Medical knowledge | Otorhinolaryngology, ear, nose, throat » Zoltán Takácsi-Nagy - The role of radiotherapy in the combined treatment of head and neck tumours

Source: http://www.doksinet The role of radiotherapy in the combined treatment of head & neck tumours Zoltán Takácsi-Nagy Ph.D Source: http://www.doksinet 550000 NEW PATIENTS/YEAR ALL OVER THE WORLD (3 %) TREATMENTS: • SURGERY • RADIOTHERAPY (60 %) • CHEMOTHERAPY Source: http://www.doksinet TUMORS OF THE HEAD AND NECK REGION CAN CAUSE HIGH VARIETY OF SYMPTOMES – BECAUSE OF THEIR LOCATION – WHICH ARE OFTEN NOT SPECIFIC OPERATION OF A NECK DISEASE (LYMPHNODE) WITHOUT DETAILED HEAD AND NECK EXAMINATION IS FORBIDDEN Source: http://www.doksinet SYMPTOMES • • • • • • • • SNUFFLES SORE THROAT HOARSENESS NASAL SOUND HAMPERED RESPIRATION SWALLOWING DIFFICULTIES PAIN RADIATING TO THE EAR (n. IX) MASS ON THE NECK Source: http://www.doksinet Source: http://www.doksinet EXAMINATION • ANAMNESIS • PHYSICAL EXAMINATION • INDIRECT AND DIRECT PHARYNGOLARYNGOSCOPY (HISTOLOGY) • ASP.CYTOLOGY • CT, MRI, PET-CT • CHEST X-RAY, ETC. • LABOR

(EBV), AUDIOLOGY Source: http://www.doksinet Source: http://www.doksinet Source: http://www.doksinet Source: http://www.doksinet Source: http://www.doksinet Teletherapy equipments • Kilovoltage equipments: – X-ray therapy - 40-300 KV X-ray photons • Megavoltage equipments: – Telecobalt - 1,25 MV gamma-photons – LINear ACcelerators - 4-29 MV photons or electrons LINAC Source: http://www.doksinet Clinical forms of brachytherapy (BT) I. • • • • interstitial BT (prostate, breast, oral cavity, base of tounge) intracavital BT (uterus, epipharynx, maxilla) intraluminal BT (oesophagus, bronchus) superficial „moulage” BT (skin, hard palate, tonsillar fossa) Source: http://www.doksinet Clinical forms of brachytherapy (BT) II. • • • • • Low-dose-rate: 0-2 Gy/h Medium-dose-rate: 2-12 Gy/h High-dose rate: > 12 Gy/h Pulse-dose-rate: ultra-fractionated HDR After-loading technique: – remote after-loading Source: http://www.doksinet Intention

of radiation therapy • Intention to treat: – Curative (total dose: 50-80 Gy) – Palliative (total dose: 20-60 Gy) • Preoperative (down-staging, organ sparing surgery, devitalisation of tumour cells) • Postoperative (eradication of microscopical residual tumour cells) • Definitive or primary • Radiotherapy alone • Combined radio-chemotherapy (head & neck, uterus, bladder, rectum, lung) Source: http://www.doksinet Treatment planning • Cross sectional imaging – CT-based 2D treatment planning – Conformal 3D radiotherapy – Irregular, individually shaped fields using “multi-leaf collimator” Source: http://www.doksinet Incidence of oral cavity and pharyngeal tumours in Middle-Europe (cases/100.000 habitants) Years Male Female Source: http://www.doksinet Head & neck tumours • Oral cavity • Pharyngeal tumours – Epipharynx, Mesopharynx, Hypopharynx • Glottic tumours • Nasal cavity, paranasal sinuses, ear • Salivary glands • Eye and

orbital tumours • Thyroid gland • 90% - squamous cell carcinoma • 10% - Others: adenocc. (salivary glands), lymphoma, sarcoma, melanoma Source: http://www.doksinet UICC TNM cancer staging Source: http://www.doksinet Source: http://www.doksinet Multidisciplinary management of head & neck tumours • Surgery • Radiotherapy (RT) • Chemotherapy • Combined treatments: – – – – surgery + postop. RT surgery + radio-chemotherapy primary radio-chemotherapy preop. RT + resection of residual tumour Source: http://www.doksinet Curative RT of head & neck tumours Standard and altered fractionation • Standard fractionation: – 66-72 Gy (2 Gy/day, 5 fractions/week) • Altered fractionation: – Hyperfractionated RT: 80,5 Gy (2x1,15 Gy/nap) – Accelerated RT - 66 Gy (2 Gy/nap, heti 6 kezelési nap) – Hyperfractionated-accelerated RT: • Concomitant boost: 72 Gy (1-4. weeks: 2Gy/day, 5-6. weeks: 2Gy + shrinked field 1,5 Gy/day) • CHART: 54 Gy (3x1,5

