Head & Neck Malignancy how to handle the emerging killer.pptx

head and neck malignacy a emerging killer , the recent updates for general physicians

1. Head & Neck Malignancy: How to Handle theEmerging Killer DR SUMITAVA DE, ASSO PROFESSOR & CLINICAL ONCOLOGIST, NRS MEDICAL COLLEGE & HOSPITAL

2. Bac k g roun d In India, the number of cancer cases is rising. According to GLOBOCAN 2020, there will be 2.1 million new cancer cases in India by 2040, an increase of 57.5% from the year 2020. Head and neck cancer being 30 % of the all-cancer cases  . The all-site cancer incidence rate( ASIR) for HNC was 25.9 (95% CI 25.7–26.1) and 8.0 (95% CI 7.9–8.1) per 100,000 population for males and females, respectively. The age-standardised mortality rate of HNC in India for males and females is 14.2 and 4.1 per 100,000 population, respectively

3. Histology of oral cavity Cell lining – Squamous epithelium with minor salivary gland 90 – 95% - Squamous cell carcinoma 5 – 10% - Lymphoma, Malignant melanoma, BCC, Adenocarcinoma, etc.

4. Risk factor Alcohol Tobacco Betel quid Poor oral hygiene, Unfit denture Virus esp. HPV strain 16, EBV Sun exposure Vitamin deficiency , Male sex and old age Synergistic effect

5. Importance of early diagnosis and treatment The   outcome of oral cancer  is best when it’s diagnosed and treated early. When oral cancer remains localized to the mouth, its 5-year survival rate is  86.3% However,  about 70%  of oral cancers are diagnosed when they’ve already spread regionally or distantly. The 5-year survival rates for these cancers are  69% and 40.4% , respectively. Because of this, early detection and treatment of oral cancer is vital.

6. Clinical manifestation Early manifestation Patches inside mouth or lip Leukoplakia Erythroplakia Nonhealing ulcer Contact bleeding at ulcer Indurated mass Difficulty or pain when swallowing Earache due to referred pain

7. Clinical manifestation

8. Places to examine during oral check up O utside and inside of the lips I nsides of both cheeks The gums S ides, top, and bottom of tongue roof and floor of mouth back of your throat lymph nodes in the neck

9. Clinical manifestation Late manifestation due to direct invasion & regional node involvement Loose teeth Limitation of tongue movement Numbness at mentum Trismus L y m p h a d en o pa t h y

10. Clinical manifestation Late manifestation due to distant organ metastases Bone metas. Pulmonary metas. Liver metas. Etc.

11. Preoperative evaluation Computer tomography : Evaluation Primary lesion Lymph node Distant metastases 2 nd primary cancer : In neck node Accuracy = 52.6% Sensitivity = 21.6% Specificity = 78% Can’t replace SOHND in clinical node negative pt. Original report, Journal of clinical oncology, V o l .24, No 27, Se p 2006.

12. Preoperative evaluation PET/CT In evaluation of T-stage increase sensitivity in detect primary tumor ; T1 lesion – false negative 3.2% ; T2 lesion – false negative 9.2% useful in pt. with neck node metas., unknown primary In evaluation of direct invasion Most reliable in detect bony invasion, metas. Original report, Journal of clinical oncology, Vol.24, No 27, Sep 2006.

13. Preoperative evaluation PET/CT In evaluation of N-stage Increase sensitivity in detect LN compare with CT – 57% (41.2% : 21.6%) Accuracy – 63% Specificity – 76% False negative 14 - 33% Can’t replace SOHND in clinical negative pt. Original report, Journal of clinical oncology, Vol.24, No 27, Sep 2006.

14. Stag i n g

15. Staging of oral cavity cancer T4 - Tumor invades through cortical bone , inferior alveolar nerve , floor of mouth , or skin of face ( ie , chin or nose ) T4a - Tumor invades adjacent structures ( eg , through cortical bone , into deep [ extrinsic ] muscle of tongue [ genioglossus , hyoglossus , palatoglossus , and styloglossus ], maxillary sinus , skin of face ) - Resectable T4b - Tumor invades masticator space , pterygoid plates , or skull base and / or encases internal carotid artery - Unresectable

16. Principle of treatment Objective Cure of disease Maintain function & contour Minimize complication Maximum quality of life Prevention of recurrence Multidisciplinary Team

17. Principle of treatment Modality of treatment Surgery Radiation Lifestyle M o d i f i c a t io n + + Chemotherapy +

18. Grouping of oral cavity cancer Oral cavity cancer Early stage Locally advanced Advanced disease Stage I & II (T 1-2 , N ) Resectable (Stage III & IVA & some IVB) U nr e s e c ta b le (T 4b disease) Metastatic disease (Stage IVC)

19. Grouping of oral cavity cancer Early stage Surgery is effective as Radiation Rx depend on tumor & patient factor Locally advanced Require combined treatment Resectable – Surgery + Radiation +/- CMT Unresectable – concurrent Chemoradiation Advanced Palliative & Supportive treatment

20. Indication for adjuvant radiation Tumor status T 3 &T 4 lesion Positive margin An gio l y m p h a ti c invasion Perineural invasion Poorly differentiation Nodal status At least N 2 disease N 1 with extranodal extension Prior node biopsy

21. Indication for adjuvant chemoradiation Major criteria Positive margin Extranodal extension Minor criteria T 3 &T 4 lesion An gio l y m p h a ti c invasion Perineural invasion Poorly differentiation Advanced nodal level metastases

22. O u tl in e Role of surgeon Management of the positive margin Management of the neck clinical node negative clinical node positive recurrent neck

23. Team Approach Surgeon Radiotherapist Medical oncologist Dentist/maxillofacial prosthedontist Anesthetist/pain control specialist Physiotherapist/speech therapist Dietitian Nursing staff

24. Indications for Multidisciplinary treatment T stage Higher T stage (III-IV) Positive margin Omnious pathologic feature N stage Higher risk of micrometas. in N neck Multiple nodal metas. (N 2b ) Massive nodal metas. Extranodal spread

25. Indications for Multidisciplinary treatment (cont.) M stage Higher risk of distant metas. (>T 3 or >N 1 ) Distant metastases

26. Patterns of failure in patients that failed treatment for cancer of the oral cavity Treatment failure in 171/595 patients (29%)

27. Cancer Recurrence in the Neck Poor prognosis Biologically more aggressive Host factors Treatment factors Initial therapy inadequate/inappropriate Loss of natural tissue barriers Reduced therapeutic options Reduced tissue perfusion 1 st opportunity for cure is the best

28. Therapeutic Options Surgery Rese c t ab le ? Morbidity? Irradiation External beam vs brachytherapy Previous irradiation? If yes: When? Portals? Dose? Tissue damage? Chemotherapy Biologic therapy

29. Prior Irradiation Affects dose, portals and method of adjuvant radiation Brachytherapy for residual tumor Improved locoregional control Spares normal tissue Determine strategy before surgery May affect extent of surgery Placement of brachytherapy catheters Resurfacing of neck with flaps

30. Thanks for your attention