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Head and Neck Cancers
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Head and Neck Cancers

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  1. Head and Neck Cancers Kazumi Chino, M.D. Radiation Oncology

  2. Epidemiology • 52,000 people diagnosed in the US annually • 3% of all cancers in the US • Men are twice as likely as women to develop a head and neck cancer • Dx is most common after age 50

  3. Risk Factors • Tobacco – approx. 85% of H&N Ca related to tobacco • Alcohol • HPV in oropharyngeal cancers • Epstein-Barr virus in nasopharyngeal cancers • Poor dental/oral hygiene • Poor nutrition – vit A and B deficiency • GERD in pharyngeal cancers

  4. Histology • 90% of H&N cancers are squamous cell carcinomas arising from the mucosal surfaces • Salivary gland tumors are typically adenocarcinomas

  5. Anatomy

  6. Anatomy: Nasopharynx • Eustachian tube • Torus Tubaris • Fossa of Rosenmuller

  7. Anatomy: Oro/Hypopharynx • From the uvula to hyoid bone • Palatine tonsils, tonsillar pillars • Base of tongue • Epiglottis and vallecula

  8. Anatomy: Laryngopharynx • From the epiglottis to the inferior cricoid cartilage • Vocal cords, piriform sinuses, arytenoid cartilage and aryepiglottic folds

  9. Anatomy: Laryngopharynx

  10. Cervical Lymph Nodes

  11. Presentation: Nasopharynx

  12. Nasopharyngeal Cancer Sx’s • Nasal obstruction, bleeding, discharge • Hearing problems if eustachian tube obstructed, otitis media • Headaches • Cranial nerve palsy with involvement of the base of skull • Neck mass, particularly at the mastoid tip

  13. Staging: Nasopharynx

  14. Staging: Nasopharynx

  15. Staging: Nasopharynx

  16. Tx & Prognosis: Nasopharynx • Stage I/II tx’d RT alone: local control rates at 5 years for T1= 93%, T2 = 79%, T3 = 68% and T4 = 53% • Intergroup 0099 compared RT alone vscisplatin 100mg/ms day 1, 22, 43 + RT for Stage III/IV • 3 yr progression free survival was 24% vs 69% in favor of concurrent chemo/RT • 3 yr overall survival was 47% compared to 78% in favor or concurrent chemo/RT • Similar trial JCO 2005 showed OS 65%  80% with chemo

  17. Nasopharynx NCCN Guidelines

  18. Recurrent or Persistent Dz

  19. Prognosis: Nasopharnx • Keratinizing squamous cell carcinoma has a higher risk of local recurrence after tx than non-keratinizing SCCa or undifferentiated • High EBV DNA titers after tx are associated with an increased risk of recurrence

  20. Presentation: Oropharynx • Globus sensation • Difficultly swallowing • Slurred speech • Pain in throat or ear • Neck mass

  21. Staging: Oropharynx

  22. Staging: Hypopharynx

  23. Staging: Oro/Hypopharynx

  24. Staging: Oro/Hypopharynx

  25. Tx & Prognosis: Oro/Hypopharynx • RTOG 73-03 randomized advanced oropharyngeal tumors to surgery with or without post-op RT • Post-op RT better LRC (48 vs 65%) & OS (26% vs 38%) • RTOG 90-03 and EORTC studies on locally advanced H&N Ca’s (excluding NPX) showed improved LC with concomitant boost with RT

  26. Tx & Prognosis: Oro/Hypopharynx • GORTEC 94-01 (JCO 2004) for Stage III/IV showed benefit of 3 cycles carboplatin/5-FU + RT vs RT alone • Chemo-RT improved LC (25 vs 48%), DFS (15 vs 27%) OS (16 vs 23%) • Intergroup Trial (JCO 2003) and Duke trials (NEJM 1998) showed similar benefit for cisplatin +/- 5FU • Bonner (NEJM 2006) showed benefit of cetuximab with RT over RT alone • Cetuximab increased 3 yr LRC (34 vs 47%) OS (45 vs 55%).

  27. Tx & Prognosis: Oro/Hypopharnx • EORTC 22931 Stage III/IV operable H&N Ca’s (excluding NPX) pT3-4 N0/+ Tl­-2N2-3, or Tl-2 N0-1 with ECE, + margin, or PNI randomized to post-op cisplatin 100mg/ms days 1, 11, 43 + RT vs RT alone • Chemo­RT improved 3/5 yr DFS (41/36 vs 59/47%) OS (49/40 vs 65/53%) 5yr LRC (69 vs 82%) • RTOG 95-01 operable H&N cancer who had > 2 LN, ECE, or + margin randomized to RT vs RT + cisplatin • Chemo-RT improved 2yr DFS (43 vs 54%), LRC (72 vs 82%)& trend for improved OS (57 vs 63%) • No difference in distant mets for either study

  28. NCCN Guidelines Orophyarnx

  29. NCCN Guidelines Oropharyx

  30. NCCN Guidelines Oropharynx

  31. NCCN Guidelines Hypophyarnx

  32. NCCN Guidelines Hypophyarnx

  33. NCCN Guidelines Hypophyarnx

  34. NCCN Guidelines Hypopharynx

  35. Presentation: Larynx • Hoarse voice • Stridor • Cough, hx of GERD • Trouble swallowing • For glottic tumors • T1-2 5% LN involvement • T3-4 20% LN involvement

  36. Staging: Larynx

  37. Staging: Larynx

  38. Staging: Larynx

  39. Staging: Larynx

  40. Staging: Larynx

  41. Tx & Prognosis: Larynx • Stage I tx’d with RT with salvage surgery if needed: 5 yr OS 80-98% • Stage II tx’d with RT with salvage surgery: 5 yr OS 68-93% • VA Laryngeal Trial: Stage III/IV laryngeal tumors randomized to surgery + post-op RT vs induction chemo with cisplatin/5FU followed by RT • 2 yr OS was 68% for both groups • Laryngeal preservation rate was 64% (36% in the chemo/RT group required salvage laryngectomy)

  42. Tx & Prognosis: Larynx • RTOG 91-11 compared RT alone vs sequential chemo/RT vs concurrent chemo + RT • LRC 56% RT alone, 61% sequential, 78% concurrent • Decreased distant mets with chemo • Bonner trial for cetuximab included laryngeal tumors as well • RTOG 95-01 and EORTC 22931 for post-op chemoRT included laryngeal tumors • Benefit for > 2LN, T3-4, + ECE, + margins

  43. NCCN Guidelines Supraglottic Larynx

  44. NCCN Guidelines Supraglottic Larynx

  45. NCCN Guidelines Supraglottic Larynx

  46. NCCN Guidelines Supraglottic Larynx

  47. NCCN Guidelines Supraglottic Larynx

  48. NCCN Guidelines Supraglottic Larynx

  49. NCCN Guidelines Glottic Larynx

  50. NCCN Guidelines Glottic Larynx