Head and Neck Cancer

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Head and Neck Cancer

• Radiation Therapy 4412

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Management of Head and Neck Cancer

• Through multidisciplinary treatment we try to
• 1. decrease deformity
• 2. maintain the reduction of the tumor
• 3. restore function
• 4. preserve the structure and esthetics
• 5. cure the cancer

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1. Compare and contrast the epidemiologic factors
prevalent in head and neck cancers

• 1/3 of patients that are treated have early stage
• 2/3 of patients will have locally advanced stages
• Lungs are the most common site for mets
• The nerve routes are important in treatment
  planning, tumors can spread this way

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• Almost half of all squamous cell ca occur in the
  oral cavity
• Head and neck cancer involves the upper
  aerodigestive tract.
• Oral cavity
• Pharynx
• Paranasal sinuses
• Larynx
• Thyroid gland
• Salivary glands

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• Men- usually 50-60 years old
• Can occur in people younger than 40 years of age
• More women are smoking
• Smokeless tobacco
• Recurrences- usually within first 2 years
• Rarely after 4 years
• Most 5 year survivors will be alive at 10 years

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2. List and describe the etiologic factors
associated with head and neck cancers

• Smokeless tobacco- squamous cell of cheek and gum
• Previous radiation exposure- thyroid /salivary
  glands
• Poor oral hygiene
• Ill fitting dentures/irritation to tissues

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• Wood mill workers- nasal cavity/paranasal sinuses
• Lip cancer- UV exposure, unfiltered cigarettes
• Viruses
• Epstein Barr virus
• Herpes simplex (cold sores)
• HPV- oral/larynx
• Chronic abuse of marijuana- degree of risk
  unknown
• Diet
• Vitamin A and E deficiency
• Plummer-Vinson syndrome- iron deficiency anemia

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• Alcohol
• Pharyngeal and laryngeal cancer
• Liver damage
• Secondary nutritional deficiencies
• Alcohol damages mucosa and makes it more
  permeable
• Impurities in the alcoholic beverages

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• Smoking
• Head and neck cancers occur 6x more frequently
  than non-smokers
• Unfiltered cigarettes
• Cigar smoking is a risk
• Laryngeal cancer mortality increases as the
  number of cigarettes smoked increases

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Smoking, tobacco, alcohol a deadly combination!

• Alcohol is synergistic to tobacco- cooperate
  together to produce a total effect greater than
  the sum of the individual elements
• Tars
• Aromatic hydrocarbons
• Ethanol suppresses the efficiency of DNA repair
• Nitrosamines most noncombustible product in snuff
  and chewing tobacco

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• Pre-cancerous signs
• Leukoplakia is a precancerous, slowly developing
  change in the mucous membrane. They are
  characterized by thickened, white, firmly
  attached patches that are slightly raised.
• Erythroplasia- A premalignant lesion that is
  shiny, velvety and reddish in color
• These are severe dysplastic changes and should be
  taken seriously

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Leukoplakia
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3. Identify the prognostic indicators in head and
neck cancers

• Prognosis decreases as
• The affected area progresses backward from the
  lips to the hypopharynx (excludes larynx)
• Lesions that cross the midline
• Exhibits endophytic growth- invades within the
  lamina propria and submucosa
• Have cranial nerve involvement
• Fixed nodes

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• Fixed lesion in the anatomic compartments
• Are poorly differentiated
• Nonsquamous cell

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5. Compare and contrast endophytic and exophytic
tumor features of head and neck cancers

• Endophytic growth- growth pattern that invades
  the lamina propria and submucosa
• -more aggressive and harder to control locally
• Exophytic- a noninvasive neoplasm that projects
  out from an epithelial surface
• -characterized by raised, elevated borders
• Most head and neck cancers are infiltrative
  lesions found in the epithelial lining

