Slide 1. Slide 2. Slide 3 RADIATION TREATMENT OPTIONS DISCLOSURES GOALS. Sharon Jamison, BSN, RN, CORLN

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1 Slide 1 RADIATION TREATMENT OPTIONS Sharon Jamison, BSN, RN, CORLN Slide 2 DISCLOSURES The presenter has no disclosures nor does she have any financial interest in any discussed topics. Slide 3 Explanation of radiation- spectrum, actions and indications GOALS Discussion of the types of radiation therapies Enumeration of radiation effects on integumentary, endocrine, vascular, pulmonary, digestive systems

2 Slide 4 ENERGY SPECTRUM Slide 5 TYPES OF RADIATION Non-Ionizing Thermal Radio waves Microwaves Infrared Visible light Ultraviolet Ionizing X rays Gamma Particle radiation Alpha Beta Neutron Slide 6 IONS What are ions? Atoms with an electrical charge Protons/ electrons Anions-Negative charge Cations- Positive charge Ionization Electrically neutral atom Loss of an electron to produce a positively charge atom Loss of a proton to produce a negatively charged atom

3 Slide 7 IONIZATION EXAMPLES Ultraviolet radiation Ionized water Metal alloys Slide 8 RADIATION IN MEDICINE X Ray CT Scanning MRI Nuclear Medicine Slide 9 LARYNGEAL CANCER STAGING Cancer staging Extent of tumor- T Lymph node involvement- N Spread to other sites- M

IVA IVB IVC T4a N0 or N1 M0 T1-T4a N2 M0 T4b Any N M0 Any T N3 M0 Any T Any N M1 Tumor growth through thyroid cartilage and/ or growth into tissues past larynx.

4 IVA IVB IVC T4a N0 or N1 M0 T1-T4a N2 M0 T4b Any N M0 Any T N3 M0 Any T Any N M1 Tumor growth through thyroid cartilage and/ or growth into tissues past larynx. No LN spread or one involved LN on same side (ipsilateral), no larger than 3 cm. No distant spread. Moderately advanced local disease Tumor may or may not have grown into structures outside larynx and it may or may not affect VC function, but: cancer has spread to a single ipsilateral LN, larger than 3 cm, OR Spread to more than one ipsilateral LN, none larger than 6 cm across, OR Has spread to at least one LN the other side (contralateral) of the neck- none larger than 6 cm across No cancer spread to distant sites Tumor growth into area in front of spine (prevertebral space), surrounds a carotid artery, or is growing down into space between lungs Very advanced local disease. Positive or negative LN involvement No cancer spread to distant sites. Tumor growth may or may not have invaded structures outside of larynx/ may or may not have affected VC function Cancer spread to at least one lymph node larger than 6 cm, OR has spread to LN has grown outside of LN (N3). No spread to distant sites. + or- growth into structures outside larynx, + or- VC affect, + or- LN spread, but, + spread to distant parts of the body. Slide 10 LARYNGEAL CANCER STAGING AJCC Stage Stage Description Stage Group 0 Tis Tumor is in top layer/ lining of larynx. No lymph node N0 involvement, no distant metastasis M0 I T1 Tumor has grown deeper into vocal cord, but, has N0 not affected movement. No lymph node M0 involvement, no spread past VC II T2 Tumor spread to supraglottis or subglottis. No lymph N0 node involvement or spread to distant parts of the M0 body III T3 Tumor still contained in larynx, but, vocal cord N0 movement is affected or tumor has spread to the M0 paraglottic space or tumor growth into inner portion of thyroid cartilage. No LN or distant spread. III T1 to T3 Tumor still within larynx with or without VC function N1 affect (tumor is less than 3 cm)/ Spread to a single M0 lymph node of the same side of neck as the tumor/ no distant spread. Slide 11 LARYNGEAL CANCER STAGING AJCC Stage Group Stage Description Stage Slide 12 LARYNGEAL CANCER TREATMENT Recommended treatments Radiation Chemotherapy Combined modality Surgery Salvage surgery

benefit to side effects Slide 14 RADIATION THERAPY Types of radiation therapy External beam Linear accelerator X-ray

5 Slide 13 Radiation Therapy Radiation therapy is a very effective tool in the treatment of head/ neck cancers Nearly 100% of H/N cancer patients treated with radiation therapy will experience oral side effects to some degree Balance of benefit to side effects Slide 14 RADIATION THERAPY Types of radiation therapy External beam Linear accelerator X-ray Electron beam Cobalt-60 Large particle Proton neutron Slide 15 RADIATION SAFETY Safety measures Time Distance Shielding Containment

