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C
E
D
Figure 17.6A-E
284
Chapter 17 Treatment of Local–Regional Recurrence
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285
Case
Study
17-7
A solitary node (red arrow) was seen in the right upper
neck (Fig. 17-7A). He underwent a right radical neck dissection and right pectoralis major ap as well as insertion of
brachytherapy catheters. Once the lymph node was removed,
6 a erloading catheters were sutured in place in parallel
fashion. Following insertion of the catheters, the wound was
closed with the rotational ap. Figure 17-7 shows catheters
A 53-year-old man was initially treated with
external beam radiation therapy for a T2 N2b
base of tongue carcinoma. He was found to
have a recurrence in the right neck 7 months
later.
arranged in 1-cm parallel rows (Fig. 17-7B,C), which were
loaded 4 days a er surgery with
at 0.65 Gy/h to the 5-mm line (Fig. 17-7D). e rst catheter had the posterior section signi cantly <1-cm separation from the second catheter. erefore, a lower activity
was loaded in the posterior half of this catheter. Large metal
clips were placed during the implant to help localize the bed
of the recurrent disease for guiding implants. Histologic
examination of surgical specimens showed squamous carcinoma in dense broadipose tissue and abutting muscle.
e other 21 nodes removed were negative for tumor. e
patient remains well 1 year following the implant.
192
Ir seeds to deliver 60 Gy
A
C
Figure 17.7A-D
B
D
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Part 2 Site-Specifi c Indications and Techniques
Occasionally, we have used high–dose rate delivery with the
HAM (Harrison-Anderson-Mick) applicator, particularly when
the tissues at risk are hard to access with catheter placement.
Sometimes small recurrences from irradiated T1 to T2
glottic cancers can be salvaged by voice-preserving procedures (e.g., laser vaporization or hemilaryngectomy). In most
cases, however, laryngectomy is necessary for salvaging local
relapse. Postoperative irradiation to the tracheal stoma and
the neck is administered when the recurrent lesion extends
to the subglottic region or when the neck dissection reveals
multiple nodes or extracapsular nodal disease. Portal overlap
is usually minimal since the initial irradiation is usually con ned to the larynx.
Technique
e majority of patients are now treated with IMRT. e treatment setup is similar to primary radiotherapy as described in
individual sites in previous chapters. e target encompasses
the clinically and radiologically detectable recurrent disease
with 1- to 2-cm margins.
A er resection of recurrent laryngeal carcinoma, an appositional electron eld is used when there is indication to treat
the stoma only. Opposed anterior–posterior photon elds are
used to irradiate jugular and supraclavicular nodes and the tracheal stoma. In this case, a slightly larger midline block is used
to shield the previously treated pharynx. Some overlap with the
previously irradiated so tissues of the neck laterally is allowed.
For reirradiation with IMRT, a virtual GTV (vGTV)
is delineated based on the clinical, surgical, and pathologic
information. One to three clinical targets are de ned. CTVHD
includes the vGTV with 1- to 2-cm margins. When indicated,
CTVID can cover CTVHD with an additional 1-cm margin
and CTVED encompasses subclinical sites at risk that were
not previously treated. Both CTVID and CTVED are optional
and individualized.
e dose for external beam irradiation is 60 Gy in
30 fractions. Occasionally, if gross residual disease is
highly suspected, a total dose of 66 Gy is prescribed to
a small volume (Case Study 17-8). When indicated, the
dose to CTVED is 50 to 54 Gy in 30 fractions. If the interval between the two courses of radiation is >2 years, the
cumulative dose to the spinal cord and brain stem is kept
below 65 Gy. More stringent dose constraints are adopted
for shorter intervals.
For stoma-only irradiation in the setting of postlaryngectomy, the dose is 50 Gy in 25 fractions delivered with
9- to 12-MeV electrons. For neck nodes and stoma irradiation, a dose of 50 Gy is delivered in 25 fractions with the
anterior eld or anterior–posterior portals depending on the
location of the positive node(s). Areas of the positive nodes
and extranodal extension then receive boost irradiation to a
total dose of 60 Gy in 30 fractions.
A erloading catheters are used for brachytherapy.
prepared in wires or ribbons of seeds are used
(seeCase Study17-7). We attempt 1-cm separation between
catheters. e catheters are placed during surgery, and loaded
3 to 5 days later. e prescribed dose is 60 Gy speci ed at 5 mm
from the plane of the implant with a dose rate of 0.4 to 0.6 Gy/h.
