ESMO Perceptorship H&N cancer Epidemiology, Anatomy and Workup 16 March PDF Free Download

ESMO Perceptorship H&N cancer Epidemiology, Anatomy and Workup 16 March 2018 Dr. Victor Ho-Fun Lee MBBS, MD, FRCR, FHKCR, FHKAM (Radiology) Clinical Associate Professor Department of Clinical Oncology The University of Hong Kong

Outlines Epidemiology and HNSCC and HPV-positive OPSCC in Hong Kong Important anatomy to oncologists Workup and investigations

Incidence rate of H&N Cancer in Hong Kong (lip, oral cavity and pharynx except NPC) Hong Kong Cancer Registry

Incidence rate of H&N Cancer in Hong Kong (tonsil and oropharynx) Hong Kong Cancer Registry

Incidence rate of H&N Cancer in Hong Kong (Hypopharynx+ larynx) Hong Kong Cancer Registry

HPV positive OPSCC JCO 2016;34:1300-8

JCO 2016;34:1300-8

HPV positivity

Laryngoscope 2016;12:894-900

HPV positivity worldwide Laryngoscope 2016;12:894-900

Local data Cancer Epidemiol Biomarkers Prev 2016;25:165-73

Cancer Epidemiol Biomarkers Prev 2016;25:165-73

Our single-centre statistics on HPV positivity at Queen Mary Hospital, Hong Kong 252 patients with cancers of the oropharynx, tonsil and posterior 1/3 of tongue including tongue basetreated at Queen Mary Hospital between 2006 to 2017 Overall 25.4% Tonsil 67.2% (>95% are small T1 tumours) Oropharynx 21.1% Posterior 1/3 of tongue 19.5% HPV routinely checked for all oropharyngeal, tonsillar and post 1/3 tongue cancers

8 th edition AJCC/UICC TNM Curr Treat Options Oncol 2017;18:40

8 th edition AJCC/UICC TNM for HPVpositive OPSCC Curr Treat Options Oncol 2017;18:40

Workup for SCC HPV testing We check for both p16 (oncoprotein) and HPV DNA (past HPV infection) mrna E6/E7 expression should be gold standard but not routinely done due to expensive cost p16 positivity is regarded as HPV-positive tumours in our institution

Other important workup Blood for hematology, biochemistry, hepatitis B serology, creatinine clearance Panendoscopyto rule out occult and synchronous tumoursin upper aerodigestivetract (before and after treatment) Random biopsies for those patients with discernible primary on clinical and imaging examinations CT, MRI head and neck PET-CT scan (90% of our patients) Swallowing assessment Pure-tone audiographyif planned for chemo or chemort

Workup for radiotherapy

Methods of immobilisation Thermoplastic cast

Immobilisationwith thermoplastic cast

Intensity modulated radiation therapy (IMRT) Makes use of multiple beams directed to the tumours at different angles The intensity of radiation dose in each beam can be further modified so as to create a dose gradient to the tumourand the surrounding normal structures (i.e. higher dose to tumourand lower dose to normal structures)

IMRT (tumourcontouring)

PET/CT & MRI co-registration in contouring Primary tumour Left level II LN

PET/CT for diagnosis of subtle synchronous tumour Current retromolar trigone cancer Incidental finding of synchronous submucosal tongue base cancer

Conformal RT employs multiple radiation beams coming in from different angles but all aiming at tumour

IMRT (9-fields) 1 9 2 8 3 7 4 6 5

Volumetric modulated arc therapy (VMAT)

MRI before brachytherapy Brachial plexus And subclavian vessels Brachial plexus And subclavian vessels

Interstitial brachytherapyof neck for NPC neck nodal recurrence

Anatomy important to oncologists

Clivus

Cavernous sinus, dura, temporal lobe and clivus

Retropharyngeal nodes

RP node down to C3/C4 level RP node

Vidiancanal Vidian canal Vidian canal

What s the pathology? NPC?

This pathology is Moderately differentiated squamous carcinoma of the tonsil pt4n2c disease, margins positive HPV p16 positive in retrospective review Surgery followed by post-operative chemoradiation

Another patient

Pathology Panendoscopyand random biopsies of NPC, posterior tongue base, posterior wall of oropharynx, right and left tonsils all negative

Left tonsillectomy Moderately differentiated squamouscell carcinoma Random biopsies may not be sufficient to rule out occult tonsillar cancer

Another patient

Another patient (1)

Another patient (2)

Another patient (3)

Left mandible involved?

Another patient (5)

Checklist for RT planning

Summary Incidence of HPV-associated OPSCC in Hong Kong has been catching up with that in Western countries Multi-modality imaging (MRI and PET-CT scan) and panendoscopyare routine investigations for accurate RT planning Proficient knowledge in head and neck anatomy is essential to accurate target contouring in radiotherapy (either as adjuvant or radical definitive treatment)

Thank you