Diagnostic radiology for advanced head and neck cancer planning

26 NOVEMBER 2014

DIAGNOSTIC RADIOLOGY FOR ADVANCED HEAD AND NECK CANCER PLANNING Venue: British Dental Association, London CPD: 6 CREDITS

Oncology Imaging Systems

Save the date

BIR ANNUAL CONGRESS 2015 4–5 NOVEMBER LONDON

Day 1 • Room 1

Primers for the nonspecialists Session organised by Dr David Wilson, Consultant Interventional MSK radiologist, Oxford University Hospitals NHS Trust

• Room 2

Radiation protection

Session organised by Mr Andy Rogers, Head of Radiation Physics, Nottingham University Hospitals NHS Trust

More information available soon at www.bir.org.uk

Day 2 Clinical hybrid imaging in oncology • Room 1

Session organised by Dr Gopinath Gnanasegaran, Consultant Physician in Nuclear Medicine, St Thomas’ Hospital

• Room 2

Musculoskeletal imaging

Session organised by Dr Richard Wakefield, Consultant in Rheumatology, St James’s University Hospital

Essentials for the radiology trainee Session organised by Dr Hardi Madani, Radiology Registrar, Royal Free London Hospital and Dr Ausami Abbas, Cardiothoracic Radiology Post CCT Fellow, University Hospital Alberta

Welcome and thank you for coming to ‘Diagnostic radiology for advanced head and neck cancer planning’ organised by the British Institute of Radiology.

We wish you a very enjoyable and educational experience.

Certificate of attendance This meeting has been awarded 6 RCR category I CPD credits.

Your certificate of attendance will be emailed to you within the next two weeks once you have completed the online event survey at: https://www.surveymonkey.com/s/headandneckcancerplanning

BIR Annual Congress 2015: 4–5 November, London

We are most grateful to

Oncology Imaging Systems

for supporting this conference

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Programme

08:45 Registration and refreshments 09:15

Welcome and introduction Dr Charles Kelly, Consultant Clinical Oncologist and Lead for

Radiotherapy, Northern Centre for Cancer Care, Freeman Hospital Dr Richard Simcock, Consultant Clinical Oncologist Brighton and Sussex University Hospitals NHS Trust

Section 1: ‘Best’ diagnostic imaging and review of techniques 09:20 Ultrasound in treatment planning - how, when and why?

Dr Rhodri Evans, Consultant Head and Neck Radiologist

Morriston Hospital, Swansea 09:50 DWI in staging and monitoring head and neck cancer

Dr Steve Connor, Consultant Head and Neck Radiologist

King’s College Hospital and Guy’s and St Thomas’ Hospital 10:15

PET-CT imaging in head and neck squamous cell carcinomas (HNSCC): applications, pitfalls and new horizons Dr Vivek Raman, Consultant Head and Neck Radiologist and Nuclear

Medicine Physician, Brighton and Sussex University Hospitals Trust

10:40 Getting the best from diagnostic CT

Lt Col Mark Ballard, Consultant Radiologist

University Hospital, Birmingham 11:05 Sentinel node biopsy in the node negative neck

Mrs Clare Schilling, Clinical Academic Lecturer, Specialist Trainee, Oral and

Maxillofacial Surgery, Guy’s Hospital 11:30 Refreshments Section 2: Organs at risk: the evidence and defining them 11:45

Organs at risk - reviewing the evidence: salivary glands, oral cavity and swallowing structures Dr Andrew Hartley, Consultant Clinial Oncologist Queen Elizabeth Hospital Birmingham

12:05

Organs at risk - defining muscles of mastication, salivary glands and brachial plexus Dr Guy Burkill, Consultant Radiologist Brighton and Sussex University Hospitals NHS Trust

12:30 New organs at risk - reviewing the evidence: carotids and cochleas

Dr Dorothy Gujral, Clinical Research Fellow, Royal Marsden Hospital 13:00 Lunch 2

Section 3: Incoporating imaging into planning with new techniques 14:00 MRI fusion in planning: the end user experience

Dr Charles Kelly, Consultant Clinical Oncologist and Lead for

Radiotherapy, Northern Centre for Cancer Care, Freeman Hospital

14:30 PET fusion in radiotherapy planning

Miss Lucy Pike, Clinical Scientist, PET Imaging Centre

St Thomas’ Hospital 15:00 Auto-contouring software - an end user evalution

Dr Keith Langmack, Head of Radiotherapy Physics

Nottingham University Hospitals NHS Trust 15:45 Volume definition after neo-adjuvant chemotherapy

Dr Tom Roques, Consultant Clinical Oncologist, Norfolk and

Norwich University Hospitals 16:15 Debate: Who should volume? radiologist or oncologist? or both?

