Oncology and Its Radiotherapy Treatment - Case Study Example

The work is devoted to the discussion of the radiotherapy role, advantages, disadvantages and options in treating larynx and langpharynx tumors at the advanced stages. The work will be based on the specific case of Mrs. W, with hypopharingeral carcinoma of the third stage. It will be necessary to look at the plan according to which Mrs. W will receive her treatment, radiation doses and the radiotherapy methods. It will also be important to compare this plan with other existing radiotherapy methods, and discuss the importance of multidisciplinary management of patients with advanced stages of cancer. Oncology and radiotherapy The paper will be designed in the form of research, based on the specific case of Mrs. W, whose diagnosis is hypopharingeral carcinoma (an advanced third stage). The diagnosis has been proved histologically, the malignancy is of epithelial origin and needs combination of the external beam radiotherapy and chemotherapy. It is necessary to make a special accent on the ways radiotherapy is applied to this specific patient, its doses and consequences, in comparison with the radiotherapy methods used in other hospitals and similar departments. At the third stage of the disease, at time when MRS. W finally decided to address the doctor, (unfortunately, most patients miss the first two stages of the disease, when their survival rates may be much higher in case they receive proper medication), the cancer has not yet spread outside the larynx, but her vocal cords could not move normally anymore, as well as there has been the threat that the cancer would also spread to the neighboring tissues. The situation was rather serious even from the medical point of view, thus there existed the following options for stopping the cancer spreading and increasing the survival chances of Mrs. W: surgery with or without radiotherapy; radiotherapy (the patient was offered a course of hyper fractionated external beam radiotherapy, used in management head and neck malignancies); chemotherapy, followed by radiotherapy, or combination of both (radio sensitizing); chemoprevention therapy to prevent the spreading of the cancer onto the neighboring tissues. The patient has been explained, that radiotherapy is the use of x-rays, which kill carcinoma cells and their main aim is to shrink tumors. The hyper fractioned radiation therapy is one of the newest means of radiotherapy, which changes the way the thyroid gland works. In creating the sample plan for Mrs. W, the following steps should be undertaken: Stage I. Creation of the detailed history of the patient and his physical examination. Special attention should be paid to the examination of the thyroid gland. The patient should be aware of possible negative effects in the form of hyperthyroidism. Stage II. The following analysis should be taken and results put down into the patient's history for further designing of the radiotherapy program: blood count; tests of kidney function; tests of liver function; X-ray of the chest; CT scanning of the primary site and the surrounding tissues; Tests of the thyroid function. As all the results appeared to be within the normal accepted range (the thyroid function was also accepted as normal with T3 displaying 78 ng/dl and T4 equaling to 10.8 ng/dl), the third step was to develop a plan of radiotherapy, taking into account the stage of the disease and possible side effects. According to the recent research, 'Recent randomized trials have revealed the effectiveness of hyper fractionated radiation therapy for treating head and neck carcinomas, especially in their local control. Because the hypopharynx is located near the larynx, increasing local control of hypopharyngeal carcinomas achieves greater laryngeal preservation, which is very important for patients' quality of life' (Tubiana 2000, p. 557). Thus, it has been decided to combine the radiotherapy with the chemotherapy to make the medication process more effective. Stage III. The proposed dose of the radiotherapy was decided to be equal to 6600 cGy in 33 fractions during the period of 45 days. The fractions should have to be delivered by Tele-cobalt machine through lateral beams (parallel opposing). The proposed radiation dose is supposed to be standard for patients with hypopharynx carcinoma. The following diagram shows the results of this type of medication in the specific hospital department through the period of 2000-2004: Hyper fractioned radiotherapy (HP) local control rates - 62.4% Pharyngolaryngectomy-free survival rates - 65.6% Overall survival rates - 70.1% Stage IV. In the striving for better effects it was also offered to combine radiotherapy with chemotherapy of Cisplatin and 5-FU (20 mg and 300 mg / sq. meter respectively). This course should have to be used once a week, during five weeks, with the simultaneous use of radiation therapy. Stage V. Receiving the results of all analysis plus physical examination and the CT scanning of the carcinoma location. Despite the fact that usually the thyroid functions tests are not included into the plans for cancer medication, it was decided to receive the results of these tests as well. 