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Staging

• Lymphatics of the head and neck are in direct
  correlation to the prognosis
• 1/3 of the bodys lymphatics are in the head and
  neck area
• Staging depends on
• Site of primary disease
• Extent of primary disease
• Size of primary tumor

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• Staging contd
• Cell type and differentiation
• Lymphatic vascular space invasion of the tumor
• The nodal status

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6. List and describe the different types of head
and neck cancers

• Most head and neck cancers will infiltrate into
  the epithelial lining of the upper digestive
  tract
• 80 of all head and neck cancers will be squamous
  cell

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7. Compare and describe the different types of
head and neck cancers.8. Describe the different
treatmentconsiderations for the different types
of head and neck cancers.
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Oral Cavity

• Oral cavity extends from the skin vermilion
  junction of the lip to the posterior border of
  the hard palate superiorly
• And the circumvallate papillae inferiorly
• Anterior 2/3 of the tongue lips, buccal mucosa,
  lower alveolar ridge, upper alveolar ridge,
  retromolar trigone, floor of the mouth, and hard
  palate
• Page 694 Washington/Leaver

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• Oral cavity cancers
• The most common aerodigestive tract cancers
• Occur mostly in men- 55 to 65 years old
• Alcohol and tobacco are synergistic
• Patients usually have poor oral and dental
  hygiene
• Plummer-Vinson syndrome is important etiologic
  factor

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• General practitioner or dentist will find the
  cancer
• Early diagnosis is important
• Leukoplakia and erythroplasia are serious
• Most oral cavity cancers will be nonhealing
  ulcers with little pain
• Localized pain is an advanced disease

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• The cancer is usually raised, centrally
  ulcerated, indurated edges and the base is
  infiltrating
• Mandatory biopsy
• Squamous cell carcinoma makes up 90-95
• Well or moderately well differentiated
• Has the lowest incidence (except glottic) of
  nodal mets
• Cervical node involvementadvanced disease

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Lips and Gum

• Lip cancer is treated with radiation the same way
  as skin cancer
• Usually involves the lower lip and spreads by
  direct invasion
• Carcinoma in-situ and early lesions of the lip
  may be surgically removed

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• Radiation Therapy
• Portal should include primary lesion with a 2 cm
• A shield (stent) of lead and bolus material (to
  absorb backscatter) is placed under the lip
• This blocks the alveolar process and gums
• Treated with external beam, interstitial implant
  or both
• 100 SSD, 100 isodose line

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Lip Cancer
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Floor of Mouth

• Floor of the mouth lesions usually arise on the
  anterior surface on either side of the midline.
• They can spread to bone and tongue
• Approx 30 of these cancers will involve the
  submaxillary and subdigastric nodes
• Opposed lateral fields are used
• The tip of the tongue can be elevated out of the
  portal with a cork or a bite block and tongue
  depressor

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• Bite blocks can also spare the roof of the mouth
  from incidental irradiation
• If the lesion has grown into the tongue, the
  tongue is flattened to reduce the superior border
  of the portal
• Radiation therapy supraclavicular and bilateral
  neck fields, followed with a boost of intraoral
  cone, needle implants, or small external photon
  beams

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Tongue

• The anterior 2/3 of the tongue is included in the
  oral cavity
• The base of the tongue is considered oropharynx
• Small tumors in the anterior 2/3 of the oral
  tongue are usually resected
• Radiation therapy is used for inoperable patients

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• Post-op radiation therapy
• Treats the primary site
• Treats the cervical lymph nodes
• And margins positive
• for tumor,
• extensive primary tumor with bone or skin
  invasion,
• and multiple positive nodes

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• The anterior tongue drains into the
• Submandibular lymph nodes
• The posterior portion of the tongue drains into
  the
• Jugulodigastric
• Posterior pharyngeal
• Upper cervical lymph nodes
• Lesions of the tongue usually appear on the
  lateral borders near the middle and posterior
  third section
• A limited number of tongue cancers can be excised
• Most are controlled with external beam and
  interstitial boost fields

