Managementof Head & Neck Radiotherapy Patients

MANAGEMENTMANAGEMENTOF OF

HEAD & NECK HEAD & NECK RADIOTHERAPY RADIOTHERAPY

PATIENTSPATIENTSDr. Gillian SoskinDr. Gillian Soskin

GeneralGeneral Medicine D344/QP344Medicine D344/QP344

Head & Neck Cancer Diagnosis

Squamous Cell CarcinomaSquamous Cell Carcinoma

• 90% of all oral cancers• 50% 5-year survival• can occur in:

• tongue• skin• throat• soft palate

Radiation Treatment Radiation Treatment Centres In OntarioCentres In Ontario

SudburyOttawa

KingstonTorontoLondon

Windsor

Treatment plan is based on:Treatment plan is based on:

• anatomical considerations


Staging of disease using Staging of disease using TNMTNM classification classification

Eg. TEg. T33NN22MM00 laryngeal carcinoma laryngeal carcinoma

T = Tumour sizeN = Nodal statusM = Metastases


• age of patient


• co-morbid conditions

MedicalDentalSpeechNutritionPsychosocialSocioeconomic

Treatment OptionsTreatment Options

Primary surgery Primary Radiotherapy

+/- +/-

Adjuvant Radiotherapy

Surgery for Salvage

+/-+/-

Concurrent Chemotherapy

Concurrent Chemotherapy

OR

Treatment OptionsTreatment Options

• no treatment• palliation

Dental ManagementDental Management

Will involve :Will involve :

General DentistHygienistDental AssistantReception Staff

Dental ManagementDental Management

And may involve:And may involve:

Radiation TherapyRadiation Therapy

External beamExternal beam

–most common–largest fields


Brachytherapy–interstitial implantation of radioisotope-filled needles

Radiation Therapy

Brachytherapy–interstitial implantation of

radioisotope-filled needles


Au grain or Iridium Implants

Radiation Dosimetry

• How much?

• Where?

How much radiation?

1 “rad” = 1 centiGray (cGy)

200 cGy per day 5 days per week 1000 cGy per week

How much radiation?

Total dose ranges from 6000 cGy – 7000 cGy

6 – 7 WEEKS of treatment

Where are the radiation fields?

• unilateral or bilateral?• neck only?• posterior mandible and neck?• oral cavity and neck?• base of skull to clavicles?

Impact on oral health!!!

Dental Consultation Dental Consultation

Clinical examinationClinical examinationcharting (odontogram)charting (odontogram)visual (other lesions?)visual (other lesions?)palpationpalpation


Radiographic examinationRadiographic examinationPanorexPanorex intra-oral films as requiredintra-oral films as required


DiagnosesDiagnoses DentalDental

CariesCaries Periodontal diseasePeriodontal disease Other PathologyOther Pathology

MedicalMedical co-morbiditiesco-morbidities

Dental Consultation (cont.)Dental Consultation (cont.)

Treatment Plan based on:Treatment Plan based on: prognosis of individual teethprognosis of individual teeth past dental history (compliance)past dental history (compliance) sequelae and potential sequelae and potential

complications from radiotherapycomplications from radiotherapy LONG TERM RISKS!LONG TERM RISKS!

Dental TreatmentDental Treatment

Must be done immediatelyMust be done immediately

no delay in radiotherapyno delay in radiotherapy cancer is progressing!!cancer is progressing!!

Dental TreatmentDental Treatment

ExtractionsExtractions abscesses, gross cariesabscesses, gross caries advanced periodontal diseaseadvanced periodontal disease heavily restored teeth w/ poor OHheavily restored teeth w/ poor OH

Must have 2 weeks healing prior Must have 2 weeks healing prior to start of radiotherapy!!!to start of radiotherapy!!!

