1. CARCINOMA OF ORAL CAVITY AND
ITS MANAGEMENT
PRESENTER: DR. GOKULA KRISHNAN
MODERATOR: DR. BUDHI SINGH, ADDITIONAL PROFESSOR.
2. Synopsis
▪ Incidence and epidemiology
▪ Etiology & Premalignant
▪ Anatomy
▪ Molecular biology
▪ Distribution
▪ Patterns of spread
▪ Clinical presentation
▪ Diagnosis
▪ Histology
▪ Staging
▪ Prognostics and predictive
factor
▪ General managementof SCC+
minor salaivary gland carcinoma.
▪ Radical Management
o Surgical treatment
o Radiation treatment
o Systemic Chemotherapy
o Molecular therapy
o Immunotherapy
▪ Toxicities
▪ Surveillance
▪ Management of recurrence
▪ Palliative treatment
▪ Conclusion
3. Incidence
Worldwide:(GLOBOCAN 2020)
• Global estimates suggest3,77,713 (2%)new cases
and 1,77,757(1.8%)deaths in 2020.
India:
• Lip and oral cavity cancers are the second most
common cancer in India, accounts for 1,35,929
(10.3%)new cases and 75,290 (8.8%)deaths in
both sexes, all ages.
• It is the mostcommon cancer in indian males
which accounts for 1,04,661new cases (16.2%).
• In India, 20 per 100000 population are affected
by oral cancer.
GLOBOCAN 2020
BOTH SEXES
MALES
4. • Age of 50 to 70 years
• The commonest age is the fifth decade of life
• Incidence of oral cancer increases by age
• Incidence rate is 4 times as higher in males (16.2%) compared to females
(4.6%).
• Mostly it is diagnosed at later stages which result in low treatment outcomes.
• CANCER registration is not strictly followed in India, so the true incidence and
mortality maybe higher, as manycases are unrecorded and loses follow up.
India
NCRP data
5. Epidemiology
Worldwide:
• Highest in Malanesia, South central
Asia and eastern Europe.
• Lowest in western Africa and
Eastern asia.
India:
• States like Uttar Pradesh, Jharkhand and Bihar in India witness more risk of
oral cancer.
MOST COMMON: CA.TONGUE f/b BUCCAL MUCOSA AND CHEEK (UP)
GLOBOCAN 2020
7. 5.Premalignant condition
Lesions Malignant risk
Leukoplakia Homogeneous(1-18%)
Nonhomogeneous(>18%)
Erythroplakia 9%-Mild to moderate dysplasia
40%-CIN
51%-invasive cancer
Oral sub-mucosal
fibrosis
25%-Dysplasia
Carcinoma in situ
8. Anatomy
▪ The oral cavity consistsof,
1. Lips
2. Oral tongue
3. Floor of the mouth
4. Buccal mucosa
5. Alveolar ridge
6. Retromolar trigone
7. Hard palate.
Boundaries:
•Anterior: Skin–vermilion junction
•Superior: Junction between the hard and soft palate
•Inferior portion: Line of Circumvallate papillae.
9. 1.Lips
Extension :
The lips begin at the junction of the
vermilion border with the skin and
includes only the vermilion surface or that
portion of the lip that comes in contact
with the opposed lip.
Lymphatic drainage:
Upper lip:
•Preauricular, Periparotid, Ia, Ib
Lower lip:
•Medial part: Ia
•Lateral part: Ib
10. 2.Oral tongue
Extension :
Anteriorly from the circumvallate papillae
to the undersurface of the tongue at the
junction of the floor of the mouth.
Lymphatic drainage:
•Tip: Ia
•Lateral: Ib, II
•Post portion: II
•Midline: Bilateral
•Sometimes directly to level-IV (skip mets)
11. 3.Floor of mouth
Extension :
•Lower alveolar ridge to the undersurface
of the tongue.
•It overlies the mylohyoid and hyoglossus
muscles.
•Posterior boundary : base of the anterior
tonsillar pillar.
•Divided into right and left by the frenulum
and its contains the ostia of the
submandibular and sublingual salivary
glands
Lymphatic drainage:
•Superficial mucosal system-crosses
midline and drains both I/L and C/L level
Ib
•Deep mucosal system-Ib,II.
12. 4.Buccal mucosa
Extension :
•All mucous membrane lining the inner
surfaces of the cheek and lips from the
line of contact of the opposing lips
•Superiorly: Line of attachmentof the
mucosa of the upper and lower
alveolar ridge.
•Posteriorly: Pterygomandibular raphe.
Lymphatic drainage:
•Periparotid lymphnodes
•Ia
•Ib
13. 5.Alveolar ridge
Alveolar processes of the maxilla and
mandible and the overlying mucosa.
Lower alveolar ridge:
•Line of attachmentof mucosa in the lower
GBS to the line of free mucosa of the floor
of the mouth.
•Posteriorly: Ascending ramus of the
mandible
Upper alveolar ridge:
•Line of attachmentof mucosa in the
upper GBS to the junction of the hard
palate.
•Posteriorly : Upper end of the
pterygopalatine arch.
Lymphatic drainage:
• Ia, Ib, II
•Sometimes retropharyngeal LN.
14. 6.Retromolar trigone
Extend:
•Triangular area overlying the ascending
ramus of the mandible.
•Base: Posterior mostmolar
•Apex: Maxillary tuberosity.
•Lymphatic drainage:
•II, Periparotid and Retropharyngeal LN.
7.Hard palate
Extend:
•Inner surface of the superior alveolar
ridge to the posterior edge of the palatine
bone.
•Lymphatic drainage:
• Ib, II and Retropharyngeal LN.
18. Patterns of spread
1.Local spread
2.Lymphaticspread:
• Most commonly involved lymph node stations:LevelsI to IV.
• Level-IIare most frequentlyinvolved.(Lindbergetal.)
• The retrostyloid space is potentially at risk for involvement by metastaticdisease when
upper level II nodes are grossly positive.
• The medial retropharyngealnodes –rare
• The lateral retropharyngeal nodes are rarely involved in oral cavity cancer unless there is
oropharyngeal involvement or a significant nodal burden.
Submental
(Ia)
Submandibular
(Ib)
Upper
Jugular (II)
Midjugular
(III)
Oral
tongue
9% 18% 73% 18%
FOM 7% 64% 43% 0
RMT 0 25% 63% 12.5%
19. Primarysite (%)
Mobile
tongue
15.4
Lower gum 25
Buccal
mucosa
0
Upper gum 0
Floor of the
mouth
0 Number of ipsilateral
metastatic lymph nodes
(%)
None 0
Simple 26%
Multiple 50%
Level of ipsilateral
metastatic lymph nodes
%
No metastasis 0
Levels I–III 35
Level IV 75
Grade %
WD 7
MD 24
PD 33%
20.
