Download - 22. Head and neck oncology
MANAGEMENTMANAGEMENTOF OF
HEAD & NECK HEAD & NECK RADIOTHERAPY RADIOTHERAPY
PATIENTSPATIENTSDr. Gillian SoskinDr. Gillian Soskin
GeneralGeneral Medicine D344/QP344Medicine D344/QP344
March 11, 2005March 11, 2005
Head & Neck Cancer Diagnosis
Squamous Cell CarcinomaSquamous Cell Carcinoma
• 90% of all oral cancers• 50% 5-year survival• can occur in:
• tongue• skin• throat• soft palate
Radiation Treatment Radiation Treatment Centres In OntarioCentres In Ontario
SudburyOttawa
KingstonTorontoLondon
Windsor
Treatment plan is based on:Treatment plan is based on:
• anatomical considerations
Treatment plan is based on:Treatment plan is based on:
Staging of disease using Staging of disease using TNMTNM classification classification
Eg. TEg. T33NN22MM00 laryngeal carcinoma laryngeal carcinoma
T = Tumour sizeN = Nodal statusM = Metastases
Treatment plan is based on:Treatment plan is based on:
• age of patient
Treatment plan is based on:Treatment plan is based on:
• co-morbid conditions
MedicalDentalSpeechNutritionPsychosocialSocioeconomic
Treatment OptionsTreatment Options
Primary surgery Primary Radiotherapy
+/- +/-
Adjuvant Radiotherapy
Surgery for Salvage
+/-+/-
Concurrent Chemotherapy
Concurrent Chemotherapy
OR
Treatment OptionsTreatment Options
• no treatment• palliation
Dental ManagementDental Management
Will involve :Will involve :
General DentistHygienistDental AssistantReception Staff
Dental ManagementDental Management
And may involve:And may involve:
Radiation TherapyRadiation Therapy
External beamExternal beam
–most common–largest fields
Radiation TherapyRadiation Therapy
Brachytherapy–interstitial implantation of radioisotope-filled needles
Radiation Therapy
Brachytherapy–interstitial implantation of
radioisotope-filled needles
Radiation TherapyRadiation Therapy
Au grain or Iridium Implants
Radiation Dosimetry
• 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
Where are the radiation fields?
• unilateral or bilateral?• neck only?• posterior mandible and neck?• oral cavity and neck?• base of skull to clavicles?
Impact on oral health!!!
Dental Consultation Dental Consultation
Clinical examinationClinical examinationcharting (odontogram)charting (odontogram)visual (other lesions?)visual (other lesions?)palpationpalpation
Dental Consultation Dental Consultation
Radiographic examinationRadiographic examinationPanorexPanorex intra-oral films as requiredintra-oral films as required
Dental Consultation Dental Consultation
DiagnosesDiagnoses DentalDental
CariesCaries Periodontal diseasePeriodontal disease Other PathologyOther Pathology
MedicalMedical co-morbiditiesco-morbidities
Dental Consultation (cont.)Dental Consultation (cont.)
Treatment Plan based on:Treatment Plan based on: prognosis of individual teethprognosis of individual teeth past dental history (compliance)past dental history (compliance) sequelae and potential sequelae and potential
complications from radiotherapycomplications from radiotherapy LONG TERM RISKS!LONG TERM RISKS!
Dental TreatmentDental Treatment
Must be done immediatelyMust be done immediately
no delay in radiotherapyno delay in radiotherapy cancer is progressing!!cancer is progressing!!
Dental TreatmentDental Treatment
ExtractionsExtractions abscesses, gross cariesabscesses, gross caries advanced periodontal diseaseadvanced periodontal disease heavily restored teeth w/ poor OHheavily restored teeth w/ poor OH
Must have 2 weeks healing prior Must have 2 weeks healing prior to start of radiotherapy!!!to start of radiotherapy!!!
Dental Treatment Dental Treatment
CleaningCleaning RestorationsRestorations
Complete these during healing phase Complete these during healing phase post-extractionpost-extraction
Dental Treatment Dental Treatment
Dentate?Dentate?fabricate custom fluoride traysfabricate custom fluoride trays
Dental Treatment Dental Treatment
Dentate?Dentate? daily topical applicationdaily topical application 1.23% APF gel1.23% APF gel 2% Neutral NaF gel2% Neutral NaF gel
4 minutesonce a day
EVERY DAY
for the rest of your life!!
