head and neck cancer

Head And Neck Head And Neck CancerCancer

Mostafa EL-HaddadMostafa EL-Haddad Kasr El-Ainy Hospital Cairo UniversityKasr El-Ainy Hospital Cairo University

NEMROCKNEMROCK 20092009

Category 1 Priority;Patients with the tumour types for which there is evidence that prolongation of treatment affects outcome, and who are being treated radically with curative intent. The data reviewed show very strong evidence that prolongation of overall treatment time affects treatment outcome or local tumour control (cure rates) in patients with the following tumours:• SCC of the head and neck region.• SCC cervix.• non-small cell carcinoma of lung (NSCLC).

Guidelines for the Management of the Unscheduled Interruption or Prolongation of a Radical Course of

Radiotherapy (2nd Edition. 2002).

MD Anderson series showed that MD Anderson series showed that completed combined treatment completed combined treatment (Surgery+Radiotherapy) in 11 weeks (Surgery+Radiotherapy) in 11 weeks is better than 11 to 13 weeks and is better than 11 to 13 weeks and more than 13 weeks is the worst.more than 13 weeks is the worst.

Why Head And Neck Is Why Head And Neck Is SpecialSpecial

Very Complicated anatomy.Very Complicated anatomy. Many risk organ in a very narrow Many risk organ in a very narrow

space.space. Needs high precision.Needs high precision. Patients in very bad shape.Patients in very bad shape. RCR report for priority.RCR report for priority.

ANATOMYANATOMY

Imaging In Head and Neck Imaging In Head and Neck CancerCancer

CT scan: Accurate information about CT scan: Accurate information about pneumatization, integrity of bony pneumatization, integrity of bony structures.structures.

MRI: soft tissue extension, Perineural, MRI: soft tissue extension, Perineural, perivascular infiltration, intracranial perivascular infiltration, intracranial extension.extension.

Base of skull CT? MRI?.Base of skull CT? MRI?.

Imaging before or after Biopsy? Imaging before or after Biopsy? Larynx?Larynx?

General Rules for General Rules for ImagingImaging

MR of choice in: Parotid, facial area, skull base MR of choice in: Parotid, facial area, skull base (intracranial extension), Any tumor with (intracranial extension), Any tumor with potential perineural affection, oral cavity and potential perineural affection, oral cavity and oropharynx.oropharynx.

T2 WI excellent tumor to muscle enhancement.T2 WI excellent tumor to muscle enhancement. T2 allows differentiation between secretions T2 allows differentiation between secretions

and mucosal thickening together with tumor and mucosal thickening together with tumor which have low signal (Low water content).which have low signal (Low water content).

In T1 look at the tumor invading Fat.In T1 look at the tumor invading Fat.

(Fat shows high signal in T1).(Fat shows high signal in T1).

CT is preferable if Swallowing may CT is preferable if Swallowing may be a problem. (Ca Larynx).be a problem. (Ca Larynx).

DON’T FORGET NECK DON’T FORGET NECK ULTRASOOUND.ULTRASOOUND.

PET and PET CT.PET and PET CT.

Thyroid.Thyroid. Parotid.Parotid. Ear.Ear. Eye and Orbit.Eye and Orbit. PNS.PNS.

FORGET IT

ImmobilizationImmobilization Comfort and immobilization.Comfort and immobilization. Unsightly setup marks.Unsightly setup marks. Mask, Tape stretched, Beam directing shell.Mask, Tape stretched, Beam directing shell. Coughing, sneezing, respiration and Coughing, sneezing, respiration and

swallowing.swallowing. Mark LNs.Mark LNs. Important land marks: (canthus, orbits, Important land marks: (canthus, orbits,

external auditory canal, oral commissures).external auditory canal, oral commissures). Before making the mask, use the Before making the mask, use the

fluoroscopy to align the patient and fluoroscopy to align the patient and put him in the suitable position.put him in the suitable position.

In Our DepartmentIn Our Department

Put all head and neck patients on the Put all head and neck patients on the CC head rest. head rest.

