Download in head and neck cancer

Head And Neck
Cancer
Mostafa EL-Haddad
Kasr El-Ainy Hospital Cairo University
NEMROCK
2009
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 completed
combined treatment (Surgery+Radiotherapy) in
11 weeks is better than 11 to 13 weeks and more
than 13 weeks is the worst.
Why Head And Neck Is Special





Very Complicated anatomy.
Many risk organ in a very narrow space.
Needs high precision.
Patients in very bad shape.
RCR report for priority.
ANATOMY
Imaging In Head and Neck Cancer
CT scan: Accurate information about
pneumatization, integrity of bony structures.
 MRI:
soft tissue extension, Perineural,
perivascular infiltration, intracranial extension.
Base of skull CT? MRI?.
Imaging before or after Biopsy? Larynx?

General Rules for Imaging
MR of choice in: Parotid, facial area, skull base
(intracranial extension), Any tumor with potential
perineural affection, oral cavity and oropharynx.
 T2 WI excellent tumor to muscle enhancement.
 T2 allows differentiation between secretions and
mucosal thickening together with tumor which have
low signal (Low water content).
 In T1 look at the tumor invading Fat.
(Fat shows high signal in T1).


CT is preferable if Swallowing may be a
problem. (Ca Larynx).

DON’T FORGET NECK ULTRASOOUND.
PET and PET CT.






Thyroid.
Parotid.
Ear.
Eye and Orbit.
PNS.
FORGET IT
Immobilization







Comfort and immobilization.
Unsightly setup marks.
Mask, Tape stretched, Beam directing shell.
Coughing, sneezing, respiration and swallowing.
Mark LNs.
Important land marks: (canthus, orbits, external
auditory canal, oral commissures).
Before making the mask, use the
fluoroscopy to align the patient and put
him in the suitable position.
In Our Department





Put all head and neck patients on the C head
rest.
PNS, Nasopharynx. (MAIN).
Ear, parotid: may be on patient side.
Pituitary in Flexion.
You can use hyperextension in any patient
where you can protect the larynx .
Facial Mask system



Thermoplastic mask.
Beam directing shell.
Plastic material.
Radioopaque Markers And Stents


Wires to mark important structures or lymph
nodes.
Stent to depress the tongue, protrude the lips.
Patient Fixation
Positioning

Mask on the Simulation, Why?
Positioning
Tilt your patient head ??
 Do you know what you did?
You re tilting the gantry.

Positioning
e.g.:
Positioning
Bad alignment for your patient, Do you know
what you are doing??
You are turning your couch
Neutral Position
Head supports

Hyperextension can be achieved by
elevating the chest without make a strain on
the head.
Head support

A comfortable head support is one that tightly
fits to the posterior surface of the head and neck
and help the patient to maintain the position
without straining.
The neck is rested
but not the head,
this open room for
a movement
Dental Impression

When you have to use tongue depressor?
Dental Impression



When the maxillary antrum is treated the
Tongue and lower half of the mouth can be
excluded.
Likewise, when a tumor of the tongue or the
floor of the mouth are treated the upper part of
the mouth can be excluded.
Used a dental impression material with a syringe
inside for breathing.
Treatment Techniques
Basic treatment technique: for the majority:
- Two lateral and one lower anterior fields.
- First including the spinal cord in phase I and
then off cord for phase II.
Overlapping Region
Problem
WHY IT’S A PROBLEM?
Ways To Solve this
Overlap
Ways To Solve this Overlap
Method1:
Midline spinal cord block in the anterior
supraclavicular field.
Against:
Can not be done when anterior structures should
be included in the field.
Why narrower?
Ways To Solve this Overlap
Method 2:
Gap between two fields calculated by :
½ field1 length x depth/SSD + ½ field2
length x depth/SSD
Against:
High uncertainty.
Ways To Solve this Overlap
Method 3:
Put a block over the spinal cord at the
posterior inferior angle of the lateral
field.
Against:
Difficult set-up.
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?
Ways To Solve this Overlap
Method 4:
Use Collimator and Couch angle.
Against:
Time consuming
(table move only from inside the room).
Errors in movement.
Anterior neck field
Lateral head and
neck field
Overlap region
Overlap region
corrected
Overlap region
Overlap region
corrected
Ways To Solve this Overlap
Method 5:
Turn the couch 90 degree and move the gantry
accordingly..
Against:
Time consuming (table move only from inside the
room), errors in movement.
???
Tracheostomy Problems



