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Two images demonstrating radiation exposure with photon vs proton therapy
Conformal dose patterns for a patient with tonsillar cancer demonstrating radiation exposure to the head and neck for (A) standard radiation therapy and (B) proton therapy.

Radiation-oncologists at Penn Medicine are using proton therapy (PT) as an option for the treatment of cancers of the head and neck. The prevailing complication for standard radiation treatment of advanced head and neck cancers is the close proximity of critical organs that are highly sensitive to radiation, including the brain, brainstem, spine, salivary glands and swallowing structures.

Classic radiation treatment protocols must consider with great care the adequate treatment of a cancer while minimizing damage to normal organs nearby. This is important for several reasons. In its application to the head and neck, radiation therapy can cause loss of sensation, dry mouth due to impaired saliva production, neurological damage and the risk of secondary cancers.

At the same time, efforts to minimize exposure to structures outside the cancer must avoid inadequate delivery of radiation doses that could increase the risk of cancer recurrence. The physical properties of proton beams may offer unique advantages for the treatment of head and neck cancers. Among the most important of these is the rapid dose fall-off at the distal edge of the target (referred to as the Bragg-Peak effect), a characteristic that allows for significant reductions in radiation dose to normal organs, improved dose homogeneity and the potential for dose escalation.

This physical feature of proton beams allows delivery of high doses to the cancer with much greater precision.  Dosimetric studies of head and neck cancer patients comparing intensity-modulated forms of standard radiation therapy (IMRT) to proton therapy (IMPT) have demonstrated that critical organs were optimally spared with IMPT, with lower estimated secondary cancer risks as a result of lower radiation dose received by normal tissue.1  

At the Roberts Proton Therapy Center at Penn Medicine, patients with head and neck cancers are being treated in clinical studies to confirm whether the dosimetric advantages of proton therapy shown in previous studies will translate to gains in treatment outcome and patient-reported improvements in side effects and quality of life. Many patients with head and neck cancers are being treated with a technique known as pencil beam scanning proton therapy at the Roberts Center, in collaboration with the Departments of Otorhinolaryngology-Head and Neck Surgery and Medical Oncology. Patients for whom the initial treatment of the cancer requires surgery are treated initially with a minimally-invasive approach via TransOral Robotic Surgery (TORS). For patients who then require additional treatment, proton therapy offers a promising option.

If surgery is not feasible or recommended, proton therapy is often combined with chemotherapy with curative intent. Pencil beam scanning proton therapy is also being used at Penn for the treatment of head and neck cancers involving the base of the skull. [1] Treatment of tumors with conventional radiation at this particular site has traditionally been limited by an inability to deliver an adequate dose in the absence of the potentially damaging effects of radiation on normal critical structures in the brain and optic apparatus. Pencil beam scanning allows for more precise delivery of radiation to the tumor while avoiding these critical structures.

Case Study

Mr. V, a 54-year-old man, was referred to an otorhinolaryngologist at Penn Medicine after presenting to his personal physician with a mass in his left neck.

At Penn, a CT scan found a 3.3 cm lesion at the left lingual tonsil. A subsequent needle biopsy determined that the mass was an HPV-positive tonsil cancer. Mr. V was scheduled for a TransOral Robotic Surgery (TORS) procedure to remove the lesion (T2 stage), followed by a left neck dissection, with the latter showing multiple involved nodes

Considered a good candidate for proton therapy, Mr. V was treated post-operatively with PT to limit morbidity associated with radiation therapy. His course of treatment and recovery were unremarkable, and he did well throughout his radiation therapy with protons, experiencing only mild and transient changes in taste (with return to normal by 6 weeks) and no weight loss as a result of treatment. He returned to work soon afterward, and remains cancer free at one year post-surgery.

Access

Penn Radiation Oncology
Perelman Center for Advanced Medicine
Concourse Level
3400 Civic Center Boulevard
Philadelphia, PA 19104

Otorhinolaryngology – Head and Neck Surgery
Hospital of the University of Pennsylvania
5th Floor Ravdin
3400 Spruce Street
Philadelphia, PA 19104

Published on: May 1, 2017

References

1. Ahn PH, Lukens JN, Teo BK, Kirk M, Lin A. The use of proton therapy in the treatment of head and neck cancers. Cancer J. 2014 Nov-Dec;20(6):421-6.

