RADIATION THERAPY

IN H$N CANCER
DR. ANAHITA ANIL JOHN
POST-GRADUATE
ORAL AND MAXILLOFACIAL
SURGERY
CONTENTS:

• Introduction history • Site specific treatment

• Advances in radiotherapy
• Radiation biology
• Beam & field arrangement in
• Factors affecting choice of treatment in oral radiotherapy
cancer • Complications of
radiotherapy – acute &
• General concepts of treatment chronic
• Radiotherapy for oral cancer • Oral care of the radiotherapy
• Preoperative – Postoperative patients
Treatment Planning
• Patient preparation
• Simulation
• Delineation of target
volumes
3D CONFORMAL RADIOTHERAPY (CRT)
INTENSITY MODULATED RADIATION THERAPY
(IMRT)
PRE-OPERATIVE RADIATION THERAPY
NCCN Guidelines
RE-IRRADIATION

Surgical resection of recurrent disease is the treatment of choice if it is technically

feasible
However, if adequate salvage surgery is not feasible or if concerns exist
about margins after salvage surgery, then re-irradiation may be considered

The important factors that have an impact on the feasibility of re-irradiation are
(1) Previous dose, volume, and tumor response;
(2) Tolerance of normal tissues to additional radiation;
(3) Radiation dose to adjacent vital structures;
(4) The feasibility of delivering a tumoricidal additional dose of radiation;
(5) The need for bringing in nonirradiated vascularized tissue to protect vital structures
ORAL CARE AFTER RT
TREATMENT
PLANNING
 Planning
RT Tr
treatment ea
r e ng De tm
P ni l iv e n
l a n er t
P y
RADIOTHERAPY
PLANNING
PROCESS
PRE- PLANNING Clinical
evaluation &
staging

Treatment intent
: Radical or
Palliative

Choice of
treatment :
Surgery /
Radiotherapy
/Chemotherapy
PLANNING RT
TREATMENT
Method of patient
immobilisation

Tumour imaging & patient

data acquisition

Delineation of tumour
volumes

Choice of technique & beam

modification

Computation & dose

distribution
TREATMENT
DELIVERY
Dose prescription

Implementation of treatment

Verification
Monitoring treatment

Evaluation of
PATIENT PREPARATION

u
 Baseline blood studies including complete blood count.
Patients undergoing treatment with curative intent will
require their hematocrit be ≥ 30 percent.
h

e
 In selected patients where high doses of radiation therapy
will include a portion of the orbits, consideration of a
baseline ophthalmologic evaluation may be indicated.
 The nutritional status of the patient will require close
attention. Any significant problems such as weight loss,
dysphagia, odynophagia and major trismus must be
aggressively addressed.

 Special dietary supplements & perhaps placement of a

percutaneous endoscopic gastrotomy tube may be required.
 Patients who are still abusing alcohol will require
specialized care.

 Those smoking cigarettes should be started on a smoking

cessation program.

 Not only are they risk factors for oral cancer but their
continued use during radiation therapy can exacerbate acute
side effects.
PATIENT POSITION

 The position of the patient for treatment must be technically ideal & yet
comfortable.
a

 It is important that the patient be treated in one position only, as changes

result in alterations in internal & external anatomy & risk of over or
under dosage.

 The choice of position for treatment may be constrained by

equipment limitations .

 The degree of immobilization required varies according to the

technique being used. Immobilization can be achieved with perplex
shells or casts for tumours of the head & neck.
Tumor localization:

Acquisition of tumor data involves clinical observation, palpation & the

use of optimum imaging modalities.

Simulation:

Is designed to place the radiation field & its dose, where the tumor is
while excluding as much of the surrounding normal tissues as
possible .
Fluoroscopy & uses diagnostic x-ray
CT SIMULATION

The patient is positioned on the flat-top couch of a CT scanner in the treatment

position. Alignment of the patient is made with lateral wall lasers and sagittal laser.