192
Ir
Case
Study
17-8
rence in the right neck as shown on an axial view on CT
scan (Fig. 17-8A, red arrow) and coronal view on an MRI
(Fig. 17-8B, red arrow). He underwent a modi ed radical
neck dissection which revealed nodal disease in level II and
III regions. e surgery extended toward the jugular foramen revealing presence of tumor in so tissue at this site.
Due to the extent of disease and probable residual
in the most superior aspect of level II nodal region, it
was elected to reirradiate the right neck with IMRT. Four
A 56-year-old man was irradiated for nasopharynx cancer using a three- eld conventional technique.
e nasopharynx and right neck received
66 Gy. Eight years later, he developed recur-
targets were de ned. CTVHD (yellow colorwash), CTVID
(blue colorwash), and CTVED (green-yellow colorwash)
were prescribed 60, 56, and 50, respectively. An additional
high-risk target in superior level II and the jugular foramen was also de ned (maroon colorwash) and prescribed
66 Gy. Figure 17-8 also shows contours and isodose distributions on axial views through mid level II (Fig. 17-8C)
and the jugular foramen (Fig. 17-8D), and on coronal
views through the neck (Fig. 17-8E) and the spinal cord
(Fig. 17-8F). e spinal cord dose was limited to 20 Gy. e
patient remains without disease 4 years later. He has severe
dysphagia, can only eat so food, and needs a gastrostomy
tube to maintain his weight. He has severe brosis of the
neck and cannot fully raise his right arm.
Chapter 17 Treatment of Local–Regional Recurrence
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A
C
B
D
E
Figure 17.8A-F
F
288
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Part 2 Site-Specifi c Indications and Techniques
Background Data
Table 17.1
Results of Reirradiation of Recurrent Nasopharyngeal Carcinoma (Literature Review)
Institutions No. of Patients Survival (5 yr) % With Severe Complications
Stanford (Hoppe et al.) 13 Median: 13 mo Not stated
UCSF (Fu et al.) 42 Overall: 41% 9
Beijing (Yan et al.) 219 Overall: 18% 29
MGH (Wang et al.) 51 T1, T2: 38%; T3, T4: 15% 2
MDACC (Pryzant et al.) 53 Confi ned to nasopharynx:
8
32%; larger: 9%
From Pryzant RM, et al. Re-treatment of nasopharyngeal carcinoma in 53 patients. Int J Radiat Oncol Biol Phys 1992;22:941, with permission.
Table 17.2
First Author, Year Patient Number
Lee, 2007 105
Results of Reirradiation Using IMRT
Postoperative
Radiation (%)
a
Concurrent
Chemotherapy (%)
2-yr Overall
Survival (%)
2-yr Local–Regional
Control (%)
34 75 37 42
b
Sulman, 2008 74 27 49 58 64
Duprez, 2009 84 23 14 35 48
Popovtzer, 2009 66 33 71 40 27
Sher, 2010 35 49 100 48 67
a
74% of patients treated with IMRT.
b
Local–regional progression-free survival.
Data from Lee N, Chan K, Bekelman JE, et al. Salvage re-irradiation for recurrent head and neck cancer. Int J Radiat Oncol Biol Phys 2007;68:731–740; Sulman
EP, Schwartz DL Le TT, et al. IMRT reirradiation of head and neck cancer—disease control and morbidity outcomes. Int J Radiat Oncol Biol Phys 2009;73:
399–409; Duprez F, Madani I, Bonte K, et al. Intensity-modulated radiotherapy for recurrent and second primary head and neck cancer in previously irradiated
territory. Radiother Oncol 2009;93:563–569; and Popovtzer A, et al. Int J Radiat Oncol Biol Phys 2009;74:1342–1347; Sher DJ, et al. Cancer 2010;116:
4761–4768.
SUGGESTED READINGS
Ang KK, Price RE, Stephens LC, et al. e tolerance of primate
spinal cord to re-irradiation. Int J Radiat Oncol Biol Phys 1993;25:459.
Delclos L, Moore BE, Sampiere VA. A disposable “a erloadable” nasopharyngeal applicator for radioactive point sources. Endo-
cur Hypertherm Oncol 1994;10:43.
Duprez F, Madani I, Bonte K, et al. Intensity-modulated radiotherapy for recurrent and second primary head and neck cancer in
previously irradiated territory. Radiother Oncol 2009;93:563.
Kupferman ME, Morrison WH, Santillan AA, et al. e role
of interstitial brachytherapy with salvage surgery for the management of recurrent head and neck cancers. Cancer 2007;109:2052.
Langer CJ, Harris J, Horwitz EM, et al. Phase II study of
low-dose paclitaxel and cisplatin in combination with split-course
concomitant twice-daily reirradiation in recurrent squamous cell
carcinoma of the head and neck: results of Radiation erapy
Oncology Group Protocol 9911. J Clin Oncol 2007;25:4800.
