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بسم الله الرحمن الرحيم ﴿ و قل رب زدنى علماً ﴾ صدق الله العظيم.

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Presentation on theme: "بسم الله الرحمن الرحيم ﴿ و قل رب زدنى علماً ﴾ صدق الله العظيم."— Presentation transcript:

1 بسم الله الرحمن الرحيم ﴿ و قل رب زدنى علماً ﴾ صدق الله العظيم

2 Head & Neck Cancers

3 Head and Neck Cancers Heterogenous group: Incidence: Pathology:
The oral cavity Pharynx Larynx Paranasal sinuses Salivary glands Thyroid gland Incidence: 3% of newly diagnosed cancers Pathology: 97% squamous cell carcinoma

4 Features by site Incidence (%) Common site Primary tumor 5 Lower lip
Head & Neck Cancers Features by site Incidence (%) Common site Primary tumor 5 Lower lip Lip 20 Tongue Oral cavity 10 Tonsillar region Oropharynx Pyriform sinus Hypopharynx 25 Vocal cord Larynx 3 Roof Nasopharynx 4 Maxilla N. cavity & sinuses 15 Parotid Salivary gland

5 Risk Factors Tobacco usage Alcohol intake
Head & Neck Cancers Risk Factors Tobacco usage Alcohol intake Nutritional deficiency (e.g. vitamin A) Field of cancerization: 20% of survivors develop 2ndprimary Oral hygiene and dental care are mandatory before radiotherapy to head and neck region ?

6 Cancer maxillary sinus

7

8 Maxillary Antrum Anatomy: Medial: nasal cavity Inferior: alveolus
Superior: orbit and ethmoid Lateral: cheek Posterior: pterygoid fossa

9 Natural History Incidence: Risk Factors: Pathology: Spread:
Maxillary Antrum Natural History Incidence: 0.2% of all cancers Age: years Male to female ratio: 2:1 Risk Factors: + Wood and leather dusts Pathology: Squamous cell carcinoma: common Adenocarcinoma, lymphoma, sarcoma: rare Spread: Local: frequent, invade adjacent tissues ? Lymphatic: infrequent, Distant metastases: infrequent

10 Advanced carcinoma of lt. maxillary antrum

11 Diagnosis Common symptoms /signs: Biopsy: Imaging:
Maxillary Antrum Diagnosis Common symptoms /signs: Unilateral sinusitis Nasal discharge, bleeding and obstruction Bulging (mass) of the cheek Ulceration of mouth Upper dental problem Proptosis Biopsy: Fenestration of the palate allows direct inspection and access for biopsy and drainage Confirm diagnosis, pathologic type Imaging: CT and MRI: assess loco regional extension Endoscope: tumor extension, 2nd primary

12 Erosion of the maxilla, ethmoid and orbit Axial CT :
Coronal CT scan: Erosion of the maxilla, ethmoid and orbit Axial CT : Involvement of the left orbit and proptosis

13 TNM Staging (AJCC) Maxillary Antrum
Tumor limited to antrum without erosion or destruction of bone T1 Tumor causing bone erosion or destruction of bone except posterior wall T2 Tumor invading any of the following: bone of posterior wall, subcutanous tissue, floor or medial wall of orbit, ethmoid sinus T3 Tumor invades anterior orbital contents, skin of cheek, pterygoid plates, cribriform plate, sphenoid sinus, or frontal sinus T4a Tumor invades any of the following: orbital apex, dura, brain, nasophraynx, clivus T4b No regional lymph node metastasis No Metastasis in a single ipsilateral lymph node,  3 cm N1 Metastasis in lymph node (s) ,  3 cm but  6 cm (single or multiple ipsilateral or bilateral or contralateral) N2 Metastasis in a lymph node  6 cm in greatest dimension N3 No distant metasasis M0 Distant metastasis M1

14 Treatment Primary Tumor: Neck Nodes: Early tumors: Advanced tumors”
Maxillary Antrum Treatment Primary Tumor: Early tumors: surgery alone Advanced tumors” Resectable: surgery + postoperative radiotherapy Unresectable: radiotherapy Neck Nodes: Involved or not ? Treatment of primary: Neck dissection Radiotherapy

15 Radical Radiotherapy Indication: Target Volume:
Maxillary Antrum Radical Radiotherapy Indication: Postoperative (complete resection ?) Patients who are unfit or refuse surgery Target Volume: No invasion of the orbit: whole antrum+ potential spread Lower margin: hard palate (vermilion line) Medial margin: inner canthus of opposite eye Upper margin: 1 cm above eye brow Lateral margin: gingivobucal sulcus Anterior margin: cheek Posterior margin: pterygoid fossa , lat. Pharyngeal wall Invasion of the orbit: must be included Critical structure: eye, optic nerve and chiasma,

