This document discusses various treatment modalities for head and neck cancers including radiation therapy, brachytherapy, chemotherapy, and their combinations. It describes different radiation techniques like external beam radiotherapy, intensity modulated radiation therapy and different chemotherapy regimens used alone or combined with radiation for curative, palliative or adjuvant purposes. It also discusses evaluation, complications and patient care during these treatments.

1. Dr Manpreet Singh Nanda
Associate Professor ENT
MMMC&H Solan

2.  Treatment of lesion with ionizing radiation
 Modes of RT
 External beam/ Teletherapy
 90% MC
 Use photon (X Rays, gamma rays) and
electron beams FROM DISTANCE
 Skin sparing, better precision, diminished
bone absorption

3.  Brachytherapy
 Uses radio active material in close contact
with lesion
 Types
 Moulds – applied to the surface of the lesion
 Interstitial implants – applied into tissues –
tumours of tongue and lips
 Intercavity implants – placed in cavity next
to the lesions – maxillary antrum,
nasopharynx
 As needles (radium 226, cobalt 60) or as
seeds or grains ( I – 125)

4.  Unsealed radionuclide therapy
 IV/oral radionuclide isotopes
 Spares normal tissue
 Eg- radioactive iodine for follicular thyroid ca
 Conformal radiotherapy
 Conforms to the size and shape of tumour
 Delivers max to target areas, min to surrounding
tissues and sharply cuts off critical areas
 Intensity modulated RT- spares normal tissue –
nasopharynx, larynx, PNS
 Cyberknife stereotactic RT

5.  RADIATION UNITS
 Energy deposited in unit of material
 Rad – radiation absorbed dose – 100 ergs
deposited/gram of material
 Gy – gray – SI unit – 1 joule deposited/kg of
material
 1 Gy = 100 rads
 1 Cgy = 1 rad

6.  TYPES
 Curative RT
 Early cancers/ small lesions
 To preserve function of organ
 Alone
 Benign lesions – angifibroma
 Dose 60-70 Gy, depend on the extent of the
lesion

7.  Palliative RT
 Indications
 Advanced lesions where total control of disease
is not expected
 Distant metatasis
 Poor nutritional status
 Systemic diseases affecting heart, lung, kidney
 Role
 To control pain, bleeding, obstruction to airway
or food passage

8.  Adjuvant RT/Combination RT
 As adjuvant to surgery or CT, before or after
 Role
 To achieve better control of disease
 To eradicate microscopic extension of tumour
 To increase survival rate in advanced lesions
 Types
 Pre op RT
 Post op RT
 Intra op RT

9.  Pre operative RT
 Advantages
 Reduces tumour bulk and make it operable
 Eliminates occult metastasis in regional ln
 Prevent distant metastasis
 Blocks lymphatics, reduces chances of dissemination
of tumour during surgery
 Response better as oxygenation of tumour not
hampered
 Note – the interval between RT and surgery < 6 weeks

10.  Dose – 45-50 Gy
 Disadvantages
 Central part of large tumour responds poorly
to RT
 Reduced vitality of tissue leading to
increased chances of post op complications
like delayed wound healing, flap necrosis,
fistula formation and carotid blowout

11.  Post operative RT
 Indications – stage III, IV
 Positive margins, invasion of bone or
cartilage, extracapsular invasion of ln,
multiple neck nodes size > 3 cm
 Within 6 weeks of surgery, dose 55-65 Gy
 Advantages
 More effective as bulk has already been
removed
 Lesser post op complications
 Can be done for residual tumours

12.  Disadvantages
 Poor response to RT due to affected blood
supply
 Tumour cells are squeezed into blood supply
and lymphatics at the time of surgery leading
to increased chances of distant metastasis
 Intra operative RT
 At time of surgery
 Single large dose given to exposed tumour
bed
 Critical areas not included in field of RT

13.  Fractionation schedules
 Normal fractionation
 2Gy/ day – fraction dose
 30 fractions
 5 days/ week for a period of 6 weeks
 Total dose 60 Gy
 Hyperfractionation – increased number of
fractions, less dose
 Hypofractionation – less number of fractions,
higher dose
 Accelerated fractionation – shorten the overall
time

14.  Split course fractionation
 RT is given in two halves with a gap of 2
weeks in between
 To allow acute reactions to settle
 Factors affecting response to RT
 Tumour size – small tumours better response
 Tumour type – lymphoid tissue, anaplastic –
more responsive
 Adeno ca – radioresistant

15.  Complications of RT
 Depend on site/ dose/ fractions
 Early
 Radiation sickness – loss of appetite, nausea
 Mucositis – stomatitis, glossitis, ulcers in oral
cavity and oropharynx, persist for 8- 12 weeks
post RT
 Skin reactions – erythema
 Pharyngeal and laryngeal oedema leading to
dysphagia and stridor
 Fungal infection – candidiasis
 Dysfunction of salivary and lacrimal glands

