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قالوا سبحانك لا علم لنا إلا ما علمتنا إنك أنت العليم الحكيم بسم الله الرحمن الرحيم

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Presentation on theme: "قالوا سبحانك لا علم لنا إلا ما علمتنا إنك أنت العليم الحكيم بسم الله الرحمن الرحيم"— Presentation transcript:

1 قالوا سبحانك لا علم لنا إلا ما علمتنا إنك أنت العليم الحكيم بسم الله الرحمن الرحيم

2 Head And Neck Cancer Mostafa EL-Haddad Kasr El-Ainy Hospital Cairo University NEMROCK 2009

3 Proposal For Work Flow Wide field with a predefined borders (between the physician and the radiographer). Wide field with a predefined borders (between the physician and the radiographer). Simulator film. Simulator film. Blocks to be drawn on the Simulator film. Blocks to be drawn on the Simulator film. (better in a predefined shapes :triangles, Rectangles, and Squares) (better in a predefined shapes :triangles, Rectangles, and Squares) Physics planning. Physics planning. Educational purposes UK system

4 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).

5 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. 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.

6 Why Head And Neck Is Special Very Complicated anatomy. Very Complicated anatomy. Many risk organ in a very narrow space. Many risk organ in a very narrow space. Needs high precision. Needs high precision. Patients in very bad shape. Patients in very bad shape. RCR report for priority. RCR report for priority.

7 ANATOMY

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13 Imaging In Head and Neck Cancer CT scan: Accurate information about pneumatization, integrity of bony structures. CT scan: Accurate information about pneumatization, integrity of bony structures. MRI: soft tissue extension, Perineural, perivascular infiltration, intracranial extension. MRI: soft tissue extension, Perineural, perivascular infiltration, intracranial extension. Base of skull CT? MRI?. Imaging before or after Biopsy? Larynx?

14 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. 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 WI excellent tumor to muscle enhancement. T2 allows differentiation between secretions and mucosal thickening together with tumor which have low signal (Low water content). 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. In T1 look at the tumor invading Fat. (Fat shows high signal in T1).

15 CT is preferable if Swallowing may be a problem. (Ca Larynx). CT is preferable if Swallowing may be a problem. (Ca Larynx). DONT FORGET NECK ULTRASOOUND. DONT FORGET NECK ULTRASOOUND. PET and PET CT. PET and PET CT.

16 Thyroid. Thyroid. Parotid. Parotid. Ear. Ear. Eye and Orbit. Eye and Orbit. PNS. PNS. FORGET IT

17 Immobilization Comfort and immobilization. Comfort and immobilization. Unsightly setup marks. Unsightly setup marks. Mask, Tape stretched, Beam directing shell. Mask, Tape stretched, Beam directing shell. Coughing, sneezing, respiration and swallowing. Coughing, sneezing, respiration and swallowing. Mark LNs. Mark LNs. Important land marks: (canthus, orbits, external auditory canal, oral commissures). 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. Before making the mask, use the fluoroscopy to align the patient and put him in the suitable position.

18 In Our Department Put all head and neck patients on the C head rest. Put all head and neck patients on the C head rest. PNS, Nasopharynx. (MAIN). PNS, Nasopharynx. (MAIN). Ear, parotid: may be on patient side. Ear, parotid: may be on patient side. Pituitary in Flexion. Pituitary in Flexion. You can use hyperextension in any patient where you can protect the larynx. You can use hyperextension in any patient where you can protect the larynx.

19 Facial Mask system Thermoplastic mask. Thermoplastic mask. Beam directing shell. Beam directing shell. Plastic material. Plastic material.

20 Radioopaque Markers And Stents Wires to mark important structures or lymph nodes. Wires to mark important structures or lymph nodes. Stent to depress the tongue, protrude the lips. Stent to depress the tongue, protrude the lips.

21 Patient Fixation

22 Positioning Mask on the Simulation, Why? Mask on the Simulation, Why?

23 Positioning Tilt your patient head ?? Tilt your patient head ?? Do you know what you did? Do you know what you did? You re tilting the gantry.

24 Positioning e.g.:

25 Positioning Bad alignment for your patient, Do you know what you are doing? ? You are turning your couch

26 Neutral Position

27 Head supports Hyperextension can be achieved by elevating the chest without make a strain on the head. Hyperextension can be achieved by elevating the chest without make a strain on the head.