Lee N, Chan K, Bekelman JE, et al. Salvage re-irradiation for
recurrent head and neck cancer. Int J Radiat Oncol Biol Phys 2007;68:731.
Low JS, Chua ET, Gao F, Wee JT. Stereotactic radiosurgery
plus intracavitary irradiation in the salvage of nasopharyngeal
carcinoma. Head Neck 2006;28:321.
Pryzant RM, et al. Re-treatment of nasopharyngeal carcinoma
in 53 patients. Int J Radiat Oncol Biol Phys 1992;22:941.
Salama JK, Vokes EE, Chmura SJ, et al. Long-term outcome
of concurrent chemotherapy and reirradiation for recurrent and
second primary head-and-neck squamous cell carcinoma. Int J
Radiat Oncol Biol Phys 2006;64:382.
Spencer SA, Harris J, Wheeler RH, et al. Final report of
RTOG 9610, a multi-institutional trial of reirradiation and chemotherapy for unresectable recurrent squamous cell carcinoma of the
head and neck. Head Neck 2008;30:281.
Sulman EP, Schwartz DL Le TT, et al. IMRT reirradiation of
head and neck cancer—disease control and morbidity outcomes.
Int J Radiat Oncol Biol Phys 2009;73:399.
Teo PML, et al. How successful is high-dose (60 Gy)
reirradiation using mainly external beams in salvaging local failures of nasopharyngeal carcinoma? Int J Radiat Oncol Biol Phys
1998;40:897.
Wang CC, McIntyre JT. Re-irradiation of laryngeal carcinoma—
techniques and results. Int J Radiat Oncol Biol Phys 1993;26:783.
Wu SX, Chua DT, Deng ML, et al. Outcome of fractionated
stereotactic radiotherapy for 90 patients with locally persistent and
recurrent nasopharyngeal carcinoma. Int J Radiat Oncol Biol Phys
2007;69:761.
INDEX
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Note: Page numbers in italics denote gures; those followed by a t denote tables.
A
ACC. See Adenoid cystic carcinoma (ACC)
Accelerated fractionation schedules, 11
Acetaminophen, 53
Acinic cell carcinoma, 32
Actinic keratosis, 59
Acute mucositis, 53
Adenoid cystic carcinoma (ACC), 36
Adjuvant postoperative radiotherapy, 26–27
AJCC. See American Joint Committee on
Cancer (AJCC)
Alcohol, as carcinogen, 4
American Joint Committee on Cancer (AJCC),
9, 260
Amifostine, 53, 54
Analgesics, 53
Anaplastic carcinomas, 246
Anatomic structures, simulation, 35–37
Antiemetics, 53–54
Aspirin, 54
B
Basal cell carcinoma
malignant skin lesions, 259t
postoperative radiotherapy, 259
primary radiotherapy, 256–259, 257, 258
treatment strategy, 256
Base of tongue
postoperative radiotherapy, 142
primary radiotherapy, 135–142
treatment strategy, 135
Bilateral irradiation, 38–41, 40
Biomarkers
circulating EBV DNA, 7, 7
epidermal growth factor receptor (EGFR),
9–10, 10
human papillomavirus (HPV) and p16, 7–9,
8, 9
prognostic and predictive, 6, 6–7
Body weight
nutritional support, 51–52
tube feeding, 52
Brachytherapy, 25, 48. See also Endocavitary
beam therapy and brachytherapy
Buccal mucosa
postoperative radiotherapy, 85–88,
85–89
primary radiotherapy, 83
treatment strategy, 83, 84, 84
C
Carcinogens, tobacco and alcohol, 4
Carcinomas
acinic cell carcinoma, 32
adenoid cystic carcinoma (ACC), 36
anaplastic carcinomas, 246
basal cell carcinoma
malignant skin lesions, 259t
postoperative radiotherapy, 259
primary radiotherapy, 256–259, 257, 258
treatment strategy, 256
follicular thyroid carcinoma, 252, 253
glottis carcinoma
primary radiotherapy, 156–158
treatment strategy, 156
locally advanced carcinoma
postoperative radiotherapy, 165–168
primary radiotherapy, 161–165
treatment strategy, 161
local–regional recurrence treatment
nasopharyngeal carcinoma, 281, 283
oropharyngeal carcinoma, 283
Merkel cell carcinoma, 263
nasopharyngeal carcinoma, 281, 283
oropharyngeal carcinoma, 283
papillary thyroid carcinoma (PTC), 248, 249
posterior hypopharyngeal wall
postcricoid carcinoma, 185t
squamous cell carcinoma, 184t
pyriform sinus, squamous cell carcinoma, 180t
squamous cell carcinoma
malignant skin lesions, 259t
