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TRATAMIENTO EN CANCER DE

OROFARINGE
1
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Cáncer de orofaringe
Base de lengua, Amigdala, paladar duro, pared faringea posterior

Ganglios
+/factores •RT
Cirugía (exsición ipsi o riesgo
bilateral de cuello)
ECC
Márgenes +
 T1,T2/N0-1 •RT/QT

Residual Cirugía/
RT sitio primario
Recurrente salvamento

T2N1 = QT/RT si hay recurrencia:


cirugía de salvamento

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Cáncer de orofaringe
Base de lengua, Amigdala, paladar duro, pared faringea posterior

Enfermedad Cirugía/
QT/RT salvamento
Residual

Cirugía ECC
Márgenes + •RT/QT
 T3,T4/N0-1

Residual Cirugía/
QT inducción + RT
Recurrente salvamento
QT/RT

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 Primario + adenopatías macroscópicas:
 66-74Gy (convencional)

 fraccionamiento alterado: 6 fracciones/semana 66-74


Gy en enfermemdad macroscopica y 44-64 Gy
enfermedad subclinica

 BOOST acelerado 72 Gy/6 semanas 1.8Gy/fx y en los


ultimos 12 dias una segunda fraccion diaria de 1.5 Gy

 Hiperfraccionado 81.6Gy/7 semanas 1.2 Gy 2 veces al


dia

RT post operatoria
•Iniciar 6 semanas PO
•1rio: 60-66 Gy
•Involucro ganglionar: 60-66 Gy
•Cuello sin involucro ganglionar: 44-64 Gy

QT/RT enfermedad irresecable


•1rio y adenopatías macroscópicas: 70Gy
•Cuello sin involucro ganglionar: 44-64 Gy
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Oropharynx Staging: AJCC7th vs. 8th Editions
• Main purpose of revised 8th Edition staging was primarily to align HPV-
associated (HPV+) case staging with good prognosis of disease comparedto
HPV-negative (HPV-) cases. Secondary purpose was to incorporate the
impact of ENEon prognosis in HPV-cases.
• Why was this necessary?
• Epidemic of HPV+ oropharynx cases (70-80%) inUS
• Rapid rise of incidence over past 20years
• Prognosis of HPV+ cases exceeds tobacco-associated cases by about 15-20%
• Using the 7th Edition staging system for HPV+ cases, outcomes for stages I-IVA were
similar.
• The 8th Edition delineates clinical and pathologic factors that actually correlate with
changes in prognosis in HPV+ cases, and eliminates consideration of factors that do
not correlate with prognosis.
ORPH-1 CANCER DE OROFARINGE

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ORPH-2 CANCER DE OROFARINGE T1-T2 N0-1 P16 NEGATIVO

ORPH-A

SURG-A

CHEM-A

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ORPH-3 CANCER DE OROFARINGE T3-T4 N0-1 P16 NEGATIVO

SURG-A

CHEM-A

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ORPH-4 CANCER DE OROFARINGE CUALQUIER T N2-3 P16 NEGATIVO

SURG-A

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ORPHPV-1 CANCER DE OROFARINGE T1-T2 N0-1 P16 POSITIVO

ORPH-A

SURG-A

CHEM-A

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ORPHPV-2 CANCER DE OROFARINGE T3-T4 N0-1 P16 POSITIVO

SURG-A

CHEM-A

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ORPHPV-3 CANCER DE OROFARINGE CUALQUIER T N2-3 P16 POSITIVO

SURG-A

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ORPH –B PRINCIPIOS DE LOS TEST P16/VPH EN CANCER OROFARINGEO

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FOLL-A 1 RECOMENDACIONES POST QUIMIOTERAPIA Y RADIOTERAPIA

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FOLL-A 2 RECOMENDACIONES POST QUIMIOTERAPIA Y RADIOTERAPIA

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ADV-1 RECOMENDACIONES PARA CANCER DE OROFARINGE AVANZADO

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ADV-2 RECOMENDACIONES PARA CANCER DE OROFARINGE AVANZADO
METASTASIS A DISTANCIA

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ADV -3 RECOMENDACIONES PARA CANCER DE OROFARINGE AVANZADO
RECURRENTE O PERSISTENTE

