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Tumor Board Conference

Case Presentation. Pt is a 64 yo female, smoker, presented with c/o difficulty in swallowing for 6 weeks; felt something in the right side of throat when she swallowed; also, c/o rt. ear pain, sore throat and dysphagia for meat; no wt. loss or voice changePMH: Hypothyroidism, COPD, anxietyPSH: CS

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Tumor Board Conference

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    1. Tumor Board Conference Sanjay Munireddy Sinai Hospital of Baltimore June 24, 2008

    2. Case Presentation Pt is a 64 yo female, smoker, presented with c/o difficulty in swallowing for 6 weeks; felt something in the right side of throat when she swallowed; also, c/o rt. ear pain, sore throat and dysphagia for meat; no wt. loss or voice change PMH: Hypothyroidism, COPD, anxiety PSH: CS x 3, TAH/BSO MEDS: Synthroid, xanax

    3. Case Presentation Social Hx: 45 pack-years smoking, Alcohol in the past PE: level III group of LNs enlarged with the largest LN about 3 cm Work-up: Laryngoscopy: showed supraglottic tumor, ulcerated, friable; biopsy showed squamous cell carcinoma CT/PET: showed lesion in rt. vocal cord and rt neck lymphadenopathy

    4. Case Presentation A/P: Supraglottic squamous cell carcinoma with LN metastases (T3N2Mx) MRND followed by chemotherapy and radiation therapy

    5. Case Presentation Operative Procedure Direct pharyngolaryngoscopy Rt. MRND PEG placement Mediport placement

    6. Head and Neck Cancer Encompasses epithelial malignancies that arise in the paranasal sinuses, nasal cavity, oral cavity, pharynx and larynx Almost all of these are squamous cell carcinoma of the head and neck (SCCHN) Risk factors: tobacco, alcohol, HPV-16

    7. Head and Neck Cancer Median age for diagnosis is early 60’s, with a male predominance 2/3rds of patients present with advanced stage disease, commonly involving regional lymph nodes

    8. Head and Neck Cancer Symptoms of presentation Lump or sore that does not heal Sore throat that does not go away Difficulty swallowing Change or hoarseness in the voice Ear pain, tongue pain, mouth ulcer, cough, stridor, mouth bleeding Signs Mass or ulceration in oral cavity or oropharynx, neck mass, vocal cord paralysis, swallowing dysfunction

    9. TNM Staging of SCCHNN

    10. Neck Metastases Powerful adverse prognostic feature Reduces survival by 50% in pts with neck nodal metastases

    11. Should N2 disease be treated with surgery first followed by CRT vs CRT first followed by surgery

    12. CRT followed by surgery Concurrent CRT followed by planned neck dissection (ND) Controversial Pts with initial N1 necks do not require ND, unless there is clinical evidence of persistent palpable disease after CRT Pts with N2-N3 necks on presentation are often considered for ND after CRT regardless of the response to treatment

    13. CRT followed by surgery Pts with complete response (CR) in neck are highly unlikely to experience a recurrence in neck after CRT CR in neck to CRT may indicate that ND is not necessary to achieve local control and improved disease-free survival

    14. CRT followed by surgery Although pts undergoing ND after CRT had a statistically improved loco-regional progression-free survival, no impact on overall survival was found No survival benefit was found for those N2 pts who underwent an ND after achieving a cCR-neck after CRT

    15. CRT followed by surgery Pts who had a cCR in neck and who did not have ND had worse disease-free and overall survival than those who had ND Clinical/radiologic response in neck is at best a crude predictor of pathologic response ND is needed in every pt with N2-N3 after CRT

    16. CRT followed by surgery Advantages Better loco-regional control Many pts are able to avoid extirpative surgery and are able to maintain quality of life1

    17. CRT followed by surgery Disadvantages Rate of neck control is poorer esp. in bulky node disease Detection of recurrence is more difficult and delayed because of fibrosis by both high dose of RT and fibrous reaction in and about neck node Salvage surgery is not often successful after a failure of RT and is attended by a high incidence of wound complications (26-35%) Carcini et al J Cr Facial Surg 2001,12(5):438-443

    18. Surgery followed by CRT Significant decrease in survival in pts who had a delay of more than 2 weeks b/w neck dissection and RT2 Timing of RT after ND; delays longer than 4 weeks are unacceptable

    19. Surgery followed by CRT Advantages May avoid the need for salvage neck surgery in a previously irradiated filed Decreases the morbidity associated with post-radiation surgery May by-pass the difficulty associated with early detection of persistent or recurrent neck disease in pts with indurated, fibrotic neck tissue

    20. Surgery followed by CRT Disadvantages Increased seeding of the wound with tumor cells Potential delay in definitive radiation treatment to the primary site

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