Radiation Treatment of Cancers in the Head and Neck

1. Radiation for Head &
Neck Cancer
Robert Miller MD
www.aboutcancer.com

3. NCCN.org

4. Treatment decisions and management
should be made by a team of
physicians
• Experienced cancer Surgeon and reconstruction
team
• Radiation oncologist with access to state of the art
equipment (IMRT, IGRT or Tomotherapy)
• Medical Oncologist (chemotherapy and targeted
therapy)
• Support personnel including nutritional support and

5. Treatment options for head
and neck cancer
 Early stages: surgery or radiation
 Advanced stage: chemoradiation or
surgery followed by radiation and
chemotherapy
 Very advanced cases: radiation
and chemotherapy

6. Radiation
 Accurate simulation and contouring
the targets
 Need for high doses
 Use IMRT or Tomotherapy to
maximize coverage and minimize side
effects
 Combine with chemotherapy

7. Simulation
A face mask is usually made to hold the
head still and allow the targeting
markings to be painted on the mask

8. CT scan is obtained at this time
CT images are then
imported into the
treatment planning
computer

9. In the
simulation
process the CT
and PET scan
images are
used to create
a computer
reconstruction
of the patient
and cancer

10. http://www.rtog.org/CoreLab/ContouringAtlases.aspx

12. Digitally Reconstructed Images: Some
patients have very short necks making the radiation
targeting more difficult

13. Location of the larynx (in red) in two typical patients, one with a short
neck and one with a long neck, in the short neck patients, the shoulders
may be in the way of the radiation beam, requiring more complex
techniques

14. For small cancers in the vocal cords it is
possible to keep the radiation far away
from other normal structures

15. Normal structures are identified on the computer
generated images, as well as the cancer
targets, more advanced case with spread to the
lymph nodes

16. Radiation zone (in blue) is designed to cover
the cancer and nodes and avoid normal
structures as much as possible

17. Radiation Dose
daily: Monday through Friday for 7
weeks

18. Radiation Dose - PostOp

19. Poor Radiation Results From
Non-compliance in Radiation
Technique Critical Impact of Radiotherapy Protocol
Compliance and Quality in the Treatment of
Advanced Head and Neck Cancer: Results
From TROG 02.02
Noncompliance, more relapses
CO June 20, 2010 vol.
28 no. 18 2996-3001

20. IMRT and Side Effects
Xerostomia Conventional IMRT
12 months 74% 38%
24 months 83% 29%
Parotid-sparing intensity modulated versus conventional radiotherapy in
head and neck cancer (PARSPORT): a phase 3 multicenter randomized
controlled trial.

21. Combine a CT scan and linear
accelerator to ultimate in targeting (IGRT)
and ultimate in delivery (dynamic, helical
IMRT) ability to daily adjust the beam
(ART or adaptive radiotherapy)

22. Low risk
parotid gland
tumor (in red)
may be
possible to
keep the
radiation zone
(blue) as small
as possible

23. Low risk parotid gland tumor, then using Tomotherapy to
ensure coverage of the tumor on the left, but avoiding
going too deep and hitting normal parotid on other side

24. Since Tomotherapy takes a CT scan daily prior to radiation it is
often possible to observe the tumor shrinking during the course of
the radiation (the radiation technique can be changed as the tumor
shrinks – Adaptive Radiotherapy

25. Tumor regression during
Tomotherapy

26. The cancer target (red circle) is expanded to give a margin around the
cancer (radiation or blue circle) The computer then fits a radiation zone to
match the blue target (red cloud or radiation zone). Daly CT scans allow the
physician to watch and see that the cancer is shrinking as expected

27. With Tomotherapy A
CT scan is performed
daily prior to every
treatment so that if the
tumor changes position
or shrink rapidly, the
radiation target can be
adjusted, this is
referred to as
‘adaptive’ therapy and
can only be done on
Tomotherapy Machine

28. Chemotherapy

29. Randomized Trial XRT versus
XRT + Erbitux
Radiation plus Erbitux
Radiation
N Engl J Med 2006; 354:567-578

30. Randomized trial XRT
alone versus XRT/Chemo
radiation/cisplatin
radiation
JCO January 1, 2003 vol. 21 no. 1 92-98

31. Chemoradiation for Advanced Head
and Neck Cancer
SURVIVAL
JCO Dec 20, 2010:5294-5300;

32. Chemoradiation
HPV +
HPV -
JCO September 20, 2010 vol. 28 no. 27 4142-4148

33. Cure Rates for Advanced Head and
Neck Cancer with Chemo-Radiation
Cisplatin
Erbitux (cetuximab)
Failure-free survival among patients with cancer of oropharynx, hypo
pharynx, or larynx; IJROBP 2011:81;915

