Principles and Practice of Radiation Therapy

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

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

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

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

Radiation therapy Borders Lateral Superior Inferior Anterior Posterior

Radiation therapy Borders SCV Superior Inferior Lateral

Radiation therapy Borders Off cord Posterior Posterior triangle Blocking

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

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

Glottic T1 T1a T1b T2 T3 T4a T4b

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)

Subglottic T1 T2 T3 T4a T4b

Hypopharyngeal T1 T2 T3 T4a T4b

N stages NX N0 N1 N2a N2b N2c N3

Hypopharynx and Larynx Treatment
Surgery Vocal cord stripping Cordectomy Laser surgery

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

Chemotherapy Agents 5-FU Cisplatin Chemoradiation

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

Radiation therapy Parallel-opposed laterals Borders Anterior Posterior Superior Inferior

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%

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

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

Types Acinic cell Polymorphous low-grade adenocarcinoma

Types Rare adenocarcinomas Basal cell Clear cell Cystadenocarcinoma Sebaceous Oncocytic Mucinous

Types Malignant mixed tumors Carcinoma ex pleomorphic adenoma Squamous cell Undifferentiated Metastatic disease

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

Chemotherapy Poor response to chemotherapy Does not improve survival

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

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

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

Principles and Practice of Radiation Therapy

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