Management of head and neck cancer

1. Flowchart of management in head and
neck cancer
Dr Pallavi Kalbande

2. Major sites
• Nasopharynx
• Oropharynx
• Oral cavity
• Larynx
• Hypopharynx

3. Investigations
US neck CT head, neck & chest
MRI head Good soft tissue
definition & useful if
artefact from dental
amalgam
PET-CT
T4 of hypopharynx or
nasopharynx
N3 cancer SCC Neck nodes
OPG Dental assessment

4. Pathology
• Biopsy– need core biopsy (not FNAC)
• IHC - HPV testing p16, p53 mutation

5. WHO prognostic groups
• HPV -ve, p16 inactivation, p53 mutation
I - High risk
• HPV +ve in smokers
• p16 inactivation
• p53 mutation
II - Intermediate risk
• HPV +ve in non-smokers
• p16 not inactivated
• p53 wildtype
III - Low risk

6. Pre-Treatment
• Smoking cessation Reduces SEs, improve outcomes, reduce chance of 2nd
cancer
• Dental assessment >2 weeks before RT
• Nutritional assessment If >10% weight loss anticipated, consider PEG
• SALT (speech and language test) assessment
• CBC, LFT, KFT Before chemo

7. General treatment considerations
• Stage I & II
Generally single modality treatment: surgery or RT
• Stage III & IV
Multi-modality treatment & aim to preserve organ function

8. Choice of Treatment Modality
• Treat primary and nodes
• elective nodes when risk of occult nodal metastases > 20%
• Risk > 20% in most sites except lip, early glottis and lower alveolar
ridge

9. Management of the neck nodes
Node Negative
• Prophylactic selective neck dissection
• Prophylactic neck RT
• Surveillance – should have regular US
• Depends upon risk of nodal involvement: treat if risk >15-20%
3 treatment options:

10. Node Positive
• N1: single ipsilateral node ≤ 3cm
• use same treatment as for primary
• N2a and above - require combined modality treatment
1. Modified radical neck dissection + resection of primary
adjuvant RT/CTRT depending on histology
2. CRT to primary and nodes
surveillance PET CT scan > 12 weeks after CRT

11. PET surveillance
surveillance PET CT scan > 12 weeks after CRT
ND in patients with uptake in neck nodes
PET -ve post CRT – surveillance

12. Surgery
• WLE +/- neck dissection +/- flaps
• Trans-oral laser micro-surgery (TLM), trans-oral robotic surgery (TORS)
• Limited role
• High chances of margin positive
• 66% require adjuvant RT/CRT

13. Adjuvant radiotherapy
• To improve loco-regional control and survival after resection in
‘intermediate’ and ‘high’ risk cases
• Start RT within 5 weeks of surgery: Aim for overall treatment time
from date of surgery to completion of RT 11 weeks
• Concurrent cisplatin: Fit and <70 yrs

14. Risk Factors
• High RF
• Positive margin (tumour 1mm )
• ECE
• Intermediate RF
• T3/T4 disease (RT alone)
• Close margin
• (tumour >1mm but 3cm or ≥2 LN)
• Multiple LN level involvement
• Multifocal disease
• Extensive CIS

15. Indications for adjuvant radiotherapy to primary
• Close margins <5mm
• Relative indications:
• T3,
• poorly differentiated
• Perineural invasion
• Lymphovascular invasion
• Depth of invasion
• T4

16. Indications for adjuvant radiotherapy to LN
• LN>3cm ie. N2a and above
• 3 or more +ve LN
• More than 3 nodal levels involved
• ECS
• Prophylactic dose RT to contralateral neck if non lateralised.

17. Indications for adjuvant chemoradiotherapy
• ECS
• Close margin eg. <1mm
• Dose 66Gy in 33 fractions
• 60Gy in 30 or
• 65Gy in 30 fractions

18. Radical Concurrent CRT
Indications
<70yrs & fit – locally advanced disease (stage III & IV)
Cisplatin 100mg/m2 (D1, D22, and D43)
or weekly cisplatin 40mg/m2 – minimum of 5 weeks

19. Concurrent Chemotherapy
• Cetuximab
• if cisplatin contra-indicated (renal function)
• but still good PS
• Start 1 week before RT (loading dose 400mg/m2 ), then give weekly
(250mg/m2 )
• Only for oropharynx, larynx, hypopharynx - Don’t give in nasopharynx,
paranasal sinus
• Carboplatin if cisplatin is contra-indicated