postoperative radiotherapy, 259
primary radiotherapy, 256–259, 257, 258
treatment strategy, 256
supraglottis carcinoma
local control and complication rates, 156t
primary radiotherapy, 152–155
squamous cell carcinoma, 155t
T2 to T3 Carcinoma, 156t
treatment strategy, 151
Cetuximab, 26
Chemotherapy, 25–26
chemoprevention, malignant
transformation,20
organ preservation, larynx cancer, 168t
with radiation
adjuvant therapy, HNSCC, 17
altered fractionation role, 16
long-term toxicity, 15–16
meta-analyses, 14–15
taxane-based induction chemotherapy, 16–17
Cisplatin, 17t
Clinical radiobiology, 3
Concurrent radiation
and cetuximab, 26
and chemotherapy, 25–26
D
Dental care, 50–51
Diet, a er completion of radiotherapy, 52
Docetaxel, 17t
Dose speci cation
base of tongue
postoperative radiotherapy, 143
primary radiotherapy, 137
buccal mucosa, 83, 85
external beam therapy
conventional technique, 44
intensity-modulated radiation therapy, 44
glottis carcinoma, 156
hard palate and upper alveolar ridge, 91, 94
lip, 60
locally advanced carcinoma
postoperative radiotherapy, 165
primary radiotherapy, 161
melanoma, 260, 262, 262
Merkel cell carcinoma, 260, 262, 262
mouth, oral tongue, and mandibular gingiva,
64, 74
nasal fossa proper
postoperative radiotherapy, 200
primary radiotherapy, 195
nasal vestibule, 188, 193
posterior hypopharyngeal wall, 183
posterior oropharyngeal wall
postoperative radiotherapy, 147
primary radiotherapy, 146
pyriform sinus, 175, 176
retromolar trigone, 81–82
so palate
postoperative radiotherapy, 122
primary radiotherapy, 118, 119
squamous cell carcinoma and basal cell carci-
noma, 257, 257, 258, 259
supraglottis (supraglottic) carcinoma, 153
thyroid, 253
tonsillar fossa, 133
E
EBV. See Epstein-Barr virus (EBV)
ECE. See Extracapsular extension (ECE)
EGFR. See Epidermal growth factor receptor
(EGFR)
Electron beam, 41–44, 42, 43
Endocavitary brachytherapy, 48
Endocavitary therapy and brachytherapy
dosimetry, 49
implant
interstitial removal, 49
operating room procedure, 48–49
patient care management, 49
target volume, 48
indications and procedures, 47–48
normal tissues, protection of, 48
types, 48
EORTC. See European Organisation for the
Research and Treatment of Cancer
(EORTC)
Epidermal growth factor receptor (EGFR),
9–10, 10
Epstein-Barr virus (EBV), 4–5
Ethmoid sinuses
postoperative radiotherapy, 213–217, 214–217
treatment strategy, 213, 214, 214
European Organisation for the Research and
Treatment of Cancer (EORTC), 16–17
External beam irradiation (teletherapy), 24–25
External beam therapy
compensating lters, 44–45, 45, 46
dose speci cation
conventional technique, 44
intensity-modulated radiation therapy
(IMRT), 44
electron beam bolus, 42, 43, 45–46
patient immobilization, 29–32, 30, 31
patient positioning, 29
portal arrangements
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Index
External beam therapy (Continued)
bilateral irradiation, 38–41, 40
IMRT, 38, 39
unilateral irradiation, 41
portal shaping
electron beam, 41–44, 42, 43
photon beam, 41, 41, 42
radiopaque markers and stents, 32,
32–37, 35
scatter plates, 46
simulation
computed tomography simulation, 37
isocenter, 35–37
marking anatomic structures and patient
positioning, 35–37
simulation lm, 37
treatment planning
intensity-modulated radiation therapy
(IMRT), 38
three-dimensional conformal
radiotherapy, 38
Extracapsular extension (ECE), 60
F
Field arrangement
base of tongue
postoperative radiotherapy, 143
primary radiotherapy, 135
buccal mucosa
postoperative radiotherapy, 85
primary radiotherapy, 83
glottis (glottic) carcinoma, 156
hard palate and upper alveolar ridge
postoperative radiotherapy, 90, 91
primary radiotherapy, 94
lip, 60
locally advanced carcinoma, 161, 165
maxillary sinus, 203
minor salivary gland tumors, 238
mouth, oral tongue, and mandibular
