Professional Documents
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Genetic factors
– Strong association with HLA Class 1 genes
Etiology
Environmental factor
– High consumption of salted fish – Dimethyl
nitrosamine
• Formaldehyde
• Tobacco smoking
• Wood dust
• Epstein Barr Virus (EBV)
– Particularly non-keratinising type
Anatomy
Natural History
Local Spread
Sphenoid sinus
Cavernous Sinus
• Neck mass
• Nerve deficits
Workup
• Proper history and clinical examination
– Head and neck examination
– Complete CNS examination
– Mirror examination
• Routine
– Laboratory studies
– Chest Radiograph(PA+lateral)
Diagnostic workup
• Biopsy
(direct visualisation/Fiberoptic
endoscopy/exmn anaesthesia)
• FNAC of neck mass
• Absence of visible mass
– Pharyngeal recess(Fossa of
Rosenmuller) on each of the lateral
wall
– Supero posterior wall
b - Undifferentiated
3. Basaloid squamous cell carcinoma
• Rare histologies
– Lymphoma 5%
– Adenocarcinoma
– Plasmocytoma
– Melanoma
– Sarcoma
Prognostic factors
• Locoregional extent of disease
– T stage
– N stage
– Parapharyngeal extension
– Prevertebral space involvement
• GTV-P
• Histology
Radiotherapy alone
• T1N0M0
Phase I
• RT to the primary tumor
and upper neck nodes in
one volume – 2 lateral
fields
• Lower neck by single AP
field
• Continued upto 40- 44Gy
Phase II
• RT to the primary by 2 lateral
fields
• Or by 2 lateral fields and a
matching anterior field
Phase III
• Boost to the gross disease
3DCRT
3DCRT
• Better LC and OS
Jen et al
• T4 control (86% vs 47%)
• Xerostomia (69.2% vs 98%)
• No significant improvement in late toxicities
IMRT
• Supplanted conventional technique
Typical plans
• 70 Gy to Gross disease
• 59.4 Gy to high risk subclinical disease
• 54 Gy to low risk
• TMC – 66 Gy in 30 #
• <42 days - Tumour Repopulation
IMRT - contd
• Recurrent disease
TREATMENT PLANNING - TMC
Sequelae to RT
Temporal lobe necrosis
• Late complication
• Classical symptoms - hallucinations, absence
attacks, déjà vu
• Other symptoms – headache, confusion,
convulsions, hemipareisis
• Accounts for up to 65% of radiation related
deaths
• 1-3% with conventional RT
• 12% with hypofractionated IMRT
Sequelae - contd
Cranial neuropathy
• Nerves IX to XII
• Slurring of speech, dysphagia, twitching of
neck muscles
• Radiation induced fibrsosis
• Parapharyngeal boost
• Rarely nerve VI, V also
Sequelae - contd
Xerostomia
• Accompanied by dental sequelae
• Lower rates with IMRT
Aural toxicity
• Cisplatin based chemotherpay
• SNHL with mean cohclear dose > 48 Gy
• Pharyngotympanic tube damage
Sequelae - contd
Endocrine dysfunction
• Hyperprolactinemia
• Hypothyroidism
• Hypoadrenalism
Second malignancy
• Maxillary osteosarcoma and soft tissue
sarcoma
• Surgery – only chance of cure
Follow up
History and physical examination
– 1 to 3 months the first year after treatment
– 2 to 6 months the second year
– 4 to 8 months 3 to 5 years
– Every year thereafter
With
✓ Imaging every 6 months
✓ Thyroid function testing every 6 to 12 months
✓ Speech and swallowing evaluation.
✓ Post treatment plasma EBV DNA surveillance if
facilities available
• Cranial nerve palsies 6 months post Rx
– The complete recovery rate was 51%
– Partial recovery rate was 19%
– Worst for 7, 12th CN
– Best for 2, 9, 11th CN
• Patient usually assessed after 6 weeks
• Residual disease after 8 weeks – persistent
• Persistent disease – boost
– Brachytherapy
– IMRT
– SRT
– EBRT
• Persistent nodal disease
– Electron boost
– Neck dissection
Results of treatment
• 5 yr local control rate with conventional
radiation
T1 – 76 to 90% N0 – 82 to 100%
T2 – 75 to 85% N1 – 70 to 92%
T3 – 60 to 70% N2 – 42 to 70%
T4 – 40 to 60% N3 – 32 to 52%
• 5 yr distant metastases rates – 10, 20, 30, 50% for
T1,2,3,4 respectively
Salvage irradiation
• Local relapse at a median period of 3 years
post RT
• Reirradiation requires atleast 60 Gy
– 2D EBRT ± brachytherapy boost/3DCRT boost
– IMRT
• Late toxicities were high
• Local control better with SRS>IMRT>EBRT+BT
Role of brachytherapy
• Intracavitary or interstitial implants
Rotterdam applicator
Role of brachytherapy
▪ Routine boost to the primary site in T1-3
lesions after EBRT
– Earlier studies – showed benefit
– Boost post CCRT showed no improvement in local
control
▪ Residual disease
▪ Recurrrent disease
Role of SRT
▪ SRT boost 7 to 12 Gy foll 66 Gy by EBRT
- Excellent LC of 98% included T1-4
▪ Persistent disease
▪ Recurrent disease
- Thank you