Radiation for Head & Neck Cancer

Robert Miller MD

www.aboutcancer.com

NCCN.org

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 dental care

Treatment options for head and neck cancer

Early stages: surgery or radiation

Advanced stage: chemoradiation or surgery followed by radiation and chemotherapy

Very advanced cases: radiation and chemotherapy

RadiationAccurate simulation and

contouring the targetsNeed for high dosesUse IMRT or Tomotherapy to

maximize coverage and minimize side effects

Combine with chemotherapy

Simulation

A face mask is usually made to hold the head still and allow the targeting markings to be painted on the mask

CT images are then imported into the treatment planning computer

CT scan is obtained at this time

In the simulation process the CT and PET scan images are used to create a computer reconstruction of the patient and cancer

http://www.rtog.org/CoreLab/ContouringAtlases.aspx

Digitally Reconstructed Images: Some patients have very short necks making the radiation targeting more difficult

Location of the larynx (in red) in two typical patients, one with a short neck and one with a long neck, in the short neck patients, the shoulders may be in the way of the radiation beam, requiring more complex techniques

For small cancers in the vocal cords it is possible to keep the radiation far away from other normal structures

Normal structures are identified on the computer generated images, as well as the cancer targets, more advanced case with spread to the lymph nodes

Radiation zone (in blue) is designed to cover the cancer and nodes and avoid normal structures as much as possible

Radiation Dosedaily: Monday through Friday for 7 weeks

Radiation Dose - PostOp

Poor Radiation Results From Non-compliance in Radiation Technique

Critical Impact of Radiotherapy Protocol Compliance and Quality in the Treatment of Advanced Head and Neck Cancer: Results From TROG 02.02

CO June 20, 2010 vol. 28 no. 18 2996-3001

Noncompliance, more relapses

IMRT and Side Effects

Parotid-sparing intensity modulated versus conventional radiotherapy in head and neck cancer (PARSPORT): a phase 3 multicenter randomized controlled trial. Lancet Oncol. 2011;12(2):127.

Xerostomia

Conventional

IMRT

12 months 74% 38%

24 months 83% 29%

Combine a CT scan and linear accelerator to ultimate in targeting (IGRT) and ultimate in delivery (dynamic, helical IMRT) ability to daily adjust the beam (ART or adaptive radiotherapy)

Low risk parotid gland tumor (in red) may be possible to keep the radiation zone (blue) as small as possible

Low risk parotid gland tumor, then using Tomotherapy to ensure coverage of the tumor on the left, but avoiding going too deep and hitting normal parotid on other side

Since Tomotherapy takes a CT scan daily prior to radiation it is often possible to observe the tumor shrinking during the course of the radiation (the radiation technique can be changed as the tumor shrinks – Adaptive Radiotherapy

Tumor regression during Tomotherapy

The cancer target (red circle) is expanded to give a margin around the cancer (radiation or blue circle) The computer then fits a radiation zone to match the blue target (red cloud or radiation zone). Daly CT scans allow the physician to watch and see that the cancer is shrinking as expected

With Tomotherapy A CT scan is performed daily prior to every treatment so that if the tumor changes position or shrink rapidly, the radiation target can be adjusted, this is referred to as ‘adaptive’ therapy and can only be done on Tomotherapy Machine

Chemotherapy

Randomized Trial XRT versus XRT + Erbitux

Radiation plus Erbitux

Radiation

N Engl J Med 2006; 354:567-578

radiation

radiation/cisplatin

Randomized trial XRT alone versus XRT/Chemo

JCO January 1, 2003 vol. 21 no. 1 92-98

Chemoradiation for Advanced Head and Neck Cancer

JCO Dec 20, 2010:5294-5300;

SURVIVAL

Chemoradiation

JCO September 20, 2010 vol. 28 no. 27 4142-4148

HPV +

HPV -

Failure-free survival among patients with cancer of oropharynx, hypo pharynx, or larynx;  IJROBP 2011:81;915

Erbitux (cetuximab)

Cisplatin

Cure Rates for Advanced Head and Neck Cancer with Chemo-Radiation

Quick Response to Radiation combined with chemotherapy, Tonsil cancer gone by 2 ½ weeks

Same patient at 4 weeks

Tongue Cancer Before and 3 Months after Radiation

Tomotherapy for Squamous Cancer of the Tonsil

Chemoradiation Right Pyriform Sinus 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 Years Later

Chemoradiation Nasopharynx

Often by the first new PET scan at 8 weeks, the cancer is no longer visible

Lymph Node Metastasis

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

Side effects of radiation are related to the structures that are near the tumor, so the radiation can effect the teeth (dental problems) throat (sore throat) and saliva glands (dryness and changes in taste)

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

Short Term Side Effects

Radiation Dermatitis

almost everyone gets a sun burned reaction in the face or neck and creams are required (like Aquaphor and Silvadene)

Radiation Dermatitis (skin burn) often the thinnest part of the neck over the voice box is affected

Radiation Dermatitis… last day and two months later

T3 Larynx treated with chemotherapy plus full dose radiation

Skin burn on neck, last day of radiation

Radiation Dermatitis

Radiation Dermatitis

Side Effects of Radiation to the Mouth

Same patient at three months

The roof of the mouth gets a white coating after 3 weeks

Mucositis (inflamed lining of the mouth) grade 2

Same patient 3 weeks later

Grade 3 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

Mucositis – same patient two months later, soreness gone, mouth still some what dry and taste improving

Lining of the roof of the mouth with radiation mucositis after 5 weeks of radiation and chemotherapy

Mucositis

Most patients need pain medication for this phase and many patients require a feeding tube to avoid dehydration or malnutrition

Mucositis

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 Side Effects

Long Term Side Effects

Mouth still dry but better lubricated

Small blood vessels on normal palate (telangectasia)

Cancer area appears pale (achromia)

Same patient at 2 years / mouth still dry and taste for food still not normal

Often palate lesions are superficial with not much to see, at 10 months there are some blotchy radiation changes or discoloration on the roof of her mouth and the mouth looks a bit dry, but no signs of the cancer

Radiation Results for Cancer of the Palate (roof of the mouth)

Discoloration of the roof of the mouth

10 Years after Mouth Radiation for Cancer of the Soft Palate

Long Term Side Effects

Dryness and discoloration of the roof of mouth is common as is problems with teeth

Long term dental care is critical to avoid osteoradionecrosis (damage to the jaw bone with exposed bone, may require hyperbaric oxygen treatment to heal)

JCO June 10, 2012 vol. 30 no. 17 2102-2111

Years

Cure Rates are better for people who stop smoking during the radiation

Support Team

Radiation for Head & Neck Cancer

Robert Miller MD

www.aboutcancer.com