gingiva
postoperative radiotherapy, 61, 64
primary radiotherapy, 73
nasal fossa proper
postoperative radiotherapy, 200
primary radiotherapy, 193
nasal vestibule, 186, 188
nasopharynx, 98–100
parotid, 225
posterior oropharyngeal wall
postoperative radiotherapy, 147
primary radiotherapy, 145–146
pyriform sinus, 174
retromolar trigone
postoperative radiotherapy, 82
primary radiotherapy, 77
so palate
postoperative radiotherapy, 122
primary radiotherapy, 117–118
squamous cell carcinoma and basal cell
carcinoma
melanoma, 260
Merkel cell carcinoma, 263
neck node metastasis, metastasis from
unknown primary, 266
postoperative radiotherapy, 259
primary radiotherapy, 256
submandibular gland, 233
supraglottis (supraglottic) carcinoma, 152
thyroid, 247
tonsillar fossa, 133
Film, taking simulation, 37
Filters, dose distribution techniques, 44–45
Floor of mouth
postoperative radiotherapy, 64–73
primary radiotherapy, 73–74
treatment strategy, 61–64, 62–64
Fluoride gel, 51
Fluorouracil, 17t
Follicular thyroid carcinoma, 252, 253
Food intake, oral hygiene, 51
Fractionation
accelerated fractionation schedules, 11
altered fractionation role, 16
G
Genetic alterations, HNSCC, 3–4
Glottic carcinoma, 160t, 170t
Glottis
primary radiotherapy, 156–158
treatment strategy, 156
GORTEC. See Groupe d’Oncologie
Radiotherapie Tete et Cou (GORTEC)
Groupe d’Oncologie Radiotherapie Tete et Cou
(GORTEC), 15, 17
H
Hard palate and upper alveolar ridge
postoperative radiotherapy, 90–94
primary radiotherapy, 90–94
treatment strategy, 90, 90
Head and neck cancers
biomarkers
circulating EBV DNA, 7, 7
epidermal growth factor receptor (EGFR),
9–10, 10
human papillomavirus (HPV) and p16,
7–9, 8, 9
prognostic and predictive, 6, 6–7
chemotherapy with radiation
adjuvant therapy, 17
altered fractionation role, 16
long-term toxicity, 15–16
meta-analyses, 14–15
taxane-based induction chemotherapy, 16–17
high-precision radiotherapy, 12–13
prevention of, 19–20
viral etiology, 4–5
Head and neck squamous cell carcinoma
(HNSCC)
biomarkers, 6–10
lifestyle-related risk factors, 4
High-precision radiotherapy, 12–13
HPVs. See Human papillomavirus (HPVs)
Human papillomavirus (HPVs), 4–5
Hypopharynx
posterior hypopharyngeal wall
postcricoid carcinoma, 185t
postoperative radiotherapy, 183, 183, 184
primary radiotherapy, 181–183, 182
squamous cell carcinoma, 184t
treatment strategy, 181
pyriform sinus
primary radiotherapy, 172–176, 173–179
radical radiotherapy, 181t
squamous cell carcinoma, 180t
treatment strategy, 172
I
Immobilization, external beam therapy, 29–32,
30, 31
Implants, brachytherapy, 49
IMRT. See Intensity-modulated radiation
therapy (IMRT)
Intensity-modulated radiation therapy
(IMRT), 25
buccal mucosa, 89
ethmoid sinuses, 217
external beam therapy, 44
glottis (glottic) carcinoma, 156
locally advanced carcinoma, 166
local–regional recurrence treatment, 283,
288t
mouth, oral tongue, and mandibular gingiva,
64–65
nasal fossa proper
postoperative radiotherapy, 195
primary radiotherapy, 193
nasopharynx, 100–108, 100–108
neck node, metastasis from unknown
primary, 267–272
oropharynx, 129–133
portal arrangements, 38, 39
posterior hypopharyngeal wall, 182
postoperative radiotherapy
maxillary sinus, 208
primary radiotherapy, 212
pyriform sinus, 175
so palate, 117t
supraglottis carcinoma, 153
thyroid, 247–253
treatment planning, 38
Interstitial brachytherapy, 49
Isocenter, external beam therapy, 35–37
L
Larynx
glottis (glottic) carcinoma
primary radiotherapy, 156–158
treatment strategy, 156
locally advanced carcinoma
postoperative radiotherapy, 165–168
primary radiotherapy, 161–165
treatment strategy, 161
supraglottis (supraglottic) carcinoma
local control and complication rates,
156t
primary radiotherapy, 152–155
squamous cell carcinoma, 155t
T2 to T3 Carcinoma, 156t
treatment strategy, 151
