This document discusses head and neck cancer and radiation therapy. It provides background information on head and neck cancers, noting they make up 6-9% of cancers and are more common in males. Risk factors include smoking, alcohol, HPV, and EBV. It then discusses the components of radiation therapy planning and delivery in detail, including patient preparation, positioning, volume definition, portal arrangement, dose and fractionation, plan acceptance, adding chemotherapy, and managing complications. The importance of a multidisciplinary team approach is also emphasized.

1. HEAD & NECK CANCER
HORIZONTAL
Mohamed Abdulla M.D.
Prof. of Clinical Oncology
Kasr Al-Aini School of Medicine
Cairo University
KASO – EXAM & RAP UP COURSE
THURSDAY 16/04/2015
GRAND NILE HOTEL & TOWER
FINDING
SIMILARITIES
IN COMMON

2. Disclosures:
• Amgen.
• Merck Serono.
• Sanofi.
• Astra Zeneca.
• Astellas.
• Roche.
• Pfizer.
• Novartis

3. Head & Neck Cancer: Basic Facts:
• 6 – 9% of all cancers.
• Males > Females; (2:1)  (4:1).
• 60% advanced at presentation.
• Substantial Geographic Variations Influenced by Risk
Factors:
• Smoking & Alcohol  5 – fold increased incidence.
• HPV  Oro-pharyngeal cancer.
• EPV  Nasopharyngeal cancer.
83%
59%
36%
0%
50%
100%
5-yearSurvival
Seminars in Oncology, Vol 41, No 6, December 2014, pp 798-806

4. Head & Neck Cancers:
Molecular & Biological Events:
• HPV-Related Cancers
• Caused by high-risk HPV
• HPV 16
• Driven by viral oncogenes
• Restricted to oropharynx
• Distinct molecular markers
• “Good” prognosis
• Young, good general health
• Environment-Related Cancers
• Caused by environmental
mutagens
• Smoking, alcohol
• Throughout oral mucosa
• Distinct molecular markers
• “Poor” prognosis, comorbidity
• Second cancers
HNC Can Now Be Divided Into 2 Large and Distinct Subtypes
HPV = human papillomavirus.
Goon et al, 2009; Rodriguez et al, 2010.

5. HPV & Oropharyngeal Cancer:
Changing Incidence Over Time:
Chaturvedi et al, 2011.

6. Sequential Combined Modality Therapy
APhase III Study: TAX 324 TPF Vs. PF
Followed by Chemoradiotherapy
R
A
N
D
O
M
I
Z
E
P
P
F
F
Carboplatinum: AUC 1.5 Wkly
Daily Radiotherapy
EUA
T
Surgery
TPF: Docetaxel 75D1 + Cisplatin 100D1 + 5-FU 1,000 CI: D1–4 q3wks x 3
PF: Cisplatin 100 D1 + 5-FU 1,000 CI: D1–5 q3wks x 3
AUC = area under the curve; EUA = examination under anesthesia.
Posner et al, 2007.

7. TAX 324: Demographics by HPV Status
HPV+
N = 56 (50%)
HPV–
N = 55 (50%) p Value
Treatment
TPF
PF
28 (50%)
28 (50%)
26 (47%)
29 (53%)
.85
Age Yrs
Median (Range) 54 (39–71) 58 (41–78) .02
Nodal Stage
N0–N1
N2–N3
13 (23%)
43 (77%)
18 (33%)
37 (67%)
.30
T stage
T1–T2
T3–T4
28 (50%)
28 (50%)
11 (20%)
44 (80%)
.001
PS WHO
0
1
43 (77%)
13 (23%)
27 (49%)
28 (51%)
.003
PS = performance status; WHO = World Health Organization.
Posner et al, 2011.

8. TAX 324: Survival and HPV Status
Posner et al, 2011.`
SurvivalOropharynxCancer
HPV+
HPV–
p < .0001

9. TAX 324: Survival, PFS, and Site
of Failure By HPV Status
HPV+
N = 56
HPV–
N = 55
p Value
Median Follow-Up
Months (95% CI) 83 (77–93) 82 (68–86) NS
Survival Status
– Alive
– Dead
44 (79%)
12 (21%)
17 (31%)
38 (69%)
< .0001
PFS Status
– No Progression/Death
– Progression/Death
41 (73%)
15 (27%)
16 (29%)
39 (71%)
< .0001
Local-Regional Failure 7 (13%) 23 (42%) .0006
Distant Metastases 3 (5%) 6 (11%) NS
Both 1 (2%) 2 (4%) NS
Total Disease Failures 9 (16%) 27 (49%) .0002
Died Without Recurrence 5 (9%) 12 (22%) .07
PFS = progression-free survival; NS = not significant.
Posner et al, 2011.

10. Head & Neck Cancer:
Current Theme of Management:
Surgery
Radiation
Therapy
Key
Components
 L.R.
 Distant
Metastases
Systemic
TherapySEER. Stat fact sheets: oral cavity and pharynx cancer. 2003-2009.
Existing Dilemma:
• Different treatment algorithms.
• Many critical structures  QoL.
• Organ Preservation.
• Impact of innovations on OAS.