Gy/day, 7 fractions/week) Local tumour control: 8-19% Source: http://www.doksinet Curative treatment of locoregionally advanced (St. IIIIV) head & neck tumours = Radio-chemotherapy (RCT) • Sequential RCT: – adjuvant – NO survival benefit! – neoadjuvant – Good local response rate, BUT NO survival gain! • Concomitant RCT: STANDARD OF CARE – – – – – Bleomycin, Methotrexate – overlapping toxicity (mucositis!) 100 mg/m2 Cisplatin (Days: 1, 22 & 43) - STANDARD Cisplatin-5FU +/- Leucovorin (mucositis!!!) Carboplatin (impaired renal function) New agents: Taxanes +/- Cisplatin, Gemcitabine Local tumour control: 18-26% Overall survival: 14-31% Source: http://www.doksinet Curative treatment of head & neck tumours • T1-T2 N0-1: – RT alone with standard fracionation • Unfavorable T2, exophyt T3 N0-1: – RT alone with altered fractionation • T3-4, T1-2 N2-3: – concomitant radio-chemotherapy – N2-3: planned neck-dissection Source:

http://www.doksinet RT of maxillary tumours Operable: Surgery + postop. RT or Preop. RT + surgery Inoperable: Primary RT Source: http://www.doksinet Cutaneous lymphoma – Primary RT Before RT After RT Source: http://www.doksinet Squamous cell cc. of the nose – Primary RT Before RT After RT Source: http://www.doksinet RT of pharyngeal tumours • Nasopharynx • Mesopharynx + – Tonsillar fossa, faucial arches, soft palate, uvula, lateral and posterior pharyngeal wall, base of tounge • Hypopharynx – sinus piriformis, posterior pharyngeal wall, postcricoid region - Radiosensitivity Source: http://www.doksinet RT of nasopharyngeal tumours • 90% poorly differentiated nasopharyngeal cc. (lymphoepitelioma) • Radiosensitive tumour! • Primary treatment = RT – 66-72 Gy EBI – 60 Gy EBI + 4 x 4 Gy BT Source: http://www.doksinet RT of nasopharyngeal tumours Lateral field- Epipharynx + upper neck Anterior field- Lower neck Source: http://www.doksinet

BT of nasopharyngeal tumours Source: http://www.doksinet RT of mesopharyngeal tumours • • • • Primary treatment: RT or concomitant RCT T1-2 N0-1 uvula, tonsillar, base of tounge: surgery T3-4, N2-3: radical surgery + postop. RT Quality of life!!! Source: http://www.doksinet RT of mesopharyngeal tumours Postop. RT: 50-60 Gy Primary RT: 66-72 Gy Source: http://www.doksinet BT – Base of tounge tumours Source: http://www.doksinet RT of hypopharyngeal tumours • Primary treatment: radical surgery + postop. RT • Irresectable tu., inoperable patient, patient’s preference: Primary RT or RCT Source: http://www.doksinet RT of glottic tumours • Glottic-supraglottic tumours: – T1-2 N0: RT alone or surgery alone, BUT Qulaity of life!!!! Source: http://www.doksinet RT of glottic tumours • Glottic-supraglottic tumours: – T1-2 N+, T3 N0/+, early T4 : concomitant RCT (70 Gy RT + Days 1, 22, 43 - 100 mg/m2 Cisplatin) or total laryngectomy (QoL!!!) – Advanced

T4 (soft tissues-base of tounge): total laryngectomy + postop. RT Primary RT or RCT organ sparing, conservation of speaching ability Residual or recurrent tumour surgical salvage Source: http://www.doksinet RT of glottic tumours • Subglottic tumours: – Poor prognosis: nodal metastasis - 10-20%, usually T4 (infiltration of cartilage/trachea) – Standard treatment: total laryngectomy + postop. RT – Selected cases: Primary RT Source: http://www.doksinet Future directions • New chemotherapy drugs (taxanes, gemcitabine) • Radio-chemotherapy + altered fractionation • Citoprotective drugs (amifostin) • Intensity modulated RT (IMRT) (sparing of contralateral parotis, xerostomy) • Targeted therapy (EGFR inhibitors - Erbitux)