Overview                                                                   

The Head and Neck region is comprised of a large number of tissues and organs.  Major components include the oral cavity (mouth), oropharynx, nasopharynx, supraglottic and glottic larynx (“voice box”), and hypopharynx.

Multiple sinuses are included in the head and neck region including the frontal, ethmoid, sphenoid, and maxillary sinuses.  Various glands are located in this region as well including the thyroid gland and salivary glands.

Head and Neck cancers comprise approximately 3% of all cancers, with nearly 40,000 new cases diagnosed each year in the United States.  A major tumor site is the larynx (12,000 new cases), predominantly arising in the vocal cords followed by the supraglottic larynx. 

Hypopharyngeal and nasopharyngeal tumors account for approximately 2500 and 2000 cases each year in this country, respectively.  Outside the United States, nasopharyngeal cancer is more common, particularly in Asia and South Africa.

Head and Neck cancers present with a wide spectrum of signs and symotoms, depending upon the organs involved and the tumor extent.  Early larynx (voicebox) tumors may present with symptoms of hoarseness, more advanced tumors may impair swallowing.  Tumors of the mouth (oral cavity) typically present with an ulcer and pain, sinus tumors may present with nasal stuffiness or nasal bleeding (epistaxis). 

A common site of spread is to the regional (neck) lymph nodes.  Tumors arising on one side preferentially spread to the same side of the neck.  Centralized tumors, as well as more advanced lesions, may result in lymph node involvement on both sides of the neck.  In some patients, an enlarged lymph node in the neck is the one and only presenting symptom and the primary tumor is never found (“unknown primary”). 

Interested in learning more about head and neck cancers? Check out the American Cancer Society website.

Role of Radiation Therapy                                     

In many head and neck cancer patients with early stage tumors, the treatment of choice is surgery.  Radiation therapy is used following surgery in patients found to have “high risk” features, for example involved (positive) tumor margins and spread to regional lymph nodes.  In many head and neck cancer patients, Radiation therapy may be used alone or, more commonly today, combined with chemotherapy (view paper).

In some early stage head and neck cancer patients, the treatment of choice may be radiation instead of surgery.  For example, small tumors of the vocal cords are preferably treated with radiation since radiation therapy is associated with better voice quality than surgery (view paper). One head and neck tumor site in which surgery is never the treatment of choice, even in patients with early stage disease, is the nasopharynx.

Radiation Therapy has long been the treatment of choice in patients with locally advanced disease.  In such patients, radiation therapy is typically delivered combined with chemotherapy [link to Head Neck Paper C].  Such patients may also undergo surgery prior to or following radiation.

Radiation Therapy Techniques                              

For many years, the standard approach in the majority of head and neck cancer patients involved opposed lateral fields encompassing the primary tumor sites and regional (neck) lymph nodes.  While effective, this approach commonly resulted in considerable toxicity due to the irradiation of the salivary (parotid) glands.  Consequently, many patients treated with such techniques suffered with long-term dry mouth (xerostomia). 

Today, opposed lateral fields have given way to a more sophisticated approach to radiation therapy known as intensity modulated radiation therapy (IMRT).  Unlike conventional approaches, IMRT conforms the radiation dose to the shape of the target tissues in 3-dimensions, reducing the dose delivered to the nearby normal tissues including the salivary glands.  IMRT has been shown to be associated with excellent outcomes with less damage to the salivary glands.

IMRT Plan in a patient with a right tonsil cancer

IMRT is the standard approach in all head and neck cancer patients treated at UCSD.

Simultaneous Integrated Boost (SIB)                                             

IMRT provides the ability to not only conform the radiation dose to the shape of the target thereby reducing dose to normal tissues, it also allows the radiation oncologist to deliver different doses each day to different parts of the target. This approach is known as a simultaneous integrated boost (SIB). 

The SIB approach provides the ability to deliver higher than conventional doses safely to the tumor and involved lymph nodes while reducing the overall treatment course.  Patients treated in this fashion are able to complete treatment faster than patients treated with conventional techniques.  Not only is treatment delivered faster, it is more effective than standard approaches.

Amifostine (Ethyol)                                      

While IMRT significantly reduces the risk of dry mouth (xerostomia) in head and neck cancer patients undergoing radiation therapy, in many patients, for example patients with large (bulky) lymph nodes adjacent to the salivary glands, it is not always possible to avoid high doses to the salivary glands.  In these patients, dry mouth is unfortunately still a common concern. 

At UCSD, such patients are treated with a combination of IMRT and a drug known as amifostine (ethyol).  Amifostine belongs to a group of drugs called cytoprotectants, which protect normal tissues from some of the side effects caused by some treatments for cancer, including radiation. 

Amifostine provides these protective effects after being broken down (metabolized) in the body.  Through various chemical reactions, the metabolites of amifostine deactivate molecules that result in tissue damage from radiation. 

