Head and Neck Cancer Service

Transcription

1 Dr Hoda Al Booz. MMedSci, MD, FFRRCSI, FRCR. Head and Neck Cancer Service Dr Hoda Al Booz Consultant in Clinical Oncology Bristol Cancer Institute

2 Dr Hoda Al Booz. MMedSci, MD, FFRRCSI, FRCR. documents/ guidelines by the government 1995 Calman Hine Report 2000 The National Cancer Plan 2007 The Cancer Reform Strategy 2011 Improving Outcomes A Strategy for Cancer 16yrs of Guidance (+ off springs!!)

3 Dr Hoda Al Booz. MMedSci, MD, FFRRCSI, FRCR. All with the aim of.. Improving: Also Generated: Clinical Outcomes Review of services Reducing deaths from cancer Challenge of practice Reducing wait for diagnosis and treatment The need to go further Patient experience Utilising best practice Highlighted further areas Poor data capture Public awareness need

4 How can you help? No. 1 An ulcer in the mouth that doesn t heal within a few weeks red or white patches in the mouth that persist for few weeks difficulty swallowing or pain when chewing or swallowing hoarseness of voice constant unilateral sore throat and earache on one side a swelling or lump in the face, mouth or neck. an unexplained loose tooth a blocked nose or nosebleeds pain or Dr numbness Hoda Al Booz. MMedSci, in the MD, face FFRRCSI, or FRCR. upper jaw.

5 Dr Hoda Al Booz. MMedSci, MD, FFRRCSI, FRCR. Improved care pathway Better access to local consultation clinics Strengthened core of centralised services Better access to local follow up clinics Increased focus on rehabilitation

6 Who is at the MDT? MDT coordinator Surgeons: ENT Surgeon, with specialist training in oncology MaxilloFacial surgeons, with specialist training in Oncology Clinical Oncologist (Radiotherapy & Chemotherapy) Dental/ oral sugery Head and Neck specialist nurse Clinical Psychologist Palliative care consultant Radiologist Pathologist Dietitian Speech and language therapist Head and Neck radiographer Dr Hoda Al Booz. MMedSci, MD, FFRRCSI, FRCR.

7 Dr Hoda Al Booz. MMedSci, MD, FFRRCSI, FRCR. Monday clinics Doctors Chemoradiotherapy Preassessments Joint MSC: SLT/ DT/ RT/ CNS Tuesday MDT Joint Clinic (All) Wednesday Thursday Friday Satellite clinics Neck Lump clinic: MFS, Radiologist (US), on-site Histopath Radiotherapy on treatment BHOC RT peer review

8 Dr Hoda Al Booz. MMedSci, MD, FFRRCSI, FRCR. Radiotherapy progress form. Consent form. Patients medical history. Pregnancy forms Chemotherapy request. Blood forms. CME forms.

9 Oropharyngeal cancers Dr Hoda Al Booz. MMedSci, MD, FFRRCSI, FRCR. 9

10 Hoda Al Booz MB Bch, MmedSci, MD, FFRRCSI, FRCR 1

11 Classification Tumour Characteristics Lateralised Tumour confined to the tonsillar fossa / lateral pharyngeal wall, with a contralateral lymph node risk <15% Non Lateralised Tumour invading or approaching midline (i.e. soft palate, base of tongue, posterior pharyngeal wall) or large lateral pharyngeal wall / tonsillar tumour, or N2c disease, or contralateral lymph node risk equal to or >15% Hoda Al Booz MB Bch, MmedSci, MD, FFRRCSI, FRCR 1

12 Node Negative Ipsilateral Level II-IVa 1 and Level Ib in case of anterior extension of tumour or involvement of anterior pillar of tonsil Lateralised Ipsilateral Level Ib-IVa 1, V 2 and Ipsilateral retropharyngeal nodes(level VIIa) at the level of oropharynx Node Positive Retrostyloid space(level VIIb), when level II is involved SCF(Level IVb &Level Vc) when Level IVa or V involved Dr Hoda Al Booz. MMedSci, MD, FFRRCSI, FRCR. 1

13 Bilateral Level II-IVa 1 and Node Negative Ipsilateral level Ib in case of anterior extension of tumour or involvement of anterior pillar of tonsil Ipsilateral Level Ib-IVa 1, V 2 ; Contralateral Level II-IVa 1 and Retropharyngeal nodes(level VIIa) at the level of oropharynx Ipsilateral Node Positive Retrostyloid space(level VIIb), when level II is involved Non- lateralised SCF (Level IVb &Level Vc) when Level IVa or V involved Bilateral Level Ib-IVa 1, V 2 and Retropharyngeal nodes (Level VIIa) at the level of oropharynx Bilateral Node Positive Retrostyloid space(level VIIb), when level II is involved SCF (Level IVb &Level Vc) when Level IVa or V involved Dr Hoda Al Booz. MMedSci, MD, FFRRCSI, FRCR. 1

