Case Study

-Courtney Chaney

Patient Information
White
62

Male

Years of Age

Social History

1 of 5 kids

Married

Father of one - Son

Retired

Lives in Cardington, Ohio

Never Smoked or used smokeless tobacco

Doesnt Drink

Medical History

Family History

Swelling, mass, or lump

in head and neck

Neck mass

Alzheimer, Prostate
Cancer, Diabetes, and
heart Disease - Father

Enlarged cervical
lymph nodes

Essential hypertension,
benign

Bleeding Stomach ulcer

- related to use of
Naprosyn

No known problems Mother

No known problems of
either Sister

No known problems Son

Surgical History

Foot fracture surgery Left foot in 2006

Tumor resection and biopsy left neck

Bilateral tonsillectomy

Lymphadenectomy - cervical

Abdominal surgery
-related to bleeding ulcer from Naprosyn

Presenting Signs & Symptoms

Weight Loss

Increase of Snoring

Tinnitus

severe pain

Trismus (spasm of the jaw muscles, causing the mouth to

remain tightly closed)

Consistent Sore throat

Enlarged Cervical Lymph Nodes

A lump in the back of the mouth, throat, or neck

Dysphagia

Odynophagia

Voice Change

Shortness of breath

Sometimes There are no symptoms

Otalgia

Hemoptysis

Pathology

Malignant neoplasm of junctional region of oropharynx

Squamous cell carcinoma of left glossal tonsillar sulcus (HPV+)

pT1N2bM0

Stage 4a

Grade 3

Anatomy & Physiology

Tonsils are part of the

oropharynx, which is the part
of the throat located at the
back of the mouth.

Glossotonsillar sulcus is the

bottom part of the palatine
tonsil where it blends into the
lingual tonsil tissue. It is
basically an area between the
tonsil and the base of tongue.

Glossotonsillar

Tonsils are the ball-shaped

structures at the back and on
the sides of the throat made up
of lymphoid tissue (tissue that
has infection-fighting cells).

Epidemiology

0.5% of all malignancies in the US are tonsillar

Head and neck squamous cell carcinomas are the sixth most common
malignancy worldwide

Tonsils are the most common site of malignancy within the oropharynx

Affect more men than women, 4.4/1

Develop in the fifth decade of life or later

Oropharyngeal cancers associated withHPV tend to occur in younger,

non-smoking individuals

HPV tumors behave differently than oropharyngeal cancers not

associated with HPV and have improved outcomes with current
treatment strategies

Etiology

Tobacco Use

Excessive Alcohol Use

HPV

Genetic Factors

Previous Exposure to Radiation

previous disease treatment

Lifestyle and Dietary Factors

Deficiencies in vitamins

poor oral hygiene

Drinking mate stimulant South American drink

Chewing betel quid Asian nut

Histopathology

Squamous cell carcinoma:

most common
arise from cells lining the oropharynx
divided into two main types HPV positive or HPV negative

Salivary gland cancers:

arise from minor salivary glands under the lining of the throat

include diagnoses such as mucoepidermoid carcinomas,

adenocarcinomas and adenoid cystic carcinomas

Lymphoma:
arise from lymphoid cells

Mucosal melanoma:
cancers from skin cells that give skin its color
rare

AJCC Staging

Tumor Staging:

Tx: Primary tumor cannot be assessed

T0: No evidence of primary tumor

Tis: Carcinoma in situ

T1: Tumor 2 cm in greatest dimension

T2: Tumor >2 cm but < 4 cm in greatest dimension

T3: Tumor >4 cm in greatest dimension

T4a: Tumor invades the larynx, deep or extrinsic muscles of the tongue, medial pterygoid muscle, hard palate, or
mandible

T4b: Tumor invades the lateral pterygoid muscle, pterygoid plates, lateral nasopharynx, skull base, or encases carotid
artery

Nodal involvement:

Nx: Regional lymph nodes that cannot be assessed

N0: No regional node metastasis

N1: Metastasis in a single ipsilateral lymph node, 3 cm or smaller

N2: Metastasis in a single ipsilateral lymph node, larger than 3 cm but not larger than 6 cm in greatest dimension is
found; multiple ipsilateral lymph nodes, none larger than 6 cm; bilateral or contralateral lymph nodes, none larger than
6 cm

N2a: Metastasis in a single ipsilateral lymph node larger than 3 cm but not larger than 6 cm

N2b: Metastasis in multiple ipsilateral lymph nodes, none larger than 6 cm

N2c: Metastasis in bilateral or contralateral lymph nodes, none larger than 6 cm

N3: Metastasis in a lymph node larger than 6 cm

Distant metastasis:

Mx: Distant metastasis cannot be assessed

M0: No distant metastasis

M1: Distant metastasis

Staging

Stage 0 (Carcinoma in Situ) - abnormal cells are found in the lining of the oropharynx.

Stage I - cancer has formed and is 2 centimeters or smaller and is in the oropharynx
only

Stage II - cancer is larger than 2 centimeters but not larger than 4 centimeters and is
found in the oropharynx only.