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ADV -4 RECOMENDACIONES PARA CANCER DE OROFARINGE AVANZADO
RECURRENTE O PERSISTENTE CON METASTASIS A DISTANCIA

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ORPHA-1 PRINCIPIOS DE RADIOTERPIA

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ORPHA-2-2 PRINCIPIOS DE RADIOTERPIA

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SURG-A PRINCIPIOS DE CIRUGIA

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SURG-A PRINCIPIOS DE CIRUGIA

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SURG-A PRINCIPIOS DE CIRUGIA

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SURG-A PRINCIPIOS DE CIRUGIA

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SURG-A PRINCIPIOS DE CIRUGIA

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CHEM-A1 PRINCIPIOS DE QUIMIOTERAPIA

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CHEM-A2 PRINCIPIOS DE QUIMIOTERAPIA

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Oropharyx: Volumes and Doses
• GTV70 is determined by multi-modality imaging (CT/PET/MRI)
• CTV70 is 5-7 mm expansion depending on clarity of GTVdelineation
• PTV70 is 3 mm expansion, assuming daily IGRT
• CTV63 is 5 mm expansion, plus inclusion of lymphatic region relatedto
primary location
• PTV63 is 3 mm expansion
• Clinically involved nodes treated to 70 Gy
• Typically cover levels II-IV, IB only if bulky level II involvement or tumor
extends to oral cavity. Retropharyngeal and retrostyloid coverage to be
discussed later.
• Nodal region doses as discussed in the last section
Definitive Oropharynx: Ipsilateral vs.bilateral
• Tongue base and soft palate are MIDLINE structures and require
bilateral RT/chemoRT
• Tonsillar cases are eligible for consideration for ipsilateral RT. How to
select?
• No T3-T4
• No more than 1 cm extension to softpalate
• No more than minimal, superficial extension to lateral tongue base
• Nodal burden is not excessive enough to cause retrograde lymphaticflow
• No bulky adenopathy—this is a judgement call (some allow single node <3 cmonly)
• No clinical ENE
Trans-Oral Robotic Surgery (TORS)/
Trans-Oral Laser Microsurgery (TLM)
• Substantial advance on previous mandible-splitting techniques
• Provides en-bloc resection of primary tumor with oncologic margins and
primary closure
• Usually accompanied by a conventional neck dissection
• Lower morbidity and faster recovery than previous surgicalapproaches
• Intent of TORSis to provide equal tumor control to definitive
RT/chemoRT with less toxicity
• This requires careful patient selection relying on the ability to predict the
post-TORS pathology report in advance
• The fundamental comparison is between TORSand the non-surgical
alternative
TORS,cont.
• Which patients are NOTeligible forTORS?
• Surgery will cause major functional deficits
• T3-T4 primaries
• More than minimal soft palateextension
• Central tongue base tumors
• Medical contra-indications
• Trismus or other difficulties with exposure
TORS,cont.
• For the rest, the post-TORS pathology report willresult in 3 possible
risk groups:
• Low-risk—This means no further treatment indicated (“homerun”)
• pT0-2N0-1 using AJCC7th edition
• Lowest possible toxicity for any curativeapproach
• Intermediate risk—This means postoperative RTalone to 60 Gyindicated
(“base hit”)
• pT3-4, PNI, LVSI, close margin, 2 or more involved nodes
• Combined toxicity of TORSand 60 Gy is roughly similar to definitive RTor chemoRT to 70
Gy
• High risk—This means postoperative chemoRT to 66 Gy (“strike out”)
• Positive margins or ENE
• Combined toxicity of TORSand 66 Gy chemoRT exceeds chemoRT to 70 Gy w/o TORS
TORS: Implications of Future TrialResults
• ECOG3311
• If the intermediate risk group results show postop RTat 50 Gy is equal to 60
Gy, this would tilt the balance in the comparison towards TORSfor this group
(TORS+ 50 Gy vs. RTor chemoRT to 70 Gy)
• NRGHN002 or following phase III study
• If definitive RTalone or chemoRT to 60 Gy is equivalent to 70 Gy, then this
would tilt the balance in the comparison towards definitive RT/chemoRT
Oropharynx Guideline Document