Dr. S. C. Joshi Senior Consultant Oncologist and Radiotherapist D/L : +91 1294253115

1. Head and Neck Cancers Management Dr. S. C. Joshi Senior Consultant Oncologist and Radiotherapist D/L : +91 1294253115 Mobile Phone : +919650099151, +919711558463 Email: sanjeev.joshi@aimsindia.co.in scjoshi71@gmail.com

2. Head and Neck Cancers Management Dr. S. C. Joshi Senior Consultant Oncologist and Radiotherapist D/L : +91 1294253115 Mobile Phone : +919650099151, +919711558463 Email: sanjeev.joshi@aimsindia.co.in scjoshi71@gmail.com

3. Epidemiology • Head and neck cancers constitute 5% of all cancers worldwide • 10th most common cancer in the world • World – annual incidence: • 643,000 new cases • Mortality of about 350,000 cases • MC in India– • 15.4 to 110.6 per 100,000 males • 2 to 51.2 per 100,000 females By: Dr.S.C.Joshi

4. Risk Factors • Smoking • Tobacco (Masala, kaini and others) • Viruses - Epstein-Barr Virus, HPV (16, 18) • Environmental/occupational • Exposures of Asbestos, Chromium, Nickel, Arsenic, Formaldehyde • Salted Fish • Ionizing Radiation • Genetic • Immunodeficiency • Poor oral hygiene • Alcohol • Betet nut By: Dr.S.C.Joshi

5. Disease Sites of the Head and Neck • Head and neck cancer may occur in diverse structures and sites: • Lip • Oral cavity • Tongue • Pharynx • Larynx • Nasal cavity • Sinuses By: Dr.S.C.Joshi

6. Mostly Arise in The Nasopharyngeal Axis • Nasal Cavity • Nasopharynx • Oral Cavity • Oropharynx • Larynx • Hypopharynx By: Dr.S.C.Joshi

7. Head and Neck Cancer Often Spreads to Regional Lymph Nodes • Lymph node involvement in up to 30%-50%. By: Dr.S.C.Joshi

8. > 75 % present with advanced disease in developing countries due to the lack of awareness, early intervention and treatment facilities By: Dr.S.C.Joshi

9. Diagnosis • 70%- 80% are diagnosed having locally advanced disease (Stage III and IV) • In the more advanced tumors (stage III and IV) • Local recurrence –up to 50% • Distant metastatic spread (approximately 10%-30%) By: Dr.S.C.Joshi

10. Diagnosis • History • General physical examination & Local ex Oral cavity • Oropharynx (palpation is very important) • Nasopharynx (mirror examination) • Laryngopharynx (indirect laryngoscopy) • Examination of the neck for lymph nodes • Direct laryngoscopy • Biopsy of any suspected areas By: Dr.S.C.Joshi

11. Laboratory Studies • Routine blood counts. • Blood chemistry profile • Urinalysis • Chest radiographs, • Plain radiographs of mandible (Panorex view) • CT Scan / MRI / PET CT By: Dr.S.C.Joshi

12. SurgeryRadiotherapyChemotherapy No substantial change in survival in 25 yrs.

13. Management Guidelines for H & N Cancers Aims • Highest Loco- regional control • Anatomical and functional organ preservation Treatment Principles • Early Stage • Single modality treatment using • Surgery or Radiotherapy • Late Stage • Surgery + Radiotherapy • Concurrent Chemoradiotherapy By: Dr.S.C.Joshi

14. Management Guidelines for H & N Cancers • When different modalities available, one with maximum chance of cure should be used • When different modalities have same results, one offering better quality of life, with organ, function preservation and good cosmetic results should be used By: Dr.S.C.Joshi

15. Surgery v/s Radiotherapy • In treatment of head and neck cancers surgery and radiotherapy produce equivalent results in early stages of carcinoma • In advanced stages of head and neck cancers surgery combined with pre or postoperative radiotherapy By: Dr.S.C.Joshi

16. Improving Efficacy of Treatment • Chemotherapy • Radiotherapy • Dose escalation schedules • Altered Fractionation Schemes • Biological Therapy And Molecular Targeting • Continuous review during treatment By: Dr.S.C.Joshi

17. Chemotherapy • Absolute benefit of Chemotherapy > 30% at 5 years • Higher For Platinum Based Regimens. • Higher doses up to 70 Gy are related with better Loco regional control, however with enhanced acute and long term complications By: Dr.S.C.Joshi

18. Radiation Therapy • Ionizing Radiation • High energy electromagnetic waves in the form of X-rays or gamma-rays • External beam radiation Utilizes LA to generate X-rays to kill cancer cells • Brachytherapy utilizes radioactive substances implanted into tumors. By: Dr.S.C.Joshi

19. How Radiation Works • X-ray photons interact with matter, knocking electrons from the orbital's of atoms • These high energy electrons can either directly damage DNA chemical bonds, or interact with water molecules forming free radicals that then cause DNA damage • Damage to DNA may result in single or double strand breaks which can cause cell death • DNA repair enzymes are more readily activated in healthy cells than in cancer cells By: Dr.S.C.Joshi

