Principles of Management of Head & Neck Cancer. Jinka Sathya Associate professor of Oncology
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1 Principles of Management of Head & Neck Cancer Jinka Sathya Associate professor of Oncology
2 Oral cavity Oro-pharynx Larynx Hypopharynx Nasophaynx Major sites of Mucosal H&N Cancers
3 Head & Neck Cancer Oral Cavity: 1) Oral Tongue 2) Floor of Mouth 3) Buccal Mucosa 4) Upper and lower Gingiva 5) Hard Palate 6) Retro-Molar trigone
4 Head & Neck Cancer-Oral Cavity T2-Cancer of Oral Tongue
5 Head & Neck Cancer- Oral Cavity T4 floor of mouth
6 Head & Neck Cancer- Oral Cavity T 2-Floor of Mouth
7 Head & Neck Cancer-Oral Cavity T2 Buccal Mucosa
8 Head & Neck Cancer-Oral Cavity Leukoplakia
9 Management of Oral Cavity Cancers Surgery is the preferred modality - Free flaps and micro vascular surgery have revolutionized the surgical outcomes - Eating, Swallowing and speech are still a problem - High doses of radiation poorly tolerated - Mandibular necrosis is dose limiting - Medium doses of Post-Op radiation - well tolerated
10 Head & Neck Cancer Oro-Pharynx: Base of Tongue Tonsil including Tonsillar pillars Soft Palate Uvula
11 Head & Neck Cancer-Oro-pharynx T3 cancer of Right Tonsil
12 Head & Neck Cancer-Oro-pharynx Cancer of Tonsil-right T3, Hypertrophy-left
13 Head & Neck Cancer-Oro-pharynx Base of Tongue-T2
14 Head & Neck Cancer- Tonsil Bulky tonsil cancer
15 Management of Oro-Pharyngeal Cancers Radiation with or without Chemotherapy is the preferred modality Significant proportion are HPV related and respond very well Surgery associated with significant swallowing dysfunction
16 Major sites of Mucosal H&N Cancers
17 Head & Neck Cancer Larynx and Hypopharynx: - Supra-Glottic Larynx - Glottic Larynx - Sub-Glottic Larynx - Pyriform Sinus - Lateral Pharyngeal wall - Post-Cricoid region
18 T1B Vocal cord Head & Neck Cancer-Larynx
19 Head & Neck Cancer-Larynx Bulky T2 with Sub-glottic extension
20 Head & Neck Cancer-Larynx T2 or T4 Cancer of Vocal Cord
21 Head & Neck Cancer Principles of management of Cancer of Larynx and Hypopharynx: - Organ preservation is the goal of therapy - Goal is to maintain speech and lack of tracheostomy - Laser surgery (organ preserved) or Radiation for early stage - Radiation±chemotherapy for advanced disease( Stage 3) - Very advanced disease( T4) -Surgery followed by RT± Chemotherapy is the treatment of choice
22 Head & Neck Cancer-Larynx Post-Laryngectomy
23 Radiation Side Effects Acute: - Radiation Dermatitis( Skin Reaction) - Mucositis - Xerostomia- Acute - Sub-Acute Chronic: - Chronic Dermatitis with Telangectasia - Mucosal Atrophy - Xerostomia & Consequences - Hearing Loss - T-M joint dysfunction - Hair loss.
24 Management of Acute Side Effects Skin Reaction: - Less of an issue with more skin sparing technique - we are seeing more of this with Cetuximab. - Glaxal base cream - Aloe base cream - Polysporin - Flamazine
25 Management of Acute Reaction Mucositis: Phase 1: Vascular/ Inflammatory Phase Treatment: - Release of free Radicals, cytokines, TNF - Oral Hygiene - Dental Care including dental amalgam during RT - Mouth Washes: - Sodium bicarbonate mouthwash - Chlorhexidine mouthwash - Mixed medication mouthwash - Calcium phosphate mouthwash - Pain Control
26 Management of Acute Reaction Mucositis: Phase 2: Epithelial Phase - Retardation of cell division - Reduction in epithelial turnover - Erythema with difficulty in swallowing, speech, mastication Management: - Continued oral care - Nutritional support - Anti-Fungal therapy - Pain Control
27 Management of Acute Reaction Mucositis: Phase 3: Management: - Ulcerative Phase - Microbial colonization of the mucosal surface occurs. - Continue Phase 2 management - May need systemic anti-fungal medication - May need antibiotics - May need aggressive nutritional support Phase 4: Healing Phase
28
29
30 Acute Radiation Toxicity Mucositis:
31
32 Management of Xerostomia Xerostomia: - Thick Saliva - Nausea & Vomitting - Altered taste - Difficulty in swallowing solids Management: - Adequate Hydration - frequent mouth washes - sips of clear fluids - Semi-solid foods
33 Xerostomia How can we reduce? - Pilocarpine - Amifostine - Morning vs. Afternoon radiation - Radiation technique- IMRT
34 IMRT to reduce Xerostomia
35 IMRT to reduce Xerostomia
36 IMRT to reduce Xerostomia
37 Xerostomia
38 Toxicity with Cetuximab and RT
39 Toxicity with Cetuximab and RT
40 Toxicity with Cetuximab and RT
41 Smoking- H&N Cancers Learning Objectives: - Does smoking cause H&N cancers? - Does smoking increase incidence of 2 nd cancers? - Do smokers present with advanced disease? - Does smoking compromise surgical outcome? - Does smoking increase radiation side-effects? - Does smoking influence efficacy of radiation therapy? - Does smoking affect cancer specific and overall survival?
42 Smoking-Therapeutic implications in H&N Cancers: Browman et al: NEJM 1993;328:159-63
43 Smoking-Therapeutic implications in H&N Cancers: Browman et al: NEJM 1993;328:159-63
44 Questions?
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