PNS, NasopharynxPNS, Nasopharynx. (MAIN).. (MAIN). Ear, parotid: may be on patient side.Ear, parotid: may be on patient side. Pituitary in Flexion.Pituitary in Flexion. You can use hyperextension in any You can use hyperextension in any

patient where you can protect the patient where you can protect the larynx .larynx .

Facial Mask systemFacial Mask system

Thermoplastic mask.Thermoplastic mask. Beam directing shell.Beam directing shell. Plastic material.Plastic material.

Radioopaque Markers Radioopaque Markers And StentsAnd Stents

Wires to mark important structures Wires to mark important structures or lymph nodes.or lymph nodes.

Stent to depress the tongue, Stent to depress the tongue, protrude the lips.protrude the lips.

Patient FixationPatient Fixation

PositioningPositioning Mask on the Simulation, Why?Mask on the Simulation, Why?

PositioningPositioning Tilt your patient head ?? Tilt your patient head ?? Do you know what you did?Do you know what you did?

You re tilting the gantry.You re tilting the gantry.

PositioningPositioninge.g.:e.g.:

PositioningPositioning

Bad alignment for your patient, Do Bad alignment for your patient, Do you know what you are doing?you know what you are doing???

You are turning your couchYou are turning your couch

Neutral PositionNeutral Position

Head supportsHead supports Hyperextension can be achieved Hyperextension can be achieved

by elevating the chest without by elevating the chest without make a strain on the head.make a strain on the head.

Head supportHead support

A comfortable head support is one A comfortable head support is one that tightly fits to the posterior that tightly fits to the posterior surface of the head and neck and surface of the head and neck and help the patient to maintain the help the patient to maintain the position without straining.position without straining.

The neck is rested but not the head,

this open room for a movement

Dental ImpressionDental Impression

When you have to use tongue When you have to use tongue depressor?depressor?

Dental ImpressionDental Impression

When the maxillary antrum is When the maxillary antrum is treated the Tongue and lower half of treated the Tongue and lower half of the mouth can be excluded.the mouth can be excluded.

Likewise, when a tumor of the Likewise, when a tumor of the tongue or the floor of the mouth are tongue or the floor of the mouth are treated the upper part of the mouth treated the upper part of the mouth can be excluded.can be excluded.

Used a dental impression material Used a dental impression material with a syringe inside for breathing.with a syringe inside for breathing.

Treatment TechniquesTreatment Techniques

Basic treatment technique: for the Basic treatment technique: for the majority:majority:

- Two lateral and one lower anterior Two lateral and one lower anterior fields.fields.

- First including the spinal cord in First including the spinal cord in phase I and then off cord for phase phase I and then off cord for phase II.II.

Overlapping RegionOverlapping RegionProblemProblem

WHY IT’S A PROBLEM?

Ways To Solve this OverlapWays To Solve this Overlap

Ways To Solve this Ways To Solve this OverlapOverlap

Method1Method1::

Midline spinal cord block in the Midline spinal cord block in the anterior supraclavicular field.anterior supraclavicular field.

AgainstAgainst::

Can not be done when anterior Can not be done when anterior structures should be included in the structures should be included in the field.field.

Why narrower?


Method 2Method 2::

Gap between two fields calculated by Gap between two fields calculated by ::

½ field½ field11 length x depth/SSD + ½ length x depth/SSD + ½ fieldfield22 length x depth/SSD length x depth/SSD

AgainstAgainst::

High uncertainty.High uncertainty.

Ways To Solve this Ways To Solve this OverlapOverlapMethod 3Method 3::

Put a block over the spinal cord at the Put a block over the spinal cord at the posterior inferior angle of the lateral posterior inferior angle of the lateral field.field.

AgainstAgainst::

Difficult set-up. Difficult set-up.

Still there is lateral and anterior overlap Still there is lateral and anterior overlap

Still there is overlap in the lateral and anterior soft tissues? How can you solve

it?

When We can not use this block?


Method 4Method 4:: Use Collimator and Couch angle.Use Collimator and Couch angle.

AgainstAgainst::Time consuming Time consuming

(table move only from inside the room).(table move only from inside the room).

Errors in movement.Errors in movement.