'There is a general agreement that hypothyroidism is a much more common complication following combined surgical and radio-therapeutic management of head and neck cancers with a frequency ranging in literature from 43 to 66 % often depending upon the duration of follow up'. (DeGroot 1998, p. 779) Upon the finishing the treatments course the following changes have been noticed: 1. The level of shrinking of the carcinoma location in comparison to its state at the moment the patient addressed the hospital - 11% 2. The level of white cells in patient's blood - +21% 3. Thyroid function tests - T3 - 94 ng/ dl, T4 - 21.1 ng/dl, which is within the normal range for patients with larynx and hypopharyngeral carcinoma. The ultimate results are presented in the form of diagram: Treatment results Side effects 0 6600 (Optimal) Radiation dose Fig. 1. The choice of the optimal radiation does based on the side effects and ultimate results The method of fractional radiotherapy is supposed to be one of the modern and effective ways of managing head and neck malignancies. It is often that it is the only means to avoid laryngectomy and to increase survival rates with keeping the high quality of life for patients with similar diagnosis. However, it is still doubtful, how much hyper fractioned radiotherapy influences further problems of patients with their thyroid function, as these negative consequences often display themselves in several years after the treatment course is finished. Thus, the patients should be aware of possible negative long-term consequences. 'Dose of radiation required to produce hypothyroidism is also confusing. DeGroot (1988, p. 784) and Hancock et al (1995, p. 1165) suggested that radiation doses in the range of 3000 to 8000 rads are required to produce hypothyroidism. At the same time Hancock et al (1995, p. 1167) reviewed 1787 patients of Hodgkin's disease treated with Mantle field irradiation in the dose of 3500 - 4500 cGy and estimated a 43% actuarial risk of developing hypothyroidism at 20 years' (Costine 1995, p. 427) Thus, in creating the treatment plan for patients with hypopharyngeral carcinoma it is necessary to carry out exact calculations in relation to the necessary radiation doses. It is also necessary to remember that treatment planning plays the key role in radiotherapy advancement. According to Duke, Wong & Craig (1998), 'a comprehensive presentation of all treatment uncertainties should be a part of any treatment planning process, and should preferably be expressed in radiobiological outcomes'. To make a general conclusion, the radiation therapy chosen and described in the plan, appeared to be effective enough, though it is still uncertain, whether the patient will need laryngectomy in future. Other hospitals use alternative radiotherapies, which should be described here. The main and one of the most widely spread kinds of radiotherapy is the intensity modulated therapy. As the whole radiation oncology is aimed at improvements displayed through higher tumor local control and decreasing the side effects, intensity modulated method is both economical and effective. In the light of the situation, when oncologists tried to include the broader area into the field of radiation for better tumor control, the IMRT provides oncologists with the opportunity to restrict the radiation fields by the exact tumor size. As it is written in literature, 'The newer "dose-painting" techniques give much less emphasis to dosimetric uniformity and much more emphasis to a careful match between the intensity of treatment and the perceived tumor risk in each area. By "modulating" treatment beams and by dividing anatomic targets into a large number of connected sub-targets (each of which may be targeted individually) a much better match between the deposited radiation and the anatomic tumor location may be achieved.' (Suit 1992, p. 659) The plan used for treatment of Mrs. W, is satisfactory and takes into account certain parameters which are usually not accounted in such treatment courses. What is meant here is the use of thyroid function tests, which are often not included into general examination before and after radiotherapy. The choice of hyper fractioned radiotherapy is based on the fact that the total radiation dose necessary for achieving any good results is fractioned into smaller doses which the patient receives during a longer period of time. This method was aimed at decreasing the number of side effects, which are very serious and at times make patients interrupt their treatment. However, the offered choice of intensity-modulated radiotherapy has its advantages, for it allows decreasing the harmful radiation exposure on the healthy tissues around the tumor, especially when larynx and langpharynx tumors are meant, making the radiation beam heterogenic, depending on the histological analysis of the tissues and the amount of radiation each part of the tumor needs. Simultaneously, it is necessary to remember, that at advanced stages of cancer radiation should be combined with chemotherapy, either before the radiotherapy course is started, or making these processes parallel, which will finally bring higher survival rates and make the patient's quality of life higher. Multidisciplinary approach to the treatment of different cancers and tumors of larynx and langpharynx is very important to provide a successful result. Each head or neck tumor case should be reviewed by a team of doctors, including oncologist, radiologist, and other specialists. To optimize the treatment planning it is important to have a deep discussion of each case within the described circle of specialists. The first important aspect to be pointed out is the stage of the disease, as the first stages give the highest chances for survival, while addressing doctors when cancer is already called 'advanced' (the third and the fourth stages) automatically decreases the chances to live longer and makes the treatment much more complex. Speaking about advanced larynx and langopharynx tumors it should be noted that at these stages surgery combined with radiation gives the best survival rates, though such medication also increases the rates of morbidity and complications. Multidisciplinary approach increases the locoregional control, though it should also be remembered that advanced cancer patients now live rather long for developing distant metastases, thus neck tumors are no longer supposed to be neck diseases, but are rather viewed as a kind of systematic, thus the approach towards their treatment is becoming more comprehensive and complex. As radiotherapy for the advanced larynx and langpharynx tumors at the advanced stages is the crucial part of the treatment plan, IMRT and CR (conformal radiation) should