6 Slide 16 PROTON THERAPY Indications for successful therapy Tumor close to surface Proximity to vital structures Availability/ access to facility Cost/ coverage Slide 17 Slide 18 EXTERNAL BEAM THERAPY (EBT)

$into equal treatments or fractions Allows for: Repair- tumor cells are killed while normal cells are allowed to recover Redistribution- with each succeeding dose of radiation, more tumor cells reach$ $the mitotic stage, increasing cell death Repopulation-favors normal tissue while eradicating tumor because normal tissues can repopulate with multi- fraction dosing Reoxygenation-tumor cells are$

7 Slide 19 THERAPEUTIC RATIO The goal of radiation therapy is to achieve maximum tumor cell kill while minimizing injury to normal tissues Slide 20 Fractionation-division of a total dose of radiation into equal treatments or fractions Allows for: Repair- tumor cells are killed while normal cells are allowed to recover Redistribution- with each succeeding dose of radiation, more tumor cells reach the mitotic stage, increasing cell death Repopulation-favors normal tissue while eradicating tumor because normal tissues can repopulate with multi- fraction dosing Reoxygenation-tumor cells are normally hypoxic or anoxic. Fractionation allows time between treatments for re oxygenation, increasing radiosensitivity EBT- FRACTIONATION Slide 21 UNITS OF MEASUREMENT RAD- radiation absorbed dose Gray/ centigray 100 RAD=100 cgy=1gray

Slide 22 COMBINE D MODALIT Y THERAPY Enhanced tumor cell kill Chemotherapeutic agentsdoxorubicin, actinomycin-d, cyclophosphamide, bleomycin, cisplatin, taxotere Radioprotectors- protect oxygenated

8 Slide 22 COMBINE D MODALIT Y THERAPY Enhanced tumor cell kill Chemotherapeutic agentsdoxorubicin, actinomycin-d, cyclophosphamide, bleomycin, cisplatin, taxotere Radioprotectors- protect oxygenated (normal) cells during radiation therapy Phase II and III clinical trials continue to search for efficacy Slide 23 COMBINED MODALITY THERAPY Neoadjuvant therapychemotherapy before local radiation: shrinks tumor burden Concomitant therapychemotherapy is given with radiation (increased/ enhanced tumor cell kill) Adjuvant therapychemotherapy given after a course of radiation Slide 24 SIMULATION Simulation-provides information to determine the exact dose required for the target volume Identification of treatment field Area marked with tattoos/ markings to replicate the target treatment field daily

Slide 25 Intensity Modulated Radiation Therapy (IMRT) Patient safety Highest dose for best effect Use of angles Use of blocks, shields Slide 26 Immobilization Immobilization

cancers acute effects Laryngeal irradiation For optimal effect, Acute side effects not consists of daily doses therapy must be obvious for up to five days/ week X 7 completed

9 Slide 25 Intensity Modulated Radiation Therapy (IMRT) Patient safety Highest dose for best effect Use of angles Use of blocks, shields Slide 26 Immobilization Immobilization mask Pen markings Tattoos Slide 27 Length of Treatment Accepted total dose Recuperation from Danger/ concern of for head/ neck head/ neck irradiation incomplete treatment cancers acute effects Laryngeal irradiation For optimal effect, Acute side effects not consists of daily doses therapy must be obvious for up to five days/ week X 7 completed three weeks into weeks Proactive intervention treatment, but, (G tube, enteral continue three weeks feedings, skin care, after treatment close monitoring) helpful for ensuring completion

10 Slide 28 ACUTE EFFECTS Acute effect of radiation therapy occur mainly in normal cells that regenerate rapidly Acute toxicities vary with the patient, area being treated, duration of treatment Resolution of acute reactions depends on tissue being treated and degree of reaction to the radiation Slide 29 SKIN EFFECTS Effects of radiation on skin Most patients experience some degree of skin dryness, itching, erythema Degree of skin reaction dependent on amount of treatment as well as anatomic location of the treatment field, proximity of the tumor to the skin surface, nutritional status of the patient, other treatment modalities at the time of radiation treatment, comorbidities Slide 30 Skin effects Erythema- transient- within hours to days Erythema proper- following 2-3 weeks of start of treatment; resolves days after last treatment Pruritis- itching occurs as epidermis thins and sebaceous and sweat gland production decreases Hyperpigmentation- tanned appearance of skin; melanin is transported to superficial skin layers Dry desquamation- occurs 3-4 weeks after radiation initiation; resolves 1-2 weeks after completion

Slide 31 Skin effects Subacute effect phase Damage is seen in weeks to a few months after completion of radiation Moist desquamation- occurs after delivery of 40 Gy or with trauma of skin or