Anterior neck field

Lateral head and neck field

Overlap region

Overlap region corrected

Overlap region

Overlap region corrected


Method 5Method 5::

Turn the couch 90 degree and move Turn the couch 90 degree and move the gantry accordingly..the gantry accordingly..

AgainstAgainst::

Time consuming (table move only Time consuming (table move only from inside the room), errors in from inside the room), errors in movement.movement.

Tracheostomy ProblemsTracheostomy Problems

Site of recurrence : 10% risk.Site of recurrence : 10% risk. No tissue, dose may be higher on the No tissue, dose may be higher on the

spinal Cord. spinal Cord. Need a doughnut bolus to avoid Need a doughnut bolus to avoid

suffocation.suffocation.

HAVE FUN!!HAVE FUN!!:):)

Clothes ClampClothes Clamp

Clothes ClampClothes ClampAnother use?Another use?

How Can You Determine the How Can You Determine the Energy for Electron beamEnergy for Electron beam

Separation=12cm

Spinal Cord

Take care for neck asymmetry

Portal ArrangementsPortal Arrangements Opposed –lateral photon fields, with the patient Opposed –lateral photon fields, with the patient

immobilized in supine position are used for immobilized in supine position are used for treatment of most cancers :treatment of most cancers :

oral cavity, Larynx, pharynx.oral cavity, Larynx, pharynx.Superior border:Superior border: Determined by the location of

the known disease and likely spread pattern. Whenever possible avoid : Optic pathways, part of

the TMJ and auditory canal from the portals.In GeneralIn General: Either it will be1- At the base of skull when we want to include the

retropharyngeal node, e.g. Hypopharynx.Hypopharynx. 2- Above base when the site is already in the base, e.g.

nasopharynxnasopharynx. 3- Just safety margin above the tumor (Larynx).

Superior border:Superior border:NasopharynxNasopharynx

HypopharynxHypopharynx

OropharynxOropharynx

Oral cavity:Oral cavity:

LarynxLarynx

Above skull base. because the primary at skull base.

Skull base? Retropharyngeal nodes

Skull base? Primary at skull base.

Do you want lymph node? So skull base/If not take only a margin (1 to 2 cm).

Glottic? Above the glottis.

Supraglottic? Lymph nodes so skull base.

Subgltic (very rare) only margin above the larynx.

Glottic with extensive supra? Skull base.

Lower border:Lower border:

Ask this question: can I protect the Ask this question: can I protect the larynx?larynx?

YES NO

Put your border above the arytenoid (below hyoid bone)

Put your as low as possible

PLEASE DON’T CUT IN A NODE

OR A TUMOR

Lower border (ctn):Lower border (ctn): It is desirable to exclude It is desirable to exclude the larynx from the fieldthe larynx from the field from the lateral field from the lateral field when this setup does not compromise the target.when this setup does not compromise the target.

How?How?- Lower border of the lateral fields is placed just Lower border of the lateral fields is placed just

superior to the arytenoids (below hyoid bone).superior to the arytenoids (below hyoid bone).- In patient who can hyperextend his neck an In patient who can hyperextend his neck an asymmetric jaw (half beam block), can be used.asymmetric jaw (half beam block), can be used.- If the patient can not hyperextend the neck, use If the patient can not hyperextend the neck, use

a slanting inferior border (by collimation), to a slanting inferior border (by collimation), to avoid matching at the sloping submental area.avoid matching at the sloping submental area.

- When the larynx can not be excluded the lower When the larynx can not be excluded the lower border is placed as low as possible, at the neck border is placed as low as possible, at the neck shoulder junction.shoulder junction.

Portal ArrangementsPortal Arrangements

Anterior border: Anterior border: - Covering skin over the larynx.Covering skin over the larynx.- Margin anterior to the tumor or its Margin anterior to the tumor or its

site.site.

? ? Take careTake care

not with:not with: tumor extend to anterior tumor extend to anterior subcutaneous tissue, large subcutaneous tissue, large submandibular nodes, jugular lymph submandibular nodes, jugular lymph nodes are present, Surgical scar? nodes are present, Surgical scar? Extracapsular extensionExtracapsular extension

A strip of the anterior A strip of the anterior midline skin is usually midline skin is usually spared whenever spared whenever possible to minimize possible to minimize lymph-drainage lymph-drainage impairment after impairment after irradiation.irradiation.

