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

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

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

2 Head & Neck Cancers

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

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

5 Risk Factors 1.Tobacco usage 2.Alcohol intake 3.Nutritional deficiency (e.g. vitamin A) Oral hygiene and dental care are mandatory before radiotherapy to head and neck region ? Field of cancerization: 20% of survivors develop 2 nd primary Head & Neck Cancers

6 Cancer maxillary sinus

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

9 Natural History Incidence:Incidence: 0.2% of all cancers Age: 55-75 years Male to female ratio: 2:1 Risk Factors:Risk Factors: + Wood and leather dusts Pathology:Pathology: Squamous cell carcinoma: common Adenocarcinoma, lymphoma, sarcoma: rare Spread:Spread: ?Local: frequent, invade adjacent tissues ? Lymphatic: infrequent, Distant metastases: infrequent Maxillary Antrum

10 Advanced carcinoma of lt. maxillary antrum

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

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

13 TNM Staging (AJCC) Tumor limited to antrum without erosion or destruction of boneT1 Tumor causing bone erosion or destruction of bone except posterior wallT2 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 Maxillary Antrum No regional lymph node metastasisNo 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 metasasisM0 Distant metastasisM1

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

15 Radical Radiotherapy Indication:Indication: Postoperative (complete resection ?)Postoperative (complete resection ?) Patients who are unfit or refuse surgeryPatients who are unfit or refuse surgery Target Volume:Target Volume: No invasion of the orbit: whole antrum+ potential spreadNo 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 includedInvasion of the orbit: must be included Critical structure : eye, optic nerve and chiasma,Critical structure : eye, optic nerve and chiasma, Maxillary Antrum

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

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18 Cancers of Salivary Glands

19 Major:Major: Parotid (80%)Parotid (80%) SubmandibularSubmandibular SublingualSublingual Minor:Minor: Widespread in mucosa of upper aerodigestive tractWidespread in mucosa of upper aerodigestive tract

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

21 Natural history Parotid gland Incidence:Incidence: 0.3% of all cancers Age: 50-60 years (younger women) Male to female ratio: 2:1 Risk Factors:Risk Factors: Previous exposure to ionizing radiation Pathology:Pathology: Mucoepodermoid carcinoma, 35% Adenocarcinoma, 25% Adenoid cystic carcinoma, 25% Others, 15% Spread:Spread: Local: frequent, invade adjacent tissues Lymphatic: infrequent, Distant metastases: infrequent (adenoid cystic)

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

23 Mass in parotid gland Parotid gland

24 TNM Staging (AJCC) Primary tumor cannot be assessedTx No evidence of primary tumorT0 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 extensionT3 Tumor invades skin, mandible, ear canal, and/or facial nerveT4a Tumor invades base of skull and/or pterygoid plates and /or encase carotid artery T4b

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

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

27 Radical Radiotherapy Parotid Gland Modality: External beam therapy, photons ± electronsModality: External beam therapy, photons ± electrons Energy:Energy: Megavoltage irradiation, 4-6 MeV photon, 8-10 MeV electronMegavoltage irradiation, 4-6 MeV photon, 8-10 MeV electron Position & immobilization:Position & immobilization: A shell is required, with patient supineA shell is required, with patient supine Head position: rotated 90 o away from the affected sideHead position: rotated 90 o away from the affected side Fields arrangements:Fields arrangements: Unilateral field using mixed photon and electron beam, orUnilateral field using mixed photon and electron beam, or Wedged pair of oblique photon fieldsWedged pair of oblique photon fields Dose/ time/ fractionation: 50 Gy in 25 fractions over 5 weeksDose/ time/ fractionation: 50 Gy in 25 fractions over 5 weeks Beam modification:Beam modification: Wedged FieldsWedged Fields Combination of the gantry and couch angle to avoid eyesCombination 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 Skin reactions Kilo- and mega-voltage irradiation ? Early: –Erythema, –Dry desquamation, –Moist desquamation, –Necrosis Late: –Pigmentation, –Thickening (fibrosis), –Telangiectasia, –Ulceration Side Effects of Radiotherapy

31 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)Epilation (loss of hair) ◘ ◘ Eye: Keratitis, conjunctivitisKeratitis, conjunctivitis Cataract (2 Gy)Cataract (2 Gy) ◘ Osteoradionecrosis ◘ Mandible: Osteoradionecrosis Side Effects of Radiotherapy

32 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 Side Effects of Radiotherapy

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