28 Head support

29 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. 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

30 Dental Impression When you have to use tongue depressor? When you have to use tongue depressor?

31 Dental Impression When the maxillary antrum is treated the Tongue and lower half of the mouth can be excluded. 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. 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. Used a dental impression material with a syringe inside for breathing.

32 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.

33 Overlapping Region Problem WHY ITS A PROBLEM?

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35 Ways To Solve this Overlap

36 Method1: Midline spinal cord block in the anterior supraclavicular field. Midline spinal cord block in the anterior supraclavicular field. Against: Can not be done when anterior structures should be included in the field.

37 Why narrower?

38 Ways To Solve this Overlap Method 2: Gap between two fields calculated by : ½ field 1 length x depth/SSD + ½ field 2 length x depth/SSD Against: High uncertainty.

39 Ways To Solve this Overlap Method 3: Put a block over the spinal cord at the posterior inferior angle of the lateral field. 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

40 Still there is overlap in the lateral and anterior soft tissues? How can you solve it?

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42 When We can not use this block?

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44 Ways To Solve this Overlap Method 4: Use Collimator and Couch angle. Use Collimator and Couch angle. Against: Time consuming (table move only from inside the room). Errors in movement.

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46 Anterior neck field Lateral head and neck field Overlap region

47 Overlap region corrected

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49 Overlap region

50 Overlap region corrected

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55 Ways To Solve this Overlap Method 5: Turn the couch 90 degree and move the gantry accordingly.. Turn the couch 90 degree and move the gantry accordingly.. Against: Time consuming (table move only from inside the room), errors in movement.

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58 Tracheostomy Problems Site of recurrence : 10% risk. Site of recurrence : 10% risk. No tissue, dose may be higher on the spinal Cord. No tissue, dose may be higher on the spinal Cord. Need a doughnut bolus to avoid suffocation. Need a doughnut bolus to avoid suffocation.

59 HAVE FUN!! :)

60 Clothes Clamp

61 Clothes Clamp Another use?

62 How Can You Determine the Energy for Electron beam Separation=12cm Spinal Cord Take care for neck asymmetry

63 Portal Arrangements Opposed –lateral photon fields, with the patient immobilized in supine position are used for treatment of most cancers : Opposed –lateral photon fields, with the patient immobilized in supine position are used for treatment of most cancers : oral cavity, Larynx, pharynx. oral cavity, Larynx, pharynx. Superior border: 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 In General : Either it will be Hypopharynx. 1- At the base of skull when we want to include the retropharyngeal node, e.g. Hypopharynx. nasopharynx 2- Above base when the site is already in the base, e.g. nasopharynx. 3- Just safety margin above the tumor (Larynx).

64 Superior border: Superior border:NasopharynxHypopharynxOropharynx 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.

65 Lower border: Lower border: Ask this question: can I protect the larynx? YES NO Put your border above the arytenoid (below hyoid bone) Put your as low as possible PLEASE DONT CUT IN A NODE OR A TUMOR

66 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. 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? 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. 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.

67 Portal Arrangements Anterior border: Anterior border: - Covering skin over the larynx. - Margin anterior to the tumor or its site. ? Take care not with: tumor extend to anterior subcutaneous tissue, large submandibular nodes, jugular lymph nodes are present, Surgical scar? Extracapsular extension A strip of the anterior midline skin is usually spared whenever possible to minimize lymph-drainage impairment after irradiation.

68 Group I: Group I: Low risk: 20%. T1 Floor of mouth, oral tongue, retromolar trigone, gingiva, hard palate, buccal mucosa

69 Group II Group II Intermediate risk 20–30% T1: Soft palate, pharyngeal wall, supraglottic larynx, tonsil T1: Soft palate, pharyngeal wall, supraglottic larynx, tonsil T2: Floor of mouth, oral tongue, retromolar trigone, gingiva, hard palate, buccal mucosa

70 Goup: III High risk>30% Goup: III High risk>30% T1–T4Nasopharynx, pyriform sinus, base of tongue. 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.