The patient is ‘‘marked’’ where the laser projection illuminates the skin and finally
the patient is removed from the couch.
DEFINITION OF TARGET VOLUME :

International Comission on Radiation Units definitions

:
GROSS TUMOUR VOLUME ( GTV )

Defined as the demonstrable macroscopic extent of tumour that is

either palpable, visible or detectable by conventional radiography,
ultrasound ,CT or MRI.
CLINICAL TARGET VOLUME (CTV):

For radiation treatment, the aim is to give a tumoricidal dose to the macroscopic
disease &/or the estimated extent of the microscopic spread.

Subclinical disease is determined by knowledge of the tumour histology.

To encompass this potential microscopic spread, a margin must be allowed
around the GTV to produce the clinical target volume ( CTV ).
INTERNAL TARGET VOLUME (ITV):
c
In practice, there are some situations in which CTV may move due to
physiological factors.

An internal margin ( IM ) has to be added to the CTV to compensate for

for expected movements & variations in the shape , position & size of the
CTV , thereby defining the internal target volume ( ITV ).
PLANNING TARGET VOLUME (PTV):
&

During a fractionated course of radiotherapy, day to day variation in patient

position in alignment of the beams with external marks will occur.
To account for these inaccuracies , a set up margin ( SM ) for each
technique can be defined. n

Combining the internal margin for physiological changes & the set up
margin for technical variations with CTV leads to the planning target
volume ( PTV ).
Delineation of tumour volumes
 ADVANCES IN
RADIOTHERAPY
Three - dimensional Conformal Radiation Therapy

 Using CT simulation computer data, beam placement in 3

dimensions using non coplanar beam arrangements that conform to
the target are developed.

 This approach replaces the conventional simulation and two

dimensional treatment planning with a computer based virtual
simulation.
 A beam’s eye view (BEV) perspective is created and linked to the treatment
unit via digitally reconstructed radiographs (DRR) that will correspond to
films taken to verify the patient treatment position.

 Complicated three-dimensional dose calculations allow for accurate

administration of radiation to the target regions based on computer
generated isodose curves.
Intensity Modulated Radiation Therapy

 In IMRT, multiple shaped radiation

beams are modulated to produce
highly conformal dose distributions.

 This approach enables the delivery of

increased doses to tumour tissue while
limiting the dose delivered to defined normal
structures such as the salivary glands,
auditory and optic apparatus, spinal cord and
larynx.
Technologies used for delivering IMRT

 Tomotherapy
 Dynamic multileaf collimation (DMLC)
 Beam attenuation
Image Guided Radiation Therapy

 IGRT is based on precise tracing of the radiation target in order to

compensate for motion uncertainty.

 An example is to implement respiratory gating for tumors in the trunk during

each fraction of irradiation by synchronizing the treatment field coverage
precisely over a tumor which moves with the patient’s respiration
COMPLICATIONS OF
RADIOTHERAPY
 Acute Late

As early as 3
months; May
COMPLICATIONS During or shortly
occur any time
after radiation
OF during the patient’s
life
RADIOTHERAPY
Effects on rapidly Manifests in slowly
dividing cells – skin, dividing tissues
mucosa, salivary such as connective
tissues and neural tissues

Trismus,
Alteration of taste, Xerostomia,
Mucositis, Infection Radiation caries,
Osteoradionecrosis
MUCOSITIS

Mucous membranes are sensitive and show dose-dependent acute toxicity

Clinical Presentation:
Regions: soft palate and tonsillar pillars, the buccal mucosa
pharyngeal walls.

At lower doses, mucosal erythema develops

Pseudomembranous-like mucositis
(HPE: accumulation of dead cells, fibrin,
inflammatory infiltrate)

The acute effects intensify, areas of mucositis

become confluent and ulcerate
Metallic dental restoration, which causes radiation scatter that leads to
significant mucositis, typically in the adjacent buccal mucosa and the lateral
border of the tongue

Occasionally, soft tissue necrosis

 WHO Scoring

RTOG Scoring
MANAGEMENT

1. No evidence based guidelines

2. Dietary changes

3. Oral hygiene measure

4. Avoidance of physical and chemical irritants

5. Antibacterial and antifungal therapy as needed

 OSTEORADIONECRO
SIS

Chronic non-healing wound, caused by Effect of radiation on tissue based on

- Hypoxia
- Hypocellularity
- Hypovascularity
-Quality & quantity of radiation
-Size of portals
-Location & extend of lesion
-Condition of teeth & periodontium
 Death of bone cells

Obliterative arteritis

RADIATION
> 5000 Rads
3-H Tissue

Tissue breakdown

NON-HEALING WOUND
Pathophysiology of osteoradionecrosis according to Marx
.

