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Head and neck radiotherapy experience
The document outlines techniques and challenges in the radiotherapy treatment of head and neck cancers, including the role of radiotherapy, chemotherapy, and various treatment modalities. It details the Southern Medical Clinic's experience with patient demographics, treatment outcomes, and the importance of timely diagnosis and management of side effects. Additionally, it highlights the workflow and protocols followed for effective radiation planning and delivery.
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Head and neck radiotherapy experience
- 1. Techniques and challengesin radiotherapy of head and neck cancers Southern Medical clinic experience DR MILIND KUMAR CONSULTANT ONCOLOGIST
- 2. Scope of presentation Overview of head and neck cancer & Radiotherapy role Contouring & radiation planning guidelines followed at SMOC SMOC experience (Rapidarc in Head and neck patients)
- 3. Management of headand neck cancers Early stage (Stage I Stage II)—(Single modality) Surgery or radiotherapy alone usually suffice Advanced stage(Stage III Stage IV)– (Multimodal) Surgery followed by post op RT or concurrent chemoradiation
- 4. Radiotherapy vs surgery Multiple sessions –70Gy/35#/7 weeks vs one OT session Acute side effects—skin reactions, mucositis, pain, fungal infection Late side effects– loss of taste, xerostomia, dental caries, skin fibrosis. Organ preservation—speech, swallowing Weight loss during RT
- 5. Radiotherapy rationale Ionizingradiation– free radicals damage DNA of tumor While dividing tumor cells undergo apoptosis and cell death Differential effect on normal tissues and they are less rapidly dividing as compared to malignant tissues. Radiotherapy want to focus on GTV-Gross tumor volume CTV-Clinical target volume for subclinical disease PTV-CTV + margin to account for daily set up errors and intra-fraction motion
- 6. Chemotherapy in headand neck cancers It is usually used in combination with radiotherapy (sequential or concurrent). It has a role in organ / voice preservation (in laryngeal / hypopharyngeal cancers) and in oropharyngeal cancers. In select patients chemotherapy can be used for palliating symptoms.
- 7. Techniques and machinesfor RT 2D RT 3DCRT IMRT Rapidarc/ VMAT Sterotactic body RT Interstitial brachytherapy MRI/PET based RT planning
- 8. Radiotherapy work flow Initial diagnosis---tissue diagnosis ---Surgical evaluation—MDT discussion Oncology consult—Diagnosis, investigations, staging and manangement planning Radiation Simulation- CT with immobilization mask Dosimetry—Identification and contouring organ at Risk Radiation oncologist—Identification and contouring GTV/CTV Dosimetry and Physicist—Planning, approval with RO, Quality assurance (patient specific checks) Treatment delivery –Radiation therapists Image guided verification of treatment delivery (CBCT/KV/MV image correction) Weekly reviews with RO (Weight/ FBC/ local exam/ analgesia) Daily reviews with oncology nurse, dietitian, Counsellor as need arises.
- 9. Contouring details OARmarked: Spinal cord Parotid Oral cavity Lacrimal glands Orbits/ optic apparatus Larynx
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- 12. Anterior tongue (postop) contouring
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- 14. Dose recommendations Grossdisease 70Gy/33#/7 ½ weeks High risk CTV 60Gy/33#/7 ½ weeks Intermediate risk CTV 54Gy/33#/7 ½ weeks Low risk CTV Post op radiotherapy 66Gy/33#/6 ½ weeks for close/ positive margin 60Gy/30#/6 weeks if margins clear
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- 18. Rapidarc planning anddelivery
- 19. Recurrent adenoid cysticmaxilla with ethmoid extension
- 20. Image guidance-Treatment delivery CBCT-Weekly CBCT CBCT on demand if weight loss >10%, if mask is loose/ not fitting well Kv-Kv imaging Daily done for matching. Adaptive RT planning—In case of significant weight loss –CBCT –correlated with planning CT scan and enables to re-CT sim and re-plan.
- 21. Ca hypopharynx post23# CBCT
- 22. Radiation toxicities -Management Radiation induced skin reactions-Saline dressings, do not bandage, povidone – iodine, flamazine Radiation induced mucositis- anbesol, magic mouthwash, soda bicarb gargles Analgesia- Tramacet, liquid morphine Weight loss- High protein diet sheet, daily monitoring by oncology nurses
- 23. SMOC experience 32patients of head and neck cancers/ radiation Nov 2015- Aug 2017 experience after commissioning of Rapidarc ix All patients received VMAT –RA Post op 60Gy-66Gy/30-33# Radical 70Gy/35#/7 or 70Gy/33#/7 ½ weeks with SIB technique 60Gy/30# 60Gy/33# 54Gy/33#
- 24. SMOC experience 32patients of head and neck cancers/ radiation Nov 2015- Aug 2017 experience after commissioning of Rapidarc ix All patients received VMAT –RA Post op 60Gy-66Gy/30-33# Radical 70Gy/35#/7 or 70Gy/33#/7 ½ weeks with SIB technique 60Gy/30# 60Gy/33# 54Gy/33#
- 25. Demographics Females- 12/32(37.5%) Males- 20/32 (62.5%) Age 50 and less: 9/32 (28%) Age 50-70: 17/32 (53%) Age 70 and above: 6/32 (19%) Pie Chart showing ratio from females to males Females Males 37.5% 62.5% Pie Chart showing Age bracket for Head and Neck Patients Age 50 and less Age 50 - 70 Age 70 and above 28.0% 19.0% 53.0%
- 26. Site distribution Carcinomaoral cavity – 9 Carcinoma larynx– 9 Carcinoma oropharynx -4 Nasal cavity/ Nasopharynx/ salivary glands /Acoustic neuroma--2 each Unknown primary,, hypopharynx-1 each 0 2 4 6 8 10
- 27. Stage distribution ClinicalPathological T1- 1 3 T2- 5 7 T3- 5 T4- 6 N1- 1 N2- 2 N3-3 Recurrence/ residual/ margin positive: 5
- 28. Chemotherapy Neoadjuvant chemo-10 Neoadjuvant and concurrent chemo- 9 Concurrent chemo only: 14 Neo Chemo Neo and Con Chemo Con Chemo Only
- 29. Outcomes –Telephonic FU NED- 23/32 (72%) Alive with Local recurrence -3 (9%) Metastatic disease- 1(3%) Defaulted RT-1(3%) Death-4 (13%) Pie Chart Showing Outcomes NED Alive with local Metastatic Defaulted RT Death
- 30. Our challenges Timelydiagnosis Timely referral to higher centre and institution of appropriate treatment PEG insertion pre-RT Dental prophylaxis Weight loss-CBCT-Adaptive RT. Social issues-compliance Financial constraints—SMARA charity supportive.
- 31. Thank you Teachers/ patients/Team @ SMC