Download Head and neck cancer

Head & Neck Ca.
(Epithelial tumors)
Mohamad KADRI. MD.
Clinical oncology.
Medical director of AlBerouni University Hospital
President of Syrian Association of Oncology (SAO)
Head and neck cancer
• In 2014, more than 55000 new cases were
diagnosed (3% of new cancer cases in USA).
• > 90% SCC…
• Alcohol, tobacco, and HPV, are now well
accepted risk factors…
NCCN Clinical Practice Guidelines in Oncology: Head & Neck Cancer, v.1. 2015
1- Head and neck epithelial ca
(Nasopharyngeal Ts are not included)
 Tis,T1, T2 and N0 : - Surgery +/- RT.
- RT.
 T3,T4, or N+ : - Surgery then RT or chemo/RT.
- RT or chemo/RT, then surgery.
- RT or chemo/RT.
 Tany Nany (maxill): Surgery and/or RT and/or Chemo/RT
NCCN Clinical Practice Guidelines in Oncology: Head & Neck Cancer, v.1. 2015
Concomitant chemo/RT
 CDDP 75-100 mg/m2, q3 wks. or
40-50 mg/m2, weekly.
 CDDP 75-100 mg/ m2, d1, q3wks.
Fu 750-1000 mg/m2, d1-d4(5), q3wks.
 CDDP 20 mg/m2, d1-d5, q4wks.
Fu 200 mg/m2, d1-d5, q4wks.
 CBDCA 70 mg/m2, d1-d5, q3-4wks.
Fu 600 mg/m2, d1-d5, q3-4wks.
 - CDDP or CBDCA + Paclitaxel.
NCCN Clinical Practice Guidelines in Oncology: Head & Neck Cancer, v.1. 2015
Concomitant Cetuximab/RT
 Cetuximab + RT:
- SCC. Cetuximab (EGFR-antibody) is the 1st
targeted therapy approved
for the treatment of HNSCC.
- Head and neck, (Non-Nasopharyngeal).
- concomitant with RT as definitive treatment.
 Cetuximab + RT:
- 400 mg/m2, 2h inf, 1week before RT.
- 250 mg/m2, 1h inf, weekly for 7wks
starting with RT.
NCCN Clinical Practice Guidelines in Oncology: Head & Neck Cancer, v.1 2015
Concomitant Cetuximab/RT
Cetuximab + RT:
• Cetuximab + RT, is equal to CDDP + RT, and
better than RT alone, (by 5.5% 3years OS), but
without increase of toxicity.
• Cetuximab, can be considered an alternative to
chemo for unfit patients to chemotherapy.
(FDA approval)
• Cetuximab + chemotherapy + RT, Not routinely
recommended now, due to toxicity.
NCCN Clinical Practice Guidelines in Oncology: Head & Neck Cancer, v.1 2015
2- Nasopharynx
 T1 N0 : definitive RT.
 T2,3,4
N+ :
- CDDP 100 mg/m2, d1,22,43,
or
40 mg/m2, weekly, during RT,
followed by:
- CDDP 80 mg/m2, d1, q3wks, 3cycles.
- Fu 1000 mg/m2, d1-d4, q3wks, 3cycles.
and/or
NCCN Clinical Practice Guidelines in Oncology: Head & Neck Cancer, v.1. 2015
Induction chemotherapy
+/- Cetuximab
• The standard chemoradiotherapy
approach for fit patients with locally
advanced disease remains concurrent
CDDP and RT.
NCCN Clinical Practice Guidelines in Oncology: Head & Neck Cancer, v.1 2015
• Induction chemotherapy is not
considered standard treatment in
advanced disease.
ESMO Guidelines. Head & Neck Cancer.
Induction chemotherapy +/- Cetuximab
1- Not approved as standard of care.
2- No significant survival benefit.
3- Category 3 for Nasopharyngeal ca..
4- May be suitable, (as optional), for some cases.
NCCN Clinical Practice Guidelines in Oncology: Head & Neck Cancer, v.1 2015
Induction chemotherapy
(optional) 2-3 cycles
• Organ preservation plan. (total laryngectomy
required)
• Very advanced H&N ca,(primary or nodes)
excluded from primary surgery.
NCCN Clinical Practice Guidelines in Oncology: Head & Neck Cancer, v.1 2015
Induction chemotherapy
(optional) 2-3 cycles
• Organ preservation plan. (total laryngectomy
required)
• Very advanced H&N ca,(primary or nodes)
excluded from primary surgery.
NCCN Clinical Practice Guidelines in Oncology: Head & Neck Cancer, v.1 2015
Induction chemotherapy
(optional) 2-3 cycles
(organ preservation plan)
1- Hypopharynx, or supraglottic larynx, selected T1-23 any N (total laryngectomy required).
2- Glottic larynx, T3 any N (total laryngectomy
required).
3- Hypopharynx, supraglottic, or glottic larynx, T4a
any N, (refuse primary surgery).
NCCN Clinical Practice Guidelines in Oncology: Head & Neck Cancer, v.1. 2015
Induction chemotherapy
(optional) 2-3 cycles
(organ preservation plan)
2-3 cycles induction chemotherapy, then restaging:
- CR or PR in primary site
chemo/RT,
followed by surgery to residuals.
- Less than PR in primary site
surgery,
followed by RT or chemo/RT.
NCCN Clinical Practice Guidelines in Oncology: Head & Neck Cancer, v.1. 2015
Induction chemotherapy
(optional) 2-3 cycles
• Organ preservation plan. (total laryngectomy
required)
• Very advanced H&N ca,(primary or nodes)
excluded from primary surgery.
NCCN Clinical Practice Guidelines in Oncology: Head & Neck Cancer, v.1. 2015
Induction chemotherapy
(optional) 2-3 cycles
1- Oropharynx, T3-4 and/or N2-3, excluded from primary
surgery.
2- Very advanced H&N ca,(primary or nodes)
Induction CT, then RT or chemo/RT, followed by surgery or follow up. (increase
locoregional/systemic control).
NCCN Clinical Practice Guidelines in Oncology: Head & Neck Cancer, v.1. 2015
Induction chemotherapy(optional)
2-3 cycles
PF:
- CDDP 75-100 mg/m2 d1, q3wks.
- Fu 750-1000 mg/m2 d1-4(5), q3wks.
TPF :
- Docetaxel 75 mg/m2 d1, q3wks.
- CDDP 75-100 mg/m2 d1, q3wks.
- Fu 750-1000 mg/m2 d1-4(5), q3wks.
PPF:
- Paclitaxel 175 mg/m2, d1, q3-4wks.
- CDDP 60 mg/m2 d1, q3-4wks.
- Fu 750-1000 mg/m2 d1-4(5), q3wks.
NCCN Clinical Practice Guidelines in Oncology: Head & Neck Cancer, v.1. 2015
Induction chemotherapy….
• CDDP-based induction chemotherapy
followed by high dose q3w CDDP
chemoradiotherapy is not recommended now
due to toxicity concerns…
• After induction chemotherapy, multiple
options can be used for the RT-based
chemoradiation portion of therapy, RT alone,
weekly carboplatin, cetuximab, and weekly
CDDP for Nasopharyngeal ca.
Recurrent, resistant, or metastatic disease
Single agent:
- Bleomycin.
- MTX.
- FU.
- Docetaxel.
- Paclitaxel.
- CDDP.
- CBDCA.
- Capecitabine.
- Gemcitabine. (Nasopharyngeal ca. only)
- Venorelbine. (Non-Nasopharyngeal ca)
- Cetuximab. (Non-Nasopharyngeal ca)
NCCN Clinical Practice Guidelines in Oncology: Head & Neck Cancer, v.1. 2015
Recurrent, resistant, or metastatic disease
Combination chemotherapy :












CDDP or Carboplatin + 5-Fu.
Docetaxel + CDDP + Fu.
CDDP + Epirubicin + Bleomycin. (Nasopharyngeal only)
Paclitaxel or Docetaxel + CDDP or CBDCA.
CDDP + Paclitaxel or Docetaxel + Cetuximab. (Non-nasopharyngeal)
CDDP or CBDCA + Paclitaxel + Ifosfamide.
Ifosfamide + Folinic acid + Fu. (Nasopharyngeal only)
Gemcitabine + CDDP. (Nasopharyngeal only)
CDDP or Carboplatin + 5-Fu + Cetuximab. (Non-nasopharyngeal)
CDDP + Cetuximab. (Non-nasopharyngeal)
Carboplatin + Cetuximab. (Nasopharyngeal only)
Gemcitabine + Venorelbine. (Nasopharyngeal only)
 CDDP + Mitoxantrone. (salivary glands Ts.)
 CDDP + Doxorubicin. (salivary glands Ts.)
NCCN Clinical Practice Guidelines in Oncology: Head & Neck Cancer, v.1. 2015
Radiation therapy technique
FIRST CURE OF CANCER BY
X-RAYS
1899 - BASAL CELL
CARCINOMA
X-rays were used to cure cancer very soon
after their discovery
•
•
•
The first patient received
radiation therapy from the
medical linear accelerator
Stanford
2-year-old boy with
retinoblastoma
Head and Neck Immobilization devices
Organs at Risk
PTV (70 Gy) = GTV (70)+ 1cm
PTV (54-60 Gy) = CTV(54-60)+1cm
Organs at Risk-DVH
Cord max < 45 Gy.
Brainstem max < 54 Gy.
Optic nerves max < 50 Gy.
Optic Chiasm max < 50 Gy.
Retina max < 45 Gy.
Target mean = 70 Gy, +/-5%.
Non-involved tissue minimize.
Fields Setup
L - Nodes (AP - PA)
R - Nodes (AP - PA)
PTV – primary tumor (70 Gy)
PTV - Node (70 Gy)
Plan Sum
Dose Volume Histogram
MLC Multileaf collimator
• Advanced computerization
and Hardware control and
processing.
• Advanced radiation safety
devices
Portal Imaging
Lateral Isocenter Verification
Thank you
Mohamad KADRI. MD.
Clinical oncology.
Medical director of AlBerouni University Hospital
President of Syrian Association of Oncology (SAO)