Group I: Group I:

Low riskLow risk: 20%.: 20%.

T1 Floor of mouth, oral tongue, T1 Floor of mouth, oral tongue, retromolar trigone, gingiva, hard retromolar trigone, gingiva, hard palate, buccal mucosa palate, buccal mucosa

Group II Group II

Intermediate riskIntermediate risk 20–30% 20–30%

T1: Soft palate, pharyngeal wall, T1: Soft palate, pharyngeal wall, supraglottic larynx, tonsil supraglottic larynx, tonsil

T2: Floor of mouth, oral tongue, T2: Floor of mouth, oral tongue, retromolar trigone, gingiva, hard retromolar trigone, gingiva, hard palate, buccal mucosa palate, buccal mucosa

Goup: III High risk>30% Goup: III High risk>30% T1–T4Nasopharynx, pyriform sinus, base T1–T4Nasopharynx, pyriform sinus, base

of tongue. of tongue.

T2–T4: Soft palate, pharyngeal wall, T2–T4: Soft palate, pharyngeal wall, supraglottic larynx, tonsil .supraglottic larynx, tonsil .

T3–T4: Floor of mouth, oral tongue, T3–T4: Floor of mouth, oral tongue,

retromolar trigone, gingiva, hard retromolar trigone, gingiva, hard palate, buccal mucosa. palate, buccal mucosa.

Posterior border:Posterior border:- If NIf N00 with low risk of subclinical with low risk of subclinical

spread to the posterior cervical nodes, spread to the posterior cervical nodes, the posterior border is placed behind the posterior border is placed behind the insertion of the sternomastoid.the insertion of the sternomastoid.

- If N+ cases or primary tumors with If N+ cases or primary tumors with substantial spread to the posterior substantial spread to the posterior cervical nodes, posterior border cervical nodes, posterior border placed behind the spinous process or placed behind the spinous process or with good safety margin to the with good safety margin to the

SHOWER??SHOWER??

NO evidence that taking shower will NO evidence that taking shower will increase the skin reaction!!.increase the skin reaction!!.

IF you can let your patient take a IF you can let your patient take a shower in the day before his shower in the day before his replanning day.replanning day.

And in patients tattooed.And in patients tattooed.

To SummarizeTo Summarize

Nasopharynx, oropharynx, or Oral Nasopharynx, oropharynx, or Oral Cavity the junction should be made Cavity the junction should be made above the thyroid notch (thus the above the thyroid notch (thus the anterior spinal cord shield protect anterior spinal cord shield protect the larynx as well).the larynx as well).

In the hypopharynx and the larynx In the hypopharynx and the larynx we avoid midline shield.we avoid midline shield.

3D CRT3D CRT IN HEAD AND NECK IN HEAD AND NECK

CANCERCANCER

How to define and delineate How to define and delineate your target volumeyour target volume

How to Approach your How to Approach your PatientPatient

Ask yourself the following questions:Ask yourself the following questions:

1-Where is the tumor?.1-Where is the tumor?.

2- Is there is any Lymph nodes?2- Is there is any Lymph nodes?

3- If No Lymph nodes is it a site rich in 3- If No Lymph nodes is it a site rich in lymphatic?.lymphatic?.

4- What’s the role of surgery: - 4- What’s the role of surgery: - resectable?resectable?

5- Lymph nodes dissected or Not?5- Lymph nodes dissected or Not?

Early stage DiseaseEarly stage Disease

Surgery Vs Radio and Chemo.Surgery Vs Radio and Chemo.

How to decide? If functional outcome How to decide? If functional outcome is better with CRT go for it if not ! is better with CRT go for it if not ! Go for Surgey.Go for Surgey.

TAKE CARE!!!TAKE CARE!!!

Not only ChemoRT but good Not only ChemoRT but good ChemoRT.ChemoRT.

Late Stages T3-T4Late Stages T3-T4 Usually Surgery first if resectable.Usually Surgery first if resectable. You still can Try CRT if organ preservation is You still can Try CRT if organ preservation is

required. (provided salvage surgery may still be required. (provided salvage surgery may still be an option. e.g. patient reliable for good follow-up. an option. e.g. patient reliable for good follow-up. Surgeon reliable for good surgery.Surgeon reliable for good surgery.

