Pyriform sinus tumours principles of management

PRINCIPLES OF MANAGEMENT OF PFS TUMOURS

1. PYRIFORM SINUS TUMOURS PRINCIPLES OF MANAGEMENT DR.ROOHIA

2. The goals of treatment for this patient population are: (1) cure with preservation of function (2) palliation with minimal morbidity

3. Factors Affecting Choice of Treatment Age: pts above the age of 75yrs hv poor prognosis due to their general poor condition surviaval rate is about 10% comparable to others . Associated Medical Conditions should be included when considering treatment options Eligibility criteria for investigational nonsurgical chemoradiation protocols include adequate performance status as well as reasonable hematologic, hepatic, renal and cardiovascular function

4. Past Medical/Surgical History previous exposure to platinum compounds makes significant responses less likely. Repeat external irradiation or brachytherapy are poor options for patients who have received prior radiotherapy to the head and neck

5. TNM Staging, Quality of life

6. NTPL/TOTAL LP with Neck dissection +post op RT T4;N0/N+

7. Radiotherapy Radiotherapy as a single treatment modality for early (T1-T2) pyriform sinus carcinoma(curative RT)  The rates of local control decrease in bulky T2 lesions, in those larger than 2.5 cm, and in those extending to the apex of the pyriform sinus.  Better results in terms of local control are observed in patients with favorable T2 lesions characterized by exophytic tumor , good airway, normal cord mobility, and uninvolved apex. 

8. Conventionally fractionated radiotherapy employing total doses of 60-70 Gy in 30-35 fractions,(2Gy/fraction) over 6-7 weeks Accelerated fraction RT : same dose given over shorter period HyPer fraction RT : traditional dose broken into smaller fractions over same time Prevents repopulation of tumour Decrese duration of treatment and hos stay

9. In too advanced disease,distant metastasis,poor condition for sugery palliative RT . Dose depends on extent &tolerance of tissues. If RT alone- can be delivered with external beam or brachytherapy or both

10. Combined RT with surgery or CT Preop RT: poorly oxygenated cells are much less susceptible to irradiation than oxygenated cells

11. Indications for post- oP radiotherapy

12. POST OP RT: Identification of tumour extent more accurate Technical performance easier in tissue planes have not been altered by fibrosi,fusions,increased vascularity due to RT. Results are poor if delayed beyond 6 wks Minimum tumour dose 50-60Gy daily fractions 2Gy to whole operative bed with boost 63Gy to sites of increased risk. DFS- 2yrs -74% Over all survival 5yrs -31%(RTOG)

13. RT to nodes : >3cm nodes oor response to RT 53-83% response rste seen in nodal involvement N0,N1- cotrol with RT N2,N3- needs CT/RT if clinically radiologically incomplete resonse then surgery. If neck dissetion lanned after 4-6wks of RT then dose can be reduced frm 70 to 50Gy. Involvement of low level nodes –needs reduction in dose to avoid damage to brachial plexus

14. Advances in RT: Ct based high precision RT IMRT IGRT Advantage increased QOL Eg : decreased dose to arotid gland –saliva flow preserved- xerostomia reduced

15. Common acute & late toxicities of radiation

16. CHEMOTHERAPY Goals of organ preservation : Maintainance of oral alimentation Protection of laryngeal airway Intelligible laryngeal speech

17. Chemotherapy Role of chemotherapy is mainly as combination or for palliation Neoadjuvant chemotherapy followed by R T (The Veteran’s Affairs study) CT given before surgery/ RT.more efficient drug delivery can occur. A)CT responders well respond to RT B)CT response downstage disease may allow RT effective C)CT may reduce incidence of distance metastasis when local disease well controlled Laryngeal preservation 62% Overall survival35%

18. Concurrent chemo-RT (RTOG)(T3/T4) RT &CT used simultaneously in uresectable disease. 3arm study 1) neoadjuvant CT(cisplatin+5FU) followed by RT. 2)RT with concurrent CT(cisplatin100mg/m2 on 1,22,43 days) 3)RT alone Excluded T4 those cartilage eroded,inavde tongue

19. Resultsat A)2 yr intact larynx in 88% RT+concurrent CT 75% neoadjuvant CT followed RT 70% RT alone B) Locoregional control 78%,61%,56% C)Distant metastasis suressed inCT based regeme …. Over all survival rate is same D) High-grade toxic effects greater with CT Based regeme E)Mucosal toxicity concurrent RT+cisplatin higher

20. Adjuvant CT: CT after surgery or RT goal of this secondary treatment is palliation &rarely has longterm benefits. Induction CT+ concurrent chemoRT : Addition of taxane tomcisplatin ,5FU under study to imrove survival outcomes.

21. Commonly used CT agents in pyriform sinus tumours Cis platinum: Inorganic metal comound binds to DNA causes inter or intra strands cross linking Dose:80-120mg/m2 every 3-4wkly with mannitol diuresis . 5FU: Competes with enzyme thymidylate synthetase,inhibiting tymidine formation decrese in DNA synthesis. Dose:10-15mg/kg/wk 400-500mg/m2 daily for 5days IV as loading dose followed by 400-500mg/m2 wkly IV.OR

22. Side effects of chemotherapy

23. TAXANES :paclitaxel-135-250mg/m2 3-24hrs every 3wks docetaxel-60-100mg/m2 bolus every 3wks These act on G2 phase cause arrest of cell cycle Toxocity:neutropenia,infection

24. Novel CT agents which acts on EGFR: Monoclonal antibodies- cetuximab 4oomg/m2 initially followed by 250mg/m2 per wk Small molecular tyrosine kinase inhibitors - erlotinib - gefitinib 80-90% of H&N cancers over expresses EGFR…

25. SURGICAL MANAGEMENT THANK YOU