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Tumor Board Conference

Sanjay Munireddy
Sinai Hospital of Baltimore
June 24, 2008

Case Presentation
Pt is a 64 yo female, smoker, presented with
c/o difficulty in swallowing for 6 weeks; felt
something in the right side of throat when she
swallowed; also, c/o rt. ear pain, sore throat
and dysphagia for meat; no wt. loss or voice
change
PMH: Hypothyroidism, COPD, anxiety
PSH: CS x 3, TAH/BSO
MEDS: Synthroid, xanax

Case Presentation
Social Hx: 45 pack-years smoking, Alcohol in
the past
PE: level III group of LNs enlarged with the
largest LN about 3 cm
Work-up:
Laryngoscopy: showed supraglottic tumor,
ulcerated, friable; biopsy showed squamous cell
carcinoma
CT/PET: showed lesion in rt. vocal cord and rt
neck lymphadenopathy

Case Presentation
A/P:
Supraglottic squamous cell carcinoma with
LN metastases (T3N2Mx)
MRND followed by chemotherapy and
radiation therapy

Case Presentation
Operative Procedure
Direct pharyngolaryngoscopy
Rt. MRND
PEG placement
Mediport placement

Head and Neck Cancer


Encompasses epithelial malignancies
that arise in the paranasal sinuses,
nasal cavity, oral cavity, pharynx and
larynx
Almost all of these are squamous cell
carcinoma of the head and neck
(SCCHN)
Risk factors: tobacco, alcohol, HPV-16

Head and Neck Cancer


Median age for diagnosis is early 60s,
with a male predominance
2/3rds of patients present with
advanced stage disease, commonly
involving regional lymph nodes

Head and Neck Cancer


Symptoms of presentation

Lump or sore that does not heal


Sore throat that does not go away
Difficulty swallowing
Change or hoarseness in the voice
Ear pain, tongue pain, mouth ulcer, cough, stridor,
mouth bleeding

Signs
Mass or ulceration in oral cavity or oropharynx, neck
mass, vocal cord paralysis, swallowing dysfunction

TNM Staging of
SCCHNN

Neck Metastases
Powerful adverse prognostic feature
Reduces survival by 50% in pts with
neck nodal metastases

Should N2 disease be treated


with surgery first followed by
CRT vs CRT first followed by
surgery

CRT followed by surgery


Concurrent CRT followed by planned neck
dissection (ND)
Controversial
Pts with initial N1 necks do not require ND,
unless there is clinical evidence of persistent
palpable disease after CRT
Pts with N2-N3 necks on presentation are
often considered for ND after CRT regardless
of the response to treatment
McHam et al Head & Neck; 2003 (25):791-798

CRT followed by surgery


Pts with complete response (CR) in
neck are highly unlikely to experience a
recurrence in neck after CRT
CR in neck to CRT may indicate that
ND is not necessary to achieve local
control and improved disease-free
survival
Clayman et al Arch Oto-Head Neck Surg 2001; 127(2):135-139

CRT followed by surgery


Although pts undergoing ND after CRT
had a statistically improved locoregional progression-free survival, no
impact on overall survival was found
No survival benefit was found for those
N2 pts who underwent an ND after
achieving a cCR-neck after CRT
McHam et al Head & Neck; 2003 (25):791-798

CRT followed by surgery


Pts who had a cCR in neck and who did not
have ND had worse disease-free and overall
survival than those who had ND
Clinical/radiologic response in neck is at best
a crude predictor of pathologic response
ND is needed in every pt with N2-N3 after
CRT
Brizel et al Int J Rad Onc Biol Phys 2004; 58(5); 1418-1423

CRT followed by surgery


Advantages
Better loco-regional control
Many pts are able to avoid extirpative
surgery and are able to maintain quality of
life1
Pfister et al J Clin Onc 1995;13:671-680

CRT followed by surgery


Disadvantages
Rate of neck control is poorer esp. in bulky node
disease
Detection of recurrence is more difficult and
delayed because of fibrosis by both high dose of
RT and fibrous reaction in and about neck node
Salvage surgery is not often successful after a
failure of RT and is attended by a high incidence of
wound complications (26-35%)
Carcini et al J Cr Facial Surg 2001,12(5):438-443

Surgery followed by CRT


Significant decrease in survival in pts
who had a delay of more than 2 weeks
b/w neck dissection and RT2
Timing of RT after ND; delays longer
than 4 weeks are unacceptable

Byers et al Head Neck Surg 1996; 18:277-282

Surgery followed by CRT


Advantages
May avoid the need for salvage neck
surgery in a previously irradiated filed
Decreases the morbidity associated with
post-radiation surgery
May by-pass the difficulty associated with
early detection of persistent or recurrent
neck disease in pts with indurated, fibrotic
neck tissue
Thomas et al Laryngoscope 1997; 107(8):1129-1137

Surgery followed by CRT


Disadvantages
Increased seeding of the wound with tumor
cells
Potential delay in definitive radiation
treatment to the primary site

Thomas et al Laryngoscope 1997; 107(8):1129-1137