Chair: Dr Richard Simcock, Consultant Clinical Oncologist

Brighton and Sussex University Hospitals NHS Trust 16:45 Close of event ________________________________________________________________________ Certificate of attendance This meeting has been awarded 6 RCR category I CPD credits.

Your certificate of attendance will be emailed to you within the next two weeks once you have completed the online event survey at: https://www.surveymonkey.com/s/headandneckcancerplanning

BIR Annual Congress 2015: 4–5 November, London

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Speaker profiles Lt Col Mark Ballard Consultant Radiologist, University Hospital Birmingham Mark Ballard is a consultant radiologist working at the Centre for Defence Radiology at the Queen Elizabeth Hospital Birmingham. His sub-specialist interests are in both trauma imaging and head and neck imaging. The prior has seen him deployed on operations to the Camp Bastion field hospital in Afghanistan but it is the latter which encompasses much of his day to day work in the UK. The Queen Elizabeth Hospital is a tertiary referral centre for head and neck cancer with a busy weekly multidisciplinary meeting.

Mark completed his radiology specialist training in the Kent, Surrey and Sussex Deanery at the Royal Sussex County Hospital, Brighton and undertook a fellowship in head and neck imaging at Barts Health NHS trust prior to his consultant appointment.

Dr Guy Burkill Consultant Radiologist, Brighton and Sussex University Hospitals NHS Trust I have been a consultant Radiologist for 13 years following fellowship training at The Royal Marsden Hospital. My sub-specialty interest is in oncological imaging, including Head and Neck Cancer, having been a founder member of our local MDT in 2004. The past 4 years I have been an anatomy examiner for the Royal College of Radiologists.

Dr Steve Connor, Consultant Head and Neck Radiologist King’s College Hospital and Guy’s and St Thomas’ Hospital Dr Steve Connor was trained in radiology on the West Midlands scheme with subsequent neuroradiology subspecialty training at King’s College Hospital. He was appointed as a neuroradiology consultant at King’s College Hospital in 2001. He has also been an honorary consultant in head and neck radiology at Guy’s and St Thomas’ hospital since 2005. His subspecialty interests are skull base, head and neck cancer and temporal bone imaging. He lectures nationally and internationally on head and neck imaging topics. He acts as associate editor for three journals and has authored over 100 publications. Current research activity includes a study comparing quantitative diffusion weighted MRI and 18F-FDG PET-CT in the prediction of loco regional residual disease following radiotherapy and chemoradiotherapy for head and neck cancer. He is the current Chairman of the British Society of Head and Neck Imaging having previously acted as vice-Chairman (2012-14) and secretary (20102012).

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Dr Rhodri Evans Consultant Head and Neck Radiologist, Morriston Hospital, Swansea Consultant Radiologist-Morriston, Singleton and Neath Port Talbot hospitals. Chair in Medical Imaging, ILS 2, College of medicine, Swansea University.

Consultant Radiologist since 1992. Organiser Morriston head and neck ultrasound workshop, since 1995 (www.headandneckultrasound.co.uk). Author of 2 texts on head and neck ultrasound/Imaging. Examiner for RCS and RCR. Member of BMUS Council and Hon.Treasurer BMUS. Honorary Chair Medical Imaging, College of Medicine, Swansea University, 2013.

Dr Dorothy Gujral Clinical Research Fellow, Royal Marsden Hospital Dr Gujral is a Clinical Oncology SpR in the South London rotation. She has recently completed a PhD fellowship in the Head and Neck Unit at the Royal Marsden Hospital. Her PhD investigated the effects of radiotherapy on the carotid artery in patients with head and neck cancer using a range of advanced imaging techniques, including contrast-enhanced ultrasound and speckle tracking in order to seek earlier surrogate endpoints for radiation-induced atherosclerosis. In addition, she has been involved in clinical trial management in the head and neck unit at the Royal Marsden Hospital and provided support for national head and heck radiotherapy trials in terms of radiotherapy quality assurance.

Dr Andrew Hartley Consultant Clinial Oncologist, Queen Elizabeth Hospital, Birmingham Andrew Hartley has been a Consultant Radiation Oncologist in head and neck cancer at the Queen Elizabeth Hospital since 2002. He teaches Radiobiology at the University of Birmingham.