Dental Treatment Dental Treatment

CleaningCleaning RestorationsRestorations

Complete these during healing phase Complete these during healing phase post-extractionpost-extraction


Dentate?Dentate?fabricate custom fluoride traysfabricate custom fluoride trays


Dentate?Dentate? daily topical applicationdaily topical application 1.23% APF gel1.23% APF gel 2% Neutral NaF gel2% Neutral NaF gel

4 minutesonce a day

EVERY DAY

for the rest of your life!!


Edentulous?Edentulous? Poorly-fitting dentures?Poorly-fitting dentures?

Candida? Candida? Rx Nystatin before radiotherapy startsRx Nystatin before radiotherapy starts

Acute SequelaeAcute Sequelae

GeneralGeneral Weight loss (variable)Weight loss (variable) Nausea +/- vomitingNausea +/- vomiting FatigueFatigue DepressionDepression


Extra-OralExtra-Oral Cutaneous burnsCutaneous burns AlopeciaAlopecia XerodermaXeroderma


Intra-OralIntra-Oral MucositisMucositis

erythemaerythema ulcerationulceration

TREATMENT:

1. Nystatin 100,000 u/ml oral suspension

5 mL (1 tsp.) P.O. qid

Swish for 1 min. and swallow

**If another organism or systemic infection is

suspected, alert the medical oncologist

immediately**

CANDIDIASIS

TREATMENT:

2. Diphenhydramine (Benadryl) elixir

Mixed with Kaopectate or Maalox 1:1

by pharmacist

15 mL (1 Tbsp.) P.O. prn pain

Swish for 30 sec. then spit out

ORAL MUCOSITIS

TREATMENT:

3. 0.1% Hydrocortisone rinse

15 mL P.O. tid

Swish for 30 sec. then spit out

**contra-indicated if active viral lesions

are present intra-orally**

ORAL MUCOSITIS


Intra-OralIntra-Oral XerostomiaXerostomia


Intra-OralIntra-Oral Hypogeusia (diminished taste)Hypogeusia (diminished taste) Odynophagia (painful swallowing)Odynophagia (painful swallowing)

22oo to mucositis/ulceration to mucositis/ulceration


Intra-OralIntra-Oral Dysphagia (difficulty Dysphagia (difficulty

swallowing)swallowing) may necessitate J-may necessitate J-

tubetube may persist 2may persist 2oo to to

esophageal esophageal scarringscarring

Chronic SequelaeChronic Sequelae

XerostomiaXerostomia begins ~ 1 week into treatmentbegins ~ 1 week into treatment permanent!permanent!


Problems with xerostomiaProblems with xerostomia increased increased cariescaries risk risk

daily topical fluoride applicationdaily topical fluoride applicationfrequent recalls - every 3 monthsfrequent recalls - every 3 monthsincreased cost to patientincreased cost to patient


Problems with xerostomiaProblems with xerostomia increased increased traumatrauma risk risk

soft tissues very drysoft tissues very dry easily injuredeasily injured


Problems with xerostomia Problems with xerostomia thick secretionsthick secretions

change in mucous:serous ratiochange in mucous:serous ratio increased “gag”increased “gag” difficulty wearing denturesdifficulty wearing dentures


Problems with xerostomia Problems with xerostomia difficulty swallowingdifficulty swallowing

H2O with/between meals H2O with/between meals chronic Candidiasischronic Candidiasis

Chronic SequelaeChronic Sequelae TrismusTrismus

22oo to fibrosis of muscles to fibrosis of muscles exacerbated by pre-XRT trauma (ie. exacerbated by pre-XRT trauma (ie.

