Head & Neck Cancer


MOVING TOWARDS PERSONALIZED TREATMENT IN HEAD AND NECK CANCER; MEDICAL ONCOLOGY ASPECT

Assistant Professor Chanida Vinaynauwattikun, MD PhD

Departname of Medicine, Chulalongkorn University and The King Chulalongkorn Memorial Hospital, Bangkok, Thailand


SYNOPSIS

Head and neck cancer is the sixth most common cancer, with high morbidity and mortality in Thailand and worldwide. Multimodality treatment including surgery, radiation and chemotherapy had been conducted for this deadly disease. Incorporate novel genetic testing, including next-generation sequencing had been explored to elucidate molecular mechanisms that contributing to oncogenesis, progression and metastasis. Most frequently mutated gene in head and neck cancer squamous cell carcinoma (SqCA) included TP3 (67.5%), CDKN2A (16.7%), PIK3CA (16.5%), NOTCH1 (8%), EGFR amplification. However, the genetic alterations that had been translated to potential clinical impact was limited only integrated virus of HPV or EBV in viral-associated head and neck cancer.  

HPV-related oropharynx SqCA had diverse genomic pattern, biology, radiologic appearing and outcome of treatment compare to HPV negative oropharynx. It had been stratified as difference disease in latest 8th AJCC classification and represented favorable prognosis of disease outcome. De-escalating treatment strategy had been explored in this selected population. However, latest two phase III randomized control study in HPV-related locally advanced oropharynx SqCA; RTOG 1016 (1) and De-ESCALaTE trial (2) had been conducted to compare the efficacy of concurrence cetuximab vs. high-dose cisplatin with radiation. The result of those 2 studies had consistent and shown superiority of high-dose cisplatin in term of progression-free survival and overall survival. However further de-escalating strategy in early stage HPV-related SqCA has been currently conducted. 

Another effort to personized treatment is using plasma EBV viral load, the significant prognostic biomarker in nasopharyngeal carcinoma (NPC). Detectable plasma EBV viral in locally advanced NPC patient after complete radiation was explored to define benefit of adjuvant 6 cycle of gemcitabine plus cisplatin compare to surveillance but didn’t demonstrate difference in relapse-free survival (3). Various efforts of personalized treatment such as immunomodulatory agent and targeted therapy guided by biomarker-driven might be novel treatment paradigm in head and neck cancer. 

Reference; 

  1. Gillison ML, Trotti AM, Harris J, Eisbruch A, Harari PM, Adelstein DJ, et al. Radiotherapy plus cetuximab or cisplatin in human papillomavirus-positive oropharyngeal cancer (NRG Oncology RTOG 1016): a randomised, multicentre, non-inferiority trial. Lancet. 2019;393(10166):40-50.
  2. Mehanna H, Robinson M, Hartley A, Kong A, Foran B, Fulton-Lieuw T, et al. Radiotherapy plus cisplatin or cetuximab in low-risk human papillomavirus-positive oropharyngeal cancer (De-ESCALaTE HPV): an open-label randomised controlled phase 3 trial. Lancet. 2019;393(10166):51-60.
  3. Chan ATC, Hui EP, Ngan RKC, Tung SY, Cheng ACK, Ng WT, et al. Analysis of Plasma Epstein-Barr Virus DNA in Nasopharyngeal Cancer After Chemoradiation to Identify High-Risk Patients for Adjuvant Chemotherapy: A Randomized Controlled Trial. J Clin Oncol. 2018:JCO2018777847.