16 Radical Radiotherapy (cont.,)
Maxillary Antrum Radical Radiotherapy (cont.,) Modality (method): External beam therapy, photons Energy: Megavoltage irradiation, 4-6 MeV Position & immobilization: Full head mould with mouth bite Head position: if orbit is not involved ? Fields arrangements: Anterior and lateral wedged fields Dose/ time/ fractionation:60 Gy in 30 fractions over 6 weeks Beam modification: Wedged Fields Beam shaping to spare optic Nerve and chiasma Angulation of lateral filed 10o posteriorley ? Shielding of lacrimal glands

17

18 Cancers of Salivary Glands

19 Cancers of Salivary Glands
Major: Parotid (80%) Submandibular Sublingual Minor: Widespread in mucosa of upper aerodigestive tract

20 Parotid Gland Between the mandible and mastoid process Two lobes:
Superficial: overlies masseter and sternomastoid muscles Deep: 2nd cervical vertebrae, lateral phrayngeal wall Facial Nerve Drains: to Preauricular LN Jugulodigastric LN

21 Natural history Incidence: Risk Factors: Pathology: Spread:
Parotid gland Natural history Incidence: 0.3% of all cancers Age: years (younger women) Male to female ratio: 2:1 Risk Factors: Previous exposure to ionizing radiation Pathology: Mucoepodermoid carcinoma, 35% Adenocarcinoma, 25% Adenoid cystic carcinoma, 25% Others, 15% Spread: Local: frequent, invade adjacent tissues Lymphatic: infrequent, Distant metastases: infrequent (adenoid cystic)

22 Diagnosis Common symptoms /signs: Biopsy: Imaging:
Parotid gland Diagnosis Common symptoms /signs: Mass in parotid gland (often painless, fixed) Facial nerve palsy Biopsy: Pathologic type Grade Imaging: CT and MRI: primary site and neck

23 Parotid gland Mass in parotid gland

24 TNM Staging (AJCC) Primary tumor cannot be assessed Tx
Parotid gland TNM Staging (AJCC) Primary tumor cannot be assessed Tx No evidence of primary tumor T0 Tumor  2 cm without extraparenchymal extension T1 Tumor 2 cm but no longer than 4 cm in its greatest dimension without extraparenchymal extension T2 Tumor more than 4 cm or with extraparenchymal extension T3 Tumor invades skin, mandible, ear canal, and/or facial nerve T4a Tumor invades base of skull and/or pterygoid plates and /or encase carotid artery T4b

25 Treatment Primary Tumor: Neck Nodes: Surgery: Radiotherapy:
Parotid gland Treatment Primary Tumor: Surgery: The treatment of choice (resectable) Radiotherapy: Postoperative: Positive surgical margins Nerve involvement High grade histology Radiotherapy alone: unresectable Neck Nodes: Surgery alone: involved (early , low grade): Surgery +postoperative RT: involved (advance ,high grade )

26 Target Volume The whole parotid bed
Upper margin: zygomatic arch Lower margin: incorporate Jugulodigastric LN Anterior margin: include masseter muscle Posterior margin: mastoid process Medial margin: cover the Para pharyngeal space Lateral margin: cover surgical scar (palpable disease) Critical structure: brain stem, eye

27 Parotid Gland Radical Radiotherapy Modality: External beam therapy, photons ± electrons Energy: Megavoltage irradiation, 4-6 MeV photon, 8-10 MeV electron Position & immobilization: A shell is required, with patient supine Head position: rotated 90o away from the affected side Fields arrangements: Unilateral field using mixed photon and electron beam, or Wedged pair of oblique photon fields Dose/ time/ fractionation:50 Gy in 25 fractions over 5 weeks Beam modification: Wedged Fields Combination of the gantry and couch angle to avoid eyes

28 Mixed beam photon + electron photon beam wedged pair fields

29 Side Effects of Radiotherapy

30 Side Effects of Radiotherapy
Skin reactions Kilo- and mega-voltage irradiation ? Early: Erythema, Dry desquamation, Moist desquamation, Necrosis Late: Pigmentation, Thickening (fibrosis), Telangiectasia, Ulceration

31 Side Effects of Radiotherapy
Head and Neck Region ◘ Parotid glands: Dryness of mouth (Xerostomia) Alteration of taste ◘ Mucosa of the mouth, pharynx and larynx: Mucositis ◘ Ear (external, middle or internal): Otitis ◘ Hair: Epilation (loss of hair) ◘ Eye: Keratitis, conjunctivitis Cataract (2 Gy) ◘ Mandible: Osteoradionecrosis

32 Side Effects of Radiotherapy
Spinal cord ◘ Lhermitte’s Syndrome: Electric-shock like sensation in upper limbs with neck flexion Occur 1-6 months after treatment and resolve gradually Mechanism: temporary demylineation Not a precursor of permanent myelopathy ◘ Myelopathy: Serious (permanent paralysis) Greater in childhood Greater after exposure of cervical region

33 Thank You


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