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Head and Neck Cancers PowerPoint Presentation

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Published on : Feb 24, 2014
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Slide 1 - Head and Neck Cancers Kazumi Chino, M.D. Radiation Oncology
Slide 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
Slide 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
Slide 4 - Histology 90% of H&N cancers are squamous cell carcinomas arising from the mucosal surfaces Salivary gland tumors are typically adenocarcinomas
Slide 5 - Anatomy
Slide 6 - Anatomy: Nasopharynx Eustachian tube Torus Tubaris Fossa of Rosenmuller
Slide 7 - Anatomy: Oro/Hypopharynx From the uvula to hyoid bone Palatine tonsils, tonsillar pillars Base of tongue Epiglottis and vallecula
Slide 8 - Anatomy: Laryngopharynx From the epiglottis to the inferior cricoid cartilage Vocal cords, piriform sinuses, arytenoid cartilage and aryepiglottic folds
Slide 9 - Anatomy: Laryngopharynx
Slide 10 - Cervical Lymph Nodes
Slide 11 - Presentation: Nasopharynx
Slide 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
Slide 13 - Staging: Nasopharynx
Slide 14 - Staging: Nasopharynx
Slide 15 - Staging: Nasopharynx
Slide 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 vs cisplatin 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
Slide 17 - Nasopharynx NCCN Guidelines
Slide 18 - Recurrent or Persistent Dz
Slide 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
Slide 20 - Presentation: Oropharynx Globus sensation Difficultly swallowing Slurred speech Pain in throat or ear Neck mass
Slide 21 - Staging: Oropharynx
Slide 22 - Staging: Hypopharynx
Slide 23 - Staging: Oro/Hypopharynx
Slide 24 - Staging: Oro/Hypopharynx
Slide 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
Slide 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%).
Slide 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
Slide 28 - NCCN Guidelines Orophyarnx
Slide 29 - NCCN Guidelines Oropharyx
Slide 30 - NCCN Guidelines Oropharynx
Slide 31 - NCCN Guidelines Hypophyarnx
Slide 32 - NCCN Guidelines Hypophyarnx
Slide 33 - NCCN Guidelines Hypophyarnx
Slide 34 - NCCN Guidelines Hypopharynx
Slide 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
Slide 36 - Staging: Larynx
Slide 37 - Staging: Larynx
Slide 38 - Staging: Larynx
Slide 39 - Staging: Larynx
Slide 40 - Staging: Larynx
Slide 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)
Slide 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
Slide 43 - NCCN Guidelines Supraglottic Larynx
Slide 44 - NCCN Guidelines Supraglottic Larynx
Slide 45 - NCCN Guidelines Supraglottic Larynx
Slide 46 - NCCN Guidelines Supraglottic Larynx
Slide 47 - NCCN Guidelines Supraglottic Larynx
Slide 48 - NCCN Guidelines Supraglottic Larynx
Slide 49 - NCCN Guidelines Glottic Larynx
Slide 50 - NCCN Guidelines Glottic Larynx
Slide 51 - NCCN Guidelines Glottic Larynx
Slide 52 - NCCN Guidelines Glottic Larynx
Slide 53 - NCCN Guidelines Glottic Larynx
Slide 54 - Overview of Treatment Surgery: First choice when possible, but often limited by disfigurement and preservation of organ function such as speech and swallowing Radiation: Most head and neck cancer is sensitive to radiation while preserving organ function Side effects can be severe; Mucositis, permanent xerostomia, osteoradionecrosis of the mandible, altered taste, weight loss, and tooth decay Chemotherapy: Can have dramatic response to treatment, but is often not a durable response Side effects can also be severe; decreased blood counts, anemia, infections, weight loss, nausea, vomiting, and hair loss Newer targeted therapies have lower side effects
Slide 55 - IMRT
Slide 56 - Recent Advances and Future Directions PET imaging may allow detection of occult LN metastasis negating the need for post-RT neck dissection Sentinel LN bx in the neck is showing use especially in oral cancers IMRT improves SE’s from radiation therapy Taxanes are showing some promise with cisplatin Targeted therapies: phase III trials with zalutumumab and panitumumab, sorafenib (an inhibitor of the intracellular domain of VEGFR, PDGFR and c-Kit) and afatinib (an irreversible inhibitor of pan-HER tyrosine kinase)