Lead mask, 42, 42, 257
Lifestyle-related risk factors, HNSCC, 4
Lip
postoperative radiotherapy, 60
primary radiotherapy, 60
treatment strategy, 59–60
Local–regional recurrence treatment
adjuvant reirradiation, 283–286, 284, 285
reirradiation for, 275–281, 276–280, 288t
treatment strategy and planning
IMRT, 283, 288t
nasopharyngeal carcinoma, 281, 283
oropharyngeal carcinoma, 283
virtual GTV (vGTV), 286, 287
M
MACH–NC, Meta–analysis of chemotherapy
on head and neck cancer (MACH–NC)
Mandible and so tissues, 118, 119, 119
Mask
lead, 42, 42, 257
thermoplastic, 30, 31
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291
Maxillary sinus
postoperative radiotherapy, 203–212
primary radiotherapy, 212, 213
treatment strategy, 203
Medullary carcinoma, 246
Melanoma
postoperative radiotherapy, 260–262
treatment strategy, 260
Merkel cell carcinoma, 263
Meta-analysis of chemotherapy on head and
neck cancer (MACH–NC), 14
Metastasis
cervical, 243t
neck node, 266
Minor salivary gland tumors
postoperative radiotherapy, 238–242
treatment strategy, 238
Molds, 48
Molecular biology concepts, HNSCC, 4
Mouth. See Oral cavity
Mucositis, acute, 53
N
Nasal cavity
nasal fossa proper
postoperative radiotherapy, 195–200,
196–200
primary radiotherapy, 193–195, 194, 195
treatment strategy, 193
nasal vestibule
primary radiotherapy, 186–193, 187–192
treatment strategy, 186
survival rates, 201t
Nasal fossa proper
postoperative radiotherapy, 195–200,
196–200
primary radiotherapy, 193–195, 194, 195
treatment strategy, 193
Nasal vestibule
primary radiotherapy, 186–193, 187–192
treatment strategy, 186
Nasopharyngeal carcinoma (NPC)
circulating EBV DNA titers, 7, 7
IMRT, 113t
local–regional recurrence treatment, 281, 283
reirradiation, 288t
treatment strategy and planning, 281–283
Nasopharynx
radiotherapy
dose, 98
intensity-modulated radiation therapy
(IMRT), 100–108, 100–108
setup and eld arrangement, 98, 98–100, 99
target volume, 97–98
treatment strategy, 97
Neck node, metastasis from unknown primary
comprehensive radiotherapy
dose, 267
intensity-modulated radiation therapy,
267–272
setup and eld arrangement, 266, 267
target volume, 265–267, 266, 267
treatment strategy, 265
Neutron therapy, adenoid cystic carcinoma,
224t
Nose. See Nasal cavity
NPC. See Nasopharyngeal carcinoma (NPC)
Nutritional support
assessment and guidance, 51–52
diet a er completion of radiotherapy, 52
swallowing assessment and rehabilitation, 52
tube feeding, 52
O
Opioids, pain, 53
Oral cavity
buccal mucosa
postoperative radiotherapy, 85–88, 85–89
primary radiotherapy, 83
treatment strategy, 83, 84, 84
hard palate and upper alveolar ridge
postoperative radiotherapy, 90–94
primary radiotherapy, 90–94
treatment strategy, 90, 90
lip
postoperative radiotherapy, 60
primary radiotherapy, 60
treatment strategy, 59–60
mouth, oral tongue, and mandibular
gingiva
postoperative radiotherapy, 64–73
primary radiotherapy, 73–74
treatment strategy, 61–64, 62–64
retromolar trigone
postoperative radiotherapy, 82
primary radiotherapy, 77, 81–82
treatment strategy, 76–78, 76–78
Oral hygiene, 51
ORN. See Osteoradionecrosis (ORN)
Oropharyngeal carcinoma
local–regional recurrence treatment, 283
Oropharynx
base of tongue
postoperative radiotherapy, 142
primary radiotherapy, 135–142
treatment strategy, 135
posterior oropharyngeal wall
postoperative radiotherapy, 146–147
primary radiotherapy, 144–146
treatment strategy, 144
so palate
intensity-modulated radiation therapy
(IMRT), 117t
postoperative radiotherapy, 122
primary radiotherapy, 118–122
T stage, 122t
treatment strategy, 115–117, 116t, 117t
tonsillar fossa
ipsilateral radiation, 135t
late complications, 134t
local control analysis, 134t
postoperative radiotherapy, 133
primary radiotherapy, 123–133
regional control analysis, 134t
Osteoradionecrosis (ORN), 51