Site of recurrence : 10% risk.
No tissue, dose may be higher on the spinal
Cord.
Need a doughnut bolus to avoid suffocation.
HAVE FUN!!
:)
Clothes Clamp
Clothes Clamp
Another use?
How Can You Determine the Energy
for Electron beam
Spinal Cord
Separation=12cm
Take care for neck asymmetry
Portal Arrangements
Opposed –lateral photon fields, with the patient immobilized in
supine position are used for treatment of most cancers :
oral cavity, Larynx, pharynx.
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 General: Either it will be
1- At the base of skull when we want to include the retropharyngeal
node, e.g. Hypopharynx.
2- Above base when the site is already in the base, e.g.
nasopharynx.
3- Just safety margin above the tumor (Larynx).

 Superior
border:
Nasopharynx
Hypopharynx
Oropharynx
Oral cavity:
Larynx
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:
Ask this question: can I protect the larynx?

YES
PLEASE DON’T CUT NO
IN A NODE OR A
TUMOR
Put your border above the
arytenoid (below hyoid bone)
Put your as low as possible

Lower border (ctn): It is desirable to exclude the larynx from
the field from the lateral field when this setup does not
compromise the target.
How?
-
-
Lower border of the lateral fields is placed just superior to the
arytenoids (below hyoid bone).
In patient who can hyperextend his neck an
asymmetric jaw (half beam block), can be used.
If the patient can not hyperextend the neck, use a slanting
inferior border (by collimation), to avoid matching at the sloping
submental area.
When the larynx can not be excluded the lower border is placed
as low as possible, at the neck shoulder junction.
Portal Arrangements

-
Anterior border:
Covering skin over the larynx.
Margin anterior to the tumor or its site.
A strip of the anterior
midline skin is usually
spared whenever
possible to minimize
lymph-drainage
impairment after
irradiation.
?
Take care
not with: tumor extend to anterior
subcutaneous tissue, large
submandibular nodes, jugular lymph
nodes are present, Surgical scar?
Extracapsular extension
Group I:
Low risk: 20%.
T1 Floor of mouth, oral tongue, retromolar
trigone, gingiva, hard palate, buccal mucosa

Group II
Intermediate risk 20–30%
T1: Soft palate, pharyngeal wall, supraglottic
larynx, tonsil
T2: Floor of mouth, oral tongue, retromolar
trigone, gingiva, hard palate, buccal mucosa

Goup: III High risk>30%
T1–T4Nasopharynx, pyriform sinus, base of
tongue.

T2–T4: Soft palate, pharyngeal wall, supraglottic
larynx, tonsil .
T3–T4: Floor of mouth, oral tongue, retromolar
trigone, gingiva, hard palate, buccal mucosa.

-
-
Posterior border:
If N0 with low risk of subclinical spread to the
posterior cervical nodes, the posterior border is
placed behind the insertion of the
sternomastoid.
If N+ cases or primary tumors with substantial
spread to the posterior cervical nodes, posterior
border placed behind the spinous process or
with good safety margin to the
SHOWER??



NO evidence that taking shower will increase
the skin reaction!!.
IF you can let your patient take a shower in the
day before his replanning day.
And in patients tattooed.
To Summarize


Nasopharynx, oropharynx, or Oral Cavity the
junction should be made above the thyroid
notch (thus the anterior spinal cord shield
protect the larynx as well).
In the hypopharynx and the larynx we avoid
midline shield.
3D CRT
IN HEAD AND NECK CANCER
How to define and delineate your
target volume
How to Approach your Patient
Ask yourself the following questions:
1-Where is the tumor?.
2- Is there is any Lymph nodes?
3- If No Lymph nodes is it a site rich in
lymphatic?.
4- What’s the role of surgery: - resectable?
5- Lymph nodes dissected or Not?

Early stage Disease
Surgery Vs Radio and Chemo.
How to decide? If functional outcome is better
with CRT go for it if not ! Go for Surgey.
TAKE CARE!!!
Not only ChemoRT but good ChemoRT.