21. Patterns of spread
3.Distant metastasis: 15-20%
▪ The risk is increases with the degree of lymph node involvement.
▪ Patients with recurrent disease are also at higher risk for distant metastases.
▪ Patients without clinically appreciable neck disease rarely fail distantly after
treatment.
Sites Percentages
Lungs 66%
Bones 22%
Liver 9.5%
Serve as a site for distant metastasisfrom
another anatomic primary tumour site.
Rare
22. 1.Carcinoma lip:
▪ M/C: lower lip
▪ Non-healingulcer with pain.
▪ Anesthesia of the lower lip and teeth may indicateinvolvementof
the mandibularcanaland inferior alveolarnerve.
2.Carcinoma oral tongue:
▪ M/C: Lateralborders of the tongue
▪ Usually presents as small ulcers and graduallyinvadethe
musculature of the tongue.
▪ Advanced lesionsmay be either ulcerativeor exophytic.
▪ Sometimes painfulat early stages.
▪ Cervical metastases occur early (30% to 40%) of patients
harbouring cervical lymph node metastases at diagnosis.
Clinical presentation
23. 3.CarcinomaFOM:
▪ M/C: Frenulum
▪ Often infiltrativeandmay invadebone, the muscles of the
floor of the mouth, and the tongue.
▪ Clinicalfixationof the tumour to the mandiblesuggests
periosteal involvement,which may occur early.
4.CarcinomaBM:
• M/C: Adjacent to the lower molars along the occlusal line
of the teeth.
• Rarely symptomatic early in its course.
• May be papillary or erosive and located near the dental
occlusal line
• Often associated with leukoplakia
24. 5.Carcinoma Alveolus:
▪ M/C: Edentulous areas or along the free margin of the
mandibular alveolus.
▪ May present with pain while chewing, loose teeth, or ill-fitting
dentures in edentulous patients.
6.Carcinoma RMT :
• May present as exophytic growth patternand limited
involvement of underlying bone or
• Infiltratecortical bone and spread along regional tissue planes
to involve the pterygoid complex and parapharyngeal space.
• Produce trismus early in the clinical course.
7.Carcinoma hard palate:
• Often painless.
• Irregularity in the mucosa or ill-fitting dentures.
• Non-healing ulcers of the hard palate, intermittent bleeding,
and pain
25. Diagnosis
History
Physical examination (visual and digital examination)
Routine blood investigation (CBC, RFT, LFT, Sr.Electrolytes)
Biopsy of the lesion and FNAC of lymph node/ Slide review
Endoscopy
Orthopantogram
X-ray chest PA view
USG neck
CECT BOS to T4
MRI Head and neck
PET-CT
HPV testing
26. Physical examination
Inspection:
▪ Entire oral cavity and teeth.
▪ Neck
Palpation:
▪ Help to bony involvement, tongue fixation, and
depth of involvement.
▪ Bimanual palpation: the depth of tumour
invasion into musculature of the tongue and floor
of the mouth.
▪ Neck node palpation
Core needle Biopsy of the lesionand FNAC of
lymph-node
27. Endoscopy
▪ Routine indirect laryngoscopy examinationshould be done.
▪ Panendoscopy is also considered by many head and neck oncologists as
the optimal screening procedure in smokers.
▪ Because the rates of synchronous and metachronous second primaries are
ranging from 8% to 21% in various literatures which was explained by the
‘‘field cancerization’’ hypothesis [Slaughter et al}.
29. USG
• Chaukar et al. reported that ultrasonography is insufficient as a stand-alone
method for evaluating cervical lymph nodes (sensitivity 79%, specificity 69%)
• If USG combined with fine-needle aspiration may be superior to CT or MRI
for staging the neck in experience hands. [Van den Brekel et al.]
To evaluate:
1. Superficial lesions
2. Metastaticlymph nodes
3. Guide needle aspirationbiopsies
(NAB).
4. To assess the lymph nodes following a
radicalsurgical resection with or
without adjuvantradiation therapy.
30. CT scan
1.Most commonly used modality to determine the,
1. Extent of soft tissue
2. Bony involvement
3. Occult disease in the neck
2.CT may be used to determine the extent of invasion into thedeep musculature of the
tongue and adjacentstructures.
Disadvantage:
▪ CT cannot differentiate between recurrence, surgical scars and adverse reactions after
radiationtherapy.
A Review of Literature by Paulina palasz et al.
Sensitivity Specificity
Tumour detection 41-82% 82-100%
Bony invasion 63-80% 81-100%
Exclusion of LN mets 74% 85%
Cervical nodal mets 40-68% 75-82%
Recurrence 50% 80%
32. MRI
To determine the involvement of,
• Local soft tissues
• Bone marrow and bones (sensitivity 82%, specificity 66.7%)
• Vessels
• Nerves (PNI)
• To useful in Contrast allergy and significantdental artifact.
Ca.Tongue Ca.Tongue (myelohyoid inv) PNI-inferior alveolarnerve
33. PET-CT
▪ To evaluate,
o Perineuralinvolvement
o Skull base involvement
o Distant metastases
• Clinicalapplication ofPET/CT is limitedby the suboptimaldetection of small
metastases.
▪ The overallsensitivity and specificity of PET is superior to CT/MRI for evaluating
persistent or recurrent disease, particularlyin patientswho have received previous
radiotherapy.
• PET scan not be performed until 8 to 12 weeks post treatment to minimize the risk
of both FN and FP interpretations.
Sensitivity
[Liao et al]
Specificity PPV
[Maddipatla etal]
NPV
Nodal
mets
77% 58% 83% 97%
34. Histology (AJCC 8th )
SCC-Most common-90%
o Conventional SCC-WD/MD/PD
o Acantholytic SCC
o Adenosquamous SCC
o Basoloid SCC
o Carcinoma cuniculatum
o Papillary SCC
o Spindle cell SCC
o Verrucous SCC
o Lymphoepithelial SCC
Adenocarcinoma< 10%:(minor
salaivary glands)
o Acinic cell ca
o Mucoepidermoid carcinoma
o Adenoidcysticcarcinoma-30 to
40%
o Polymorphous adenoca
o Basal cell carcinoma
o Epithelial myoepithelial carcinoma
o Clear cell carcinoma
o Mucinous adenocarcinoma
o Oncocytic carcinoma
o Salaivary duct carcinoma
o Myoepithelial carcinoma.