81
CLINICAL
FINDINGS
•Pain evidence of exposed bone

•Trismus, fetid odour , increased temp

•Intra /Extra oral sinus/ fistulae

•Pathologic Fracture

•Discomfort because of abrasion of exposed bone

•Induration & ulceration

TREATMENT
• Control of infection
• Hospitalization
• Gentle irrigation of soft
tissue
Necrotic area
• Aerobic & anaerobic culture
• Supportive treatment
Initiation of bleeding points
• Debridement of bone
• Initiation of bleeding points
Normal bone • NSAIDS/ Narcotic
analgesics
• HBO therapy
MANDI.CROSS SECTION
HYPERBARIC OXYGEN THERAPY

Increases arterial & venous tension -- additional O2 being carried in

plasma

EFFECT
Direct bacteriostatic effect on micro-organisms
Increases Leukocyte bactericidal activity
Fibroblastic activity
Proliferation of granulation tissue
Enhances the formation of Sequestra
HOW HBO IS GIVEN?

100% O2 at 2.4 atmospheric absolute pressure

-1 dive ---- 90 min
-5 days a week
-30 to 60 dives
-Given in monoplace / large chambers
INFECTIONS

The most common infectionvis Candidiasis.

The infection is the result of decreased salivary flow & is
exacerbated by dental prostheses & the continued use of
alcohol & tobacco products.
XEROSTOMIA

 The major salivary glands are at times unavoidably

exposed during radiotherapy for cancer in the oral cavity or
oropharynx.

 The parenchymal component of the salivary glands is rather

radiosensitive (parotid gland more so than submandibular or
sublingual glands).
When major salivary glands are within the radiation field, salivary
dysfunction develops immediately and predictably and in a
radiation dose-dependent manner

A 50–60% decrease is salivary flow occurs during the first week.

The saliva becomes viscous and mucoid, indicating that some
mucous acini are still functional

The flow rate of normal unstimulated saliva is 0.3–0.5 ml/min. If it

decreases to less than 0.1–0.2 ml/min, one would
experience xerostomia
The hallmarks of irradiated salivary glands are
1.Acinar atrophy and chronic inflammation
2.Fibrosis and chronic inflammation are found in periductal and intralobular areas, with
ductal system remains relatively intact
3.Degranulation, degeneration, and necrosis of serous acinar cells are observed 1 h after
treatment with a dose of 2.5 Gy.
At 6 h after single-dose irradiation, a parotid gland treated with doses of 2.5–7.5 Gy
showed necrosis of serous cells, whereas with doses of 10.0–15.0 Gy whole acini were
found to be lost
The loss of salivary parenchyma is the most probable cause of decreased salivary flow

Radiation-induced xerostomia: pathophysiology, clinical course and supportive treatment – Guchelaar et al

 Biochemical Changes:
Sialochemistry shows that both the acinar and the ductal functions are affected by
radiation
Sodium and chloride levels are increased, suggesting that ductal reabsorption of these
electrolytes is defective. Potassium, which is secreted by the ductal cells, remains
normal. The primary salivary buffer bicarbonate is significantly decreased

Sodium
Chloride
Potassium levels - Normal

Bicarbonate

Radiation-induced xerostomia: pathophysiology, clinical course and supportive treatment – Guchelaar et al