Late Stages T3-T4
Usually Surgery first if resectable.
 You still can Try CRT if organ preservation is required.
(provided salvage surgery may still be an option. e.g. patient
reliable for good follow-up. Surgeon reliable for good surgery.
Famous Laryngeal preservation trials:
Veterans Affairs (larynx neoadjuvant), EORTC (Hypopharynx
neoadjuvant),
(RTOG 91-11 larynx Concurrent CRT value).
Recently Urba et al JCO 2006(NEW is the use of concurrent CRT
if good response to the neoadjuvant treatment.

Organs At Risk (OARs)







Chiasma: 50-52
Optic Nerves: 50- 52
Eyes (Lens) : 10Gy
Spinal Cord: 5cm: 50Gy, 10 cm: 50 , 20cm: 45Gy
Brain Stem: 60Gy but 2/3: 53Gy whole 50Gy.
Brachial plexus: 60Gy.
Salivary Glands: situlation 26Gy, without 23Gy,
complete loss of function 32Gy.
(TD5/5 Emami et al 1991)
Computer Tomography
with or without MRI
fusion
Toxicity



Hypogeusia.
Ageusia.
Dysgeusia.
Target Volume Delineation
ANATOMIE
Lymphatic System

Basic Anatomical Consideration:
- Well lateralized tumor spread to ipsilateral L.N.
- Midline tumors may spread to both sides.
- Patients with huge L.N (N3) may have contralateral L.N.
(lymphatic obstruction leads to Lymph shunts).
- Which parts in head and neck has very little incidence of
lymphatic spread?
Middle ear, Vocal Cord, PNS???.
Risk of Lymph node involvement depends on:
1- T stage.
2- Lymphatic invasion (in biopsy).
3- Degree of differentiation.

Group I:
Low risk: 20%.
T1 Floor of mouth, oral tongue, retromolar
trigone, gingiva, hard palate, buccal mucosa

Group II
Intermediate risk 20–30%
T1: Soft palate, pharyngeal wall, supraglottic
larynx, tonsil
T2:Floor of mouth, oral tongue, retromolar
trigone, gingiva, hard palate, buccal mucosa

Goup: III High risk>30%
T1–T4Nasopharynx, pyriform sinus, base of
tongue.

T2–T4: Soft palate, pharyngeal wall, supraglottic
larynx, tonsil .
T3–T4: Floor of mouth, oral tongue, retromolar
trigone, gingiva, hard palate, buccal mucosa.
1- Oral Cavity and oropharynx:
a- lateralized. b- Middle line.
2- Larynx and Hypopharynx.
3- Nose, NHH, and Nasopharynx
Nasopharynx


-
-
Target: differ according to treatment phase
Phase I: structures included?
GTV1: include mass seen in MRI.
GTV2: LNs affected
CTV1: nasopharynx proper, sphenoid air sinus,
basiocciput, base of skull to include, posterior
ethmoids, posterior one third of maxillary antrum,
neck nodes (retropharyngeal, posterior cervical ,
jugular).
Lateral and posterior pharyngeal wall to the level of mid
tonsillar fossa
Nasopharynx
LOOK HERE CAREFULLY
Maxillary Antrum
Different position WHY??
 HOW??
 Eye opened looking forward.
If rotating the eye ??.
Putting the retina in the high dose region.

Maxillary Antrum
Maxillary Antrum And PNS
GTV all gross tumor that can be seen in imaging.
 PTV include: GTV with 2-3 cm margin.
Then reduce it to 1-2 cm margin.
(this may not fulfill what you need so do it if you don’t
know what to do!!).

Some centers now include the submandibular and
subdigastric L.Ns in patients with Squamous cell or
poorly differentiated carcinoma.
Maxiallry Antrum ctn
Volume include:

Upper border:
above Crista galli?
Why?
To include the ethmoids.
Or Lower edge of the cornea if no orbital
infiltration.
Lower Border: 1cm below the floor of the sinus.
 Medial border: 1-2 cm across the midline to
cover the contralateral ethmoid sinus.
 Lateral border: extend one cm beyond the apex
of the sinus.
 Lateral portal:
Anterior border: is anterior to the anterior wall.
Posterior border: is behind the pterygoid plates.

Maxillary sinus conformal
Volume to be included:
1- Maxillary sinus.
2- Palate.
3- Alveolar ridge.
4- Nasal Cavity.
5- Medial orbit.
6- nasopharunx.
7- pterygopalatine and infratemporal fossae.

LETS HAVE SOME PRACTICE
ATLAS CT