Epithelium has been destroyed Skin regrowth after moist desquamation- Usually complete after 2-3 months after completion of treatment Slide 32 SKIN EFFECTS Dry/ moist desquamation Resolution of

11 Slide 31 Skin effects Subacute effect phase Damage is seen in weeks to a few months after completion of radiation Moist desquamation- occurs after delivery of 40 Gy or with trauma of skin or excessive friction; skin sloughs, bright erythema, serous exudate, pain. Epithelium has been destroyed Skin regrowth after moist desquamation- Usually complete after 2-3 months after completion of treatment Slide 32 SKIN EFFECTS Dry/ moist desquamation Resolution of desquamation Slide 33 LATE SKIN EFFECTS Photosensitivity- lifelong. Due to destruction of melanocytes and slower melanin response to UV rays Pigmentation changes- hypo or hyperpigmentation- disruption of melanocytes Atrophy- permanent. Thin and fragile epidermis Fibrosis- usually begins 4-6 months after completion of treatment. May worsen over time Telangiectasia- may occur up to 8 years after treatment

12 Slide 34 LATE SKIN EFFECTS Ulceration and necrosis- uncommon. May happen up to 20 years after treatment. Usually result of trauma or inflammation Connective tissue damage Painful, non-healing ulcers Slide 35 EARLY HEAD NECK EFFECTS Skin Skin changes Throat Sore throat Hoarseness, loss of voice Coughing Swelling of airway, blockage Oral/Taste Reduced and thickened saliva Loss of taste Altered sense of smell GI Loss of appetite Nausea Slide 36 MUCOSITIS/ ORAL THRUSH/XEROSTOMIA

13 Slide 37 HEAD NECK LATE EFFECTS Dry mouth (xerostomia) Altered sense or loss of taste Tooth decay, gum changes Bone ( jaw) damage, stiffness or limitation of jaw movement, Swelling of tissues under chin (lymphedema) Throat damage (difficulty swallowing, breathing, hoarseness, pain) Thyroid gland damage ( may require long term hormone replacement) Slide 38 LYMPHEDEMA Lymphedema presentation Heaviness, tightness of skin Difficulty swallowing No obvious reason for complaints Lack of treatment leads to facial, neck swelling, impaired range of motion, fibrosis Dysphagia due to internal lymphedema May impact breathing Definite negative impact to quality of life Slide 39 INTERNAL LYMPHEDEMA

Slide 40 CONCLUSION External beam radiation therapy Treatment of choice for T1 and T2 laryngeal cancers May be combined with chemotherapy, radiosensitizers, targeted therapies May be used for more

14 Slide 40 CONCLUSION External beam radiation therapy Treatment of choice for T1 and T2 laryngeal cancers May be combined with chemotherapy, radiosensitizers, targeted therapies May be used for more advanced cancers, assist in debulking Side effects of XRT may intensify, become more troublesome later on Exciting advances in XRT options may reduce side effects, increase treatment success Slide 41 Questions? Slide 42 REFERENCES American Cancer Society. (12/2017). Laryngeal cancer stages. Retrieved December 28, 2018 from: Furlow,B. (Feb 2018). Cost vs. benefits: The controversy over proton beam radiotherapy. Oncology Nurse Advisor. Retrieved January 4,2018 from: Ganley, I.; Patel, S.; Matuso, J.; et al. (January 2006). Results of surgical salvage after failure of definitive radiation therapy for early- stage squamous cell carcinoma of the glottic larynx. Archives of Otolayngology Head Neck Surgery, 132(1): doi: /archotol Liu, A.; Swisher-McClure, S.; Millar, L.; Kirk, M.; Yeager, C.; Boong- Keng, A.; Teo, K.; Hahn, S. (Dec. 2012). Proton therapy for head and neck cancer: Current applications and future directions. Department of Radiation Oncology, University of Pennsylvania, Philadelphia. Translational Cancer Research. Dec 2012 (1), 4. doi: /jssn x Sandulache, V.; Vandelaar, L.; Skinner, H.; Cata, J.; Hutcheson, K.; Fuller, C.; Phan, J.; Siddiqui, Z.; Lai, S.; Weber, R.; Zafereo, M. (April 2016). Salvage total laryngectomy following external beam radiation therapy: A 20 year experience. Head Neck, Apr; 38(suppl 1): E1962-E1968. doi: /hed Tian, X.; Liu, K.; Hou, Y.; Cheng, J.; Zhong, J. (Nov. 2017). The evolution of proton beam therapy: Current and future status. Molecular and Clinical Oncology. 2018, Jan. (1): doi: /mco

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