About Penn Radiation Oncology

Among the largest and most respected programs in the world, Penn Radiation Oncology offers a variety of innovative treatment options to patients with cancer. In addition, as a national leader in basic science, translational research and clinical trials, Penn Radiation Oncology offers patients access to the latest treatment options––including proton therapy––before they are widely available elsewhere.

Performing Proton Therapy, Oncology Services and Surgery for Head and Neck Cancers

Penn Faculty Team

Michelle Alonso-Basanta, MD, PhD

Vice Chair, Clinical Division, Radiation Oncology

Chief, Central Nervous System Service, Radiation Oncology

Associate Professor of Radiation Oncology at the Hospital of the University of Pennsylvania

Alexander Lin, MD

Chief, Head & Neck Service, Radiation Oncology

Vice Chair, Faculty Affairs, Radiation Oncology

Medical Director, Roberts Proton Therapy Center, Radiation Oncology

Associate Professor of Radiation Oncology at the Hospital of the University of Pennsylvania

John Nicholas Lukens, MD

Assistant Professor of Radiation Oncology at the Hospital of the University of Pennsylvania

Robert Lustig, MD

Chief, Clinical Operations, Radiation Oncology

Professor of Clinical Radiation Oncology

Samuel D. Swisher-McClure, MD, MSHP

Co-Director, Head & Neck Cancer Service Line, Abramson Cancer Center

Assistant Professor of Radiation Oncology at the Hospital of the University of Pennsylvania

Charu Aggarwal, MD, MPH

Leslye M. Heisler Associate Professor for Lung Cancer Excellence

Joshua M. Bauml, MD

Assistant Professor of Medicine at the Hospital of the University of Pennsylvania

Christine A. Ciunci, MD, MSCE

Section Chief, Hematology Oncology, Penn Presbyterian Medical Center

Physician Lead, Cancer Service Line, Penn Presbyterian Medical Center

Assistant Professor of Clinical Medicine

Roger B. Cohen, MD

Associate Director of Clinical Research, Abramson Cancer Center

Director, Hematology/Oncology Fellowship Program

Professor of Medicine at the Hospital of the University of Pennsylvania

Arati Desai, MD

Assistant Professor of Clinical Medicine

Assistant Professor of Neurosurgery

Steven B. Cannady, MD

Director, Microvascular Surgery and Education

Otorhinolaryngology Safety Officer

Head and Neck Cancer Service Line Director, Pennsylvania Hospital

Associate Professor of Clinical Otorhinolaryngology: Head and Neck Surgery

Ara A. Chalian, MD

Director, Facial Plastic Reconstruction

Patient Safety Officer

Director, Microvascular Lab

Professor of Otorhinolaryngology: Head and Neck Surgery at the Hospital of the University of Pennsylvania

Jason G. Newman, MD, FACS

Director, Head & Neck Surgery, Pennsylvania Hospital

Co-Director, Cranial Base Center

Professor of Otorhinolaryngology: Head and Neck Surgery at the Hospital of the University of Pennsylvania and the Pennsylvania Hospital

Christopher H. Rassekh, MD

Director, Penn Medicine Sialendoscopy Program

Co-Chair, Hospital University of Pennsylvania Airway Safety Committee

Director of Risk Reduction and Director of Professional Practice, Department of Otorhinolaryngology-Head and Neck Surgery

Professor of Clinical Otorhinolaryngology: Head and Neck Surgery

Rabie M. Shanti, DMD, MD

Assistant Professor of Oral and Maxillofacial Surgery

Assistant Professor of Otorhinolaryngology: Head and Neck Surgery

Gregory S. Weinstein, MD, FACS

Vice Chairman, Department of Otorhinolaryngology: Head and Neck Surgery

Director, Head and Neck Surgery Division and Head and Neck Surgery Clinic

Director, Center for Head and Neck Cancer

Director, Head and Neck Cancer Service Line

Professor of Otorhinolaryngology: Head and Neck Surgery at the Hospital of the University of Pennsylvania

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