Stage III - cancer is either:

- 4 centimeters or smaller and spread to one lymph node on the same side of the
neck as the tumor and the lymph node is 3 centimeters or smaller
- larger than 4 centimeters
- spread to the epiglottis

Stage IV - divided into stage IVA, IVB, and IVC:

stage IVA: cancer spread to the larynx, front part of the roof of the mouth, lower jaw,
or muscles that move the tongue or are used for chewing and/or to more than one
lymph node on the opposite side of the tumor in the neck

stage IVB: tumor surrounds the carotid artery or has spread to the muscle that opens
the jaw, the bone attached to the muscles that move the jaw, nasopharynx, or base
of the skull or has spread to one or more lymph nodes that are larger than 6
centimeters.

stage IVC: tumor has spread beyond the oropharynx to other parts of the body

Grading

tells you how normal or abnormal tumor cells appear

4 grades of oral and oropharyngeal cancer cells

Grade 1 (low grade) the cancer cells look very much like normal mouth or
oropharyngeal cells

Grade 2 (intermediate grade) the cancer cells look slightly different to

normal mouth or oropharyngeal cells

Grade 3 (high grade) the cancer cells look very abnormal and not much
like normal mouth or oropharyngeal cells

Grade 4 (high grade) the cancer cells look very different to normal mouth
or oropharyngeal cells

Diagnostic Testing

CT scan of Abdomen, Pelvis, and chest to rule out mets

CT scan of neck to support

Chest X-ray to scan for mets

PET scan of brain to scan for mets

PET scan of neck for initial staging for metastatic squamous cell carcinoma of the
head and neck

Laryngoscope showed enlarged tonsillar

Bronchoscopy - diagnose

Esophagoscopy diagnose

HPV testing determine the status

Physical Exam

Biopsy

Treatment Options

Surgery remove the primary tumor with or without removal of

lymph nodes from the neck one or both sides of the neck

Radiation Therapy- IMRT or stereotactic

Chemotherapy IV, orally, or intramuscularly

Treatment Plan

Left Base of Tongue/ Neck

3-Arc V-Mat (321 degree arcs)

6MV

Prescription of 6600 cGy

Gtv before surgery

Ptv 6600

- PTV 6600 will get this total

PTV

33 Fx

200 cGy/day

PTV is the structures we plan to treat as our target area

GTV before is the tumor bed of the tumor he once had

Treatment Plan

Treatment Plan Parameters

Supine, head first

Long aquaplast mask

Q2 q-fix headrest

Short blue conformed head rest

2 mm shims

Hands holding bars at H5

Conformal board

Knee sponge

MLCs

Treatment Borders

MLCs block uninfected portions

Anterior: 2cm above tumor

Posterior: behind Spinous process

Superior: entire jugular chain and above c1

Inferior: supraclavicular area

DRR

MLC Field

Dose Distribution

Dose Distribution

Critical Structure (cGy)

Optic Chiasm 5000

Optic Nerve 5000

Brain 4700

Spinal Cord- 4700

Parotid Gland - 3200

Brian Stem 5000

Larynx 7000
Vocal cords - 4500

Retinas 4500

Ears 3000 or 5500

Eyes 1000

Lens - 1000

TMJ joint & Mandible 6000

Lacriminal Gland 2600

Esophagus-5500

Side Effects
ACUTE fatigue

Pain Percocet

Xerostomia magic mouth wash

Skin break down lidocaine gel

Dysphagia biotene mouth rinse

Weight loss peg tube

Voice changing

Chronic - Potential disfigurement

Fatigue, Fistula formation, Trismus, Velopharyngeal insufficiency, skin

roughness, loss of feeling

Prognosis and Survival

Better prognosis for HPV+ tumors

Prognosis depends on HPV status, Mets status, stage, lymph node

involvement, and tumor margins.
5 year Survival Rate
Stage
1

58%

Stage
2

56%

Stage
3

55%

Stage
4

43%

Metastatic Sites

Direct extension mets, lymphatics, or blood

Most common site is the lungs

If lymph node involvement, risk of bilateral disease or cervical nodes

Can travel to bone, lung, liver, etc.

Complications

Claustrophobic

Anxious

Patient Point of View

Glad therapists personable, talk to

him, and makes sure hes
comfortable

Likes music playing to get his mind

off things

Spit that does go down curdles the

food in his stomach

Body aches

Throat constantly burns inside and out

Cant eat without feeling nausea

Thick acidic saliva when he has it

Dont have energy to do activities

Mouth wash doesnt help with

swallowing, eating, or dry mouth

Constantly tired and weak

Cant drink water because it makes it burn more

Collars rub his burns

Neck a different color

Changed his routine and has to make a schedule around

treatment
Insomnia

The nausea medication (Zofran and

Compazine) makes him more
nauseous

Dry mouth

Taste changes

Constant vomiting

Wish there was different treatment

without side effects

Dehydrated, so had to get IVs in his

arm for fluids to not feel sick

Anxiety

Painful

Feels like cancer can happen to anyone, glad he is getting it

taken care of

References

1. IHIS

2. Aria

3. Notes

4. National Cancer Institute. Oropharyngeal Cancer Treatment. July 23, 2015.

September 23,
2015. http://www.cancer.gov

5. Thanc Foundation. Tonsil Cancer. 2015. September 23, 2015.

http://www.headandneckcancerguide.org/

6. Washington, C. (2010). Chapter 5: Detection and

Diagnosis.Principles and
Practice of Radiation Therapy(3rd ed.). St. Louis, Mo.: Mosby Elsevier