Head And Neck Cancer

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diagnosing and treating cancers of the head and neck area with radiation and chemotherapy

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Head And Neck Cancer

  1. 1. Head & Neck Cancer <ul><li>Understanding the disease </li></ul><ul><li>Treatment options </li></ul><ul><li>Side effects of treatment </li></ul>
  2. 4. Larynx or Vocal Cord Anatomy
  3. 8. There are multiple lymph nodes in the head and neck area
  4. 10. <ul><li>Occipital </li></ul><ul><li>Postauricular </li></ul><ul><li>Upper mastoid tip </li></ul><ul><li>Middle spinal accessory </li></ul><ul><li>Lower, supraclavicular </li></ul><ul><li>Preauricular </li></ul><ul><li>Infra-auricular –parotid </li></ul><ul><li>Buccinator </li></ul><ul><li>Submandibular </li></ul><ul><li>Submental </li></ul><ul><li>Jugulodigastric </li></ul><ul><li>Midjugular </li></ul><ul><li>Lower jugular </li></ul><ul><li>Prelaryngeal </li></ul><ul><li>pretracheal </li></ul>Names for the lymph node regions
  5. 11. Neck Node Levels
  6. 12. Location of the Salivary Glands – is important in order to limit radiation side effects such as a dry mouth
  7. 13. Cross section anatomy of the neck
  8. 14. Cross section anatomy of the neck
  9. 15. Cross section anatomy of the neck
  10. 16. CT Scan and Anatomy
  11. 17. CT-Pet Anatomy
  12. 18. The value of PET scans
  13. 19. PET Scans are valuable in finding hidden cancers, such as this patient with cancer in the left base of tongue, which was not visible when looking in the mouth
  14. 20. CT and PET Scans
  15. 21. Small base of tongue cancer with spread to a lymph node CT Scan PET Scan
  16. 22. Tongue cancer, hard to see on the CT scan but obvious on the PET scan CT Scan PET Scan
  17. 23. Anatomy and Spread from Cancer in the Head and Neck Area <ul><li>Oral cavity </li></ul><ul><li>Oral pharynx </li></ul><ul><li>Hypopharynx </li></ul><ul><li>Supraglottic Larynx </li></ul><ul><li>Larynx </li></ul>
  18. 24. Patterns of spread. The primary cancer (oral cavity) invades in various directions, which are color-coded vectors (arrows) representing stage of progression: Tis, yellow; T1, green; T2, blue; T3, purple; T4A, red; and T4B, black.
  19. 25. The three-planar views are crucial to understanding the malignant gradient. A. Coronal. B. Sagittal. C. Transverse. (1) Maxillary sinus. (2) Inferior concha. (3) Tongue. (4) Mandible. (5) Mylohyoid. (6) Sublingual gland. (7) Pharyngeal tonsil. (8) Retromolar trigone. (9) Axis (C2). (10) Epiglottis. (11) Retropharyngeal space. (12) Palatine tonsil. (13) Parotid gland. (14) Carotid sheath. (15) Cavity of pharynx.
  20. 26. Oral Cavity Lymph Node Spread The red node highlights the sentinel node, which is the submaxillary and jugulodigastric node. A. Coronal. B. Sagittal.
  21. 27. The primary cancer (oropharynx) invades in various directions, which are color-coded vectors (arrows) representing stage of progression: Tis, yellow; T1, green; T2, blue; T3, purple; T4a; red; and T4b, black.
  22. 28. Lymph Node Spread from oropharyngeal cancer . The red node highlights the sentinel node, which is the jugulodigastric node. A. Coronal. B. Sagittal.
  23. 29. The primary cancer (hypopharynx) invades in various directions, which are color-coded vectors (arrows) representing stage of progression: Tis, yellow; T1, green; T2, blue; T3, purple; T4a, red; and T4b, black.