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• Lesions at the base and posterior 1/3 of the
  tongue invade
• The floor of the mouth
• Tonsils
• or the muscles
• Are advanced
• Have a higher incidence of nodal mets

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• Hemiglossectomy- surgical removal of half the
  tongue. It is used for treatment of an early
  stage lesion of the tongue
• Radiation therapy- three field technique
• Utilizes external beam, electron beam
• Possibly an iridium implant and neck dissection
• Isocentric lateral opposed fields
• Lower anterior neck field
• Fields include subdigastric and submaxillary
  nodes
• Upper cervical nodes

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T1 Squamous cell of tongue
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Buccal Mucosa

• Buccal mucosa is the mucous membrane lining the
  inner surface of the cheeks and lips
• Most lesions arise on the lateral walls
• Have a history of leukoplakia
• Are raised, exophytic growths
• Lesion invades the skin and bone
• First sign is a bump on the tip of the tongue
• No pain associated at first until the nerves to
  the tongue or ear become involved
• Advanced lesions will bleed

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• Stensens duct (parotid duct) can become
  obstructed
• The parotid gland becomes enlarged
• Small lesions are surgically removed
• Large lesions are treated with surgery and
  radiation therapy or
• Radiation therapy alone
• Complications- fibrosis of the cheek and trismus

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Hard Palate

• Located between the upper alveolar ridge and
  mucous membrane covering the palatine process of
  the maxillary palatine bones
• Mostly adenocarcinomas and rare
• Spread to the bone, invade the maxillary antrum
• Treatment- surgical resection, post-op radiation
  therapy
• History of ill fitting dentures or trauma

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Retromolar Trigone

• Triangular space behind the last molar tooth
• Rare carcinomas
• Symptoms- tongue, ear canal pain, trismus
• Usually moderately differentiated squamous cell
  carcinoma
• Lymphatic spread to the submaxillary
  subdigastric nodes
• Treated with radiation therapy

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PHARYNX

• Subdivided into three anatomic divisions
• Oropharynx
• Nasopharynx
• hypopharynx
• Common symptoms
• Persistant sore throat
• Painful swallowing
• Referred otalgia
• Cervical node enlargement
• Fetor oris, dyspnea, dysphasia, hoarseness,
  dysarthria, hypersalivation indicates advanced
  disease

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• Diagnosis- indirect mirror exam, palpation,
  biopsy, CT, MRI
• Histopathology- squamous cell carcinomas
• Staging- AJCC Classification
• Mets- cervical lymph nodes (bilateral),
  retropharyngeal nodes, lung

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Oropharynx

• Consists of the base of the tongue, the tonsils
  (fossa and pillars), soft palate, oropharyngeal
  walls
• The oropharynx is located between the axis and C3
  vertebral bodies
• Soft tissue regions- anterior tonsillary pillars,
  soft palate, uvula, base of the tongue and the
  lateral-posterior pharyngeal walls

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• Tonsils are the most common site for disease
• Symptoms- sore throat and pain during swallowing
• Upper spinal accessory nodes are involved
  bilaterally in 50 to 70 of the patients
• Radiation therapy is treatment of choice

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Cancer of tongue
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Hypopharynx

• Pyriform sinuses, postcricoid, and lower
  posterior pharyngeal walls below the base of the
  tongue
• It is situated between C3 to C6
• The cricoid cartilage is the inferior border
• Epiglottis is the superior border
• Hypopharyngeal cancer is advanced
• High rate of nodal mets

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• Tumor is highly infiltrative
• The highest area for incidence is the pyriform
  sinus
• Radical surgery and radiation therapy is the
  treatment of choice
• Rouvieres (lateral retropharyngeal) lymph nodes
  at the base of the skull are included with other
  nodal groups in treatment (page 706, Washington)

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• Tonsillar, pharyngeal wall and posterior cricoid
  are treated using radiation therapy
• (page 709, figure 30-28, Washington)

