Tumor Board Conference

1
Tumor Board Conference

• Sanjay Munireddy
• Sinai Hospital of Baltimore
• June 24, 2008

2
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

3
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

4
Case Presentation

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

5
Case Presentation

• Operative Procedure
• Direct pharyngolaryngoscopy
• Rt. MRND
• PEG placement
• Mediport placement

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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

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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

8
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

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TNM Staging of SCCHNN
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Neck Metastases

• Powerful adverse prognostic feature
• Reduces survival by 50 in pts with neck nodal
  metastases

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Should N2 disease be treated with surgery first
followed by CRT vs CRT first followed by surgery
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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
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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
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CRT followed by surgery

• Although pts undergoing ND after CRT had a
  statistically improved loco-regional
  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
15
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
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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

1Pfister et al J Clin Onc 199513671-680
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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

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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

2Byers et al Head Neck Surg 1996 18277-282
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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
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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