ILL EFFECTS OF RADIOTHERAPY IN THE MANAGEMENT OF ORAL CANCER

byDr kashif ali

Assistant professor

ORAL CANCER

Approximately 90% of oral cancer is SCC

Particularly common in developing world

Multifactorial etiology life styleHabits and

dietOthers

Other1%

Leukemias5%Lymphomas

9%

Salivary gland tumours

7%

Squamous cell carcinomas

78%

Head & Neck Cancer Diagnosis

Squamous Cell Carcinoma

• 90% of all oral cancers• 50% 5-year survival• can occur in: • tongue• skin• throat• soft palate

Treatment plan is based on:

• anatomical considerations

Treatment plan is based on:

Staging of disease using TNM classification

Eg. T3N2M0 laryngeal carcinoma

T = Tumour sizeN = Nodal statusM = Metastases

Treatment Options

Primary surgery Primary Radiotherapy

+/- +/-

Adjuvant Radiotherapy

Surgery for Salvage

+/-+/-

Concurrent Chemotherapy

Concurrent Chemotherapy

OR

Aims of radiotherapy

Radical radiotherapy --- curative intent

Palliative radiotherapy --To control symptoms

Radiation Therapy

External beam–most common–largest fields

Radiation Therapy

Brachytherapy–interstitial implantation of

radioisotope-filled needles

Radiation Therapy

Au grain or Iridium Implants

Radiation

• How much?

• Where?

How much radiation?

1 “rad” = 1 centiGray (cGy)

200 cGy per day 5 days per week 1000 cGy per week

How much radiation?

Total dose ranges from 6000 cGy – 7000 cGy

6 – 7 WEEKS of treatment

ORAL CANCERTREATMENT MODALTIES

Ablative Surgery Surgery and / or radiotherapy Radiotherapy and Chemotherapy

ORAL CANCERRADIOTHERAPY

Advantages Normal Anatomy and function Is maintained GA not needed Can be used to debulk inaccessible

lesions

ORAL CANCERRADIOTHERAPY

Conventionally upto 60 Gys dose is given

Post radiotherapy complaints increase tremendously when the radiation dose is increased

ORAL CANCERRADIOTHERAPY

ill effects Oral mucositis Xerostomia Loss of tasteOsteoradionecrosis

Oral mucosaSeen in 1-2 weeksErythema with sever mucositis With or without ulcerationPain and disphagiaLoss of test- test bud atrophyDelayed healing Pale and less vascular mucosaRadiotherapy induced Submucous

fibrosis

ORAL CANCERRADIOTHERAPY

Salivary glands

1st week of radiotherapyXerostomia Difficulty in swallowing Nasua Rampant cariesPeriodontitisRecovery 3 to 4 months

Management

Sipped of water Salivary substitute Mucous based sprays -saliva orthane

sprayCellulose --- glandosane, glycerin Pilocarpine hydrocloride 5mg QIDCevimelive hydroloride 30mg TDSStimulation of exocrine gland

Skin

Erythema 3rd weekDose greater than 50 gy Healing 7 to 10 days

Bone

OsteoradionecrosisIs devitilization of bone after

cancericidal dose of radiationEndarteritis Bone turn over become slow,

remolding dose not occur leads to exposed bone

ORAL CANCERRADIOTHERAPY

ORAL CANCERRADIOTHERAPY

ORAL CANCERRADIOTHERAPY

ORAL CANCERRADIOTHERAPY

Other effects

Alteration of floraInc anaerobic speciesInc fungi , Candida Nystatin0.1% chlorexidine

Late effects of radiation

Eyes Cataract 10 gyBlindness 50 gySpinal cord Paraplegia dose Inc 45gyCarotid artery stenosis

ORAL CANCERRADIOTHERAPY

Conclusion Surgery is the first choice Surgery may be followed by

Radiotherapy or Chemotherapy if required

Where bone is involved, Radiotherapy / Chemotherapy do not work

Radiotherapy / Chemotherapy alone only work as palliative therapy

Radiotherapy must be done under the supervision of experienced oncologist

ORAL CANCERRADIOTHERAPY

THANK YOU

Evaluation of dentition before radiotherapy

Most feared side effect is ORN Factor determine the fate of teeth1. Condition of residual dentition-- ?2. Pt awareness – past care pt with good oral hygiene , the

clinician must retain as many of teeth as possible

Neglected oral health --ext

Factor determine the fate of teeth

3 Immediacy of radiotherapy

4 Radiation location Pre radiation ext considered 1- 2 week

delay radiation5 Radiation doseInc 50 GY--- ext indicated Less than 50 – conservative

Preparation of dentition for radiotherapy

Pre radiation Restorations Topical fluoride applicationOral hygiene measures and

instructionsPrevention of mechanical trauma Encourage to stop habitts

Preparation of dentition for radiotherapy cont

Per radiation Rinse mouth with saline at least 10 times

daily Chlorhaxidine mouth wash 2 times Dental evaluation twice a week during

radiotherapy If overgrowth of candida than nystatin /

clotimazole Exercise – maintain mouth opening Weight loss should be checked NG tubes

Post radiationRegular follow up every 3- 4 weekTopical fluoride

Method of preparing preirradiation extraction

atraumatic extraction Interval B/w preirradiation ext and

beginning of radiotherapy 7-14 days 3 weeks if possible

Impacted 3rd molar removal before radiotherapy

Partially erupted Complete embedded

Carious teeth after radiotherapy

Treatment accordingly Composite , amalgamNecrotic pulp __ RCTIf RCT is difficult – amputation above

the gingiva left at place

Tooth ext after radiotherapy

4 month gap HBO before and after ext 20- 30 dives

Denture after radiation

Yes Soft liners