Others:
o Mucosal melanoma-0.2 to 8%
o Lymphoma-2%
o Carcinoma type cannot be
determined
35. AJCC 8th staging
Include only:
1. Squamous cell carcinoma
2. Minorsalivary gland carcinoma
3. Neuro-endocrinecarcinoma
Modifications:( 7 to 8 th staging):
▪ T: The incorporation ofDOI.
Extrinsic muscle invasionno longer used in T4.
▪ N: The incorporationof ENE.
Essential features:
▪ Includes- all of oral cavity plus mucosa of lip but not the external (dry) lip (dry
vermillionborder).
▪ DOI increasesthe T category by 1 for each 5 mm of tumour depth (until ≥ 10 mm)
▪ Pathologic ENE+ will increase the nodal category by 1
36. ▪ It is not required for recurrent tumours or for metastatictumours that are
resected at a different time than the primary tumour.
▪ Carcinomas of minor salivary glands are stagedaccording to the
corresponding anatomic site of occurrence.
▪ Reporting of surgical margins for carcinomas of the minor salivary glands
should follow those used for SCC of oral cavity.
Terminology:
▪ TUMOURTHICKNESS
▪ DEPTH OF INVASION
▪ TUMOR BED VERSUS SPECIMEN MARGINS
▪ ENE
▪ WORST PATTERN OF INVASION 5
37. AJCC 8th staging
TX: Primary tumor cannot be assessed
Tis: Carcinoma in situ
T1: Tumor ≤ 2 cm with depth of invasion(DOI)*≤ 5 mm
T2: Tumor ≤ 2 cm with DOI*> 5 mm and ≤ 10 mm or
Tumor > 2 cmand ≤ 4 cm with DOI*≤ 10 mm
T3: Tumor > 4 cm or any tumor with DOI*> 10 mm but ≤ 20 mm.
T4a: Moderately advanceddisease:
ORAL CAVITY: Tumor with DOI* > 20 mm or
Tumor invades adjacent structures only (e.g. through corticalbone of the mandible or maxilla or involves
the maxillary sinus or skin of the face).
LIP: Tumour invades through corticalbone or involves inferior alveolar nerve , FOMor skin of face (Chin or
nose).
T4b: Very advanceddisease:
Tumor invades masticator space, pterygoid plates or skull baseor encases the internal carotid artery
CLINICAL:(cN)
NX: Regional lymph nodes cannot be assessed
N0:No regional lymph node metastasis
N1:Single ipsi lymph node, ≤ 3 cm size and(ENE)-.
N2a:Single ipsi. lymph node that is > 3 cm but ≤ 6 cm size and ENE-..
N2b:Multiple ipsil. lymph nodes, none > 6 cm sizeand ENE-.
N2c: Any bilateral or contralaterallymph node(s), none > 6 cm size and ENE-
N3a:Metastasis in a lymph node that is > 6 cmsize and ENE-.
N3b:Metastasis in any nodes and clinically overt ENE(+).
PATHOLOGICAL:(pN)
N2a:Single ipsi. lymph node / contra-lateral lymph nodethat is ≤ 3 cm and ENE+ or
N3b:Metastasis in either
Single ipsilateral lymphnode, >3 cm and ENE+ or
Multiple ipsilateral, contralateral or bilateral lymphnodes, any withENE+ or
Minor changes: 29 December 2020, Kelly Magliocca, CAP
38. Staging
Distant metastasis:
• M0: No distantmetastasis
• M1: Distantmetastasis
T N M
Stage 0: Tis N0 M0
Stage I: T1 N0 M0
Stage II: T2 N0 M0
Stage III: T3 N0 M0
T1 - 3 N1 M0
Stage IVA: T4a N0 - 1 M0
T1 - 4a N2 M0
Stage IVB: Any T N3 M0
T4b Any N M0
Stage IVC: Any T Any N M1
39. Management
▪ Treatment decisionsfor all patientsmade in a multidisciplinaryjoint clinic with the
goal for maximizing survival and preservation of form and function.
▪ Availabletreatment optionsare
• Choice of treatment modality, either singly or in combination,dependson the
stage and size of the tumuor, toxicity, performance status, comorbid disease, and
patientsconvenience.
Surgical resection
Radiation
Combined modality treatment
± Molecular therapy
40. Treatment decision
Assess performance status and
stage of disease
Curativeintent treatment
Palliativeintenttreatment
Supportive care
ST-IVB, IVC
Investigations
Pre-op work up
Pre RT work up
Referrals:
Dentalprophylaxis
Speech therapy
Nutritional
Poor GC
Poor PS
Counseling and
symptomatic care
Advanced/
unresectable/
metastaticdisease
Good GC
Good PS
Palliativetreatment
PalliativeRT
PalliativeCT
43. Surgical management
• Most commonly used treatment of choice for lesions of the oral cavity.
• Expeditious,effective, and associated with modest morbidity and good functional
outcome particularlyfor patientswith small- to moderate-sized lesions.
• Goal: Tumourfree resection margin and appropriatereconstructionfor restorationof
form and function.
• Successful treatment relies on effective management of regionallymphatics as well as
primary cancer
44. Assesment for resectability
Unresectable:
Primarydisease:
▪ Adequate surgical clearance is not achievable.
▪ Extensive Infratemporal Fossa involvement
▪ Extensive involvement of base skull.
▪ Extensive induration /soft tissue disease till zygoma or hyoid.
Nodal Disease:
▪ Clinically fixed nodes.
▪ Infiltration of Internal /Common carotid artery.
▪ Extensive infiltration of prevertebral muscles, skull base.
45. Principles of resection
▪ En bloc resection of primary tumour whenever feasible
▪ In continuity neck dissection when direct extension of primary into neck
▪ Third dimension (the base) should be taken carefully into accountbefore excision.
• Adequate margin: 1.5 – 2 cm (outcome of intra-operativepositive margins followed by
immediate repeat resection revised to negative margins is associated with worse
survival compared to negative margins achieved with initial resection (31% vs. 49%,
respectively)[Scholl P et al.]
▪ Clear margin: > 0.5 cm
• Close margin < 0.5 cm (LRC : Significantlyimproved with margins of 0.5cm or greatervs
<0.5 cm (36% vs. 18%, respectively) [Loree TR et al.]
▪ Frozen section confirmation for margins may be done if the facility is available.
▪ Contralateralneck should be addressed when the probability of bilateral / contralateral
metastases is high. Eg. Tumourscrossing the midline / midline tumours.
46. Surgical management of primary
Trans-oralapproach:
• Ca.Oraltongue/FOM/Buccalmucosa/Hard palate/Maxillaryalveolarridge.
Transcervical: (lip-splittingincision/Visorflap with lingualrelease)
• ORAL TONGUE: Posterior extent /trismus /obstrucive dentition.
• Buccal mucosal resections.
Combined with mandibulectomy:
• Ca.RMT
• Marginalmandibulectomy : Small tumors with periosteal involvement.
• Segmental mandibulectomy: Pre- or intraoperativefindingsof bone invasion,
tooth loss with low mandibularbone height, and bone that has previouslybeen
irradiated.
TORS:
• Resecting more posterior tumours without mandibulotomy.
47. Surgical management of neck
• High rate of cervical nodal metastasis associatedwith oral cavity cancers.
• Regional control and survival rates do not decrease with more selective
approaches if adjuvant therapies are used in high-risk patients. [Byers RM,
et al]
• There is a chance of 15.8% skip metastasis to level III or IV, without
involvement of levels I or II.[Byers RM],[Huang SH],[Shah JP et.al]
Neck node (CLINICAL/IMAGING) Neck dissection Levels
cN0 (20% probability of occult nodal disease) Elective neck dissection
(END)
SOHND (LEVEL-III)
Exception for oral
tongue (LEVEL I-IV)
cN+ Selective neck dissection
(SND)
Level I-IV or
Level I-V
1. cN3+
2. Disease extending into level V
3. Invading critical structures in the neck.
Radical and modified
neck dissection. (MRD)
LEVEL I-V
48. ELECTIVE NODAL DISSECTION vs DEPTH OF INVASION
• END is the standard of care.
• DOI is the best predictor for regional metastasis in the cN0 neck.
Sites Cut off Chance of occult metastasis
Oral tongue ≥ 4 mm 41.9% [Sparano A, et al]
FOM >1.5 mm 33% [Mohit-TabatabaiMA et.al]
Buccal carcinomas,
Maxillaryalveolarridge
Hard palate
Depth has not been
extensively studied
9% (T4) [Huang SF, et al]
49. ELECTIVE NODAL DISSECTION VS OBSERVATION
▪ 70% of END are found to have pN0 at pathologic review and neck
dissection also morbid and costly.
Trail Comparison Results
Anil K. D’Cruz
(TMH)
END vs observation
with TND (n-500)
(END vs obs):
3 yr OS: 80% vs 60.5% (pN+)
Recurrence: 81 vs 146
Deaths: 40 vs 149
DFS: 69.5% vs 45.9%
Adverse events: 6.6% vs 3.3%
DOI: >3 mm predictor of regional metastasis
Anthony Po-Wing
Yuen et al.
END vs observation(n-35) Recurrence: 6% vs 37%
Node-related mortality: 22% VS 10%
ELECTIVE NODAL DISSECTION vs SLNB
▪A meta-analysisshowed a pooled NPV of 96% in early-stage oral cavity tumors, with no
difference in regional recurrence between SLNB and END (6.7% vs 6%). [no level I
evidence]
50. Carcinoma Oral cavity–RT±CT Indications
▪ Adjuvant treatment-CMT
PORT alone indication:
o T1-T2N0 tumours with adverse pathological features
o One positive node without adverse features
PORT alone or consider CRT:
o pT3 tumours with adverse pathological features
o pT4a disease
o ≥2 Node positive
o Level IV/V involved
o LVI
o PNI
o Mandibular bone involvement
High risk features: CRT
o Positive margin: Re-resection /Chemoradiation
o ENE+
▪ Definitive treatment-Radical RT alone/CRT
▪ Palliative treatment
51. Surgery+PORT vs RT alone
Trail stages Results
Robertsonet al
Interim analysis
T2–T4/N0–N2(N-350) Surgery+PORT vs RT alone
2 yr LCR: 60% vs 45%
Deaths: 2 VS 12
Survival: Extreme P-value of less than
0.001
MD Anderson Cancer Center [Phase III study] showed treatment
delay >6 weeks result decrease LRC.
Ideal time for PORT: within 4 to 6 weeks after completion of
surgery
52. ▪N-521 pts, cN0
▪27.4 per cent of the patientsthe neck was
partiallyirradiatedin conjunctionwith
treatment to the primary lesion.
▪ In 26 per cent of the group nodaldisease
subsequentlydeveloped.
▪Complete elective treatment of neck is
not advocated.Irradiation oftile proximal
lymphatics is useful.
53. RT techniques
Conventional
• EBRT:
• Manual marking
• 2D-Simulator based
• DRR based
Conformal
• EBRT:
• 3DCRT
• IMRT
• Proton therapy
• Electron therapy
• Brachytherapy
54. Manual marking
Marking:
▪ Patient is in supine positionwith extended neck and retracted shoulder.
▪ Use head rest
▪ B/L PARRALLEL OPPOSED
Subsites: [Ca.Lip/Oraltongue/FOM/Alveolus/Hardpalate/BM and RM(crossingmidline)]
▪ Superior: Upper border of zygomatic arch
▪ Inferior: Early stage: Hyoid bone, Advancedstage: Inner border of clavicle
▪ Anterior: 1 cm flash
▪ Posterior: Tip of mastoid process (INTIAL PHASE), corresponding to ear lobule (CORD
OFF)
▪ Energy: C0-60 /6-MV
Dose
prescription
Total dose Ph-1 Ph-2 (Cord off) Ph-3 (Boost)
Radical RT 66Gy-70 Gy 40Gy/20#/4
weeks
20Gy/10#/2 weeks 6Gy Boost
PORT 60Gy 40Gy/20#/4
weeks
20Gy/10#/2 weeks If Residual disease/high risk
feature: 6Gy Boost
55. Manual marking
Marking:
▪ Patient is in supine position with extended neck and retracted shoulder.
▪ Use head rest
▪ ANTERO-LATERAL WEDGE PAIR
Subsites: [BM and RM(Well lateralized lesion)]
Anterior field:
▪ Superior: Upper border of zygomatic arch
▪ Inferior: Early stage: Hyoid bone, Advanced stage: Inner border of clavicle
▪ Medial: Midline
▪ Lateral: 1 cm flash
Lateral field:
▪ Superior and inferior border same
▪ Anterior: 1 cm flash
▪ Posterior : Tip of mastoid (INTIAL)
Ear lobule (CORD OFF)
▪ Energy: C0-60 /6-MV
Dose
prescription
Total dose Ph-1 Ph-2 (Cord
off)
Ph-3 (Boost)
Radical RT 66Gy 40Gy/20#/4
weeks
20Gy/10#/2
weeks
6Gy Boost
PORT 60Gy 40Gy/20#/4
weeks
20Gy/10#/2
weeks
If Residual
disease/high
risk feature:
6Gy Boost
56. 2D-Simulation
▪ Supine position with the neck extended and retracted shoulder.