Dr Charles Kelly Consultant Clinical Oncologist and Lead for Radiotherapy Northern Centre for Cancer Care, Freeman Hospital Charles Kelly, is a Consultant Clinical Oncologist, specialising in head and neck cancer, skin cancer melanoma and is Clinical Lead for Radiotherapy, at the Northern Centre for Cancer Care in Newcastle. He also initiated and is one of the directors of the Newcastle University online MSc/diploma in Part which has been running successfully for over a decade now, and at present is Newcastle University’s most successful online course.

He has an interest in quality of life in head neck cancer and is PI on several head neck cancer studies at present. He is also active in developing radiotherapy research within NCCC, especially in promoting advanced imaging techniques in radiotherapy planning.

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Dr Keith Langmack Head of Radiotherapy Physics, Nottingham University Hospitals NHS Trust After graduation with a doctorate in molecular biophysics from Oxford, Keith joined the Radiotherapy Physics Team at Addenbrooke’s Hospital in Cambridge. He spent over 10 years there developing specific interests in brachytherapy and imaging.

After a brief spell in Lincoln as Deputy Head of Radiotherapy Physics he moved to Nottingham in 2002. He has been there ever since. His current interests are imaging and improving the efficiency of the radiotherapy process.

Miss Lucy Pike Clinical Scientist, PET Imaging Centre, St Thomas’ Hospital Lucy Pike is a Clinical Scientist at the King’s College London and Guy’s and St Thomas’ PET Centre, London. Her current role involves providing support for clinical and research applications of PET-CT including the use of novel PET tracers and complex imaging techniques. In addition, she manages the NCRI PET Core Lab, which provides technical support and develops standards for PET imaging in multi-centre clinical trials.

Dr Vivek Raman Consultant Head and Neck Radiologist and Nuclear Medicine Physician Brighton and Sussex University Hospitals Trust Dr Raman is a Radionuclide Radiologist at Brighton and Sussex University Hospital.

He performed his medical training at Kings College London and his Radiology at Guy’s and St Thomas’ Hospital London. He was appointed as a consultant in 2006 at Conquest Hospital Hastings before moving in 2009 to Brighton and Sussex University Hospitals NHS trust to pursue his interests in PET/CT, Head and Neck Imaging and Cardiac imaging. He works within both the nuclear medicine and radiology departments within the trust. He is involved in teaching both undergraduate and postgraduate students at Brighton and Sussex University. He has papers published in peer review journals and has presented research at international meetings.

Dr Tom Roques Consultant Clinical Oncologist, Norfolk and Norwich University Hospitals Tom qualified as a doctor in 1994 and trained as a clinical oncologist in London and Vancouver before becoming a consultant in Norwich in 2004. He specializes in head and neck and thyroid cancers but also treats a variety of other tumour sites including upper GI and hepatobiliary cancers. He has particular interests in technical radiotherapy and in doctor-patient decision-making. He leads the Anglia East head and neck cancer multidisciplinary team has been clinical director for oncology and palliative medicine in Norwich since 2009. He has written and spoken widely about target volume definition in head and neck cancer and is part of the quality assurance team for two international radiotherapy-based trials.

A lifelong Norwich City fan, he would prefer not to engage in conversation about the canaries given how this season is turning out.

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Mrs Clare Schilling Clinical Academic Lecturer, Specialist Trainee, Oral and Maxillofacial Surgery Guy’s Hospital Clare Schilling is a Clinical Academic Lecture and Specialist Trainee in Oral and Maxillofacial Surgery based at Guy’s Hospital in London. Her PhD is in smart surgical techniques with a particular interest in sentinel node biopsy. Clare, along with Professor Mark McGurk, ran the Sentinel European Node Trial (SENT), the largest trial to date looking at sentinel node biopsy in oral cancer. Clare has won numerous prizes for her work including the British Association of Oral and Maxillofacial Surgery prize for research. She is a co-author of the Oxford Handbook of Oral and Maxillofacial Surgery.

Dr Richard Simcock Consultant Clinical Oncologist Brighton and Sussex University Hospitals NHS Trust Consultant Clinical Oncologist at the Sussex Cancer Centre since 2003 treating head and neck cancer. He has interests in survivorship issues in head and neck cancer and has led trials in xerostomia and is currently collaborating on a study on psychosocial issues in HPV+ patients. He is one of the co-editors of ‘The ABC of Cancer Care’ published in 2013. This year he became a Macmillan Consultant Medical Adviser working with the charity to develop survivorship issues. In 2014 in collaboration with radiation oncologists in the US, Australia and Spain he launched the first Radiation Oncology journal clubs on Twitter.