16.  Late
 Non healing ulcer
 Atrophy of skin and mucosa, SMF
 Bone marrow depression
 Dental decay
 Recurrent infections
 Osteo and chondroradionecrosis (mandible >
maxilla)
 Malignancy – papilly thyroid ca, orbital
osteosarcoma
 Middle ear effusion, SNHL, vestibular symptoms
 Retinopathy and cataract
 Hypothyroidism and pituitary defect

17.  Patient care during RT
 Nutrition
 Diet rich in proteins, vitamins, iron and
minerals
 NG feed, blood transfusion
 Avoid alcohol, tobacco, spicy food
 Teeth care
 Dental evaluation and extraction if needed 2-
3 weeks before RT to prevent
osteoradionecrosis

18.  Skin care
 Keep skin dry – avoid wetting or shaving
 Avoid exposure to sunlight
 Wear soft clothes
 Use antibiotic steroid ointment
 Oral care
 Avoid irritating mouth washes
 Milk of magnesia used to prevent erosion of
teeth and protect inflammatory area
 Xylocaine viscus to relieve pain and
discomfort

19.  Care against infection
 Topical application of nystatin and
clotrimazole ointment over oral cavity and
oropharynx
 Protective against candida infection

20.  Use of chemical compounds in treatment of
neoplastic diseases so as to destroy the
offending ca cells without affecting the
normal cells
 Classification
 Alkylating agents – cyclophasphamide,
cisplatin (dose – 50-100 mg/m2 IV over 3
weeks), carboplatin (dose – 360 mg/m2 IV
over 4 weeks)
 Antimetabolites – methotrexate, 5 FU,
bleomycin, mitomycin
 Vinca alkaloids – vincristine, vinblastin

21.  Taxanes – paclitaxel, docetaxel
 Radio active isotopes – radio active iodine
 Hormones – androgen, oestrogen,
progesterone
 Indications
 To make RT more effective for primary
tumour
 Combined with RT for organ preservation
 Lesser extensive surgery
 To control metastatic disease

22.  Types
 Palliative CT
 In advanced lesions or recurrence with aim
to relieve symptoms
 Cisplatin + 5 FU, cisplatin + mtx, carboplatin
+ 5 FU, cisplatin + bleomycin, cisplatin +
bleomycin + mtx
 Combined modality treatment
 Before, during or after RT/surgery

23.  Induction/ anterior/ NAC
 Before surgery or RT
 To reduce tumour burden, downstaging of
tumour
 Organ preservation – preservation of functions of
organs like swallowing, speech
 Increase survival rate
 Decrease distant metastasis
 Improve quality of life
 Response rate 60-90% after 3 cycles
 Complete response 20-30%, cisplatin, 5 FU,
carboplatin

24.  Chemoradiation/ concomittant CT RT/
concurrent CT RT
 Simultaneous
 Unresectable tumours
 To improve regional and local control of
disease
 Increases toxicity
 Survival rates not increased
 Cisplatin, 5 FU, bleomycin, mitomycin

25.  Adjuvant or posterior RT
 After surgery or RT
 To cure micrometastasis and distant
metastasis
 Surgery not delayed
 No blurring of tumour margins
 Intra arterial CT
 In advanced salivary glands and PNS tumours
 PNS – superficial temporal artery

26.  Single agent CT
 33% response
 Complete response 5 %
 Combination CT
 Using 2 or more drugs
 Not much improved survival rate though
much improved response rate
 Cisplatin + 5 FU – oral cavity, oropharynx,
nasopharynx, hypopharynx, larynx ca
 3 cycles

27.  Pre CT work up
 History and clinical exam – exclude renal,
cardiac, pulmonary disease
 CBC – Hb, TLC, DLC, platelets
 Urine exam.....
 RFT, LFT – cisplatin/mtx
 Radiology – X Ray chest, CT, MRI, USG
abdomen
 PFT - bleomycin
 ECG - adriamycin
 Audiometry - cisplatin

28.  Response
 Complete response – no evidence of tumour for 4
weeks
 Partial response – 50% tumour regression
 Minor response - < 50% tumour regression
 Stable disease – no tumour regression
 Progressive disease – 25% increase in tumour growth
 Factors affecting response – TNM staging, site, nodal
extension, nutrition, h/o previous surgery, CT, RT

29.  Toxicity
 Stomatitis, alopecia of skin
 Nausea, vomiting
 Diarrhoea
 Bone marrow depression, myelosuppression
 Nephrotoxic – mtx, cisplatin
 Ototoxic – cisplatin
 Neurotoxic – vincristine, vinblastin
 Cardiotoxic – adriamycin (doxorubicin)
 Bladder haemorrhage – cyclophosphamide
 Pulmonary fibrosis - bleomycin

30.  Chemoprevention
 Administration of drugs which inhibit carcinogenesis
or reverse a premalignant condition
 Indications – premalignant lesions, family history,
high risk cases
 Agents
 Retinoids – synthetic and natural analogues of vitamin
A
 Carotenoids – beta carotene, yellow skin
 Vitamin E
 Calcium, selenium, N acetyl cysteine