14 Topographical distribution of neck node metastases in oropharyngeal cancers. Hoda Al Booz MB Bch, MmedSci, MD, FFRRCSI, FRCR 1

15 Topographical distribution of neck node metastases by sub-site Hoda Al Booz MB Bch, MmedSci, MD, FFRRCSI, FRCR 15

16 Hypopharynx & Larynx Hoda Al Booz MB Bch, MmedSci, MD, FFRRCSI, FRCR 16

17 Primary site Larynx -Node positive Larynx - Node negative Hypopharynx- Node positive Hypopharynx- Node negative At risk nodal levels II-V Include ipsilateral Ib if ipsilateral II involved II-V RP, Ib-V RP, Ib-V Hoda Al Booz MB Bch, MmedSci, MD, FFRRCSI, FRCR 17

18 Chemotherapy Day Dr Hoda Al Booz. MMedSci, MD, FFRRCSI, FRCR. Unit CDU

19 Dr Hoda Al Booz. MMedSci, MD, FFRRCSI, FRCR. RADIOTHERAPY Patient is seen and consented in clinic Clinical Oncologist completes a progress form (Booking form) Booking form goes to planning office Planning office initiates a schedule an A4 letter sent to patient with appointments for Planning/ Verification/ Radiotherapy treatment

20 Hoda Al Booz MB Bch, MmedSci, MD, FFRRCSI, FRCR

21 Dr Hoda Al Booz. MMedSci, MD, FFRRCSI, FRCR. Radiotherapy journey Simulator/ planning

22 Dr Hoda Al Booz. MMedSci, MD, FFRRCSI, FRCR.

23 Treatment Dr Hoda Al Booz. MMedSci, MD, FFRRCSI, FRCR.

24 Hoda Al Booz MB Bch, MmedSci, MD, FFRRCSI, FRCR 24

25 Dr Hoda Al Booz. MMedSci, MD, FFRRCSI, FRCR. RCR published guidelines guidelines for the management of unscheduled interruption or prolongation of a radical course of radiotherapy. Unscheduled interruptions of 1 day 1.4% reduction in local control. 1 week 3-25% reduction in local control Barton MB et al, 1992, 24:

26 How can you help? No.2 Patient support is hospital based at this point. Keep contact details for H&N CNSs (on letters) Dr Hoda Al Booz. MMedSci, MD, FFRRCSI, FRCR.

27 Dr Hoda Al Booz. MMedSci, MD, FFRRCSI, FRCR. Head and Neck Multidisciplinary support Speech And Language Therapy (SALT) Dietitian Head and Neck Specialist nurse (palliative care) Head and Neck specialist radiographer (Acute radiation reaction and ongoing assessments)

28 Dr Hoda Al Booz. MMedSci, MD, FFRRCSI, FRCR. Schedule of review 2 weeks before treatment starts 2 weeks, 4 weeks and 6 weeks of treatment 2 weeks post treatment All, with validated tools

29 Dr Hoda Al Booz. MMedSci, MD, FFRRCSI, FRCR. Accurate validated tools Frequent dietetic contact has been shown to enhance outcomes (Grade A) Patients with head and neck cancer should be nutritionally screened using a validated screening tool Screening Tool The Subjective Global Assessment (SGA) tool The patient generated subjective global assessment (PG-SGA) The Malnutrition Screening Tool (MST) The Malnutrition Universal Screening Tool (MUST)

30 Dr Hoda Al Booz. MMedSci, MD, FFRRCSI, FRCR. Macmillan Support Clinic Name Date of birth : NHS number : Address Telephone Number Diagnosis Treatment Previous Medical History Social History

31 Dr Hoda Al Booz. MMedSci, MD, FFRRCSI, FRCR. Date of completion of radiotherapy Skin care/dressings advice Mouth care Swallowing Nutrition Communication Emotional well being Pain Assessment Details of community follow-up Other information

32 Dr Hoda Al Booz. MMedSci, MD, FFRRCSI, FRCR. Report to be completed before Date: Report Started Name: Adam Cockle Date: SLT Sections Completed Name: Date: Dietetic Sections Completed Name: Date: Report Sent Name: Date:

33 Dr Hoda Al Booz. MMedSci, MD, FFRRCSI, FRCR. A Centralised service Good multidisciplinary support surgeons on site Other centres within reach Specialist H&N Dietitian Specialist H&N SLT Specialist H&N Nurse Specialist H&N Radiographer Dental and Oral surgery consultants and hygienists So,

34 Dr Hoda Al Booz. MMedSci, MD, FFRRCSI, FRCR.

35 Dr Hoda Al Booz. MMedSci, MD, FFRRCSI, FRCR. HPV status Smoking status (>10 pack yrs) For HPV+ve : nodal status (N2b-N3) For HPV-ve : T4

36 Dr Hoda Al Booz. MMedSci, MD, FFRRCSI, FRCR. Retrospective analysis of the association between tumour HPV status and survival patients with stage III or IV oropharyngeal squamous-cell carcinoma enrolled in a randomized trial comparing acceleratedfractionation radiotherapy (with acceleration by means of concomitant boost radiotherapy) with standard-fractionation radiotherapy, each combined with cisplatin therapy All had squamous-cell carcinoma of the head and neck. Ang, NEJM, 2010