Famous Laryngeal preservation trials:Famous Laryngeal preservation trials:Veterans Affairs (larynx neoadjuvant), EORTC Veterans Affairs (larynx neoadjuvant), EORTC

(Hypopharynx neoadjuvant), (Hypopharynx neoadjuvant), (RTOG 91-11 larynx Concurrent CRT value).(RTOG 91-11 larynx Concurrent CRT value).Recently Urba et al JCO 2006(NEW is the use of Recently Urba et al JCO 2006(NEW is the use of

concurrent CRT if good response to the concurrent CRT if good response to the neoadjuvant treatment.neoadjuvant treatment.

Organs At Risk (OARs)Organs At Risk (OARs) Chiasma: 50-52Chiasma: 50-52 Optic Nerves: 50- 52Optic Nerves: 50- 52 Eyes (Lens) : 10GyEyes (Lens) : 10Gy Spinal Cord: 5cm: 50Gy, 10 cm: 50 , 20cm: Spinal Cord: 5cm: 50Gy, 10 cm: 50 , 20cm:

45Gy45Gy Brain Stem: 60Gy but 2/3: 53Gy whole Brain Stem: 60Gy but 2/3: 53Gy whole

50Gy.50Gy. Brachial plexus: 60Gy.Brachial plexus: 60Gy. Salivary Glands: situlation 26Gy, without Salivary Glands: situlation 26Gy, without

23Gy, complete loss of function 32Gy.23Gy, complete loss of function 32Gy.

((TD5/5 Emami et al 1991TD5/5 Emami et al 1991))

Computer TomographyComputer Tomographywith or without MRIwith or without MRI

fusion fusion

ToxicityToxicity

Hypogeusia.Hypogeusia. Ageusia.Ageusia. Dysgeusia.Dysgeusia.

Target Volume Target Volume DelineationDelineation

ANATOMIEANATOMIE

Lymphatic SystemLymphatic System

Basic Anatomical Consideration:Basic Anatomical Consideration:- - Well lateralized tumor spread to ipsilateral L.N.Well lateralized tumor spread to ipsilateral L.N.- Midline tumors may spread to both sides.Midline tumors may spread to both sides.- Patients with huge L.N (N3) may have Patients with huge L.N (N3) may have

contralateral L.N.contralateral L.N.

(lymphatic obstruction leads to Lymph shunts).(lymphatic obstruction leads to Lymph shunts).- Which parts in head and neck has very little Which parts in head and neck has very little

incidence of lymphatic spread?incidence of lymphatic spread?

Middle ear, Vocal Cord, PNS???Middle ear, Vocal Cord, PNS???..

Risk of Lymph node involvement Risk of Lymph node involvement depends on: depends on:

1- T stage.1- T stage.

2- Lymphatic invasion (in biopsy).2- Lymphatic invasion (in biopsy).

3- Degree of differentiation.3- Degree of differentiation.

Group I: Group I:

Low riskLow risk: 20%.: 20%.

T1 Floor of mouth, oral tongue, T1 Floor of mouth, oral tongue, retromolar trigone, gingiva, hard retromolar trigone, gingiva, hard palate, buccal mucosa palate, buccal mucosa

Group II Group II

Intermediate riskIntermediate risk 20–30% 20–30%

T1: Soft palate, pharyngeal wall, T1: Soft palate, pharyngeal wall, supraglottic larynx, tonsil supraglottic larynx, tonsil

T2:Floor of mouth, oral tongue, T2:Floor of mouth, oral tongue, retromolar trigone, gingiva, hard retromolar trigone, gingiva, hard palate, buccal mucosa palate, buccal mucosa

Goup: III High risk>30% Goup: III High risk>30% T1–T4Nasopharynx, pyriform sinus, base T1–T4Nasopharynx, pyriform sinus, base

of tongue. of tongue.

T2–T4: Soft palate, pharyngeal wall, T2–T4: Soft palate, pharyngeal wall, supraglottic larynx, tonsil .supraglottic larynx, tonsil .