  24. 30. The three planar views are crucial to understanding the malignant gradient. A. Coronal. B. Sagittal. C. Transverse. (1) Root of tongue. (2) Epiglottis. (3) Thyroid gland. (4) Esophagus. (5) Superior pharyngeal constrictor. (6) Glossopharyngeal nerve. (7) Middle pharyngeal constrictor. (8) Vagus nerve. (9) Inferior pharyngeal constrictor. (10) Thyroid lamina. (11) Trachea. (12) Larynx. (13) Vestibular fold. (14) Pharynx. (15) Retropharyngeal space. (16) Common carotid artery. (17) Internal jugular vein.
  25. 31. Lymph Node Spread form Hypopharynx Cancer The red node highlights the sentinel node, which is the jugulo-omohyoid node. A. Coronal. B. Sagittal.
  26. 32. The primary cancer (supraglottic larynx) invades in various directions, which are color-coded vectors (arrows) representing stage of progression: Tis, yellow; T1, green; T2, blue; T3, purple; T4a, red; and T4b, black.
  27. 33. The three planar views are crucial to understanding the malignant gradient. A. Coronal. B. Sagittal. C. Transverse. (1) Epiglottis. (2) Thyroid cartilage. (3) Vestibular fold. (4) Vocal fold. (5) Ventricle of larynx. (6) Vestibule of larynx. (7) Pharynx. (8) Retropharyngeal space. (9) Inferior pharyngeal constrictor. (10) Pre-epiglottic space. (11) Para-epiglottic space.
  28. 34. Supraglottic Larynx lymph node spread The red node highlights the sentinel node, which is the jugulodigastric node. A. Coronal. B. Sagittal.
  29. 35. The primary cancer (glottic larynx) invades in various directions which are color-coded vectors (arrows) representing stage of progression: Tis, yellow; T1, green; T2, blue; T3, purple; T4a, red; and T4b, black .
  30. 36. Glottic Cancer The three planar views are crucial to understanding the malignant gradient. A. Coronal. B. Sagittal. C. Transverse. (1) Vestibule. (2) Vestibular fold. (3) Ventricle. (4) Vocal fold. (5) Trachea. (6) Epiglottic cartilage. (7) Vocal ligament. (8) Corniculate cartilage. (9) Arytenoid cartilage. (10) Thyroid cartilage.
  31. 37. Lymph Node Spread from Glottic Cancer The red node highlights the sentinel node, which is the pretracheal node. A. Coronal. B. Sagittal.
  32. 38. Stage 0: Tis N0 M0 Stage I: T1 N0 M0 Stage II: T2 N0 M0 Stage III: T3 N0 M0, T1 N1 M0, T2 N1 M0, T3 N1 M0 Stage IVA: T4a N0 M0, T4a N1 M0, T1 N2 M0, T2 N2 M0, T3 N2 M0, T4a N2 M0 Stage IVB: Any T N3 M0, T4b Any N M0 Stage IVC: Any T Any N M1 NX: Regional nodes cannot be assessed N0: No regional lymph node metastasis N1: Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension N2: Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension; or in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension; or in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension   N2a: Metastasis in single ipsilateral lymph node more than 3 cm but not more than 6 cm in greatest dimension   N2b: Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension   N2c: Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension N3: Metastasis in a lymph node more than 6 cm in greatest dimension 2002 American Joint Committee on Cancer (AJCC) TNM Staging System for the Lip and Oral Cavity Tx; Primary tumor cannot be assessed T0: No evidence of primary tumor Tis: Carcinoma in Situ T1: Tumor 2 cm or less in greatest dimension T2: Tumor more than 2 cm but not more than 4 cm in greatest dimension T3: Tumor more than 4 cm in greatest dimension T4 (lip): Tumor invades through cortical bone, inferior alveolar nerve, floor of mouth, or skin of face (ie, chin or nose) T4a: (oral cavity) Tumor invades adjacent structures (eg, through cortical bone, into deep [extrinsic] muscle of tongue [genioglossus, hyoglossus, palatoglossus, and styloglossus], maxillary sinus, skin of face) T4b: Tumor invades masticator space, pterygoid plates, or skull base and/or encases internal carotid artery
  33. 39. Stage 0: Tis N0 M0 Stage I: T1 N0 M0 Stage II: T2 N0 M0 Stage III: T3 N0 M0, T1 N1 M0, T2 N1 M0, T3 N1 M0 Stage IVa: T4a N0 M0, T4a N1 M0, T1 N2 M0, T2 N2 M0, T3 N2 M0, T4a N2 M0 Stage IVb: T4b Any N M0, Any T N3 M0 Stage IVc: Any T Any N M1 Nx: Regional lymph nodes cannot be assessed N0: No regional lymph node metastasis N1: Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension N2: Metastasis in a single ipsilateral lymph node, more than 3cm but not more than 6 cm in greatest dimension, or in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension, or in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension   N2a: Metastasis in a single ipsilateral lymph node more than 3cm but not more than 6 cm in greatest dimension   N2b: Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension   N2c: Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension N3: Metastasis in a lymph node more than 6 cm in greatest dimension 2002 American Joint Committee on Cancer (AJCC) TNM Staging System for the Pharynx (Including Base of Tongue, Soft Palate, and Uvula) T1: Tumor 2 cm or less in greatest dimension T2: Tumor more than 2 cm but not more than 4 cm in greatest dimension T3:Tumor more than 4 cm in greatest dimension T4a: Tumor invades the larynx, deep/extrinsic muscle of tongue, medial pterygoid, hard palate, or mandible T4b: Tumor invades lateral pterygoid muscle, pterygoid plates, lateral nasopharynx, or skull base or encases carotid artery
  34. 40. Stage 0: Tis N0 M0 Stage I: T1 N0 M0 Stage IIa: T2a N0 M0 Stage IIb: T1 N1 M0, T2 N1 M0, T2a N1 M0, T2b N0 M0. T2b N1 M0 Stage III: T1 N2 M0, T2a N2 M0, T2b N2 M0, T3 N0 M0, T3 N1 M0, T3 N2 M0 Stage IVa: T4 N0 M0, T4 N1 M0, T4 N2 M0 Stage IVb: Any T N3 M0 Stage IVc: Any T Any N M1 NX: Regional lymph nodes cannot be assessed N0: No regional lymph node metastasis N1: Unilateral metastasis in lymph node(s), 6 cm or less in greatest dimension, above the supraclavicular fossa* N2: Bilateral metastasis in lymph node(s), 6 cm or less in greatest dimension, above the supraclavicular fossa* N3: Metastasis in a lymph node(s)* more than 6 cm and/or to supraclavicular fossa   N3a: More than 6 cm in dimension   N3b: Extension to the supraclavicular fossa** 2002 American Joint Committee on Cancer (AJCC) TNM Staging System for Nasopharynx Cancer T1: Tumor confined to the nasopharynx T2: Tumor extends to soft tissues   T2a: Tumor extends to the oropharynx and/or nasal cavity without parapharyngeal extension*   T2b: Any tumor with parapharyngeal extension* T3: Tumor invades bony structures and/or paranasal sinuses T4: Tumor with intracranial extension and/or involvement of cranial nerves, infratemporal fossa, hypopharynx, orbit, or masticator space *Note: Parapharyngeal extension denotes posterolateral infiltration of tumor beyond the pharyngobasilar fascia.
