Head and Neck cases for radiotherapy in Sri Lanka

About head and neck radiotherapy in Sri lanka

1. Symposium 05- Evolving paradigms of Head and neck cancer Treatment Sri Lanka college of oncologists - Annual academic sessions

2. Case 1 65 Year old Lady R tongue Non healing ulcer CECT H&N: 2*2*1.5 cm enhancing lesion, No abnormal lymph nodes Biopsy Squamous cell Carcinoma How to proceed

3. Decisions individualised but usually: Surgery ± adjuvant radiotherapy ± chemo Surgery = removal of primary tm reconstruction and neck dissection Management of oral cavity

4. Neck needs to be electively treated for all but v. early lesions of oral cavity >4mm depth for tongue and 1.5mm for FOM confers increased LN risk Unilateral or bilateral guided by laterality of lesion Usually selective neck dissection eg. levels I-III, I-IVa Management of neck

5. Case 1 She underwent left lateral tongue resection and ipsi-lateral neck dissection Pat hology reported as Mod differentiated SCC, Maximum tumour size - 19 mm, depth of invasion 6 mm, peri-neural involvement - Negative , LVI (-), surgical margin more than 5 mm , LN (Level I - 0/3, Level II – 0/4 , Level 3 0/2 ) TNM7 PT1N0Mo TNM8 pT2N0M0

6. Staging of oral cavity

7. Oral cavity – Depth of Invasion DOI

8. Management of T1-T2 oral cavity

9. • cT3-4a (if no adverse factors are present and pN0,some patients may be spared). • cN2a-3. • Close surgical margins. • Peri-neural invasion. Indications for adjuvant radiotherapy

10. Management of oral cavity

11. Case 1 She was offered follow up , However she defaulted follow up and presented with R tongue mass and Grade 2 Trismus CECT report: Irregular enhancing mass lesion in right tongue 4.2cm(AP) * 2.4 cm(TR)* 3.3cm ( depth) in size Crosses midline Invades the intrincic muscle below in to the right mylohyoid muscle. Invasion into the medial pterigoid muscle is seen superiorly No adjacent bone erosion seen in the mandible No abnormal ipsilateral lymph nodes Two level 1 contralateral nodes seen 0.5 SAD FOL : lesion invading in to the oropharynx

12. Case 1 Operability / MDT - Inoperable tumour Offered radical chemo radiotherapy Weekly vs 3 weekly Cisplatin High dose CTV ( 65Gy): GTV + 0.5 Intermediate dose ( 60 Gy) : GTV +1 , R Level 1-3, Low dose (54Gy ): Left Level 1-4, R level 4 Vs two dose levels

13. Case 2 62-year-old retired teacher Smoking History: 30 pack-years (quit 5 years ago) Alcohol Use: Social drinker Presents With: Progressive hoarseness over 4 months Difficulty swallowing (dysphagia) Mild shortness of breath Physical Exam Findings: Hoarseness of voice No palpable cervical lymphadenopathy

14. Diagnostic Work-up Contrast-enhanced CT: Enhancing mass (2.5 cm) localized to the left vocal cord. No cartilage invasion or extralaryngeal spread. No lymph node enlargement (N0) or distant metastasis (M0). Direct Laryngoscopy & Biopsy: Confirmed squamous cell carcinoma (Stage T2N0M0).

15. Initial Treatment Radical Radiotherapy: 6 weeks, 65 Gy in 30 fractions Complete response post-treatment (confirmed by Post treatment CECT and Laryngoscopy)

16. Recurrence (1.5 Years Later) Symptoms: New onset of hoarseness and dysphagia. Imaging Findings: CT/PET-CT: Recurrent lesion in the glottis, no distant metastasis. Biopsy: Reconfirmed recurrent squamous cell carcinoma

17. Salvage Surgery Procedure: Total laryngectomy with neck dissection. Pathology Report: Recurrent moderately differentiated squamous cell carcinoma (2.8 cm). Proximal margin positive (subglottic area). Lateral and distal margins negative . No lymph node involvement (0/12 nodes). No perineural or lymphovascular invasion

18. Post-Surgery: Re-Irradiation Adjuvant Therapy: Re-irradiation offered due to positive proximal margins . 60 Gy in 40 fractions over 4 weeks, twice day fractionations.

19. Residual Disease (3 Months Post-Re-Irradiation) Symptoms: Persistent hoarseness and mild dysphagia. Imaging and Biopsy: PET-CT showed persistent uptake in the glottis. Biopsy confirmed residual/recurrent squamous cell carcinoma at proximal margin

20. Prognosis & Treatment Options Prognosis: Poor, due to early recurrence post-re-irradiation and salvage surgery. Options Discussed: Palliative chemotherapy (cisplatin-based) Immunotherapy (PD-1/PD-L1 inhibitors