1. Radiation Therapy for the Management of Oral Cavity and Oropharyngeal Cancers
Samir Narayan, M.D.
9/9/2016

2. Introduction Indications for Radiation Therapy
Radiation Therapy Principles and Techniques
Managing side effects
Pre-treatment evaluation
Acute Effects
Late Effects
Survivorship
Restoring Function

3. Cancers of Oral Cavity and Oropharynx
48,000 cases estimated in U.S.
9500 deaths
Twice as common in men
Average age at diagnosis is 62
Risk factors:
Tobacco
Alcohol
HPV
Betel nut chewing
American Cancer Society

4. Radiation as a Treatment Modality: Indications
Adjuvant (postoperative)
Decreases locoregional recurrence after surgery
Concurrent chemotherapy for high risk features
Organ preservation (definitive)
Avoids surgery for anatomic and functional preservation
Surgery reserved for salvage of primary or neck dissection
Stage I/II- RT can be used as an alternative to surgery
Stage III/IV- Combined modality (RT + concurrent chemotherapy or cetuximab)
Palliative (symptom control)

5. Radiation Dose and Prescription
Total Dose:
Definitive treatment of HN SCCA: 70 Gy
Adjuvant Gy
Microscopic areas need Gy
Dose Per Fraction:
Conventional fractionation is Gy per fraction, once daily, 5 days/week.
Duration:
70 Gy/35 fx/7 weeks
Accelerated fractionation:
Decreases the total time for radiation therapy
Ex. 70 Gy in 6 weeks, one day of B.I.D.

6. Radiation Therapy Simulation Process
Positioning and Immobilization
CT image acquisition and reference marking

7. Radiation Therapy Treatment Planning
Image Fusion
Target Delineation
Normal Tissue Contouring
Treatment Plan Optimization

8. Radiation Treatment Plan Design and Evaluation

9. Radiation Treatment Delivery

10. Managing Side Effects Acute effects: Occur during treatment
Manifest in varying degrees
Resolve after recovery period
May result in treatment breaks
Late effects:
Occur months to years after treatment
Result from sublethal injury repair and host response
Injury to stromal elements or supporting tissues such as the vasculature

11. Pre-Treatment Evaluation
Dental Assessment
Nutritional Assessment and counseling
Psychosocial Evaluation and Support
smoking cessation
financial
caregiver education
Speech/Swallow Evaluation
Audiometry

12. Acute effects Dermatitis Mucositis Odynophagia Dysphagia Hoarseness
Taste alteration
Thick saliva
Weight loss

13. Oral Mucositis Develops two to three weeks after starting RT.
The incidence of mucositis is variable depending upon the field, total dose and duration of RT.
No proven benefit for pharmacologic prevention of radiation-induced mucositis
Cochrane review 2013
Chlorhexidine mouth rinse is not effective

14. Managing Mucositis Oral hygiene protocol Dietary modification
Mouthwashes:
Baking soda +salt
2% viscous lidocaine, Maalox, diphenhydramine with or without nystatin.
Opiate pain meds
Mucoprotective devices
Careful attention to radiation technique

15. Late effects Dry mouth Dental Decay Osteoradionecrosis
Taste alteration
Fibrosis
Swallowing impairment
Hypothyroidism

16. Survivorship Care Dental Care Speech/Swallow/Physical Therapy
Psychosocial support
Nutritional support
Reinforce healthy lifestyle

17. References

18. References http://www.mascc.org/isoo-publications
nt/ReferenceGuideforOncologyPatients.htm
effects/mouth-throat/oral-complications-pdq
ancer/detailedguide/oral-cavity-and-oropharyngeal-cancer- treating-radiation-therapy

19. Summary
Radiation therapy is an integral treatment of Oral Cavity and Oropharynx CA.
An experienced and multidisciplinary team of providers optimizes outcomes for patients.