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Unresectible T4 pyriform sinus tumor, surrounding
carotid artery
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Nasopharynx

• Posterosuperior pharyngeal wall and lateral
  pharyngeal wall, the eustachian tube orifice and
  adenoids
• The nasopharynx is a cuboidal structure lying on
  a line from the zygomatic arch to the external
  auditory meatus (EAM), extending inferiorly to
  the mastoid tip
• The nasopharynx lies behind the nasal cavities
  and above the level of the soft palate

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• The nasal cavity drains into the nsopharynx via
  the two posterior nares
• Two eustachian tubes are on the lateral walls
  which connect to the middle ear
• Nasopharyngeal disease can mimic an inflammatory
  process
• Can cause considerable respiratory or auditory
  dysfunction

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• The cranial nerve is frequently involved
• The ninth to the twelfth cranial nerves can be
  affected
• Enlargement of the retropharyngeal nodes
• Can affect the external carotid artery
• A lesion can invade directly into the third
  cranial nerve
• Commonly involves the sixth cranial nerve

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• When cranial nerves are involved, this means the
  disease is advanced and widespread
• Histology- squamous cell
• Nasopharyngeal cancer is usually poorly
  differentiated and shows an unusual growth
  pattern
• This disease is not associated with tobacco
  consumption

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• NPC is associated with the Epstein Barr virus
• Can occur in adolescence and young adults
• Occurs again between 50 and 70 years of age
• Uncommon in white populations
• Found mostly in southern China and the Middle East

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• Positive cervical nodes in 75 to 85 of NPC
  patients
• About half of all cases will have bilateral or
  contralateral disease
• Radiation ports are large
• The lateral retropharyngeal (node of Rouviere)
  which cannot be surgically removed, and
  jugulodigastric nodes are almost always treated

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• Primary lesion is small but the nodal disease is
  extensive
• Bone and lung common mets sites
• NPC spreads to adjacent sites and has a high
  recurrence rate
• Aggressive, large volume curative radiation
  therapy is given

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Larynx

• The larynx is contiguous with the lower portion
  of the pharynx above and is connected with the
  trachea below.
• It extends from the tip of the epiglottis at the
  level of the lower border of the C3 vertebra to
  the lower border of the cricoid cartilage at the
  level of C6

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• There are 3 main parts to the larynx.  These
  parts are
• The supraglottis - the area above the vocal cords
  that contains the epiglottis cartilage    
• The glottis - the area around the vocal cords   
• The subglottis - the part below the vocal
  cords, containing the cricoid cartilage.  It
  continues down into the windpipe

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• Glottic cancer- 65
• Supraglottic cancer- 25 to 33
• Subglottic- make up the rest of the cases
• Most common cancer in the aerodigestive tract is
  the larynx
• Male dominated disease
• 50-60 years of age
• Smoking high risk factor

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• Extensive use of voice in occupation is risk
  factor (singers, auctioneer) for laryngeal cancer
• Alcohol high risk factor for supraglottic cancer
• Cancer of the glottis (true vocal cord) is not
  life threatening
• Choice of treatment is based on the preservation
  of speech and airway

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• Laryngeal cancer shows a mutation of the p53 gene
• Classic Symptoms- persistent sore throat and
  hoarseness
• Cervical lymph nodes involvement is associated
  with supraglottic lesions
• Carcinoma in situ is common on the vocal cords

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• Glottic lesions are well to moderately
  differentiated
• Supraglottic lesions are less differentiated and
  more aggressive
• Glottic lesions will appear of the anterior 2/3
  of one cord (approx 65-75)
• Cord mobility is a factor in the classification
  of lesions

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• Treatment- radiation therapy is the treatment of
  choice for nonfixed surface glottic lesions that
  have not invaded muscle, bone or cartilage
• Glottic cancer is treated with lateral opposing
  fields 5X5cm or 6X6 cm
• Large, fixed lesions will require aggressive
  treatment
• Radiation therapy offers the best voice
  preservation