  35. 41. 2002 American Joint Committee on Cancer (AJCC) TNM Staging System for the Larynx Supraglottis T1: Tumor limited to one subsite of supraglottis with normal vocal cord mobility T2: Tumor invades mucosa of more than one adjacent subsite of supraglottis or glottis or region outside the supraglottis eg, mucosa of base of tongue, vallecula, medial wall of pyriform sinus) without fixation of the larynx T3: Tumor limited to larynx with vocal cord fixation and/or invades any of the following: postcricoid area, preepiglottic tissues, paraglottic space, and/or minor thyroid cartilage erosion (eg, inner cortex) T4a: Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx (eg, trachea, soft tissues of neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus) T4b: Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures Glottis T1: Tumor limited to the vocal cord(s) (may involve anterior or posterior commissure) with normal mobility   T1a: Tumor limited to one vocal cord   T1b: Tumor involves both vocal cords T2: Tumor extends to supraglottis and/or subglottis, and/or with impaired vocal cord mobility T3: Tumor limited to the larynx with vocal cord fixation and/or invades paraglottic space, and/or minor thyroid cartilage erosion (eg, inner cortex) T4a: Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx (eg, trachea, soft tissues of neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus) T4b: Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures
  36. 42. 2002 American Joint Committee on Cancer (AJCC) TNM Staging System for the Larynx Supraglottis Nx:: Regional lymph nodes cannot be assessed N): No regional lymph node metastasis N1: Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension N2: Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension; or in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension, or in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension   N2a: Metastasis in single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension   N2b: Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension   N2c: Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension N3: Metastasis in a lymph node, more than 6 cm in greatest dimensionStage 0: Tis N0 M0 Stage I: T1 N0 M0 Stage II: T2 N0 M0 Stage III: T3 N0 M0, T1 N1 M0, T2 N1 M0, T3 N1 M0 Stage IVa: T4a N0 M0, T4a N1 M0, T1 N2 M0, T2 N2 M0, T3 N2 M0, T4a N2 M0 Stage IVb: T4b Any N M0, Any T N3 M0 Stage IVc: Any T Any N M1
  37. 45. Treatment options for head and neck cancer <ul><li>Early stages: surgery or radiation </li></ul><ul><li>Advanced stages:chemoradiation or surgery followed by radiation and chemotherapy </li></ul><ul><li>Very advanced cases: radiation and chemotherapy </li></ul>
  38. 46. Simulation A face mask is usually made to hold the head still and allow the targeting markings to be painted on the mask.
  39. 47. CT scan is obtained at this time CT images are then imported into the treatment planning computer
  40. 48. In the simulation process the CT and PET scan images are used to create a computer plan
  41. 49. Computer plans are then generated from the CT scan images
  42. 50. CT scan and computer generated targets and avoidance structures so that the ideal plan (hit the cancer and avoid the normal structures) can be created
  43. 51. Computer generated images of small vocal cord cancer
  44. 52. Radiation field surrounds the target in the larynx (avoiding critical structures like the jaw, skull or spinal cord
  45. 53. Radiation dose cloud completely surrounds the target
  46. 54. For small cancers in the vocal cords it is possible to keep the radiation far away from other normal structures
  47. 55. Image Fusion (merging a PET scan with a CT scan) Step 1 Cancer on PET Scan Cancer on CT Simulation Red - cancer Purple – radiation zone
  48. 56. Image Fusion step 2 cancer cancer radiation
  49. 57. Normal structures are identified on the computer generated images
  50. 58. Radiation zone is designed to cover the cancer and nodes and avoid normal structures as much as possible
  51. 59. PET Scan transformed into radiation target PET Scan lights up cancer in left neck nodes Cancer nodes (green) surrounded by radiation zone (orange) with lower dose radiation to other targets
  52. 60. PET Scan used to create radiation target PET Scan , showing cancer in right tongue Computer generated reconstruction, the target area is in red
  53. 61. Cancer (blue) surrounded by large field low dose radiation and then high dose boost field
  54. 62. Shrinking field technique, the first phase covers a large area and the final boost phase is more targeted
  55. 64. In the treatment the lasers are used to line up the beam and the patient receives the radiation treatment
  56. 67. 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)
  57. 68. Low risk parotid gland tumor (in red) may be possible to keep the radiation zone (blue) as small as possible
  58. 69. 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
  59. 71. Radiation combined with Chemotherapy
  60. 72. Combining chemotherapy with radiation, complete remission
  61. 73. Stage III larynx cancer, PET scan showing complete response after radiation
  62. 75. Radiation targeting and results on PET scan
  63. 77. Side Effects of Radiation to the Throat <ul><li>Skin irritation </li></ul><ul><li>Dry Mouth and changes in taste and possible problems with teeth </li></ul><ul><li>Sore throat and problems with swallowing and dehydration and possible need for a feeding tube </li></ul><ul><li>Pain management problems </li></ul><ul><li>Laryngitis </li></ul><ul><li>Fatigue </li></ul>
  64. 78. Radiation prescription for # Diagnosis: squamous cell carcinoma of the # Stage: Stage # Chemotherapy: # Number of radiation treatments: #

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