1. Head and Neck Cancers Management
Dr. S. C. Joshi
Senior Consultant Oncologist and Radiotherapist
D/L :
Mobile Phone : ,

2. Head and Neck Cancers Management
Dr. S. C. Joshi
Senior Consultant Oncologist and Radiotherapist
D/L :
Mobile Phone : ,

3. Epidemiology
Head and neck cancers constitute 5% of all cancers worldwide
10th most common cancer in the world
World – annual incidence:
643,000 new cases
Mortality of about 350,000 cases
MC in India–
15.4 to per 100,000 males
2 to 51.2 per 100,000 females
By: Dr.S.C.Joshi

4. Risk Factors Smoking Tobacco (Masala, kaini and others)
Viruses - Epstein-Barr Virus, HPV (16, 18)
Environmental/occupational
Exposures of Asbestos, Chromium, Nickel, Arsenic, Formaldehyde
Salted Fish
Ionizing Radiation
Genetic
Immunodeficiency
Poor oral hygiene
Alcohol
Betet nut
By: Dr.S.C.Joshi

5. Disease Sites of the Head and Neck
Head and neck cancer may occur in diverse structures and sites:
Lip
Oral cavity
Tongue
Pharynx
Larynx
Nasal cavity
Sinuses
By: Dr.S.C.Joshi

6. Mostly Arise in The Nasopharyngeal Axis
Nasal Cavity
Nasopharynx
Oral Cavity
Oropharynx
Larynx
Hypopharynx
By: Dr.S.C.Joshi

7. Head and Neck Cancer Often Spreads to Regional Lymph Nodes
Lymph node involvement in up to 30%-50%.
By: Dr.S.C.Joshi

8. > 75 % present with advanced disease in developing countries due to the lack of awareness, early intervention and treatment facilities
By: Dr.S.C.Joshi

9. Diagnosis
70%- 80% are diagnosed having locally advanced disease (Stage III and IV)
In the more advanced tumors (stage III and IV)
Local recurrence –up to 50%
Distant metastatic spread (approximately 10%-30%)
By: Dr.S.C.Joshi

10. Diagnosis History General physical examination & Local ex Oral cavity
Oropharynx (palpation is very important)
Nasopharynx (mirror examination)
Laryngopharynx (indirect laryngoscopy)
Examination of the neck for lymph nodes
Direct laryngoscopy
Biopsy of any suspected areas
By: Dr.S.C.Joshi

11. Laboratory Studies Routine blood counts. Blood chemistry profile
Urinalysis
Chest radiographs,
Plain radiographs of mandible (Panorex view)
CT Scan / MRI / PET CT
By: Dr.S.C.Joshi

12. Surgery Radiotherapy Chemotherapy
No substantial change in survival in 25 yrs.

13. Management Guidelines for H & N Cancers
Aims
Highest Loco- regional control
Anatomical and functional organ preservation
Treatment Principles
Early Stage
Single modality treatment using
Surgery or Radiotherapy
Late Stage
Surgery + Radiotherapy
Concurrent Chemoradiotherapy
By: Dr.S.C.Joshi

14. Management Guidelines for H & N Cancers
When different modalities available, one with maximum chance of cure should be used
When different modalities have same results, one offering better quality of life, with organ, function preservation and good cosmetic results should be used
By: Dr.S.C.Joshi

15. Surgery v/s Radiotherapy
In treatment of head and neck cancers surgery and radiotherapy produce equivalent results in early stages of carcinoma
In advanced stages of head and neck cancers surgery combined with pre or postoperative radiotherapy
By: Dr.S.C.Joshi

16. Improving Efficacy of Treatment
Chemotherapy
Radiotherapy
Dose escalation schedules
Altered Fractionation Schemes
Biological Therapy And Molecular Targeting
Continuous review during treatment
By: Dr.S.C.Joshi

17. Chemotherapy Absolute benefit of Chemotherapy > 30% at 5 years
Higher For Platinum Based Regimens.
Higher doses up to 70 Gy are related with better Loco regional control, however with enhanced acute and long term complications
By: Dr.S.C.Joshi

18. Radiation Therapy Ionizing Radiation
High energy electromagnetic waves in the form of X-rays or gamma-rays
External beam radiation Utilizes LA to generate X-rays to kill cancer cells
Brachytherapy utilizes radioactive substances implanted into tumors.
By: Dr.S.C.Joshi

19. How Radiation Works
X-ray photons interact with matter, knocking electrons from the orbital's of atoms
These high energy electrons can either directly damage DNA chemical bonds, or interact with water molecules forming free radicals that then cause DNA damage
Damage to DNA may result in single or double strand breaks which can cause cell death
DNA repair enzymes are more readily activated in healthy cells than in cancer cells
By: Dr.S.C.Joshi

20. The Changing Paradigm
Conformal radiation
IMRT/IGRT/Rapid arc
Clinical motivation for high-precision techniques
More conformality = Better sparing
By: Dr.S.C.Joshi

21. Standard Radiation Techniques (old)
Conventional external beam radiation usually consists of two opposed lateral fields and a matched anterior field that encompass the cancer and lymph nodes in the neck.
Treatment is delivered daily for about 7 weeks.
When this technique developed, physicians used regular X-rays or fluoroscopy to setup these fields.
By: Dr.S.C.Joshi