Dental Treatment Dental Treatment
Edentulous?Edentulous? Poorly-fitting dentures?Poorly-fitting dentures?
Candida? Candida? Rx Nystatin before radiotherapy startsRx Nystatin before radiotherapy starts
Acute SequelaeAcute Sequelae
GeneralGeneral Weight loss (variable)Weight loss (variable) Nausea +/- vomitingNausea +/- vomiting FatigueFatigue DepressionDepression
Acute SequelaeAcute Sequelae
Extra-OralExtra-Oral Cutaneous burnsCutaneous burns AlopeciaAlopecia XerodermaXeroderma
Acute SequelaeAcute Sequelae
Intra-OralIntra-Oral MucositisMucositis
erythemaerythema ulcerationulceration
TREATMENT:
1. Nystatin 100,000 u/ml oral suspension
5 mL (1 tsp.) P.O. qid
Swish for 1 min. and swallow
**If another organism or systemic infection is
suspected, alert the medical oncologist
immediately**
CANDIDIASIS
TREATMENT:
2. Diphenhydramine (Benadryl) elixir
Mixed with Kaopectate or Maalox 1:1
by pharmacist
15 mL (1 Tbsp.) P.O. prn pain
Swish for 30 sec. then spit out
ORAL MUCOSITIS
TREATMENT:
3. 0.1% Hydrocortisone rinse
15 mL P.O. tid
Swish for 30 sec. then spit out
**contra-indicated if active viral lesions
are present intra-orally**
ORAL MUCOSITIS
Acute SequelaeAcute Sequelae
Intra-OralIntra-Oral XerostomiaXerostomia
Acute SequelaeAcute Sequelae
Intra-OralIntra-Oral Hypogeusia (diminished taste)Hypogeusia (diminished taste) Odynophagia (painful swallowing)Odynophagia (painful swallowing)
22oo to mucositis/ulceration to mucositis/ulceration
Acute SequelaeAcute Sequelae
Intra-OralIntra-Oral Dysphagia (difficulty Dysphagia (difficulty
swallowing)swallowing) may necessitate J-may necessitate J-
tubetube may persist 2may persist 2oo to to
esophageal esophageal scarringscarring
Chronic SequelaeChronic Sequelae
XerostomiaXerostomia begins ~ 1 week into treatmentbegins ~ 1 week into treatment permanent!permanent!
Chronic SequelaeChronic Sequelae
Problems with xerostomiaProblems with xerostomia increased increased cariescaries risk risk
daily topical fluoride applicationdaily topical fluoride applicationfrequent recalls - every 3 monthsfrequent recalls - every 3 monthsincreased cost to patientincreased cost to patient
Chronic SequelaeChronic Sequelae
Problems with xerostomiaProblems with xerostomia increased increased traumatrauma risk risk
soft tissues very drysoft tissues very dry easily injuredeasily injured
Chronic SequelaeChronic Sequelae
Problems with xerostomia Problems with xerostomia thick secretionsthick secretions
change in mucous:serous ratiochange in mucous:serous ratio increased “gag”increased “gag” difficulty wearing denturesdifficulty wearing dentures
Chronic SequelaeChronic Sequelae
Problems with xerostomia Problems with xerostomia difficulty swallowingdifficulty swallowing
H2O with/between meals H2O with/between meals chronic Candidiasischronic Candidiasis
Chronic SequelaeChronic Sequelae TrismusTrismus
22oo to fibrosis of muscles to fibrosis of muscles exacerbated by pre-XRT trauma (ie. exacerbated by pre-XRT trauma (ie.