71 Posterior border: Posterior border: - If N 0 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

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75 SHOWER?? NO evidence that taking shower will increase the skin reaction!!. 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. IF you can let your patient take a shower in the day before his replanning day. And in patients tattooed. And in patients tattooed.

76 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). 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. In the hypopharynx and the larynx we avoid midline shield.

77 3D CRT IN HEAD AND NECK CANCER How to define and delineate your target volume

78 How to Approach your Patient Ask yourself the following questions: 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- Whats the role of surgery: - resectable? 5- Lymph nodes dissected or Not?

79 Early stage Disease Surgery Vs Radio and Chemo. 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.

80 Late Stages T3-T4 Usually Surgery first if resectable. 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. 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.

81 Organs At Risk (OARs) Chiasma: 50-52 Chiasma: 50-52 Optic Nerves: 50- 52 Optic Nerves: 50- 52 Eyes (Lens) : 10Gy Eyes (Lens) : 10Gy Spinal Cord: 5cm: 50Gy, 10 cm: 50, 20cm: 45Gy Spinal Cord: 5cm: 50Gy, 10 cm: 50, 20cm: 45Gy Brain Stem: 60Gy but 2/3: 53Gy whole 50Gy. Brain Stem: 60Gy but 2/3: 53Gy whole 50Gy. Brachial plexus: 60Gy. Brachial plexus: 60Gy. Salivary Glands: situlation 26Gy, without 23Gy, complete loss of function 32Gy. Salivary Glands: situlation 26Gy, without 23Gy, complete loss of function 32Gy. (TD5/5 Emami et al 1991)

82 Computer Tomography with or without MRI fusion

83 Toxicity Hypogeusia. Hypogeusia. Ageusia. Ageusia. Dysgeusia. Dysgeusia.

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87 Target Volume Delineation

88 ANATOMIE

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90 Lymphatic System Basic Anatomical Consideration: 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???.

91 Risk of Lymph node involvement depends on: Risk of Lymph node involvement depends on: 1- T stage. 2- Lymphatic invasion (in biopsy). 3- Degree of differentiation.

92 Group I: Group I: Low risk: 20%. T1 Floor of mouth, oral tongue, retromolar trigone, gingiva, hard palate, buccal mucosa

93 Group II Group II Intermediate risk 20–30% T1: Soft palate, pharyngeal wall, supraglottic larynx, tonsil T1: Soft palate, pharyngeal wall, supraglottic larynx, tonsil T2:Floor of mouth, oral tongue, retromolar trigone, gingiva, hard palate, buccal mucosa

94 Goup: III High risk>30% Goup: III High risk>30% T1–T4Nasopharynx, pyriform sinus, base of tongue. 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.

95 1- Oral Cavity and oropharynx: a- lateralized. b- Middle line. 2- Larynx and Hypopharynx. 3- Nose, NHH, and Nasopharynx

96 Nasopharynx Target: differ according to treatment phase Target: differ according to treatment phase Phase I: structures included? 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

97 LOOK HERE CAREFULLY Nasopharynx

98 Maxillary Antrum Different position WHY?? Different position WHY?? HOW?? HOW?? Eye opened looking forward. Eye opened looking forward. If rotating the eye ??. Putting the retina in the high dose region.

99 Maxillary Antrum

100 Maxillary Antrum And PNS GTV all gross tumor that can be seen in imaging. GTV all gross tumor that can be seen in imaging. PTV include: GTV with 2-3 cm margin. 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 dont know what to do!!). Some centers now include the submandibular and subdigastric L.Ns in patients with Squamous cell or poorly differentiated carcinoma.

101 Maxiallry Antrum ctn Volume include: Upper border: Upper border: above Crista galli? Why? To include the ethmoids. Or Lower edge of the cornea if no orbital infiltration.

102 Lower Border: 1cm below the floor of the sinus. Lower Border: 1cm below the floor of the sinus. Medial border: 1-2 cm across the midline to cover the contralateral ethmoid 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 border: extend one cm beyond the apex of the sinus. Lateral portal: Lateral portal: Anterior border: is anterior to the anterior wall. Posterior border: is behind the pterygoid plates.

103 Maxillary sinus conformal Volume to be included: 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.

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105 LETS HAVE SOME PRACTICE ATLAS CT

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