▪ A thermoplastic mask is used to immobilize patients during simulation and treatment.
▪ Shoulder immobilization by using either a three-/four-point Aquaplast mask.
▪ A bite block should be used to depress the tongue away from the hard palate
(Oral tongue and FOM lesions)
▪ Some institutions use a cork and tongue blade or a custom intraoral stent for this purpose
▪ For patients with a short neck, Retractors are used to depress the shoulders.
▪ Post op scar/palpable lymph node marked with wire.
57. Conventional field borders
▪ The Superior border: 1.5- to 2.0-cm above the border on the
tumor bed.
▪ The inferior border: Thyroid notch, just above the true vocal
cords.
▪ The posterior border:
1. Early stage disease (N0) -Mid-vertebral body level (ENI:I, II,
and III).
2. Advanced neck disease (N+) or positive level V lymph nodes-
Behind the C1 vertebral body spinous process (cover L-V)
▪ Two lateral parallel–opposed fields are used.
▪ The portals are then reduced at approximately 40 Gy to spare
high dose to the spinal cord.
▪ If patients harbor cervical lymph node metastases, or
high-risk disease, then the lower neck will also be
treated.
58. ▪ In this case, half-beam–blocked AP or opposed AP/PA fields are used
▪ The superiorborder: Matched to the inferior border of the opposed lateralfields
at the level of the thyroidnotch.
▪ The inferiorborder:Inner border of clavicle
▪ Anteriorly:Larynx block was used to protects the central larynx and spinalcord
overdose because of three-field overlap.
Low anterior neck
59. Dose and Fractionation
PORT:
▪ Dose fractionationis 1.8 to 2.0 Gy/day.
▪ Primarytumour with involved Lymph-node: 60 Gy/30#/ 6wks in 2 phases with
CORD OFF.
▪ High risk(Close or positive microscopicmarginsor ENE)
– SIB to 66 Gy (e.g., 2.2 Gy per fraction over 30 fractions) or
– Sequential6.0 Gy localized boost
▪ Gross residualdisease, either further surgical resection or
focal boosting up to 70 Gy.
▪ Low risk: (Clinicallyor pathologicallyuninvolved necks):54 to 56 Gy
Radical RT alone:
▪ 66-70Gy/33-35#/ 6-7 wks in 2 phases with CORD OFF.
.
60. Electron Boost
▪ Indications:
– Any residuallymph node after initial phase of radiotherapy in posterior
triangle.
▪ Target volume is residual node + 1cm margin all around.
▪ Electron field was matched with photonfield.
▪ An electron energy of 9 to 12 MeV is usuallyused depending upon the depth of
node from skin.
▪ DOSE: 20Gy-26/10#-13#/2-2weeks
62. Immobilization and positioning
▪ Patient has to be lie down in supine position with arms by side.
▪ The shoulder has to be retract adequately.
▪ 3 or 5- clamp thermoplatic cast (orfit cast) to be used for immobilizationof
head and neck.
63. CT Simulation
▪ Patient has to be lie down in same positionin CT simulator couch.
▪ Intravenous contrast (inj. Omnipaque)should be utilized in patientswith adequate
renal function to facilitatestarget volume delineation(LN).
• For oral tongue cancers, a bite block can be used during simulationand throughout
the course of treatment to elevatethe hard palateand decrease dose to the superior
oral cavity.
• For cases in which the hard palateis target, a bite block can be employed to limit dose
to the tongue and inferior oral cavity.
▪ CT scan from top of skull to carina with slice thickness of ≤3 mm.
▪ After the CT scan , images was transferred to Treatment planningsystem and the
target has to delineate.
▪ If available,MRI or PET scans obtainedat the time of simulationcan often be helpful
in defining target volumes.
64. IMRT
Target
volumes
Definition and description
CTV 66 Primary: preoperativetumour volume can guide the targeting of CTV66.
Regions of soft tissue invasion,bone invasion,or microscopically
positive margins should be includedin this volume
Neck nodes: regions of extracapsularextension
CTV 60 Primary: preoperativegross disease and the entire operativebed
Neck nodes: preoperativegross disease and adjacent ipsilateral or
contralateral nodalregions at high risk for subclinicaldisease
CTV 54 Ipsilateral and/orcontralateral uninvolvednodallevels at low risk for
subclinicaldisease
1. Immobilizationand positioning and
CT simulation same
2. Target volume delineation-PORT
65. Site-specific guidelines for clinical target delineation of oral
cavity cancers
Tumour site Stage Clinical treatment volume (CTV)
▪Oral tongue
▪Floor of the
mouth
T1–T4,N0 ▪Include the tumour bed, the entire oral tongue and
the base of the tongue.
▪For floor of the mouth lesions, consider includingthe
alveolarridge, due to its proximity to the floor of the
mouth.
▪Both sides of the neck should be treated with
radiotherapy(even for well-lateralizedT1–T2N0
lesions, if the depth of invasionis >4 mm), although
physiciandiscretion can be used to determine if these
should be in the low- or high-risk CTV.
▪Consider ipsilateral and/orcontralateral levelsI–IV
T1–T4,N1–3 ▪Same as above
▪Consider ipsilateral and/orcontralateral levelsI–V
Textbookof Nancy Y lee
66. 1.Squamous cell carcinoma of the oral tongue, pathologic stageT2N1, status
post partial glossectomyand left neck dissection, with one positive lymph
node and multiple close margins
Textbookof Nancy Y lee
67. 2.Squamous cell carcinoma of the floor of the mouth, pathologic stage
T2N2b, status post resection and right modified radical neck dissection
Textbookof Nancy Y lee
68. Site-specific guidelines for clinical target delineation of oral
cavity cancers
Tumour site Stage Clinical treatment volume (CTV)
Buccal
mucosa
T1–T4N0 ▪It is importantto be generous with target volumes when
treating the inner cheek.
▪Include the tumor bed and the entire buccal mucosa.
▪Posteriorly, this should extend to retromolartrigone.
▪Superiorly, this should extend to near the inferior orbitalrim
▪If the tumor is well lateralized,ipsilateral levelsI-IV alonecan
be treated.
▪Otherwise, consider treating bilateralcervical lymph nodes
T1–T4N1–3 Same as above
Ipsilateral levelsI-IV should be treated within the neck.
Depending on pathologicfindingsand discussions with the
surgeon, considerationcan be given to treating the
contralateral neck as well.
