Published on March 19, 2013
Radiation for Head & Neck Cancer Robert Miller MD www.aboutcancer.com
Treatment decisions and management should be made by a team of physicians• Experienced cancer Surgeon and reconstruction team• Radiation oncologist with access to state of the art equipment (IMRT, IGRT or Tomotherapy)• Medical Oncologist (chemotherapy and targeted therapy)• Support personnel including nutritional support and
Treatment options for headand neck cancer Early stages: surgery or radiation Advanced stage: chemoradiation or surgery followed by radiation and chemotherapy Very advanced cases: radiation and chemotherapy
Radiation Accurate simulation and contouring the targets Need for high doses Use IMRT or Tomotherapy to maximize coverage and minimize side effects Combine with chemotherapy
SimulationA face mask is usually made to hold thehead still and allow the targetingmarkings to be painted on the mask
CT scan is obtained at this time CT images are then imported into the treatment planning computer
In thesimulationprocess the CTand PET scanimages areused to createa computerreconstructionof the patientand cancer
Digitally Reconstructed Images: Somepatients have very short necks making the radiationtargeting more difficult
Location of the larynx (in red) in two typical patients, one with a shortneck and one with a long neck, in the short neck patients, the shouldersmay be in the way of the radiation beam, requiring more complextechniques
For small cancers in the vocal cords it ispossible to keep the radiation far awayfrom other normal structures
Normal structures are identified on the computergenerated images, as well as the cancertargets, more advanced case with spread to thelymph nodes
Radiation zone (in blue) is designed to coverthe cancer and nodes and avoid normalstructures as much as possible
Radiation Dosedaily: Monday through Friday for 7weeks
Radiation Dose - PostOp
Poor Radiation Results FromNon-compliance in RadiationTechnique Critical Impact of Radiotherapy Protocol Compliance and Quality in the Treatment of Advanced Head and Neck Cancer: Results From TROG 02.02 Noncompliance, more relapses CO June 20, 2010 vol. 28 no. 18 2996-3001
IMRT and Side EffectsXerostomia Conventional IMRT12 months 74% 38%24 months 83% 29% Parotid-sparing intensity modulated versus conventional radiotherapy in head and neck cancer (PARSPORT): a phase 3 multicenter randomized controlled trial.
Combine a CT scan and linearaccelerator to ultimate in targeting (IGRT)and ultimate in delivery (dynamic, helicalIMRT) ability to daily adjust the beam(ART or adaptive radiotherapy)
Low riskparotid glandtumor (in red)may bepossible tokeep theradiation zone(blue) as smallas possible
Low risk parotid gland tumor, then using Tomotherapy toensure coverage of the tumor on the left, but avoidinggoing too deep and hitting normal parotid on other side
Since Tomotherapy takes a CT scan daily prior to radiation it isoften possible to observe the tumor shrinking during the course ofthe radiation (the radiation technique can be changed as the tumorshrinks – Adaptive Radiotherapy
Tumor regression duringTomotherapy
The cancer target (red circle) is expanded to give a margin around thecancer (radiation or blue circle) The computer then fits a radiation zone tomatch the blue target (red cloud or radiation zone). Daly CT scans allow thephysician to watch and see that the cancer is shrinking as expected
With Tomotherapy ACT scan is performeddaily prior to everytreatment so that if thetumor changes positionor shrink rapidly, theradiation target can beadjusted, this isreferred to as‘adaptive’ therapy andcan only be done onTomotherapy Machine
Randomized Trial XRT versusXRT + Erbitux Radiation plus Erbitux Radiation N Engl J Med 2006; 354:567-578
Randomized trial XRT alone versus XRT/Chemo radiation/cisplatin radiationJCO January 1, 2003 vol. 21 no. 1 92-98
Chemoradiation for Advanced Head and Neck Cancer SURVIVAL JCO Dec 20, 2010:5294-5300;
Chemoradiation HPV + HPV - JCO September 20, 2010 vol. 28 no. 27 4142-4148
Cure Rates for Advanced Head andNeck Cancer with Chemo-Radiation Cisplatin Erbitux (cetuximab)Failure-free survival among patients with cancer of oropharynx, hypopharynx, or larynx; IJROBP 2011:81;915
Quick Response to Radiationcombined with chemotherapy, Tonsilcancer gone by 2 ½ weeks
Same patient at 4 weeks
Tongue Cancer Before and 3Months after Radiation
Tomotherapy for SquamousCancer of the Tonsil
Chemoradiation Right PyriformSinus before and at 3 Years
Chemoradiation Results for Advanced Cancer of the Oropharynx (squamous cancer of the left tonsil that extended onto the base of tongue) PET prior to Treatment 2 YearsLater