P
Pain medications, 53
Papillary thyroid carcinoma (PTC), 248, 249
Paranasal sinuses
ethmoid sinuses
postoperative radiotherapy, 213–217,
214–217
treatment strategy, 213, 214, 214
maxillary sinus
postoperative radiotherapy, 203–212
primary radiotherapy, 212, 213
treatment strategy, 203
sphenoid and frontal sinuses, 219–222,
220–222
Parotid
clinical target volumes (CTVs), 232
postoperative radiotherapy, 223, 225, 225,
226, 226
treatment strategy, 223
virtual gross target volume (vGTV), 226–231
Patients
before, during, and a er radiotherapy
dental care, 50–51
nutritional support, 51–52
symptomatic management of reactions,
53–55
external beam irradiation (teletherapy), 24,
29–32, 30, 31
Permanent interstitial brachytherapy, 48
Photon beam, 41, 41, 42
Physiotherapy, oral, 51
Pilocarpine (Salagen), 54
Pinna, carcinomas, 260t
Portal
arrangements
bilateral irradiation, 38–41, 40
IMRT, 38, 39
unilateral irradiation, 41
shaping
electron beam, 41–44, 42, 43
photon beam, 41, 41, 42
Postcricoid region, 146, 175
Posterior hypopharyngeal wall
postcricoid carcinoma, 185t
postoperative radiotherapy, 183, 183, 184
primary radiotherapy, 181–183, 182
squamous cell carcinoma, 184t
treatment strategy, 181
Posterior oropharyngeal wall
postoperative radiotherapy, 146–147
primary radiotherapy, 144–146
treatment strategy, 144
Postoperative radiotherapy, 122
basal cell carcinoma, 259
base of tongue, 142
buccal mucosa, 85–88, 85–89
ethmoid sinuses, 213–217, 214–217
hard palate and upper alveolar ridge,
90–94
lip, 60
maxillary sinus, 203–212
melanoma, 260–262
Merkel cell carcinoma, 263
mouth, oral tongue, and mandibular gingiva,
64–73
posterior oropharyngeal wall, 146–147
retromolar trigone, 82
so palate, 122
thyroid, 246, 247, 247
tonsillar fossa, 133
Preoperative radiotherapy, 27
Prevention, head and neck cancers, 19–20
Primary radiotherapy, 24–25
base of tongue, 135–142
buccal mucosa, 83
hard palate and upper alveolar ridge, 90–94
lip, 60
maxillary sinus, 212, 213
mouth, oral tongue, and mandibular gingiva,
73–74
posterior oropharyngeal wall, 144–146
retromolar trigone, 77, 81–82
so palate, 118–122
squamous cell carcinoma and basal cell carci-
noma, 256–259, 257, 258
tonsillar fossa, 123–133
PTC. See Papillary thyroid carcinoma (PTC)
Pyriform sinus
primary radiotherapy, 172–176, 173–179
radical radiotherapy, 181t
squamous cell carcinoma, 180t
treatment strategy, 172
292
https://t.me/medicina_free
Index
R
Radiation and chemotherapy, 25–26
Radiation erapy Oncology Group (RTOG),
8, 44
Radioactive iodine (RAI), 248, 250
Radiopaque markers and stents, 32, 32–37, 35
RAI. See Radioactive iodine (RAI)
Retromolar trigone
postoperative radiotherapy, 82
primary radiotherapy, 77, 81–82
treatment strategy, 76–78, 76–78
RTOG. See Radiation erapy Oncology Group
(RTOG)
S
Salagen (pilocarpine), 54
Salivary glands
minor salivary gland tumors
postoperative radiotherapy, 238–242
treatment strategy, 238
parotid
clinical target volumes (CTVs), 232
postoperative radiotherapy, 223, 225, 225,
226, 226
treatment strategy, 223
virtual gross target volume (vGTV),
226–231
submandibular gland
postoperative radiotherapy, 233–236
treatment strategy, 233
virtual gross target volume, 234, 236, 237
Second primary tumors (SPTs), 8, 19
Sennoside, 53
Sialogogues, 54
Signaling pathways, 18–19
Simulation
anatomic structures, 35–37
external beam therapy
computed tomography simulation, 37
isocenter, 35–37
marking anatomic structures and patient
positioning, 35–37
simulation lm, 37
lm, 37
Skin
melanoma
postoperative radiotherapy, 260–262
treatment strategy, 260
Merkel cell carcinoma, 263
reactions, 54
squamous cell carcinoma and basal cell
carcinoma
malignant skin lesions, 259t
postoperative radiotherapy, 259
primary radiotherapy, 256–259, 257, 258
treatment strategy, 256
So palate