Textbookof Nancy Y lee
69. Squamous cell carcinoma of the buccal mucosa, pathologic stage
T4aN0 with minimal cortical bone invasion
Textbookof Nancy Y lee
70. Site-specific guidelines for clinical target delineation of oral
cavity cancers
Tumour site Stage Clinical treatment volume (CTV)
▪Retromolar
trigone
▪Hard palate
▪Gingiva
T1–T4N0 Include the preoperativetumor volume and postoperative
tumor bed.
Consider covering ipsilateral levelsI–IV for all cases.
Treatment of the contralateral neckis at
the physician’sdiscretion.
T1–T4N1–3 Same as above
Treat the ipsilateral levelsI–IV for all cases and consider
treatment of the contralateralneck.
Textbookof Nancy Y lee
71. Adenoid cystic carcinoma of the right hard palate, pathologic stage T2N0. the
patient is status post bilateral partial maxillectomy, with extensive perineural
invasion and positive margins
Textbook of Nancy Y lee
73. Target volume delineation-Radical treatment
Target
volumes
Definition and description
GTV 70 Primary: all gross disease on physicalexamination andimaging
Neck nodes: all gross disease and physicalexaminationand imaging
CTV 70 Same as GTV 70 , althougha 5 mm margin can be added if uncertainty
exists regarding the extent of gross disease
CTV 59.4 Primary: encompass the entire CTV 70 with an additionalmargin of up
to 10 mm
Neck nodes: nodal levelswith pathologicinvolvementand adjacent
ipsilateral orcontralateral nodalregionsat high risk for subclinical
disease
CTV 54 Ipsilateral and/orcontralateral uninvolvednodallevelsat low risk for
subclinicaldisease
Textbookof Nancy Y lee
74. Locally advanced squamous cell carcinoma of the floor of the mouth, clinical
stageT2N2c, who is not a surgical candidate
Textbookof Nancy Y lee
75. Dose prescription-PORT
▪ The high-risk CTV (CTV66) :
• Receives 66Gy either as a SIB (2.2 Gy per fraction over 30 fractions) or
• as a sequentialboost.
▪ The intermediate-riskCTV (CTV60) :
• Receives 60 Gy in 2.0 Gy per fraction.
▪ The low-risk CTV (CTV54–56):
• Receives 54 to 56 Gy as a simultaneousintegratedboost in 1.8 to 1.87 Gy per
fraction.
Textbookof Nancy Y lee
Dose prescription-Definitive RT
PTV 70 : 70 Gy/33#/7 Weeks.
PTV 59.4: 59.4GY/33#/7 Weeks
PTV 54: 54GY/33#/7 Weeks
76. Critical structures QUANTEC CONSTRAINTS
Brainstem
Brain stem (+3 mm)
Max:<50Gy
Dose to 0.03 cc ≤ 52 Gyax < 50 Gy
Optic nerves Max < 54 Gy
Optic chiasm Max < 54 Gy
Spinal cord
Spinal cord (+5 mm)
Max < 45 Gy or 1 cc of the PTV cannot
exceed 50 Gy
Dose to 0.03 cc ≤ 48 Gy
Mandible Max < 70 Gy outside high dose PTV, avoid
hot spots
Brachial plexus Max < 65 Gy outside high dose PTV
Parotid gland a) Mean ≤26 Gy in one gland
(b) Or at least 20 cc of the combined volume
of both parotid glands will receive <20 Gy
(c) Or at least 50 % of one gland will receive
<30 Gy
Submandibular gland Mean dose <39 GY
Cochlea Max < 35 GY
Lens Max < 5 Gy
Glottic larynx Mean < 45 Gy
77. Energy
▪ Megavoltagebeams with an energy range between 4 and 6 MV are most suitable.
▪ Cobalt-60 remains acceptablein this region owing to the small lateralseparation
distances in the head and neck area.
▪ When higher energy beams are used, bolus materialneeded to bring dose to the
surface as required for tumours that extend to the skin.
▪Ideally, at least 95 % of the PTV for each dose level should receive the prescription
dose.
▪If contralateral lymphnodes are uninvolved,efforts should be made to spare the
contralateral parotidgland to help preserve salivaryfunction.
▪The dose to the ipsilateral parotidglandand the submandibularglands can be
compromised for maximal coverage of the PTV.
▪For advancedtumors, coverage can be compromised to meet normal tissue
constraintsif necessary.
Plan Assessment
78. Brachytherapy
Intent of treatment:
▪ Radical :
o Brachytherapy alone as treatment in selected (early-stage) tumours of the
oral cavity with good results.
o Dose prescription: 65 to 75 Gy over 6 to 7 days (LDR : 0.4 to 0.6Gy/hour).
o Recently HDR and PDR brachytherapy are commonlyused.
o The most common technique is afterloading with 192Ir.
▪ Boost: Used to boost the primary site either before or following EBRT
▪ As salvage therapy in recurrent cases who have been irradiated before or
who are unfit for surgery
79. GEC-ESTRO recommendations-2009
1.Patient selection,the pre-treatmentworkup :
▪ Easily accessible lesions
▪ Early stagediseases (Ideal implant ≤ 5 cm)
▪ Well localized tumor to organ of origin
▪ No nodal or distant metastases
▪ No local infections or inflammation
▪ Proliferative/ ulcerative lesions preferred.
▪ Favorable histology- SCC
2.Patient care:
▪ Pre treatment dental evaluation
▪ Lead shielding can be used in lesions which close to the mandible to
avoid osteoradionecrosis.
80. GEC-ESTRO recommendations-2009
3.Treatmentstrategy:
▪ When EBRT or NACT is combined with brachytherapy, the initial tumour
volume should always be considered, whatever the subsequent tumour
shrinkage.
▪ The placement of radio-opaque markers (e.g., gold seeds) or tattoos can
be very helpful in delineating the tumour volume before any shrinkage
occurs.
▪ Concomitant chemotherapy during brachytherapy is not recommended
for but useful for the treatment of recurrences.
▪ Interval between EBRT and brachytherapy should be as short as possible
and less than 2 weeks.
▪ The total duration of radiation therapy within 8 weeks to limit tumour
cell repopulation..
81. GEC-ESTRO recommendations-2009
4. Targetdefinition:
▪ The GTV: The primary tumour volume defined by the clinical examination
and imaging techniques.
▪ The CTV : GTV plus a safety margin 0.5–1 cm.
▪ The PTV is not different from the CTV in a ‘‘perfect” implant.
▪ The Treated Volume is encompassed by an isodose surface corresponding
to the minimal target dose, the isodose ideally encompassing the CTV.
▪ The skin should not be included in the CTV unless it is invaded by tumor,
and the skin dose should be minimized as much as possible.
82. GEC-ESTRO recommendations-2009
5.Implant technique:
▪ Under GA
▪ The brachytherapy technique should be based on a classic system for
interstitial brachytherapy (Paris, Manchester or New York).
