemoRT: Primary site CR: Residual neck mass  Neck dissection CR of neck  Observe or Neck dissection if initial N2-3 Primary site; residual tumor: Salvage surgery + neck dissection as indicated Or Partial supraglottic laryngectomy and comprehensive neck dissection: Observe or RT+/-Chemo if adverse features

Supraglottic Larynx Resectable; Requiring total laryngectomy (Most T3–4, N+) Laryngectomy, ipsi thyroidectomy with comprehensive neck dissection: No adverse features  Adj RT Adverse features  Adj RT+/-Chemo Or Concurrent chemoRT (preferred) Primary site CR: Residual neck mass  Neck dissection CR of neck  Observe or Neck dissection if initial N2-3 Primary site; residual tumor: Salvage surgery + neck dissection as indicated

Supraglottic Larynx High-volume T4, N+ Laryngectomy, ipsi thyroidectomy with ipsi or bilateral neck dissection or Clinical trial Adj ChemoRT

Supraglottic Larynx PRINCIPLES OF RADIATION THERAPY Definitive RT: Primary and gross adenopathy: > 70 Gy (2 Gy/day) Neck (Low-risk): > 50 Gy (2 Gy/day) Postoperative RT: Primary: > 60 Gy (2 Gy/day) Neck (High-risk): Neck (Low-risk) Postoperative chemoRT for high pathologic risk features: Concurrent single agent Cisplatin 100 mg/m q 3 wks

Cancer of the Nasopharynx WORKUP H&P Nasopharyngeal exam and biopsy Chest x-ray or Chest CT MRI with gadolinium of nasopharynx and base of skull to clavicles and/or CT with contrast Dental evaluation as indicated Speech & swallowing evaluation as indicated Imaging for distant metastases (chest, liver, bones) for N2-3 disease (PET scan and/or CT) Multidisciplinary consultation

Cancer of the Nasopharynx T1, N0, M0 T2a, N0, M0 Definitive RT to nasopharynx Elective RT to neck

Cancer of the Nasopharynx T1, N1-3; T2b-T4, any N Concurrent ChemoRT: Cis 100 mg/m on d 1, 22, 43 RT ( 70 Gy) to primary and gross nodal dz Bilateral neck > 50 Gy Then Cis 80 mg/m d 1 + 5-FU 1,000 mg/m CI x 4 d repeat every 4 wk x 3 Neck: CR  Observe Neck: residual dz  Neck dissection

Cancer of the Nasopharynx Any T, any N, M1 Platinum-based combination chemo If CR: Definitive RT to primary and neck

Cancer of the Nasopharynx FOLLOW-UP Physical exam: Year 1, every 1–3 mo Year 2, every 2–4 mo Year 3–5, every 4–6 mo > 5 years, 6–12 mo TSH every 6-12 mo, if neck irradiated Speech and swallowing evaluation and rehabilitation as indicated

Unresectable Head and Neck Ca M0; T4b, any N; or Unresectable N+ Clinical trial (preferred) PS 0-1: Concurrent Cis or Carbo-based chemo + RT or Induction chemo followed by RT Residual neck disease: Neck dissection, if feasible + primary site controlled PS 2: Induction chemo followed by RT or Definitive RT PS 3: Definitive RT or Best supportive care

Recurrent Head and Neck Cancer Locoregional recurr without prior RT: Resectable Surgery +/- RT Unresectable Locoregional recurr or 2nd primary with prior RT: Surgery ± reirradiation clinical trial preferred Reirradiation Chemotherapy or Distant mets: Clinical trial preferred PS 0–1 Combination chemo or Single-agent chemo PS 2 Single agent chemo or Best supportive care PS 3 Best supportive care

PRINCIPLES OF CHEMOTHERAPY (SCC: Maxillary Sinus, Ethmoid Sinus, Lip, Oral Cavity, Oropharynx, Hypopharynx, Glottic larynx, Supraglottic larynx, Occult Primary) Primary ChemoRT: Cisplatin alone 5-FU/hydroxyurea Cis/Taxol Cis/5-FU Carbo/5-FU Postoperative Chemoradiation: Induction chemo (followed by chemoRT): Carbo/Taxol Docetaxel/cisplatin/5-FU

PRINCIPLES OF CHEMOTHERAPY Nasopharynx ChemoRT followed by adj chemo Cis + RT followed by Cis/5-FU

PRINCIPLES OF CHEMOTHERAPY Unresectable Recurrent Head and Neck Cancers Combination therapy Cis or carbo + 5-FU Cis or carbo + taxane Cis/cetuximab Single agent Cisplatin Carboplatin Paclitaxel Docetaxel 5-FU Methotrexate Ifosfamide Bleomycin Gemcitabine (nasopharyngeal) Cetuximab

THANKS