11. MDT
Radiation
Oncologist
Medical
Oncologist
Onco-Surgeon
Radiologist
Clinical NutritionistPsychiatrist
Physiotherapist
Speech Aid
Social Worker
Oncology Nurse
Head & Neck Cancer:
Current Theme of Management:

12. Head & Neck Cancer:
Radiation Therapy Components:
1. Patient Preparation.
2. Positioning.
3. Fixation.
4. Volume to be Treated, Volumes to be Avoided.
5. Portal Arrangement.
6. Energy Used.
7. Dose, Fractionation & OAP
8. Acceptance and Quality Control.
9. Adding Systemic Therapy.
10. Management of Anticipated Complications & Follow Up

13. Radiation Therapy Components:
1. Patient Preparation: Compliance:
• Detailed history including previous HNSCC & radiation treatment.
• All investigations (Imaging, laboratory, pathologic, endoscopic) 
Accurate Staging  Clear Intention & Therapeutic Strategy.
• General Examination:
• Performance Status.
• Complexion: PALOR  ANEMIA., Depression.
• Nutritional Assessment.
• Co-morbid illness  DM
• Neurological Assessment.
• Pulmonary Assessment.
• Locoregional Examination:
• Palpable primary & lymph nodes.
• Oral Hygiene  Correction before treatment.
• Stoma Care.
• Understanding, Instructions, Interventions.
• Discuss with family.
• MDCT
• MRI
• PET/CT
• Others
• Hematological
• Organ Function
• Others

14. Poor Radiation Results From Non-compliance
in Radiation Technique
Critical Impact of Radiotherapy Protocol
Compliance and Quality in the Treatment of
Advanced Head and Neck Cancer: Results
From TROG 02.02
CO June 20, 2010 vol. 28 no. 18 2996-3001
Noncompliance, more relapses

15. Radiation Therapy Components:
2. Positioning: Comfortable & Reproducible
SUPINE
STRECHED
SHOULDERS
Snehal et al..Medical Dosimetry, Vol. 34, No. 3, pp. 225-227, 2009
• Acanthiomeatal Line is
perpendicular to table.
• Chin in neutral position.

16. Radiation Therapy Components:
3. Fixation:
• Thermoplastic Mask.
• Placement of Markings;
“Lead & Laser).
• Tongue Bite
(Depressor): In or Out.

17. Radiation Therapy Components:
4. Volume:
ICRU Reports 50 & 62:
• GTV: Gross Tumor Volume.
• CTV: Clinical Target Volume:
Extension of Subclinical
Disease.
• PTV: GTV + CTV + (3 – 5 mm).
• OAR or ORV.
ICRU Report 50 (1993) Prescribing, recording and
reporting photon beam therapy. International
Commission on Radiation Units and Measurements,
Bethesda, MD

18. • No Place for limited volumes except in Early glottic
cancers (T1-2).
• Neck nodes are usually included except in Early Glottic
Cancers and PNS.
• Bilaterality of neck nodes is mostly required.
Radiation Therapy Components:
4. Volume:
3D Techniques (Conformal, IMRT, IGRT)
 Spare Normal Tissues as much as we can
Accurate radiation dose delivery
No treatment volume Reduction.

19. Radiation Therapy Components:
4. Volume:

20. Radiation Therapy Components:
4. Volume: Larynx: Glottic:
Early Glottic Cancer T3-4 Glottic Cancer

21. Radiation Therapy Components:
4. Volume: Larynx: Supraglottic:

22. Nasopharynx Basic Considerations:
Anatomical Data:
Skull Base: Sphenoid
and Occipital Bones
Pre-
Vertebral
Fascia
Nasal
Cavity
Oropharynx

23. Basic Considerations:
Anatomical Data:

24. Basic Considerations:
Anatomical Data:

25. Basic Considerations:
Anatomical Data:

26. Basic Considerations:
Anatomical Data:Upwardextension

27. Basic Considerations:
Anatomical Data:
The Most
Common Site

28. Bounded by:
 Atlas vertebra
Axis vertebra
Sup. Constrictor ms
Buccopharyngeal
fascia
Retropharyngeal
space
Prevertebral fascia
Basic Considerations:
Anatomical Data:

29. Basic Considerations:
Anatomical Data:
Pharyngo-Basilar Fascia

30. Basic Considerations:
Anatomical Data:
Superior
Pharyngeal
Constrictor
Muscle
Skull Base
Pharyngobasilar fascia Muscle Deficiency Area
=
Sinus of Morgagni
Potential Route
for Intracranial
Spread

31. Radiation Therapy Components:
4. Volume: Nasopharynx:

32. Radiation Therapy Components:
4. Volume: Paranasal Sinuses:
Ipsilateral Tumor Bed + Ethmoid + Frontal + Openings on the
contralateral side. Nodes will be included if locally advanced or
high grade lesion.

33. Radiation Therapy Components:
4. Volume: Oropharynx:

34. Radiation Therapy Components:
4. Volume: Hypopharynx:

35. Radiation Therapy Components:
4. Volume: Oral Tongue and Floor of
Mouth:

36. • The best obtained is parallel opposed.
• Supplementations.
• IMRT.
• High Energy photon beams: 6-10 MV.
• Electron Beam: Energy according to desired depth as a
supplementation or sometimes for re-irradiation.
• Others.
Radiation Therapy Components:
5-6: Portal Arrangement & Energies:

37. Radiation Therapy Components:
7. Dose & Fractionation:

38. Radiation Therapy Components:
7. Dose & Fractionation:

39. Radiation Therapy Components:
8. Plan Acceptance:

40. Radiation Therapy Components:
9. Adding Systemic Therapy:
Seminars in Oncology, Vol 41, No 6, December 2014, pp 798-806

41. MACH-NC: 2009 Update:
93 Trials – 17346 Patients:
J.-P. Pignon et al. / Radiotherapy and Oncology 92 (2009) 4–14
CISPLATIN 100 mg/m2 (D1+22+43) +
RTH

43. • Early Reactions.
• Late Reactions.
• Follow up Strategy.
Radiation Therapy Components:
10. Management of Anticipated Complications:

44. Thank You