DR KANHU CHARTAN PATRO/ FOR ENT SURGEONS

1
ROLE OF RADIOTHERAPY
IN HEAD AND NECK CANCER
Dr Kanhu Charan Patro
MD,DNB(Radiation Oncology),MBA,FICRO,FAROI(USA),PDCR,CEPC
HOD, Radiation Oncology
ISRo- Institute of Stereotatctic Radiation Oncology
Mahatma Gandhi Cancer Hospital & Research Institute, Visakhapatnam
drkcpatro@gmail.com /M- +91-9160470564/ www.drkanhupatro.com

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VISAKHAPATNAM,1/7-MVP[AP]
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Statistics
• >9.7 million cases are detected each
year
• 6.7 million people will die from
cancer
• Every day, around 1700 Americans
die of the disease
• 20.4 million people living with
cancer in the world today
• 1 in 3 people will be diagnosed with
cancer in the UK and 1 in 4 will die
from their disease

Lung
Breast
Colon/Rectum
Stomach
Liver
Prostate
Cervix uteri
Oesophagus
Bladder
Non-Hodgkin
Lymphoma
Leukaemia
Oral cavity
Pancreas
Kidney
Ovary
1000 800 600 400 200 0 200 400 600 8001000
Men Women
From: D.M. Parkin The Lancet Oncology 2: 533-543 (2001)
(Thousands)
Incidence
Mortality
337
293
105
0
370
241
318
446
234
165
166
471
233
133
111
76
33
121
68
113
86
47
97
101
101
34
71
192
114
810
902
558
405
255
499
398
384
204
543
279
260
227
99
93
167
144
109
81
170
116
112
57
119
5.3 million cases
3.5 million deaths
4.7 million cases
2.7 million deaths
The Global Burden of Cancer 2000

Oncologist
Diagnosis
Treatment
Radiologist
Cytopathologist
Surgeon
Histopathologist
Molecular
Pathologist
Geneticist
psychiatrist
Nursing
And
Support staff
Audit

Role of radiotherapy in various cancers
• Needed for all most head and neck cancer
• Radical-
– Naso-pharynx, laryx, hypopharynx etc.
• post-op-adjuvant
– MOSTLY ALL ORAL CANCERS except T1 lesions
• Palliative
– compression, bleeding, obstruction, pain
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Radiation –Part of life

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Wilhelm Conrad Rontgen

History - radiation
1896 – Becquerel - Radioactivity
1898 – Madam Curie / Pierre Curie - Radium
1903 – Nobel Prize for Curie’s & Becquerel
1903 – First successful case of malignancy basal
cell carcinoma of face
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GOALS
 High dose to tumor tissue-Tumor control
 Normal tissue sparing
 Minimize long and short term toxicities
 Better Quality of life
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Treatment
• Delivered 5 days per week over 6-8 weeks
• Typical treatment takes around 5 minutes
• Treatment is painless--like having an X-ray taken
• No radioactive substances involved; beam goes
on/off
• Side effects usually temporary; controlled with
medication/diet
• Covered by Medicare and many other insurance
companies
•
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Types of radiotherapy
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TELETHERAPY
BRACHYTHERAPY

Radiotherapy procedure
1. Tumor board decision
2. Positioning And immobilization
3. Imaging
4. Target delineation
5. Planning
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Mahatma Gandhi Cancer Hospital &
Research Institute,Visakhapatnanm
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IMAGE GUIDED RADIATION THERAPY
EQUIPMENT REQUIRED
CT-SCAN MRI PET-CT
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Cobalt machine
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Plaster of Paris Mould-older method
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Head & Neck
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PLANNING
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CONFORMAL
CLINICAL

Evolution of Treatment Techniques
CUSTOMISED BLOCKS
MULTILEAF COLLIMATOR
BASED 3D-CRT
1990s
1980s
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Treating Head & Neck with Sliding Windows
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IMRT
• Divides each treatment field into
multiple segments
• Modulates beam intensity,
giving discrete dose to each
segment
• Uses multiple, shaped beams
(~9) and thousands of segments
IMRT Initiated in 1995
Reached the clinic in 2000

Conventional vs Conformal vs IMRT
Head and Neck
Conventional
Conformal
IMRT
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Small Volume Adjacent to Critical Structure
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3D Dose Shaping - H&N and Brain
Brain
Stem
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• CONVENTIONAL
• 3DCRT
• IMRT
• IGRT
• VMAT/RAPIDARC
• PET GUIDED RADIOTHERAPY

1. TRISMUS
2. DYSGUESIA
3. XEROSTOMIA
4. DYSPHAGIA
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ZEROING THE
XEROSTOMIA
&
DISCARDING
THE DYSPHAGIA
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Methods preventing xerostomia
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VESTIBULAR SCHWANNOMA SRS
CASE-3
68

• NAME
• UMR
• PRESENTATION • 59 year male
• Diagnosed case of vestibular schwannoma
• Right side
• P/w Slight decreasing in hearing loss-4 - 5 months
• No facial numbness
• MRI • Intracanalicular and extra canalicular component
• Touching brainstem
• No cystic component
• Minimal enhancing
• Impending 5th nerve
• SRS • SRS
• 25Gy/5#
Case details
69