37 Risk factors in the new age 3 risk categories: Dr Hoda Al Booz. MMedSci, MD, FFRRCSI, FRCR. Low risk: HPV+ / no or low smokers (50% patients) OS 3 yr 93% Intermediate: HPV+ + smokers+n2b-n3 and HPV- + low-no smoker + T % OS 3yr High risk : HPV- /high smokers or low smoker+t4 OS 3yr 46.3% Ang, NEJM, 2010

38 POST OPERATIVE RADIOTHERAPY Hoda Al Booz MB Bch, MmedSci, MD, FFRRCSI, FRCR 38

39 Lateralised Hoda Al Booz MB Bch, MmedSci, MD, FFRRCSI, FRCR 39

40 Indication Intermediate Risk group: T3/ N2a/ N2b/ Perineural invasion/ Vascular invasion/ close margins (1-5mm) High Risk group: Positive margins (<1mm) with negative marginal biopsies &/or ECS Hoda Al Booz MB Bch, MmedSci, MD, FFRRCSI, FRCR 40

41 Clinical Information: 52 year old man presenting with a 6 weeks MRI craniofacial: Enhancing mass measuring 25 x 10 x 10 mm ce Panendoscopy: Panendoscopy showed enlarged tonsil. No involve Hoda Al Booz MB Bch, MmedSci, MD, FFRRCSI, FRCR 41

42 MDT Discussion Surgery: Patient underwent transoral laser microsurgery (TLM) of right tonsil and right modified neck dissection levels II-V. MDT Discussion Post-op Histology: 24 x 15 x 10 mm poorly differentiated squamous cell cancer right tonsil. Margins close at 2mm. All marginal biopsies negative. Three nodes positive out of 42 nodes examined, at levels II and III, largest at level II measuring 50mm. No extracapsular spread. Hoda Al Booz MB Bch, MmedSci, MD, FFRRCSI, FRCR 42

43 Hoda Al Booz MB Bch, MmedSci, MD, FFRRCSI, FRCR 43

44 Hoda Al Booz MB Bch, MmedSci, MD, FFRRCSI, FRCR 44

45 Hoda Al Booz MB Bch, MmedSci, MD, FFRRCSI, FRCR 45

46 Hoda Al Booz MB Bch, MmedSci, MD, FFRRCSI, FRCR 46

47 Hoda Al Booz MB Bch, MmedSci, MD, FFRRCSI, FRCR 47

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49 Hoda Al Booz MB Bch, MmedSci, MD, FFRRCSI, FRCR 49

50 Non Lateralised tumours Hoda Al Booz MB Bch, MmedSci, MD, FFRRCSI, FRCR 50

51 Case 54 year old gentleman presents with 2 months history of left neck swelling. No other symptoms or co-morbidities. Non smoker. MRI craniofacial: Reveals a 3cm mass within the left tonsillar fossa with involvement of the lateral soft palate by more than 1cm. Tongue base not involved. Multiple metastatic lymph nodes at level 2 on the left. No contralateral lymphadenopathy. Panendoscopy: Enlarged tonsil involving adjacent soft palate by greater than 1cm. No tongue base involvement. Biopsy confirmed a poorly differentiated squamous cell carcinoma, strongly positive for p16. Hoda Al Booz MB Bch, MmedSci, MD, FFRRCSI, FRCR 51

52 Surgery: Laser resection with left modified radical neck dissecti Post-op Histology: Tonsil revealed 21mm tumour with a 2mm clo Hoda Al Booz MB Bch, MmedSci, MD, FFRRCSI, FRCR 52

53 Hoda Al Booz MB Bch, MmedSci, MD, FFRRCSI, FRCR 53

54 Hoda Al Booz MB Bch, MmedSci, MD, FFRRCSI, FRCR 54

55 Hoda Al Booz MB Bch, MmedSci, MD, FFRRCSI, FRCR 55

56 Hoda Al Booz MB Bch, MmedSci, MD, FFRRCSI, FRCR 56

57 What can you do to help No. 3 Patient completed treatment has follow up appointments with the team. support clinic liaises with community services to manage symptoms, WITH the hospital team. Dr Hoda Al Booz. MMedSci, MD, FFRRCSI, FRCR.

58 Metastatic disease Management depend on site of metastases. Palliative intent to any modality offered. involvement of palliative care colleagues essential Support arranged via hospital s CNSs to be done in the community. Dr Hoda Al Booz. MMedSci, MD, FFRRCSI, FRCR.

59 Palliation addressing issues of: pain swallowing feeding bleeding Dr Hoda Al Booz. MMedSci, MD, FFRRCSI, FRCR.

60 THANK YOU Dr Hoda Al Booz. MMedSci, MD, FFRRCSI, FRCR.