Healthy cells are preferentially protected since amifostine and its metabolites are taken up significantly better by healthy than tumor cells.  This preferential uptake is why amifostine is unlikely to protect the tumor itself from radiation.

Amifostine is typically administered intravenously (into a vein).  Amifostine is given approximately 15-30 minutes priot to radiation.  Because low blood pressure may result, patients receive the drug lying down, have their blood pressure frequently monitored and may receive intravenous fluids.

To learn more about Ethyol (Amifostine), patients can consult the MedImmune website and/or the Package Insert.

UCSD Head and Neck Cancer Team                                

The UCSD Head and Neck Cancer Team is comprised of dedicated professional with considerable experience in the treatment of patients with head and neck malignancies. 

Ajay Sandhu M.D. is the Chief of the Head and Neck Cancer Service in the UCSD Department of Radiation Oncology.

Ajay Sandhu, M.D. Chief, Head and Neck Cancer Service Department of Radiation Oncology

Dr. Sandhu has considerable experience in the treatment of head and neck cancer patients with the latest radiotherapy techniques including IMRT and image-guided radiation therapy (IGRT).

Working with Dr. Sandhu in the Department of Radiation Oncology is Radiation Nurse, Polly Nobiensky, R.N.

Polly Nobiensky, R.N., B.S.N. Radiation Nurse Department of Radiation Oncology

The treatment of Head and Neck cancer patients is a team approach. Dr. Sandhu thus works together with other specialists including Robert Weisman, M.D. and Kevin Brummond, M.D.(ENT Surgeons) and William Read, M.D. (Medical Oncology).

All patients consulted at UCSD are presented and discussed at a multi-disciplinary Head and Neck Cancer Conference.

Robert Weisman, M.D. ENT Surgeon

Kevin Brumund, M.D. ENT Surgeon

William Read, M.D. Medical Oncologist

Head and Neck Cancer Publications by UCSD Radiation Oncology Faculty        

Listed below are Head and Neck Cancer Articles published by members of the UCSD Department of Radiation Oncology.  For a full list of published articles by UCSD Radiation Oncology faculty see Research section.

Daly ME, Lieskovsky Y, Pawlicki T, et al. Evaluation of patterns of failure and subjective salivary function in patients treated with intensity modulated radiotherapy for head and neck squamous cell carcinoma. Head Neck 2007;29:211

Yao M, Epstein JB, Modi BJ, Pytynia KB, Mundt AJ, et al. Current surgical treatment of squamous cell carcinoma of the head and neck. Oral Oncol 2007;43:213

Loo BW, Draney MT, Sivanandan R, Ruehm SG, Pawlicki T, et al. Indirect MR lymphangiography of the head and neck using conventional gadolinium contrast: a pilot study in humans. Int J Radiat Oncol Biol Phys 2006;66:462

Agulnik M, Rhee EN, Yao M, Mundt AJ, et al. Paclitaxel, carboplatin and concomitant radiotherapy for resected patients with high risk head and neck cancer. J Chemother 2005;17:237

Modi BJ, Knab B, Feldman LE, Mundt AJ, et al. Review of current treatment practices for carcinoma of the head and neck. Expert Opin Pharmacother 2005;6:1143

Sharp GC, Kollipara S, Madden T, Jiang SB. Anatomic feature-based registration for patient setup in head and neck cancer radiotherapy. Phys Med Biol 2005;50:4667

Pawlicki T, et al. Lens Dose in MLC-Based IMRT Treatments of the Head and Neck. Int J Radiat Oncol Biol Phys 2004;59:293

Sandhu AP et al. Subclinical thyroid disease after radiation therapy detected by radionuclide scanning. Int J Radiat Oncol Biol Phys 2000;48:181

Lapeyre M, Hoffstetter S, Peiffert D, Guerif S, Maire F, Dolivet G, Toussaint B, Mundt AJ, et al. Postoperative brachytherapy alone for T1-2 N0 squamous cell carcinomas of the oral tongue and floor of mouth with close or positive margins. Int J Radiat Oncol Biol Phys 2000;48:37

Sandhu APS et al. Interstitial iridium-192 implantation for recurrent and/or locally advanced head and neck cancer. Clin Oncol 1999;11:371

Roeske J, Kuchnir F, Mundt AJ, et al. Photon and electron field matching in the treatment of tumors of the paranasal sinuses: a case report.  Med Dosim 1996;21:31

Saw CB, Pawlicki T, et al. Dose volume analysis of a commercially fabricated nasopharyngeal applicator. Endocuriether/Hyperther Oncol 1994;10:35

Sandhu APS, et al. Carcinoma of the larynx in Northern India: clinical spectrum and results of treatment. J Otolaryngol 1994;10:194