▪ Guide needles can be inserted either freehand or template based.
▪ Depending on the size of the lesion, a single plane, double plane, or volume
implant can be used to cover the tumor with a 1-cm margin.
▪ Catheters should be parallel and equidistant, ideally spaced at 1 to 1.5 cm.
▪ Ultrasound or fluoroscopy guidance may be helpful when implanting
catheters.
▪ Most LDR implant techniques can be used for HDR or PDR treatments.
83. GEC-ESTRO recommendations-2009
6.Dose and dose rate prescription:
▪ LDR brachytherapy, delivering a high total dose is recommended to
secure local control, and to maintain the dose rate between 0.3 and 0.6
Gy/ h in order to minimize late side effects.
▪ HDR brachytherapy, doses between 3 and 4 Gy per fraction have been
recommended with minimum of 6 h gap .
▪ PDR brachytherapy has biological advantages of LDR brachytherapy with
the technological advantages of the HDR afterloading method.
▪ Daytime PDR schedules were introduced by some authors to avoid
hospitalizationand to reduce overall treatment costs.
84. GEC-ESTRO recommendations-2009
Anatomic
al site
Patient
selection
Implant
techniq
ue
Margin Dose Result
Lip T1-3 RN 5–10 mm 60–75 Gy LDR-PDR LC: 90–95% N: 2–
10%
Buccal
mucosa
<4 cm PT 5–10 mm 65–70 Gy LDR-PDR (25–
30 Gy boost if 45–50 Gy
ERT)
LC: 80–90% N: <10%
Mobile
tongue
T1-3 PT 5–10 mm 65–75 Gy LDR-PDR (25–
30 Gy boost if 40–45 Gy
ERT)
LR: >90% N: 10–20%
Floor of
mouth
T1-2N0 RN or
PT
>5 mm 65 Gy LDR-PDR (10–25
Gy boost if 46-50 Gy
ERT)
LR: >90% N: 10–30%
For salvage implantsin a previously irradiatedterritory, a dose of 60 Gy is adequate.
HDR BT remain to be validatedin prospective studies.
85. T2N0 SCC. lower lip (3.5cm size) with excellent cosmetic and functional status.
T2N0M0, SCC left lateral oral
HDR-BT: (25-Gy tumor boost)
Superficial T1 upper lip SCC
HBR-BT:Focal mucositis 1 week after
treatment
Interstitial iridium 192 implant –HDR BT
86. The intraoral cone
▪ Use: Boost the primary lesion
▪ Selection citeria: Anterior oral cavitylesions in edentulouspatients, palatalarch
sites and the size of the lesionsup to 3 cm.
▪ Treatment : either 100 to 250 kvp x-rays or electron beams in the 6 to 12 MeV range.
▪ Intraoralcone therapyrequires careful daily positioningand verificationby the
physician.For this purpose, the device is equippedwith a periscope to visualize the
lesion.
▪ The cone abutsthe mucosa and is centered directly over the lesion.
▪ It is used prior to external beam radiationso that the lesion can be adequately
visualized.
▪ A major advantageof cone therapy is that it is highly focal to the tumor bed but non-
invasive.
▪ Hence, when available,for suitablelesions, it may be preferred over brachytherapy.
87. Proton therapy
Uses:
• Unilateral head and neck irradiation-Select oral cavity cancers
Advantage:
• High LET
• Highly conformal dose distribution and also substantial organ sparing can be
achieved with the elimination of exit dose by BRAGG peak effect.
• Comparisons of proton beam therapy with IMRT have revealed reductions of
10 times or higher in radiation dose to critical midline and contralateral
organs, including parotid gland, submandibular gland, oral cavity, spinal cord,
and brainstem.
Disadvantage:
• Reduced dose to these normal organs resulted in decreased acute toxicities,
(mucositis, dysgeusia, nausea or vomiting, and fatigue ) but the grade 2 or
worse dermatitis was observed in patients due to the use of passive
scattering.
90. No SR Gr-1 SR
Gr-2 SR Gr-3 SR
SKIN REACTIONS
Gr-4 SR
MUCOSITIS
Gr-1 Mucositis Gr-2 Mucositis
Gr-3 Mucositis Gr-4 Mucositis
91. • Pooled data from randomized trials of patientswith a
diagnosisof oral cavity, oropharynx,hypopharynx,and
larynx cancer who received chemotherapy in the
induction,concurrent, or adjuvantsetting.
• Common randomized comparison between
radiotherapyandradiotherapypluschemotherapy.
• Oral cavitypatientscomprised only 21% of the patient
population inthe pooledanalysis.
• The updatedMACH-NC (1994 and 2000) report
publishedon 2009.
• Absolute survival benefit of 4.5% at 5 years with the
additionof chemotherapy, which is mainly driven by the
effect of concurrent chemoradiation (6.5% at 5 years).
Concurrent chemotherapy
92. • No clear evidence of a benefit for inductionand adjuvantchemotherapies
• The subset analysisshowed that the benefit of chemotherapyon survival did not differ
significantlybetween the group of trials with postoperativeradiotherapyor curative
radiotherapywith conventionalor altered fractionation.
• No significantdifference was seen between mono-chemotherapy(Cisplatin > other
mono-therapies) and poly-chemotherapy.
• Decreasing effect of chemotherapyon survival with increasing age.
• Most of the randomised trials haveused a dose of cisplatinof 100 mg/m2 , three times
throughout the course of radiotherapy(cumulativedose of 300 mg/m2)
• Inductionchemotherapy provideda relativelymore pronounced effect on distant
metastases, compared to concomitantchemotherapy.
• The benefit of the addition of chemotherapy to locoregional treatment is consistent in
all tumour locations of HNSCC [Update of MACH-NC: 2011]
93. Induction chemotherapy
Indications:
o Can given prior to RT to downstagingdisease in unresectable disease.
o It could treat subclinical distantmetastaticdisease without delay
o Induction chemotherapy could improve local regional controland organ
preservation
o Induction chemotherapy can provide prognosticinformation.
▪ Early clinicaltrialsfound that cisplatin+ 5fluorouracil(PF, cisplatin-100 mg/m2,
and 5fluorouracil-1000 mg/m2/day continuous24hour infusionfor five days) given
every three weeks induced higher ratesof complete response.
• Phase III experience now exists demonstratingthe superiority of three-drug–
containingregimens (TPF-fluorouracil,cisplatin,and taxane)when compared to
fluorouraciland cisplatinalone(PF).