intensity-modulated radiation therapy
(IMRT), 117t
postoperative radiotherapy, 122
primary radiotherapy, 118–122
T stage, 122t
treatment strategy, 115–117, 116t, 117t
SPTs. See Second primary tumors (SPTs)
Squamous cell carcinoma, 256–260. See also
Basal cell carcinoma
Standard nonsurgical front-line therapy, 19
Submandibular gland
postoperative radiotherapy, 233–236
treatment strategy, 233
virtual gross target volume, 234, 236, 237
Supraglottis (supraglottic) carcinoma
local control and complication rates, 156t
primary radiotherapy, 152–155
squamous cell carcinoma, 155t
T2 to T3 Carcinoma, 156t
treatment strategy, 151
Symptomatic management of reactions, 53–54
Systemic therapy, 118, 122, 137
T
Target volume
base of tongue
postoperative radiotherapy, 143
primary radiotherapy, 135
buccal mucosa
postoperative radiotherapy, 85
primary radiotherapy, 83
glottis (glottic) carcinoma, 156
hard palate and upper alveolar ridge
postoperative radiotherapy, 90
primary radiotherapy, 94
lip, 60
locally advanced carcinoma
postoperative radiotherapy, 165
primary radiotherapy, 161
maxillary sinus, 203
melanoma, 260
Merkel cell carcinoma, 263
mouth, oral tongue, and
mandibular gingiva
postoperative radiotherapy, 61
primary radiotherapy, 73
nasal fossa proper, 195
nasal vestibule, 186
neck node, metastasis from unknown
primary, 265–267, 266, 267
posterior hypopharyngeal wall, 181
posterior oropharyngeal wall
postoperative radiotherapy, 146
primary radiotherapy, 144–145
pyriform sinus, 172
retromolar trigone
postoperative radiotherapy, 82
primary radiotherapy, 77
so palate
postoperative radiotherapy, 122
primary radiotherapy, 117
squamous cell carcinoma and basal cell
carcinoma of the skin
postoperative radiotherapy, 259
primary radiotherapy, 256
supraglottis (supraglottic) carcinoma, 152,
152–153, 153
thyroid, 246
tonsillar fossa
postoperative radiotherapy, 133
primary radiotherapy, 123
Taste distortion, 52
Teletherapy, 24–25
Temporary interstitial brachytherapy, 48
ermoplastic mask
in open neck position, 31
in supine position, 30
ree-dimensional conformal radiotherapy
treatment planning, 38
yroid
clinical target volumes, 253
dose speci cation, 253
intensity-modulated radiation therapy
(IMRT), 247–253
postoperative radiotherapy, 246, 247, 247
treatment strategy, 245–246
virtual gross target volume, 247
Tonsillar fossa
ipsilateral radiation, 135t
late complications, 134t
local control analysis, 134t
postoperative radiotherapy, 133
primary radiotherapy, 123–133
regional control analysis, 134t
Treatment strategy
basal cell carcinoma, 256
base of tongue, 135
buccal mucosa, 83, 84, 84
ethmoid sinuses, 213, 214, 214
oor of mouth, 61–64, 62–64
glottis, 156
hard palate and upper alveolar ridge, 90, 90
lip, 59–60
locally advanced carcinoma, 161
maxillary sinus, 203
melanoma, 260
minor salivary gland tumors, 238
nasal fossa proper, 193
nasal vestibule, 186
nasopharyngeal carcinoma (NPC),
281–283
nasopharynx, 97
neck node, metastasis from
unknown primary, 265
parotid, 223
posterior hypopharyngeal wall, 181
posterior oropharyngeal wall, 144
pyriform sinus, 172
retromolar trigone, 76–78, 76–78
so palate, 115–117, 116t, 117t
squamous cell carcinoma and basal cell
carcinoma of the skin, 256
submandibular gland, 233
supraglottis (supraglottic) carcinoma, 151
thyroid, 245–246
TSGs. See Tumor suppressor genes (TSGs)
Tube feeding, 52
Tumor suppressor genes (TSGs), 4
U
Unilateral irradiation, 41
Upper alveolar ridge
postoperative radiotherapy, 90–94
primary radiotherapy, 90–94
treatment strategy, 90, 90
V
Viral etiology, 4–5
Vocal cords, 152, 153, 157, 159t, 161, 163, 165
Vomiting, symptoms of radiotherapy, 53
W
Wedge-pair technique, 40, 91, 226, 232, 259
Weight. See Body weight
X
Xerostomia, prevention and management, 54
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