34. Quick Response to Radiation
combined with chemotherapy, Tonsil
cancer gone by 2 ½ weeks

35. Same patient at 4 weeks

36. Tongue Cancer Before and 3
Months after Radiation

37. Tomotherapy for Squamous
Cancer of the Tonsil

38. Chemoradiation Right Pyriform
Sinus before and at 3 Years

39. Chemoradiation Results for Advanced Cancer
of the Oropharynx (squamous cancer of the
left tonsil that extended onto the base of
tongue)
PET prior to Treatment 2 Years
Later

40. Chemoradiation
Nasopharynx

41. Lymph Node Metastasis
Often by the
first new PET
scan at 8
weeks, the
cancer is no
longer visible

42. Side Effects
Side effects
will relate to
the size and
location of
the radiation
field and the
normal
structures
that are in
the way of
the beam

43. Side effects of radiation are related to the
structures that are near the tumor, so the radiation
can effect the teeth (dental problems) throat (sore
throat) and saliva glands (dryness and changes in
taste)

44. Short Term Side Effects
1. Skin irritation
2. Dry Mouth and changes in taste
and possible problems with teeth
3. Sore throat and problems with
swallowing and dehydration and
possible need for a feeding tube
4. Pain management problems
5. Laryngitis
6. Fatigue

45. Radiation
Dermatitis
almost everyone
gets a sun
burned reaction
in the face or
neck and creams
are required (like
Aquaphor and
Silvadene)

46. Radiation
Dermatitis
(skin burn)
often the
thinnest part of
the neck over
the voice box is
affected

47. Radiation Dermatitis… last day
and two months later

48. Radiation Dermatitis
T3 Larynx
treated with
chemotherap
y plus full
dose
radiation
Skin burn on
neck, last
day of
radiation

49. Radiation Dermatitis

50. Side Effects of Radiation to the Mouth

51. Same patient at three months

52. Mucositis (inflamed lining of
the mouth) grade 2
The roof
of the
mouth
gets a
white
coating
after 3
weeks

53. Same patient 3 weeks later

54. Grade 3 mucositis

55. Mucositis
The lining of the
mouth and surface of
the tongue can get
quite inflamed from
radiation, particularly
when combined with
chemotherapy. Most
patients need pain
medication for this
phase

56. Mucositis – same patient two
months later, soreness
gone, mouth still some what
dry and taste improving

57. Mucositis
Lining of the
roof of the
mouth with
radiation
mucositis
after 5
weeks of
radiation and
chemotherap
y

58. Mucositis
Most patients need
pain medication for
this phase and many
patients require a
feeding tube to
avoid dehydration or
malnutrition

59. Long Term Side Effects
1. The dryness may be permanent,
depending on the amount of saliva glands
in the field
2. Teeth may be vulnerable to decay, and
caution is need with future dental care to
avoid jaw bone problems (osteonecrosis)
3. Some patients have long term problems
with swallowing
4. Some patients have persistent hoarseness
5. Small risk of low thyroid hormones
6. Carotid stenosis

60. Long Term Side
Effects

61. Small blood vessels on Cancer area appears
normal palate pale (achromia)
(telangectasia)
Mouth still
dry but
better
lubricated

62. Same
patient at 2
years /
mouth still
dry and
taste for
food still not
normal

63. Radiation Results for Cancer of
the Palate (roof of the mouth)
Often palate lesions are superficial with not much to see, at 10
months there are some blotchy radiation changes or discoloration
on the roof of her mouth and the mouth looks a bit dry, but no
signs of the cancer

64. 10 Years after Mouth
Radiation for Cancer of the
Soft Palate
Discoloratio
n of the roof
of the mouth

65. Long Term Side Effects
Dryness and
discoloration of
the roof of
mouth is
common as is
problems with
teeth
Long term dental care is critical to avoid
osteoradionecrosis (damage to the jaw bone
with exposed bone, may require hyperbaric
oxygen treatment to heal)

66. Cure Rates are better for people
who stop smoking during the
radiation
Years
JCO June 10, 2012 vol. 30 no. 17 2102-

67. Support Team

68. Radiation for Head &
Neck Cancer
Robert Miller MD
www.aboutcancer.co
m