Clinical Presentation:
Oral discomfort and difficulties with oral functioning
Sequelae from hyposalivation also include alterations in the oral soft tissues, a shift in oral microflora,
hyposalivation-related dental caries, and periodontal disease
Mucosal alterations such as inflammation, atrophy and ulceration
Patients have low tolerance for dental prostheses because of tissue friability and lack of lubrication.
Oral microbial populations shift, resulting in a high risk of caries and frequent occurrence of oral
candidiasis
Abnormal swallowing patterns, in which the movement of a bolus from mouth to pharynx is slowed
 The loss of salivary flow and decreased oesophageal pH may contribute to the development of gastro-
oesphageal reflux disease

Radiation-induced xerostomia: pathophysiology, clinical course and supportive treatment – Guchelaar et al

Management

Moisten and lubricate the oral mucosa - Saliva

substitutes duplicate the properties of normal
saliva.
Levine et al. - carboxymethylcellulose (CMC),
mucins, sorbitol or xylitol, mineral salts,
fluorides and preservatives - has been shown to
provide considerable relief without significant
side effect

Moistening agents
Chewing sugarless gum, sucking sugarless candies, or taking frequent sips of liquids
are the most common methods of relieving oral dryness
Unfortunately, these measures provide only temporary relief of dryness

Radiation-induced xerostomia: pathophysiology, clinical course and supportive treatment – Guchelaar et al

 Sialogogues increase the flow of saliva and therefore require functional salivary gland
parenchyma in order to be effective

The residual function of the salivary glands can be evaluated by measuring salivary
gland flow rate and salivary gland scintigraphy

Sialogogues
Pilocarpine
Neostigmine
Nicotinic acid
Potassium iodide
Bromhexine
Carbacholine

Radiation-induced xerostomia: pathophysiology, clinical course and supportive treatment – Guchelaar et al

FIBROSIS

The mechanism of RIF is similar to that of any chronic wound healing process

An initial injury incites an acute response that leads to inflammation, followed by

fibroblast recruitment and activation with extracellular matrix deposition

This involves the interaction of ionizing radiation with water molecules to form free
radicals, including superoxide, hydrogen peroxide, and hydroxyl radical
which accounts for 60–70 % of the total damage - Terasaki et al. 2011;
Zhao and Robbins 2009

In a study where, subjectively measured trismus revealed that non-irradiated patients

had significantly less trouble with mouth opening compared to those treated with
either primary or postoperative radiation therapy - Tschudi D et al 2003
Treatment Algorithm
TREATMENT OPTIONS

An increasing number of tongue blades can be forced between the anterior teeth, acting
both as a wedge and as a visual gage to the degree of opening

When trismus is severe, an attempt can be made to increase the oral opening with a
‘dynamic bite opener.

A threaded, tapered screw is made of acrylic resin. The patient places the screw
between his posterior teeth and gradually turns it to wedge his teeth apart
Regular stretching exercises of these muscles can mitigate the effects of this
complication

Before radiation therapy commences, and if the exercises are stopped during
treatment, they must be resumed as soon as the acute side effects of radiation
therapy have subsided

The exercises should be performed in multiple cycles throughout every day and can
be assisted with appliances

Alternatively, patients may be instructed to use their thumb and fingers to forcefully
open the mouth to the point of tolerance

It is crucial for the clinician to reinforce the importance of preventing trismus at

every opportunity, because difficulty in opening the mouth not only affects quality of
life but also interferes with adequate post-treatment monitoring for recurrent or
new cancer and providing routine dental care
CONCLUSION

The cancer patient who is to receive curative doses of

radiation to the head and neck presents an interesting
challenge to the Maxillofacial surgeon.

Dental management of the irradiated patient is a serious

undertaking since the standard of care has an effect on
the patient’s quality of life.
 References

Head and neck oncology – Jatin Shah

Oral & Maxillofacial surgery 2nd edition vol II – Stell and Maran
Oral and maxillofacial pathology - Fonseca Volume -5.
Peterson’s principles of oral and maxillofacial surgery
Oral and maxillofacial surgery – Peterward Booth
Radiation-induced xerostomia: pathophysiology, clinical course and
supportive treatment – Guchelaar et al
THANK YOU!