be taken into account as possible means of radiotherapy. IMRT should be given special attention, as this is the very technique, which minimizes healthy tissue exposure to radiation. As a consequence, the level of morbidity becomes lower and lower damage to the surrounding healthy tissues is preferable in cases of neck and head tumors. Simultaneously, this and other types of radiotherapy, including hyper fractional radiotherapy, are the main means to avoid surgery, thus keeping the high patient's quality of life. Reviewing a number of different researches in the field of chemotherapy, there were not found any reliable proofs that chemotherapy alone can be effective for treating larynx and langpharynx tumors. Thus, in most cases of advanced cancer the combination of chemo- and radiotherapy provides the best alternative to surgery. However, the difference between the neoadjuvant and concurrent chemotherapies should be made, as the first one does not increases the survival rates, while the latter is preferable for the stage IV cancer with poor prognosis, for patients at unresectable stage IV cancer. The results of many investigations and practices show excellent results of combined chemo and radiation therapy. In multidisciplinary approach towards cancer treatment, surgery should also be noted as one of the integral parts of treatment planning, though in the exact case described in the present work such option was not given appropriate attention, being rather a radical method, but for advanced stages of cancer this means of medical treatment should always be present or included into the treatment plan. In discussing the multidisciplinary approach towards cancer treatment one of the most important parts is the complications, which the chemo and radiation therapy usually bring to the patient, and these complications should also be included into the treatment plan and the patient should be aware of these complications. 'Mucositis is a common acute accompaniment of radiation therapy, chemotherapy and combined therapy. Extensive ulceration may cause difficulty in swallowing, pain and lead to interruption of treatment'. (Eisbruch & Dawson 1999, p. 828), thus the patient should be ready to such consequences and understand that these are the only means to go through the whole process. In such cases when pain becomes unbearable and patient tends to interrupt treatment, lidocaine and other anesthetics may give some relief. However, the main problem of the life quality for cancer patients is xerostomia. This usually causes difficulties in talking, swallowing, etc. It is important to understand that multidisciplinary approach towards the creation of treatment plan in case with advanced stages of head and neck cancer should be carried out on the systematic basis; each similar case should be reviewed by a group of specialists, making treatment effective, as it often influences how many years more the patient will be able to live and how he will go through the side effects, which are inevitable in the course of chemo- or radiotherapy. Before offering any treatment methods to each specific patient, the group of specialists should perform detailed examination and further treatment course should be controlled by each specialists included into the examination group, which will provide the highest results in management advanced stages of larynx and langpharynx cancers. Conclusion 'Treatment planning can be defined as the radiotherapy preparation process in which treatment strategies are defined in terms of planning target volumes, dose distributions tailored to these volumes, and sets of treatment instructions to deliver to dose distributions. Treatment planning plays a key role in the advancement of radiotherapy.' (Robert & Remy 2001, p. 197) This work was an example of proving that multidisciplinary approach in management the patients with cancer at advanced stages is crucial for increasing their standards of life and their survival rates. The main directions in planning the course of radiotherapy and making this course as perfect as possible should be the following: 1. First of all, it is essential to better visualize the tumor tissues and normal tissues, creating the exact picture of the disease and thus making the correct choice in terms of the radiotherapy type to be applied; 2. Then there should be presented all uncertainty bands as for the isodoses; 3. During the whole course of treatment the target tissue should be constantly monitored; 4. If the state of patient's health allows reducing the treatment volumes, this should be done to decrease the side effects. The advanced conformal techniques will be successfully applied only if they are highly accurate both in planning and executing of treatment. Treatment discrepancies, especially concerning the planning calculations, even when are not so significant in magnitude, create systematic errors and thus need better attention. In planning treatment for larynx and langpharynx tumors the accuracy and accuracy requirements should be based on the radiobiological behavior of both tumor and normal tissues. However, despite the fact that uncertainties are rarely present in any treatment plans, radiotherapy remains the main means of treating neck and head cancers of the advanced stages. Thus, multidisciplinary approach is essential here for achieving better results. References Airoldi, M, De Stefani A, et al 2001, 'Survival in patients with recurrent head and neck carcinoma treated with bio-chemotherapy'. Head Neck, vol. 23, pp. 298-304 Costine, LS 1995, 'What else do we know about the late effects of radiation in patients treated for head and neck cancer' Int J Radiat Oncol Biol Phys no. 31, pp. 427-429 DeGroot LJ 1988, 'Radiation and thyroid disease'. Bailliere Clin Endocrinol Metabol no. 2, pp. 777-791 Dyk, Van J, Wong, E & Craig, j 1998, 'Uncertainty analysis: a guide to optimization in radiation therapy'. 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