20. RT Doses
• Radical
• 65Gy/30# or 55Gy/20# (small volume e.g. larynx)
• 65Gy/30# GTV + 1cm and involved nodal levels
• 60Gy/30# High risk sites adjacent to gross disease
• 54Gy/30# Prophylactic dose: uninvolved nodal levels at risk of involvement
Adjuvant
• 60Gy/30#
• Boost to 65 - 66Gy à positive margins or ECS (high risk features)
Palliative
• 20Gy/5#
• 30Gy/10#
• 27Gy/6# over 2 weeks (4.5Gy per #)

21. Radiotherapy planning
• Set up
• Supine, head rest, knee support
• 5-point thermoplastic H&N shell
• Mouth bite Oral cavity and Maxillary sinus
tumours
• Scan from vertex to carina in 2mm slices with
IV contrast
• Consider bolus: if needing to treat skin or
superficial tissue
• Wire scars if required

22. Radical CTRT
• CTV65
GTV + 1cm edit off muscle, bone, air Extend to
include adjacent high-risk regions (e.g.
parapharyngeal spaces, remaining
oropharynx/larynx)
• CTV54
At risk nodal levels: Levels Ib – Vb are irradiated in
most node +ve necks
If level II involved, include Ib and VIIb (retrostyloid
nodes)
Node –ve neck: RT when risk is >15-20%, (Include
II-IV for most sub-sites)

23. When are LN GTV?
• >10mm in short axis (5mm for retropharyngeal LN, 1.5cm for
jugulodigastric)
• Inhomogenous node – any size
• Necrotic core
• Evidence of ECS
• Rounded

24. Nodal CTV
• Include ipsilateral retrostyloid if bulky level II or
ipsilateral VIIa involvement
• Include bilateral retropharyngeal LN for
posterior pharyngeal well involvement
• Usually include ipsilateral VIIa for
oropharyngeal cancer
• Gregoire Radiother Oncol. 2006 Apr;79(1):15-20.

25. Adjuvant RT
• GTVp & GTVn Recreate pre-operative GTVs
• CTV65 or CTV_60
GTVp + 1-1.5cm GTVn + 1cm
If ECS - include whole muscle at involved nodal level
include all pathologically involved nodal levels
Include seromas/other post operative changes
• CTV54
All uninvolved nodal levels in dissected neck and other at-risk nodal
levels

26. Management of neck
• Neck needs to be electively treated for all but v. early lesions
of oral cavity (eg. early with <3mm depth)
• Unilateral or bilateral guided by laterality of lesion
• Usually selective neck dissection eg. levels I-III, I-IVa

27. Indication of adjuvant RT/CRT
• Primary
• T3/T4
• • +ve margin (<1mm)
• Close margin
• LVI
• PNI
• G3
• High Risk:
• Nodes
• ≥ N2a
• ECS
CRT if PS0-1, <70year old, SCC, adequate renal function
Dose: 66Gy/33#

28. Define laterality of tonsil tumour

30. Unilateral RT for lateralised tonsil
squamous cell carcinoma
• GTV confined to tonsillar fossa or lateral pharyngeal wall
• <1cm extension onto soft palate or BOT
• >1cm from midline

31. Organ preservation
• Eligiblity of larynx preservation:
• Laryngeal or hypopharyngeal ca T2/3 (or T4) without
massive cartilage destruction or extension to soft tissues
• Functioning larynx (no NG, no aspiration, pre-Tx tracheostomy)
• Age <70 fit for chemo, adequate PS
• >70yrs can offer but higher chance of needing salvage
laryngectomy

32. Neo-adjuvant chemotherapy
• T4 disease or Nasopharynx
• Bulky nodes: N2C – in order to reduce bulk in neck prior to RT
• TPF if fit and <65yrs
Docetaxel 75mg/m2
Cisplatin 100mg/m2
5FU 1000mg/m2 D1-4
re-stage after C2 and plan during C3 , often may just give 2 cycles

33. Palliative chemotherapy
• 1st line
Cisplatin/5FU
Cisplatin/5FU + Cetuximab
only use in oral cavity - recurrent or metastatic
• 2nd line
Docetaxel 10% RR
Nivolumab