22. CT Based Radiation Planning
With the advent of CT guided planning, a new era in RTP has emerged.
We are now better able to customize our treatment plans to fit the individual patient anatomy
By: Dr.S.C.Joshi

23. IMRT – Intensity Modulated Radiation Therapy
In this intensity of the radiation beam in a given treatment field is varied via multiple multi leaf blocking arrangements called segments
Intensity modulation combined with multiple fields (radiation beam angles) or arcs allows for conformal radiotherapy (ie high radiation iso dose lines conform to the target volume and spare normal tissues).
By: Dr.S.C.Joshi

24. Intensity Modulated Radiation Therapy (IMRT)
IMRT is an advanced form of 3D-CRT technique in which a computer aided optimisation process is used to determine customised non-uniform intensity distribution through inverse planning to attain certain specified dosimetric and clinical objectives
By: Dr.S.C.Joshi

25. Intensity Modulated Radiation Therapy (IMRT)
Multiple beam angles or arcs
Multi-leaf collimator
Accurate patient positioning and immobilization
Physics quality assurance measures
Well trained radiation therapy staff
By: Dr.S.C.Joshi

26. Multi-leaf Collimator
The multi-leaf collimator is inside the linear accelerator.
It is comprised of multiple 1 cm thick metal radiation blocks each driven by an independent motor and controlled by a central computer.
The multi-leaf collimator allows for multiple blocking patterns in each radiation field which in turn allows for intensity modulation of the radiation dose.
By: Dr.S.C.Joshi

27. Immobilization
By: Dr.S.C.Joshi

28. Head and Neck Immobilization Devices
3 Clamp
4 Clamp
5 Clamp
Random Errors with different Fixation devices
By: Dr.S.C.Joshi
Radiotherapy Oncology,2001

29. Time Interval
Importance of the time interval between surgery and postoperative RT in the combined management of head and neck cancers
PORT within 6-7 weeks / later
LRC : 70% (PORT within 7 weeks)
>27% (PORT more than 7 weeks)
Therefore patient must be seen by oncologist immediately after surgery and HPE report.
By: Dr.S.C.Joshi
Bhadrasain V,IJROBP,1979

30. Isodose Distribution of an IMRT Plan
By: Dr.S.C.Joshi

31. IMRT - Hypopharynx
By: Dr.S.C.Joshi

32. IGRT – Image Guided Radiation Therapy
Daily X-rays or CT scansAre done and overlaidwith the planning CT
Millimeter adjustments are made with automatic couch position shifts
Treatment becomes more accurate and consequently smaller target volumes will result in less side effects
By: Dr.S.C.Joshi

33. IGRT – MV X-rays
By: Dr.S.C.Joshi

34. IGRT – kV X-rays
By: Dr.S.C.Joshi

35. IGRT – Cone Beam CT (CBCT)
By: Dr.S.C.Joshi

36. IGRT - CBCT
By: Dr.S.C.Joshi

37. Rapid arc cases
By: Dr.S.C.Joshi

39. Rapid arc cases
By: Dr.S.C.Joshi

40. Rapid arc cases

41. In Developing World Infectious diseases are the main killers
Patients present in an advanced stage
Fund allocation to health is less than that of developed countries
No or poor social health security system
Geographic clustering of facilities to urban areas
Linear accelerators are expensive, with high operational costs.
High precision facilities available in only selected centers.
By: Dr.S.C.Joshi

42. How to Optimize Treatment for Developing Countries?

43. Optimization of Treatment
Prompt treatment in a good referral centre
Optimal Infrastructure support required for implementation of CTRT/AFRT schedules
Avoidance of Treatment Breaks
Integration of Chemotherapy
Integration of high-precision technique
Good Nutritional Support.
Affordable cost
By: Dr.S.C.Joshi

44. Our Oncology Facilities
Linear accelerator from Varian trilogy with rapid arc
Brachytherapy
Chemotherapy
Daycare facilities for out patient’s and isolation wards
Complete nuclear medicine with Radionuclide Therapy
Palliative care
Cancer screening
Cancer awareness program
By: Dr.S.C.Joshi

45. Radiotherapy Team Consultant Oncologist Medical Physicist
Radiation Therapist
Radiation Therapist Aide
By: Dr.S.C.Joshi

46. By: Dr.S.C.Joshi

47. By: Dr.S.C.Joshi

48. Linac Room
By: Dr.S.C.Joshi

49. By: Dr.S.C.Joshi

50. By: Dr.S.C.Joshi

51. Summary
Head and neck cancer is a serious illness that affects thousands of Indians each year
Smoking cessation and tobacco chewing is critical in the prevention of the disease
Multimodality treatment interventions have a proven track record against the disease, but come with significant morbidity
Targeted chemotherapy regimens are being developed to reduce side effects
IMRT/IGRT and rapid arc have also significantly reduced the incidence of side effects from treatment.
By: Dr.S.C.Joshi

52. Thank You For Your Kind Attention
Dr. Sanjeev Chandra Joshi