Surgery)Surgery)


Problems with trismusProblems with trismus impaired nutrition if severeimpaired nutrition if severe very limited access for dental very limited access for dental

treatmenttreatment restorationsrestorations cleaningcleaning inability to make/wear denturesinability to make/wear dentures


Physiotherapy for trismusPhysiotherapy for trismus


EdemaEdema 22oo to decreased to decreased

lymphatic drainage lymphatic drainage from fibrosisfrom fibrosis

not usually a not usually a functional problem functional problem but cosmeticbut cosmetic


Impaired wound healingImpaired wound healingincreased fibrosis increased fibrosis decreased circulation decreased circulation


Impaired wound healingImpaired wound healingNO extractions without NO extractions without consultationconsultation

wait 6-9 months before wait 6-9 months before denturesdentures

ComplicationsComplications

Post- radiotherapyPost- radiotherapy potential for healing worsepotential for healing worse length of time is length of time is NOTNOT self-limiting self-limiting


Soft tissue necrosisSoft tissue necrosis 22oo to trauma to trauma 2 2oo to ischemia to ischemia


Areas most susceptibleAreas most susceptible hard/soft palatehard/soft palate FOM, ventral surface of tongueFOM, ventral surface of tongue mucosa overlying internal oblique mucosa overlying internal oblique

ridgeridge Treatment ***REFER***Treatment ***REFER***


Definition:Definition: OsteoradionecrosisOsteoradionecrosis

““death of bone death of bone

following radiation”following radiation”


OsteoradionecrosisOsteoradionecrosis hypoxic injuryhypoxic injury devitalized bone will often not be painful!devitalized bone will often not be painful! patient may not be aware of it - LOOK!patient may not be aware of it - LOOK! radiographic changes may/may not be radiographic changes may/may not be

presentpresent CLD often a problem, source of traumaCLD often a problem, source of trauma

Complications Complications

Problems with OsteoradionecrosisProblems with Osteoradionecrosis superinfection with bacteria/fungussuperinfection with bacteria/fungus sharp spicules will traumatize other soft sharp spicules will traumatize other soft

tissues - more problemstissues - more problems can be progressive, potential “en bloc” can be progressive, potential “en bloc”

resectionresection Treatment ***REFER***Treatment ***REFER***

Hyperbaric Oxygen Therapy

• helps to promote vascularity• growth of new blood vessels• increased oxygen tension within tissues

Therefore helps healing process


Prior to HBO


During HBO


Following HBO


Only 2 facilities in Ontario:

• Hamilton• Toronto


Marx Protocol (Prophylaxis):

• 20 treatments• Extractions• 10 treatments


Marx Protocol (Osteoradionecrosis):

• 30 treatments• Resection• 10 treatments

SummarySummary

Squamous cell carcinoma (head & neck) Squamous cell carcinoma (head & neck) represents 4% of new casesrepresents 4% of new cases

Average age of population increasingAverage age of population increasing Average practice will see these patientsAverage practice will see these patients Long-term follow-up necessaryLong-term follow-up necessary Medical/dental management of these Medical/dental management of these

patients is complicated and requires a patients is complicated and requires a team approachteam approach

ReferencesReferences The Head & Neck Radiotherapy PatientThe Head & Neck Radiotherapy Patient

Part I:Part I: Oral Manifestations of Radiation Therapy Oral Manifestations of Radiation Therapy

Part II:Part II: Management of Oral Complications Management of Oral Complications

CompendiumCompendium (1994), vol. 15(2), pp.250-260 (1994), vol. 15(2), pp.250-260

15(4), pp.442-45415(4), pp.442-454

Head & Neck Cancer Patients Receiving Head & Neck Cancer Patients Receiving Radiation TherapyRadiation Therapy

ADA Oral Health Care SeriesADA Oral Health Care Series

ReferencesReferences

National Institute of Dental & Craniofacial National Institute of Dental & Craniofacial Research (Research (www.nohic.nidcr.nih.govwww.nohic.nidcr.nih.gov))

Canadian Cancer Society (Canadian Cancer Society (www.cancer.cawww.cancer.ca))

Oral Cancer FoundationOral Cancer Foundation

((www.oralcancerfoundation.orgwww.oralcancerfoundation.org))

Managementof Head & Neck Radiotherapy Patients

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