Surgery)Surgery)
Chronic SequelaeChronic Sequelae
Problems with trismusProblems with trismus impaired nutrition if severeimpaired nutrition if severe very limited access for dental very limited access for dental
treatmenttreatment restorationsrestorations cleaningcleaning inability to make/wear denturesinability to make/wear dentures
Chronic SequelaeChronic Sequelae
Physiotherapy for trismusPhysiotherapy for trismus
Chronic SequelaeChronic Sequelae
EdemaEdema 22oo to decreased to decreased
lymphatic drainage lymphatic drainage from fibrosisfrom fibrosis
not usually a not usually a functional problem functional problem but cosmeticbut cosmetic
Chronic SequelaeChronic Sequelae
Impaired wound healingImpaired wound healingincreased fibrosis increased fibrosis decreased circulation decreased circulation
Chronic SequelaeChronic Sequelae
Impaired wound healingImpaired wound healingNO extractions without NO extractions without consultationconsultation
wait 6-9 months before wait 6-9 months before denturesdentures
ComplicationsComplications
Post- radiotherapyPost- radiotherapy potential for healing worsepotential for healing worse length of time is length of time is NOTNOT self-limiting self-limiting
ComplicationsComplications
Soft tissue necrosisSoft tissue necrosis 22oo to trauma to trauma 2 2oo to ischemia to ischemia
ComplicationsComplications
Areas most susceptibleAreas most susceptible hard/soft palatehard/soft palate FOM, ventral surface of tongueFOM, ventral surface of tongue mucosa overlying internal oblique mucosa overlying internal oblique
ridgeridge Treatment ***REFER***Treatment ***REFER***
ComplicationsComplications
Definition:Definition: OsteoradionecrosisOsteoradionecrosis
““death of bone death of bone
following radiation”following radiation”
ComplicationsComplications
OsteoradionecrosisOsteoradionecrosis hypoxic injuryhypoxic injury devitalized bone will often not be painful!devitalized bone will often not be painful! patient may not be aware of it - LOOK!patient may not be aware of it - LOOK! radiographic changes may/may not be radiographic changes may/may not be
presentpresent CLD often a problem, source of traumaCLD often a problem, source of trauma
Complications Complications
Problems with OsteoradionecrosisProblems with Osteoradionecrosis superinfection with bacteria/fungussuperinfection with bacteria/fungus sharp spicules will traumatize other soft sharp spicules will traumatize other soft
tissues - more problemstissues - more problems can be progressive, potential “en bloc” can be progressive, potential “en bloc”
resectionresection Treatment ***REFER***Treatment ***REFER***
Hyperbaric Oxygen Therapy
• helps to promote vascularity• growth of new blood vessels• increased oxygen tension within tissues
Therefore helps healing process
Hyperbaric Oxygen Therapy
Prior to HBO
Hyperbaric Oxygen Therapy
During HBO
Hyperbaric Oxygen Therapy
Following HBO
Hyperbaric Oxygen Therapy
Only 2 facilities in Ontario:
• Hamilton• Toronto
Hyperbaric Oxygen Therapy
Marx Protocol (Prophylaxis):
• 20 treatments• Extractions• 10 treatments
Hyperbaric Oxygen Therapy
Marx Protocol (Osteoradionecrosis):
• 30 treatments• Resection• 10 treatments
SummarySummary
Squamous cell carcinoma (head & neck) Squamous cell carcinoma (head & neck) represents 4% of new casesrepresents 4% of new cases
Average age of population increasingAverage age of population increasing Average practice will see these patientsAverage practice will see these patients Long-term follow-up necessaryLong-term follow-up necessary Medical/dental management of these Medical/dental management of these
patients is complicated and requires a patients is complicated and requires a team approachteam approach
ReferencesReferences The Head & Neck Radiotherapy PatientThe Head & Neck Radiotherapy Patient
Part I:Part I: Oral Manifestations of Radiation Therapy Oral Manifestations of Radiation Therapy
Part II:Part II: Management of Oral Complications Management of Oral Complications
CompendiumCompendium (1994), vol. 15(2), pp.250-260 (1994), vol. 15(2), pp.250-260
15(4), pp.442-45415(4), pp.442-454
Head & Neck Cancer Patients Receiving Head & Neck Cancer Patients Receiving Radiation TherapyRadiation Therapy
ADA Oral Health Care SeriesADA Oral Health Care Series
ReferencesReferences
National Institute of Dental & Craniofacial National Institute of Dental & Craniofacial Research (Research (www.nohic.nidcr.nih.govwww.nohic.nidcr.nih.gov))
Canadian Cancer Society (Canadian Cancer Society (www.cancer.cawww.cancer.ca))
Oral Cancer FoundationOral Cancer Foundation
((www.oralcancerfoundation.orgwww.oralcancerfoundation.org))