20. The Changing Paradigm Conformal radiation IMRT/IGRT/Rapid arc Clinical motivation for high-precision techniques More conformality = Better sparing By: Dr.S.C.Joshi

21. Standard Radiation Techniques (old) • Conventional external beam radiation usually consists of two opposed lateral fields and a matched anterior field that encompass the cancer and lymph nodes in the neck. • Treatment is delivered daily for about 7 weeks. • When this technique developed, physicians used regular X-rays or fluoroscopy to setup these fields. By: Dr.S.C.Joshi

22. CT Based Radiation Planning • With the advent of CT guided planning, a new era in RTP has emerged. • We are now better able to customize our treatment plans to fit the individual patient anatomy By: Dr.S.C.Joshi

23. IMRT – Intensity Modulated Radiation Therapy • In this intensity of the radiation beam in a given treatment field is varied via multiple multi leaf blocking arrangements called segments • Intensity modulation combined with multiple fields (radiation beam angles) or arcs allows for conformal radiotherapy (ie high radiation iso dose lines conform to the target volume and spare normal tissues). By: Dr.S.C.Joshi

24. Intensity Modulated Radiation Therapy (IMRT) • IMRT is an advanced form of 3D-CRT technique in which a computer aided optimisation process is used to determine customised non-uniform intensity distribution through inverse planning to attain certain specified dosimetric and clinical objectives By: Dr.S.C.Joshi

25. Intensity Modulated Radiation Therapy (IMRT) • Multiple beam angles or arcs • Multi-leaf collimator • Accurate patient positioning and immobilization • Physics quality assurance measures • Well trained radiation therapy staff By: Dr.S.C.Joshi

26. Multi-leaf Collimator • The multi-leaf collimator is inside the linear accelerator. • It is comprised of multiple 1 cm thick metal radiation blocks each driven by an independent motor and controlled by a central computer. • The multi-leaf collimator allows for multiple blocking patterns in each radiation field which in turn allows for intensity modulation of the radiation dose. By: Dr.S.C.Joshi

27. Immobilization By: Dr.S.C.Joshi

28. Head and Neck Immobilization Devices • 3 Clamp • 4 Clamp • 5 Clamp • Random Errors with different Fixation devices By: Dr.S.C.Joshi Radiotherapy Oncology,2001

29. Time Interval • Importance of the time interval between surgery and postoperative RT in the combined management of head and neck cancers • PORT within 6-7 weeks / later • LRC : 70% (PORT within 7 weeks) >27% (PORT more than 7 weeks) • Therefore patient must be seen by oncologist immediately after surgery and HPE report. By: Dr.S.C.Joshi Bhadrasain V,IJROBP,1979

30. Isodose Distribution of an IMRT Plan By: Dr.S.C.Joshi

31. IMRT - Hypopharynx By: Dr.S.C.Joshi

32. IGRT – Image Guided Radiation Therapy • Daily X-rays or CT scansAre done and overlaidwith the planning CT • Millimeter adjustments are made with automatic couch position shifts • Treatment becomes more accurate and consequently smaller target volumes will result in less side effects By: Dr.S.C.Joshi

33. IGRT – MV X-rays By: Dr.S.C.Joshi

34. IGRT – kV X-rays By: Dr.S.C.Joshi

35. IGRT – Cone Beam CT (CBCT) By: Dr.S.C.Joshi

36. IGRT - CBCT By: Dr.S.C.Joshi

37. Rapid arc cases By: Dr.S.C.Joshi

39. Rapid arc cases By: Dr.S.C.Joshi

40. Rapid arc cases

41. In Developing World • Infectious diseases are the main killers • Patients present in an advanced stage • Fund allocation to health is less than that of developed countries • No or poor social health security system • Geographic clustering of facilities to urban areas • Linear accelerators are expensive, with high operational costs. • High precision facilities available in only selected centers. By: Dr.S.C.Joshi

42. How to Optimize Treatment for Developing Countries?

43. Optimization of Treatment • Prompt treatment in a good referral centre • Optimal Infrastructure support required for implementation of CTRT/AFRT schedules • Avoidance of Treatment Breaks • Integration of Chemotherapy • Integration of high-precision technique • Good Nutritional Support. • Affordable cost By: Dr.S.C.Joshi

44. Our Oncology Facilities • Linear accelerator from Varian trilogy with rapid arc • Brachytherapy • Chemotherapy • Daycare facilities for out patient’s and isolation wards • Complete nuclear medicine with Radionuclide Therapy • Palliative care • Cancer screening • Cancer awareness program By: Dr.S.C.Joshi

45. Radiotherapy Team • Consultant Oncologist • Medical Physicist • Radiation Therapist • Radiation Therapist Aide By: Dr.S.C.Joshi

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48. Linac Room By: Dr.S.C.Joshi

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