p16+/HPV+ Tonsil and Base of Tongue Cancer

• Understanding the disease
• Treatment options
• Side effects of treatment

Stephen Shamp, MD MSEE

David Bloom, MD PhD

Matthew Culbert, MD

Tonsil

Tonsil

Base of Tongue

There are multiple lymph nodes in the head and neck area

HPV Left Tonsil Cancer

Photo

PET Scan

50 yo non-smoker, white male present with a lump in his left neck and the PET scan as noted

HPV = Human Papillomavirus

Most HPV infections don't lead to cancer but certain types of HPV infection cause cancers. More than 100 varieties of human papillomavirus (HPV) exist.

HPV is a very common virus; nearly 80 million people—about one in four—are currently infected in the United States. 

HPV Types

Dramatic Rise in HPV + Tonsil Cancer

HPV Most Common

Smoking Less Common

Vaccine to Prevent HPV

Since mid-2006, a licensed human papillomavirus (HPV) vaccine has been available and recommended

​

CDC analyzed data from the 2007–2013 National Immunization Survey-Teen (NIS-Teen) and national post licensure vaccine safety data among females and males.

​

Vaccination coverage with ≥1 dose of any HPV vaccine increased significantly from 53.8% (2012) to 57.3% (2013) among adolescent girls and from 20.8% (2012) to 34.6% (2013) among adolescent boys.

MMWR July 25, 2014 / 63(29);620-4

Survival for Tonsil Cancer

HPV +

HPV -

Survival much better

Staging

www.nccn.org

Treatment options, T1-2 N0 Stage 1

Treatment options, T0-2 N1 (single <3cm) Stage 1

Treatment options with N2 or bulky or multiple N1

Treatment options, N3 Stage 3

CT simulation (planning session)

• We will build a face mask to hold you in the same position with each treatment.
• Marks will be made on the mask
• CT images are obtained and then imported into the treatment planning computer
• Your other imaging including PET/CT may be fused to allow for targeting of the tumor(s)
• If you have a thick beard it will have to be shaved

​

RapidArc IMRT Radiation Plan

We will create a customized radiation plan to target high doses of radiation where it is needed while minimizing radiation to nearby uninvolved structures to reduce side effects and risks.

​

For many head and neck cancers nearby uninvolved lymph nodes are targeted as well, sometimes with lower doses of radiation. Sometimes on both sides of your neck

Logistics of radiation treatment:

• Usually 30-35 daily treatments, starting the same day as chemotherapy (if recommended).
• Treatment days are Monday-Friday 5 days per week, 6-7 weeks in total
• Daily treatment takes 15 minutes or less. You will be given a schedule
• You do not feel anything during treatment, you will not be radioactive, you are allowed to drive yourself to and from treatment if you are currently allowed to drive

• Lasers and daily CBCT imaging is used to precisely deliver the daily radiation treatment.
• Expect to be on the treatment table less than 15 minutes.
• You will not feel any immediate effects.

With IG-IMRT A CT scan is performed daily prior to every treatment so that if the tumor changes position or shrink rapidly, the radiation target can be adjusted, this is referred to as ‘adaptive’ therapy

Side Effects of Head and Neck Radiation

Side effects will relate to the size and location of the radiation field and the normal structures that are in the way of the beam

Short Term Side Effects of Radiation to the Throat/Tonsil and Neck

1. Fatigue
2. Skin irritation
3. Dry Mouth
4. Poor taste
5. Thick mucus
6. Sore throat and problems with swallowing and dehydration and possible need for a feeding tube
7. Pain management problems

Radiation Dermatitis (skin burn)��almost everyone gets a sun burned reaction in the face or neck and creams are required (like Aquaphor and Silvadene)

Radiation Dermatitis

Last day of treatment

2 months later

The mucus membranes in the area near the radiation treatment can get irritated, usually towards the end of treatment, particularly when combined with chemotherapy. Most patients need numbing or pain medication for this phase. Some may even need a feeding tube

Mucositis

Mucositis – same patient two months later, soreness gone, mouth still somewhat dry, and taste improving

​

Long Term Side Effects of Radiation to the Throat and Neck

1. Mouth dryness may be permanent, depending on the amount of saliva glands in the field
2. Teeth may be vulnerable to decay, and caution is need with future dental care to avoid jaw bone problems (osteonecrosis)
3. Some patients have long term problems with swallowing or taste
4. Some patients have persistent hoarseness
5. Risk of low thyroid (daily pill to replace)
6. Carotid stenosis
7. Rare but serious complications including but not limited to secondary malignancy, osteoradionecrosis, bleeding, injury to muscles, nerves, bones

Long Term Effects of Radiation on the Teeth

If the teeth have received a high dose of radiation and later require surgical removal it may be necessary to take special precautions by the dentist or oral surgeon to ensure proper healing (like hyperbaric oxygen)

​

The dose to be concerned about is 50Gy to the mandible and 55Gy to the maxilla

Follow-up

Follow-up varies by site and stage.

• Most patients will be followed by their ENT with serial exams, usually with laryngoscopy as well
• Radiation works slowly, so usually we wait 3-4 months until getting a PET/CT if indicated
• Some patients will be followed with further imaging as well

Patient Results

Imaging and Exam

Head and Neck Cancer

Stage IVA Squamous Cancer Before and After ChemoRadiation

First Pet Scan (yellow is cancer) 2 Months after Completing Radiation

IMRT for Squamous Cancer of the Tonsil

PET Scan Before after Chemo-Radiation

nodes

Base of tongue

nodes

Back to normal by 3 Months

Tonsil Cancer after Radiation plus Erbitux

3 Months

Diagnosis

2 Years