General principles and outline of management
History & Clinical Examination :
Goals of Treatment:
Surgery and radiotherapy are the definitive therapies in the treatment of head and neck squamous cell carcinomas.
It is used as a single modality in early disease (stage I & II).
External beam radiotherapy and / or brachytherapy are used either as a single modality or as a part of multi-modality treatment.
Three Dimensional Conformal Radiotherapy (3-DCRT)
Intensity Modulated Radiation Therapy (IMRT) or Image Guided radiotherapy ( IGRT) are useful advances in radiotherapy techniques that can be used in primary treatment with radiation therapy. These techniques allow for better sparing of adjacent critical structures like the spinal cord, parotids thereby enabling better tumor coverage and may help in dose escalation to the target volume.
It is usually used in combination with radiotherapy (sequential or concurrent. Current evidence favors concurrent administration of chemo radiotherapy). It has a role in organ/ voice preservation (in laryngeal / hypo pharyngeal cancers) and in oropharyngeal cancers. In select patients chemotherapy can be used for palliating symptoms.
General guidelines for selecting a treatment modality:
Surgery is preferred over radiotherapy as a single modality in
RT is preferred over surgery as a single modality, where
Criteria of Unresectability :Primary disease: Adequate surgical clearance is not achievable
Indications for post operative radiotherapy
Lymph nodes :
Indications for Brachytherapy (BRT):
Tumour suitable for Brachytherapy
Primary and nodal disease: 50-60 Gy/25-30 fr/5-6 weeks, using reducing fields.
On every follow up thorough head and neck examination for locoregional control, second primary tumour and late sequelae of treatment.
T1, T2 Tumours: Surgery or RT
T3, T4 Tumours: Surgery + Post operative RT/ CT-RT
T3, T4 Tumours:
Oral Tongue & Floor of Mouth
Lower Alveolus & Retro Molar Trigone Mandible uninvolved or minimally involved
Mandible Grossly Involved
Orfit cast for external beam radiotherapy
Upper Alveolus & Hard Palate
Post operative RT/ CT-RT as per guidelines mentioned earlier.
Stage III - T1-2 N1 / T3N0-1
Stage IV - T4a N0-1 / T1-4aN2-3
Post Cricoid & Posterior Pharyngeal Wall
Nasal Cavity & Paranasal Sinuses
Treatment of Primary: