ill effects of radiotherapy in the management of oral cancer by dr kashif ali assistant professor
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ILL EFFECTS OF RADIOTHERAPY IN THE MANAGEMENT OF ORAL CANCER
byDr kashif ali
Assistant professor
ORAL CANCER
Approximately 90% of oral cancer is SCC
Particularly common in developing world
Multifactorial etiology life styleHabits and
dietOthers
Other1%
Leukemias5%Lymphomas
9%
Salivary gland tumours
7%
Squamous cell carcinomas
78%
Head & Neck Cancer Diagnosis
Squamous Cell Carcinoma
• 90% of all oral cancers• 50% 5-year survival• can occur in: • tongue• skin• throat• soft palate
Treatment plan is based on:
• anatomical considerations
Treatment plan is based on:
Staging of disease using TNM classification
Eg. T3N2M0 laryngeal carcinoma
T = Tumour sizeN = Nodal statusM = Metastases
Treatment Options
Primary surgery Primary Radiotherapy
+/- +/-
Adjuvant Radiotherapy
Surgery for Salvage
+/-+/-
Concurrent Chemotherapy
Concurrent Chemotherapy
OR
Aims of radiotherapy
Radical radiotherapy --- curative intent
Palliative radiotherapy --To control symptoms
Radiation Therapy
External beam–most common–largest fields
Radiation Therapy
Brachytherapy–interstitial implantation of
radioisotope-filled needles
Radiation Therapy
Au grain or Iridium Implants
Radiation
• How much?
• Where?
How much radiation?
1 “rad” = 1 centiGray (cGy)
200 cGy per day 5 days per week 1000 cGy per week
How much radiation?
Total dose ranges from 6000 cGy – 7000 cGy
6 – 7 WEEKS of treatment
ORAL CANCERTREATMENT MODALTIES
Ablative Surgery Surgery and / or radiotherapy Radiotherapy and Chemotherapy
ORAL CANCERRADIOTHERAPY
Advantages Normal Anatomy and function Is maintained GA not needed Can be used to debulk inaccessible
lesions
ORAL CANCERRADIOTHERAPY
Conventionally upto 60 Gys dose is given
Post radiotherapy complaints increase tremendously when the radiation dose is increased
ORAL CANCERRADIOTHERAPY
ill effects Oral mucositis Xerostomia Loss of tasteOsteoradionecrosis
Oral mucosaSeen in 1-2 weeksErythema with sever mucositis With or without ulcerationPain and disphagiaLoss of test- test bud atrophyDelayed healing Pale and less vascular mucosaRadiotherapy induced Submucous
fibrosis
ORAL CANCERRADIOTHERAPY
Salivary glands
1st week of radiotherapyXerostomia Difficulty in swallowing Nasua Rampant cariesPeriodontitisRecovery 3 to 4 months
Management
Sipped of water Salivary substitute Mucous based sprays -saliva orthane
sprayCellulose --- glandosane, glycerin Pilocarpine hydrocloride 5mg QIDCevimelive hydroloride 30mg TDSStimulation of exocrine gland
Skin
Erythema 3rd weekDose greater than 50 gy Healing 7 to 10 days
Bone
OsteoradionecrosisIs devitilization of bone after
cancericidal dose of radiationEndarteritis Bone turn over become slow,
remolding dose not occur leads to exposed bone
ORAL CANCERRADIOTHERAPY
ORAL CANCERRADIOTHERAPY
ORAL CANCERRADIOTHERAPY
ORAL CANCERRADIOTHERAPY
Other effects
Alteration of floraInc anaerobic speciesInc fungi , Candida Nystatin0.1% chlorexidine
Late effects of radiation
Eyes Cataract 10 gyBlindness 50 gySpinal cord Paraplegia dose Inc 45gyCarotid artery stenosis
ORAL CANCERRADIOTHERAPY
Conclusion Surgery is the first choice Surgery may be followed by
Radiotherapy or Chemotherapy if required
Where bone is involved, Radiotherapy / Chemotherapy do not work
Radiotherapy / Chemotherapy alone only work as palliative therapy
Radiotherapy must be done under the supervision of experienced oncologist
ORAL CANCERRADIOTHERAPY
THANK YOU
Evaluation of dentition before radiotherapy
Most feared side effect is ORN Factor determine the fate of teeth1. Condition of residual dentition-- ?2. Pt awareness – past care pt with good oral hygiene , the
clinician must retain as many of teeth as possible
Neglected oral health --ext
Factor determine the fate of teeth
3 Immediacy of radiotherapy
4 Radiation location Pre radiation ext considered 1- 2 week
delay radiation5 Radiation doseInc 50 GY--- ext indicated Less than 50 – conservative
Preparation of dentition for radiotherapy
Pre radiation Restorations Topical fluoride applicationOral hygiene measures and
instructionsPrevention of mechanical trauma Encourage to stop habitts
Preparation of dentition for radiotherapy cont
Per radiation Rinse mouth with saline at least 10 times
daily Chlorhaxidine mouth wash 2 times Dental evaluation twice a week during
radiotherapy If overgrowth of candida than nystatin /
clotimazole Exercise – maintain mouth opening Weight loss should be checked NG tubes
Post radiationRegular follow up every 3- 4 weekTopical fluoride
Method of preparing preirradiation extraction
atraumatic extraction Interval B/w preirradiation ext and
beginning of radiotherapy 7-14 days 3 weeks if possible
Impacted 3rd molar removal before radiotherapy
Partially erupted Complete embedded
Carious teeth after radiotherapy
Treatment accordingly Composite , amalgamNecrotic pulp __ RCTIf RCT is difficult – amputation above
the gingiva left at place
Tooth ext after radiotherapy
4 month gap HBO before and after ext 20- 30 dives
Denture after radiation
Yes Soft liners
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