HEAD & NECK CANCER (RADIOTHERAPY)

Poompis Pattaranutaporn, MD

Department of Radiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand


SYNOPSIS

Radiotherapy has a significant role in head and neck cancer treatment both in early and locally advanced stages. In the last decade, advanced radiation techniques with sophisticated individualized planning such as IMRT or VMAT are accepted as standard of care, which could improve local control and decrease long-term complications compared to conventional radiotherapy. Advance in image-guidance system of radiotherapy machines make a significant improvement in accuracy and precision of radiation delivery which allow radiation to be delivered in smaller margin and more of normal tissue could be spared. However, radiation therapy with x-ray beam is almost reached its physical properties limitation. Proton and other particles are now emerging, and size and cost of the machine are reduced, making it more available in hospitals and cancer centers. With its special property called Bragg’s Peak, it could deliver a higher dose of radiation to targets while decreasing radiation dose to surrounding organs. Not only the machine but planning system is also improved. Better tumor visualization with better oncologic imaging such as MRI and PET/CT are more available and used in clinics. Biologic and physiologic imaging such as hypoxic imaging with PET/CT are used to identify the area for dose escalation. There is more evidence coming to prove the benefits of the advanced imaging. 

Since head and neck cancer treatment is required multidisciplinary approach, there is no one best treatment for all patients. The selection of modalities is now could be more individualized based on information of biologic and genetic markers such as overexpression of p16 status. However, these bio-molecular testing might not represent the behavior of the whole tumors. With the advancement of imaging technologies, computer sciences and data sciences, there is emerging approach called “Radiomics” which objectively measures the phenotypic expression of tumors by extracting features from imaging studies. It is now in a beginning stage but the early results are promising.


HEAD & NECK CANCER

Warut Pongsapich, MD

Faculty of Medicine Siriraj Hospital/ Mahidol University, Bangkok, Thailand


SYNOPSIS

Nowadays, robotic system becomes a novel device in operative frontier to combat against many diseases including head and neck cancer. Although, overall incidence of upper aero-digestive tract tumors seem to be slightly decreased, but that of oropharyngeal tumor seems rather to be increased. The epidemiological pattern was explained by reduction of alcohol and smoking consumption but an increase in HPV-related carcinoma.

According to data from the 1990s, chemoradiotherapy treatment of oropharyngeal cancer could yield equivalent oncological outcomes, when compared to classical open surgery, with less morbidity. Nevertheless, the disadvantages of non-operative treatments are severe mucositis, gastrostomy and/or tracheostomy dependence.

Following FDA clearance of transoral robotic surgery (TORS) in 2009, the trend of T1/T2 oropharyngeal cancer feasibly returns to surgical resection. The primary aim of TORS is to provide adequate local disease control with appropriate functional outcomes, good quality of life, and cosmetic. The procedure may be an alternative to non-surgical modalities, particularly for patients intolerable to drugs toxicity or morbidity associated treatments. Whilst, TORS is also an ideal for salvage therapy in residual/recurrent diseases. Thus, robotic surgery in head and neck surgery is much beneficially attributed to its minimally invasive nature, with lower rate of complications, such as radiation-related mandibular necrosis, carotid exposure, and orocutaneous fistula.

Up until now, TORS has been operated in more than 40 patients in Siriraj Hospital. Most of the patients were diagnosed with oropharyngeal or supraglottic cancer. Preliminary data showed one serious surgical associated event which was delayed postoperative bleeding. No patient requires additional tracheotomy after TORS, while only few of them need long term gastric feedings. Moreover, the oncological outcomes were comparable to standard treatment protocols.

A number of publications confirm the critic role of TORS as a novel modality for surgical treatment of head and neck cancer. Additionally, knowledge sharing, team training, and technology refinement are essential for quality improvement of surgical outcomes. Hence, a comprehensive understanding from both our own perspective and relating specialties is crucial for the multidisciplinary team approach.

Event Hours(1)

  • Lotus 3-4.

    01:00 pm – 02:30 pm

    Speakers:
    1. Dr. Chanida Vinayanuwattikun (CU)
    2. Dr. Nuttapong Ngamphaiboon (Rama)
    3. Dr. Poompis Pattaranutaporn (Rama)
    4. Asst. Prof. Warut Pongsapich (SI)

    Moderator:
    Dr. Nuttapong Ngamphaiboon (Rama)