Lymph Node Metastasis Often by the first new PET scan at 8 weeks, the cancer is no longer visible
Side Effects Side effects will relate to the size and location of the radiation field and the normal structures that are in the way of the beam
Side effects of radiation are related to thestructures that are near the tumor, so the radiationcan effect the teeth (dental problems) throat (sorethroat) and saliva glands (dryness and changes intaste)
Short Term Side Effects 1. Skin irritation 2. Dry Mouth and changes in taste and possible problems with teeth 3. Sore throat and problems with swallowing and dehydration and possible need for a feeding tube 4. Pain management problems 5. Laryngitis 6. Fatigue
RadiationDermatitisalmost everyonegets a sunburned reactionin the face orneck and creamsare required (likeAquaphor andSilvadene)
RadiationDermatitis(skin burn)often thethinnest part ofthe neck overthe voice box isaffected
Radiation Dermatitis… last dayand two months later
Radiation Dermatitis T3 Larynx treated with chemotherap y plus full dose radiation Skin burn on neck, last day of radiation
Side Effects of Radiation to the Mouth
Same patient at three months
Mucositis (inflamed lining ofthe mouth) grade 2 The roof of the mouth gets a white coating after 3 weeks
Same patient 3 weeks later
Grade 3 mucositis
Mucositis The lining of the mouth and surface of the tongue can get quite inflamed from radiation, particularly when combined with chemotherapy. Most patients need pain medication for this phase
Mucositis – same patient twomonths later, sorenessgone, mouth still some whatdry and taste improving
Mucositis Lining of the roof of the mouth with radiation mucositis after 5 weeks of radiation and chemotherap y
MucositisMost patients needpain medication forthis phase and manypatients require afeeding tube toavoid dehydration ormalnutrition
Long Term Side Effects 1. The dryness may be permanent, depending on the amount of saliva glands in the field 2. Teeth may be vulnerable to decay, and caution is need with future dental care to avoid jaw bone problems (osteonecrosis) 3. Some patients have long term problems with swallowing 4. Some patients have persistent hoarseness 5. Small risk of low thyroid hormones 6. Carotid stenosis
Long Term SideEffects
Small blood vessels on Cancer area appearsnormal palate pale (achromia)(telangectasia) Mouth still dry but better lubricated
Samepatient at 2years /mouth stilldry andtaste forfood still notnormal
Radiation Results for Cancer ofthe Palate (roof of the mouth)Often palate lesions are superficial with not much to see, at 10months there are some blotchy radiation changes or discolorationon the roof of her mouth and the mouth looks a bit dry, but nosigns of the cancer
10 Years after MouthRadiation for Cancer of theSoft Palate Discoloratio n of the roof of the mouth
Long Term Side Effects Dryness and discoloration of the roof of mouth is common as is problems with teethLong term dental care is critical to avoidosteoradionecrosis (damage to the jaw bonewith exposed bone, may require hyperbaricoxygen treatment to heal)
Cure Rates are better for peoplewho stop smoking during theradiation Years JCO June 10, 2012 vol. 30 no. 17 2102-
Radiation for Head & Neck Cancer Robert Miller MD www.aboutcancer.co m
Calcification Inhibitors in CKD and Dialysis Patients
Dealing with Dry Mouth in Head and Neck Cancer Patients #UCLAMDChat - Julie Jung Kang, MD, PhD - Duration: 28:47. UCLA Health 5,562 views
Learn about the radiation therapy provided at WellSpan for head and neck cancer ... video will automatically ... Radiation Treatment for Throat ...
Are You Being Treated With Radiation for Cancer in Your Head or Neck? If so, this booklet can help you.
What are the symptoms of head and neck cancers? ... Treatment for head and neck cancer can ... Patients who receive radiation to the head and neck may ...
... of the latest advances in head and neck cancer treatment. ... video camera that is attached ... of head and neck cancer, our radiation ...
If you get radiation therapy to the head or neck, ... Before starting radiation, talk to your cancer care team about whether you should get a complete ...
... you need to know exactly what type of head and neck cancer you have and what ... Oral Complications of Chemotherapy and Head/Neck Radiation (PDQ ...
Head and neck cancer includes cancers of the mouth, ... Oral Complications of Chemotherapy and Head/Neck Radiation (PDQ) (National Cancer Institute) ...
Radiation Therapy for Nonmelanoma Skin Cancer. Radiation therapy ... types of therapy to treat aggressive or recurrent skin cancer. ... View All Video.