LT. Fifth
nerve
RT. Fifth
nerve
70

• NAME
• UMR
• PRESENTATION • Headache, difficulty in swallowing, Hoarseness of voice, Tinnitus
, reduced hearing, Nasal regurgitation × 6 months
• MRI • 2.5 x2 cm, Brilliantly enhancing, extracranial lesion in Left jugular
foramen
• Hypo on T1 and Iso on T2
• Erosion of carotid canal and jugular foramen
• SURGERY • Excision of Glomus jugulare done by FISCH type approach
• BIOPSY • well defined nests separated by highly vascularized fibrous
septae[zelle ballen pattern]
• SRS • 14Gy/1#
• IHC • Synaptophysin positive
• S100 positive
• COURTESY • DR PSB
Case details
74

Where is the Target?
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Mahatmagandhi cancer hospital and
research institute
SPARE THE ROD AND SPOIL THE CHILD
DO NOT LOOSE SHIGHT OF FOREST [OAR]FOR THE TREE

CT-MRI FUSION
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TRIPLE FUSION
PET
CT
MRI
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Concept of triple-fusion
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Mahatmagandhi cancer hospital and
research institute

Target volume definition
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Imaging
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86

IMAGING
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PET vs.MRI
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PET vs.MRI
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Avoid unnecessary toxicity
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90

Unknown primary
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91

Impact on radiotherapy
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92
1.Elective nodal irradiation
2.Nodal boost

G.P., m, 46y; LN-Metastasis of Hypopharynxcarcinoma
Head and Neck Cancer: Example
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Pet CT planning
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94

PET-CT-WIN-WIN SITUATION
PARAMETER VOLUME
CHANNGE
T STAGE INCREASE
UPSTAGING
1. PREVENTS TUMOR TISSUE MISSING
2. CHANGES TT FROM CURATIVE TO PALLLIATIVE
DECREASE
DOWN STAGING
1. PREVENTS EXTRA DOSE TO NORMAL TISSUE
2. CHANGES TT. FROM PALLIATIVE TO CURATIVE
3. DOSE ESCALATION IS POSSIBLE
N STAGE INCREASE
UPSTAGING
1. PREVENTS TUMOR TISSUE MISSING
2. CHANGES TT FROM CURATIVE TO PALLLIATIVE
DECREASE
DOWN STAGING
1. PREVENTS EXTRA DOSE TO NORMAL TISSUE
2. CHANGES TT. FROM PALLIATIVE TO CURATIVE
3. DOSE ESCALATION IS POSSIBLE
M STAGE INCREASE CURATIVE-TO PALLIATIVE
DECREASE PALLIATIVE TO CURATIVE
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Bird’s eye view Eagle’s eye view
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RADIOTHERAPY DELIVERY
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97

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Brachytherapy
• Short distance /contact with tumor
• Expertise needed
• Invasive procedure
• Adequetly sparing normal structure
• Well established
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Brachytherapy in oral cavity cancers
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• COSMETIC DEFECT
• FUNCTIONAL DEFECT
• IMPAIRED QUALITY OF LIFE
SURGERY
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PROCEDURE
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• HEAD AND NECK CANCERS
• BREAST CANCERS
• ESOPHAGUS CANCERS
• PENILE CANCER
• SOFT TISSUE SARCOMA
• BLADDER CANCERS
• CANAL CANCERS
ORGAN PRESERVATION
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ORGAN PRESERVATION FOR
CANCER TONGUE
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TONGUE IMPLANT IN PROGRESS
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BUCCAL MUCOSA
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Hard palate
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Lip cancer
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Floor of mouth
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ORGAN PRESERVATION FORCANCER LIP

Complete response –towards healing
hypo-pigmentation

KELOIDS
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• HEAD AND NECK CANCERS
• BREAST CANCERS
• ESOPHAGUS CANCERS
• PENILE CANCER
• SOFT TISSUE SARCOMA
• BLADDER CANCERS
• CANAL CANCERS
ORGAN PRESERVATION
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• GOOD COSMETIC
• FUNCTIONAL PRESERVATION
• GOOD QUALITY OF LIFE
• ESTABLISHED PROCEDURE
• EXPERTISE REQUIRED
• AVAILABLE LITERATURES
• LESS TOXIC
FACTS
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SMART THINKING
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166
METASTASIS
-please do not watch crying

METASTASIS- give a smiling death
168

Palliative radiation
Skeletal X-Ray
Bone scan
MRI
PET-CT

Superscan-extensive bone mets
176

CAUTION
C - Change in bowel or bladder habits
A - A sore that does not heal
U - Unusual bleeding or discharge
T - Thickening or lump in the breast or any part of the body
I - Indigestion or difficulty swallowing
O - Obvious change in a wart or mole
N - Nagging cough or hoarseness

Change in bowel habits
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Change in bladder habits
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A sore that does not heal
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Unusual bleeding or discharge
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Thickening or lump in the
breast or any part of the body
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Indigestion or difficulty swallowing
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Obvious change in a wart or mole
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Liver cancer-
hepatitis B vaccine

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LOTS OF BLOOD REQUIRE

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All specialities under one roof

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TABLET FORMS

Cervix cancer vaccine
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Nagging cough or hoarseness
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Promise-Stop drinking alcohol
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Meditation
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210
Dietary protective factors

Just “Doing It” is not good enough !
You must know “what” to do and “where” to do it !
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EMPOWER
•EQUIPMENT
•EXPERT
•EXPERIENCE
•EASY ACCESSES

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Whenever not
possible,
make friends

Kanhu
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DR Nandhitha

DR KANHU CHARTAN PATRO/ FOR ENT SURGEONS

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