T3–T4: Floor of mouth, oral tongue, T3–T4: Floor of mouth, oral tongue,

retromolar trigone, gingiva, hard retromolar trigone, gingiva, hard palate, buccal mucosa. palate, buccal mucosa.

1- Oral Cavity and oropharynx: 1- Oral Cavity and oropharynx:

a- lateralized. b- Middle line.a- lateralized. b- Middle line.

2- Larynx and Hypopharynx.2- Larynx and Hypopharynx.

3- Nose, NHH, and Nasopharynx3- Nose, NHH, and Nasopharynx

NasopharynxNasopharynx Target: differ according to treatment phaseTarget: differ according to treatment phase Phase I: structures included?Phase I: structures included?- GTV1: include mass seen in MRI.GTV1: include mass seen in MRI.- GTV2: LNs affectedGTV2: LNs affected- CTV1: nasopharynx proper, sphenoid air CTV1: nasopharynx proper, sphenoid air

sinus, basiocciput, base of skull to include, sinus, basiocciput, base of skull to include, posterior ethmoids, posterior one third of posterior ethmoids, posterior one third of maxillary antrum, neck nodes maxillary antrum, neck nodes (retropharyngeal, posterior cervical , (retropharyngeal, posterior cervical , jugular).jugular).

- Lateral and posterior pharyngeal wall to Lateral and posterior pharyngeal wall to the level of mid tonsillar fossa the level of mid tonsillar fossa

LOOK HERE CAREFULLY

NasopharynxNasopharynx

Maxillary AntrumMaxillary Antrum

Different position WHY??Different position WHY?? HOW??HOW?? Eye opened looking forward.Eye opened looking forward.

If rotating the eye ??.If rotating the eye ??.

Putting the retina in the high dose Putting the retina in the high dose region.region.

Maxillary AntrumMaxillary Antrum

Maxillary Antrum And Maxillary Antrum And PNSPNS

GTVGTV all gross tumor that can be seen in all gross tumor that can be seen in imaging.imaging.

PTVPTV include: GTV with 2-3 cm margin. include: GTV with 2-3 cm margin.Then reduce it to 1-2 cm margin.Then reduce it to 1-2 cm margin.(this may not fulfill what you need so do it if you (this may not fulfill what you need so do it if you

don’t know what to do!!).don’t know what to do!!).

Some centers now include the submandibular Some centers now include the submandibular and subdigastric L.Ns in patients with and subdigastric L.Ns in patients with Squamous cell or poorly differentiated Squamous cell or poorly differentiated carcinoma.carcinoma.

Maxiallry Antrum ctnMaxiallry Antrum ctn

Volume include:Volume include: Upper borderUpper border: :

above Crista galli? above Crista galli?

Why? Why?

To include the ethmoids.To include the ethmoids.

Or Lower edge of the cornea if no Or Lower edge of the cornea if no orbital infiltration.orbital infiltration.

Lower Border: Lower Border: 1cm below the floor of the 1cm below the floor of the sinus.sinus.

Medial border:Medial border: 1-2 cm across the midline 1-2 cm across the midline to cover the contralateral ethmoid sinus.to cover the contralateral ethmoid sinus.

Lateral borderLateral border: extend one cm beyond : extend one cm beyond the apex of the sinus.the apex of the sinus.

Lateral portal: Lateral portal:

Anterior border:Anterior border: is anterior to the anterior is anterior to the anterior wall. wall.

Posterior border:Posterior border: is behind the pterygoid is behind the pterygoid plates.plates.

Maxillary sinus Maxillary sinus conformalconformal

Volume to be includedVolume to be included::1- Maxillary sinus. 1- Maxillary sinus. 2- Palate.2- Palate.3- Alveolar ridge.3- Alveolar ridge.4- Nasal Cavity.4- Nasal Cavity.5- Medial orbit.5- Medial orbit.6- nasopharunx.6- nasopharunx.7- pterygopalatine and infratemporal 7- pterygopalatine and infratemporal

fossae.fossae.

LETS HAVE SOME LETS HAVE SOME PRACTICEPRACTICE

ATLAS CT ATLAS CT

head and neck cancer

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