3/12/2018. Head & Neck Cancer Review INTRODUCTION

Transcription

1 Head & Neck Cancer Review Joseph Rosales, MD March 12, 2018 INTRODUCTION Epidemiology/Risk Factors Anatomy Presentation/Workup Treatment Surgery vs Radiation Chemotherapy Side effects Special circumstances 2 National Cancer Institute, SEER 18 Database 3 4 1

2 5 6 RISK FACTORS Tobacco Alcohol Viral HPV, EBV Gender Age Poor oral/dental hygiene Malnutrition GERD Immunodeficiency 7 8 2

3 Presenting Symptoms 9 Persistent/recurrent throat pain Dysphagia/odynophagia/globus sensation Hoarseness/change in phonation Sinus congestion/obstruction Epistaxis/epiphora Unexplained halitosis Pain Hemoptysis Neck mass In 24 months prior to diagnosis, patients sought care 10.5 times 10 PHYSICAL EXAM Skin/scalp Cranial Nerves Oral exam Remove dentures/appliances Manual exam Neck Signs of inflammation

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6 TREATMENT General Principles Multidisciplinary Evaluation Determination of Resectability Post-operative QOL Neoadjuvant/Adjuvant Therapy Other Considerations Smoking/Alcohol cessation Dental Examination Nutritional Evaluation Surgery General Principles Goal is clear margins Clear > 5mm Close < 5mm Positive = DCIS/Invasive tumor at margin En bloc resection preferred Nerve sparing possible? Laryngeal preservation possible? Reconstructive surgery Common Surgery Contraindications Surgery Neck Management T4b inability to obtain clear margins Pterygoid muscle involvement/cranial neuropathy Extension to skull base/cervical vertebrae Direct extension to nasopharynx/eustachian canal Encasement of common/internal carotid artery Direct extension to external skin Direct extension to mediastinal structures Subdermal metastases Extent of lymphatic evaluation depends on primary tumor Ipsilateral lymphatics dissected Bilateral lymph node dissection for base of tongue, palate, supraglottic larynx, hypopharynx Sentinel lymph nodes for early stage oral cavity tumors If positive, neck dissection is required Inappropriate for some sites (floor of mouth, gingiva, hard palate)

7 Radiation Therapy General Principles Post-operative Positive margins Extracapsular nodal extension Multiple nodal involvement, pt3/pt4 primary, invasion of neural/lymphatic/vascular bundle, level 4/5 nodal involvement Definitive Anatomically unresectable tumor Physiologically poor surgical candidate Small volume local disease Radiation Therapy Higher RT Dose Better Tumor Control Increased tissue toxicity Lower RT Dose Less Tumor Control Less tissue toxicity Standard Dose 70 Gy in 2Gy fractions total 6-7 weeks Lower dose to lower-risk areas Gy Other considerations 3D Conformal Radiation vs IMRT Brachytherapy Proton Beam Irradiation Stereotactic Body Radiation (SBRT)

8 Radiation Therapy - Toxicities H+N SCCA T1-T4 N0-N Gy 30 Fractions (n=98) Conventional RT IMRT XEROSTOMIA 12 MONTHS 24 MONTHS 74% 83% 38% 29% PARSPORT Clinical Trial, 2011 Acute Skin reactions/breakdown Mucositis Dehydration Malnutrition/weight loss Late Xerostomia Secondary malignancies Lymphedema Tooth decay Radiation Therapy - Lymphedema Radiation therapy tooth decay 2-6 months after end of treatment Risk Factors Total RT dose Extent of LN dissection Chemotherapy BMI, nutrition Treatment Manual lymphatic drainage CDT Weight loss Positional Medications not generally helpful Dental Evaluation Prevention! Oral moisturizaiton Baking soda mouthwash Avoid acidic/alcoholic oral intake 31 Avoid dentures 32 8

9 Systemic Therapy General Principles Curative Concurrent with radiation therapy Induction chemotherapy Palliative Types of systemic therapy Cytotoxic chemotherapy Monoclonal antibody Immunotherapy (checkpoint inhibitors) Types of systemic therapy Chemotherapy Platinum (Cisplatin, Carboplatin) Taxanes (Paclitaxel, Docetaxel) 5-Fluorouracil Monoclonal antibody Cetuximab (Erbitux) Immunotherapy Pembrolizumab (Keytruda) Platinum Attaches to DNA and prevents replication Direct cytotoxic effect Chemosensitization

10 Taxanes Bind microtubules and prevents depolymerization Interferes with mitosis Taxanes Common Toxicities Nausea/vomiting Myelosuppression Allergic reaction Paclitaxel Peripheral Neuropathy Docetaxel Nail dystrophy Ocular Canalicular Stenosis Fluorouracil Blocks thymidylate synthase Prevents generation of Cytosine and Thymidine Prevents DNA replication and cell division

11 Cetuximab Cetuximab - toxicities Allergic reactions Dermatitis Hair/nail toxicity Pulmonary toxicity Infection/sepsis when combined with RT Cetuximab - dermatitis Treatment Options Clindamycin Steroids hydrocortisone Doxycycline/Minocycline Discontinuation of therapy Chemotherapy Regimens High-dose cisplatin Cetuximab (single agent) Weekly cisplatin Carboplatin/5FU Carboplatin/Taxol Cisplatin/Docetaxel/5FU

12 45 46 IMMUNOTHERAPY Nivolumab Checkmate patients, platinum refractory recurrent disease Nivolumab vs standard therapy (chemo or cetuximab) OS 7.5 months vs 5.1 months in favor of nivolumab Toxicities 13.1% vs 35.1% in favor of nivlumab Pembrolizumab Keynote 12 (Phase 2 study) ORR 16% DoR > 6 months Keynote 40 trend toward but not definitive improvement OS

13 Nasopharyngeal Cancer SPECIAL CIRCUMSTANCES What s so special? Less common in US EBV associated More likely to metastasize More likely to recur without chemo How is treatment different? T1N0 EBRT >T1N0 ChemoRT + chemo Human papilloma virus (HPV p16) In oropharyngeal carcinoma, HPV is prognostic P16 positive patients had better survival & less toxicity P16 negative patients did worse with RT (vs surgery) P16 positive patients with metastatic disease had better survival Consequently P16 patients may need less aggressive therapy P16 patients may need to be in separate clinical trials INDUCTION CHEMOTHERAPY CONS: Did not result in improved survival Decreased ability to receive definitive chemo/rt PROS: Decreased metastatic recurrence Allowed for organ preservation Response to induction predicted survival

14 INTRODUCTION Epidemiology/Risk Factors Anatomy Presentation/Workup Treatment Surgery vs Radiation Chemotherapy Side effects Special circumstances Thank You