Head and Neck Cancers PowerPoint Presentation

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

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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

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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

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

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Anatomy

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Anatomy: Nasopharynx Eustachian tube Torus Tubaris Fossa of Rosenmuller

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

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

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Anatomy: Laryngopharynx

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Cervical Lymph Nodes

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Presentation: Nasopharynx

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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

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Staging: Nasopharynx

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Staging: Nasopharynx

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Staging: Nasopharynx

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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

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Nasopharynx NCCN Guidelines

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Recurrent or Persistent Dz

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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

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

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Staging: Oropharynx

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Staging: Hypopharynx

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Staging: Oro/Hypopharynx

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Staging: Oro/Hypopharynx

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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

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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%).

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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

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NCCN Guidelines Orophyarnx

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NCCN Guidelines Oropharyx

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NCCN Guidelines Oropharynx

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NCCN Guidelines Hypophyarnx

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NCCN Guidelines Hypophyarnx

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NCCN Guidelines Hypophyarnx

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NCCN Guidelines Hypopharynx

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

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Staging: Larynx

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Staging: Larynx

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Staging: Larynx

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Staging: Larynx

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Staging: Larynx

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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)

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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

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NCCN Guidelines Supraglottic Larynx

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NCCN Guidelines Supraglottic Larynx

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NCCN Guidelines Supraglottic Larynx

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NCCN Guidelines Supraglottic Larynx

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NCCN Guidelines Supraglottic Larynx

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NCCN Guidelines Supraglottic Larynx

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NCCN Guidelines Glottic Larynx

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NCCN Guidelines Glottic Larynx

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NCCN Guidelines Glottic Larynx

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NCCN Guidelines Glottic Larynx

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NCCN Guidelines Glottic Larynx

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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

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IMRT

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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)