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• Supraglottic lesions are usually large and bulky
• They do not usually invade the inferior false
  cord or the ventricles
• These lesions usually spread superiorly to the
  epiglottis
• Lymph nodes are usually involved in 40-50 of
  the patients

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• Subglottic lesions are treated with total
  laryngectomy with
• Post-op radiation therapy

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Larynx- squamous cell, Rt anterior vocal fold
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Salivary Glands

• Salivary glands are made up of
• Parotid-largest gland, located superficial to and
  partly behind the ramus of the mandible, and
  covers the masseter muscle
• It fills the space between the ramus of the
  mandible and the anterior border of the
  sternocleidomastoid muscle
• Contains extensive lymphatic capillary plexus
  many aggregates of lymphocytic cells
• Numerous intraglandular lymph nodes in the
  superficial lobe

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• Submandibular glands
• Sublingual glands
• Tumors of the salivary gland are rare
• The parotid is the most common site for tumors
• Nearly 2/3 of these tumors will be benign
• Low-dose ionizing radiation in childhood may have
  been a risk factor
• Dental x-rays have been implicated for both
  benign and malignant tumors

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• Most major and minor salivary gland cancers are
  of unknown origin
• Adenoid cystic, mucoepidermoid, and
  adenocarcinoma are the most common cell types
• Symptoms- asymptomatic parotid mass lasting 4-8
  months before the tumor arises
• Presenting symptoms- localized swelling and pain,
  facial palsy, rapid growth
• Facial nerve involvement suggests malignancy
• Diagnosis is done through lobectomy

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• Treatment- Although most tumors are benign, local
  recurrence is high
• Total resection with margins sparing facial
  nerves
• Radiation therapy- post-op for residual,
  recurrent or inoperable tumors
• Accelerated fractionation- provides similar dose
  levels of radiation therapy in a shorter amount
  of overall time. This counteracts quick cellular
  proliferation of aggressive tumors by giving more
  dose in a shorter period of time.

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Maxillary Sinus

• Maxillary sinus is a pyramid shaped cavity lined
  by ciliated epithelium and bound by thin bone or
  membranous partitions.
• Carcinomas arising from the ciliated epithelium
  or mucous glands perforate the bony walls almost
  from the beginning
• Tumors will also involve the superior portion of
  the sinus and extend into the floor of the orbit

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• Maxillary sinus cancers- 80 of all sinus cancers
• Long history of sinusitis, nasal obstructions and
  bloody discharge
• Squamous cell carcinomas
• Invade the floor of the orbit, ethmoid sinuses,
  hard palate zygomatic arch
• Displacement of the eye is common

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• Nasal cavity and paranasal sinus tumors are often
  associated with cranial nerve palsies- trigeminal
  branches
• CT and MRI are the most useful studies
• Submandibular node will be the first involved,
  although cervical node spread is uncommon

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• Treatment- Surgery is the treatment of choice
• Primary radiation therapy has a chance of optic
  nerve damage from the high dose required for
  tumor control
• Surgery and radiation therapy used in most cases
• Lateral and anterior ports are used
• When the orbit is involved, eye blocking will not
  be used
• Care should be taken to miss the cord and
  contralateral lens

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• Angling the anterior beam a few degrees off the
  vertical spares brain tissue
• Nasal cavity risk- Bolus material will be
  inserted to improve dose homogeneity
• Angling the lateral port a few degrees off the
  horizontal plane spares the contralateral optic
  nerve and lens

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Management of the Head and Neck Patient
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• Washington, Page 718, Table 30-3, dose-tissue
  response schedule
• Page 719, Box 30-11, recommended skin care
  program
• Care of the head and neck patient
• Peridontal disease and caries
• Nutrition
• Mucositis/stomatitis

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• Xerostomia
• Cataract formation
• Lacrimal glands
• Taste changes
• Skin reactions