• 3 large phase III studies [TAX324], [TAX323] , [GORTEC] demonstrated a survival
benefit favoring the three-drug inductionregimen response rates between 75%
and 100%, excellent survival, and high pathologiccomplete response rates at the
primary sites.
94. Controversies:
1.DeCIDE112and PARADIGM(PHASE-III TRAIL):
▪ Induction chemotherapy followed by concurrent chemoradiotherapy to
concurrent CRT alone failed to show a survival advantagewith the
sequential treatment strategy.
▪ The DeCIDE trial had a 5% incidence of treatment-induced mortality in the
sequential arm compared to 0% in the CRT arm.
2.A meta-analysis : [Zhang L, et al.]
▪ Decreased distant metastasis rate.
▪ No statisticallysignificant differences
in OS, PFS, (ORR), LRR.
95. Molecular therapies
• EGFR is up-regulated -90% of patients with squamous cell HNC and has
been associated with a poor prognosis.
• Indications: Recurrent/metastatic disease not amenable to local therapies.
• Benefit was greater in patients with oropharynx cancers, smaller primary
tumors, and more advanced nodal involvement.[Bonner et al]
Controversies:
• RTOG 0522:(Concurrent RT+Cisplatin +Cetuximab with RT+ Cisplatin
alone)- No survival benefit.
• [Vermorken JB et al]:(Cis+5FU vs Cis+5FU +Cetuximab) : addition of
cetuximab resuts in improvement in survival. [N Engl J Med 2008;359]
▪ Other drugs: Panitumumab and zalutumumab, Tirapazamine,
96. Immunotherapy
Indications:
• Recurrent/metastaticdisease not amenable to local therapies.
• Refractory to platinum-based chemotherapy
FDA approved drug(2016):
▪ KEYNOTE 012 (PHASE IB)- Pembrolizumab
▪ CHECKMATE(PHASEIII)-Nivolumab
Overall RR Median OS Toxicity
KEYNOTE 012-
Pembrolizumab
18%
HPV+: 25%
HPV-: 14%
13 months 2 pts-Grade 3 LFT
abnormalities
1 pt-Gr 3 rash
CHECKMATE-
Nivolumab
13.3% 7.5 months 13%-Gr 3 events
97. Follow up
History and physicalexam (includingcomplete H&N examination,includingmirror and
fiberoptic exam as indicated)
▪Year 1, every 1–3 mo
▪Year 2, every 2–6 mo
▪Years 3–5, every 4–8 mo; >5 y every 12 mo
▪Baseline imaging of primary and neck within 6 mo of therapy.
Serial reimaging as clinicallyindicated basedon signs/symptoms, continuedtobacco
use, and areas inaccessible to exam; routine imaging may be indicatedin areas
difficult to visualize on exam
Chest imaging as clinicallyindicatedfor patientwith smoking history for lung cancer
screening
TSH every 6–12 mo if neck irradiated
Ongoing dental evaluationfocused on patienteducation,prevention/managementof
caries,xerostomia, osteoradionecrosis,and oral candidiasis
Supportive care and rehabilitation
▪Speech/hearing and swallowingevaluationas clinicallyindicated
Surveillance
98. Management of recurrence
▪ Recurrence rate: 25%–48% [Liao et al],[Jones KR],[Whitehurst JO,]
▪ Despite the salvage treatment, survival remains poor with range of 15-67%.
Options:
• Salvage surgery
• Reirradiation (EBRT± IBT)
• Chemotherapy
▪ [Liao et al] :
– DFS cutoffof > 10 months associatedwith improved OS compared with < 10
months DFS (54% v 12%, respectively; P <.001).
– Early recurrences, either surgery or chemoradiotherapyhad similar outcomes.
– late recurrences,surgical salvage was superior to chemoradiotherapy
(84.4%v 52%, respectively).
99. Site of
recurrence
%
Local 57.9
Locoregional 26.3
Regional 15.8
Stage of
recurrence
%
Stage I-II 47.4
Stage III-IV 52.6
Recurrenttumour
site
Salvage cure
rate
Local 33%
Locoregional 20%
Regional 0
100. Re-irradiation
Indications:
• Surgical salvage is unsuccessful
• Surgery is not feasible
Consider:
• Age
• Primary site
• Stage
• Field size
• Maximum energy
• Fractionation scheme
• Technique (conventional or conformal)
• Total dose
• Duration between radiotherapy and recurrence
101. ▪ 13-year experience with patients reirradiated (1970 and 1988 ) by both EBRT alone or IBT +
EBRT with minimum follow-up of 3 years.
▪ Improvement in local control: (50% vs 29 %) for the IRT + EBRT series and the EBRT series,
respectively.
▪ The improvement in local control was not reflected in a survival benefit. (actuarial overall
survival of 20 ~o at 5 years was observed in both series).
▪ No treatment-related deaths occurred.
▪ 28% (4/16 of the EBRT series and 3/9 of the IRT + EBRT series) did experience severe side
effects.
Site Technique Total dose to
primary tumour
(GY)
Total dose torecurrent
tumour (GY)
Cumulative doses
Oralcavity EBT alone
(1970-80)
30-80 57
mean
30-84 50 mean 70-154 107
FOM EBRT+IBT
(1985-1988)
60 (EBRT) 50 (EBRT)+30 (IBT) 112
103. Palliative Radiotherapy
• Indications: Incurable cancers (ST-IVB/IVC), Poor PS 2 or 3
• Palliative RT Dose: 30GY/10#/2weeks or SFRT: 8GY/ 6GY
• QUAD SHOT: (Previously untreated patients)
o 14 Gy/4#/2# per day with 6 h apart/2 days. Repeated at 4 weekly intervalsfor
a further two courses if there was no tumour progression.
o [June corry et.al] reported it was very well toleratedwith minimaltoxicity and
a good responserate (53%) with median OS: 5.7 months. It also improved QoL
(44%).
• Split-course RT :
o 20 Gy/5#/1 week followed by a 2 week gap, and then a further 20 Gy/5#/1.
o It is an effective palliativeregimen with acceptable toxicity. Symptomatic
improvement-79% at 4–6 weeks of follow-up with CR (39%) )and PR(33%).
[K.N.Kancherla et al.]
104. Metronomic chemotherapy
Options:
• Single agent cisplatin
• Methotrexate
• Cetuximab
• Phase II trial comparing oral MCT [daily Celecoxib (200 mg twice daily) and
weekly methotrexate(15 mg/m2)] to i.v single agent cisplatin (IP)
(75 mg/m2) given 3 weekly in ECOG PS 0–2 status patients. [Vijay
MarutiPatil et al.]
mPFS mOS
Oral MCT 101 days 249 Days
Single agent Cisplatin 66 days 152 Days((p = 0.02)