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Abstracts Ultrasound in treatment planning - how, when and why?

Dr Rhodri Evans Ultrasound in combination with either a fine needle aspiration or a core biopsy is a prerequisite skill for radiologists who want to stage patients with carcinoma efficiently and effectively. This talk will concentrate on the various techniques of biopsy, signs to look for and tips on decision-making that will enable radiologists to stage their patients more effectively.

DWI in staging and monitoring head and neck cancer Dr Steve Connor Diffusion imaging is a MRI technique which depicts the Brownian motion of water molecules in biological tissues. A cellular tumour in the head and neck will result in impeded diffusion, and is demonstrated as increased signal on diffusion weighted imaging (DWI) with a corresponding decreased signal on an apparent diffusion coefficient (ADC) map. There are technical challenges to performing diffusion imaging in the head and neck. Diffusion imaging may be interpreted on a qualitative or quantitative basis. Qualitative analysis can be useful for detecting and delineating certain tumours and recurrent disease, however it should be remembered that other normal structures (e.g. lymphoid tissue) and pathology (e.g. abscesses) are also of increased DWI signal.

Quantitative analysis requires calculation of ADC by placing regions of interest on the ADC map. This has been used to characterise head and neck tumours (e.g. benign versus malignant, squamous cell versus lymphoma and high grade versus low grade), and to distinguish benign from malignant lymph nodes. There should be caution in utilising ADC thresholds from the literature for these purposes, as they may not be applicable across different centres. The greatest impact of DWI in head and neck cancer is likely to be in therapy monitoring and the early detection of treatment failure. There is ongoing investigation into its role both in the early stages of chemo-radiotherapy (in order to predict treatment response and guide therapeutic options), and at 6-12 weeks post therapy (in order to detect residual viable tumour for salvage surgery or staged neck dissection).

There is likely to be standardisation of techniques and newer forms of data analysis in the future.

Educational aims: • To understand the basis of the diffusion weighted imaging sequence and the meaning of the terms diffusion weighted imaging/apparent diffusion coefficient. • To appreciate the major roles of qualitative and quantitative interpretation in head and neck cancer diffusion imaging.

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PET-CT imaging in head and neck squamous cell carcinomas (HNSCC): applications, pitfalls and new horizons Dr Vivek Raman Learning Objectives: 18 • F-FDG PET/CT imaging: technique/interpretation/pitfalls • Impact and evidence based use of 18F-FDG PET/CT in diagnosis/staging • Treatment response • Prognostication • Other PET Tracers There is a weight of evidence-based data supporting the use of 18F-FDG PET-CT in the management of head and neck squamous cell cancers such that its use within this field is now common place. In particular, applications demonstrating significant clinical impact include location of the primary in patients presenting with metastatic lymph node disease, distant metastasis/second primary detection and in the post chemo-radiotherapy treatment scenario, to identify patients with complete treatment response, thus obviating the need for subsequent neck dissection. There are also a number of new PET tracers that have shown promise in identifying certain tumour characteristics to help guide therapy and also in assessing early treatment response and but none have reached the clinical arena.

Getting the best from diagnostic CT Lt Col Mark Ballard The talk will discuss the optimal imaging techniques for CT acquisition in the neck addressing issues including contrast administration, scan timing and management of artefact. Examples of good and bad technique will be demonstrated as well as methods for image reconstruction to aid reporting.

Sentinel node biopsy in the node negative neck Mrs Clare Schilling Sentinel node biopsy is a technique well suited to oral squamous cell carcinoma, a tumour that predictably metastasizes to the cervical lymph nodes. Despite best imaging techniques there is an occult metastasis rate of up to 30% in the radiologically N0 neck. Commonly held surgical dictum is that if there is a >20% risk of metastasis then elective neck dissection should be performed. This means that up to 80% of patients are undergoing unnecessary surgery with consequent morbidity and treatment cost. By mapping the lymphatic drainage of each individual tumour we can offer a patient specific surgical approach to retrieve just the at risk (sentinel) lymph nodes. This is a much smaller operation than elective nodal clearance, and many patients can be discharged the day after surgery.

The Sentinel European Node Trial, which prospectively staged 420 patients with oral cancer, showed that >70% of patients avoided a neck dissection without compromising outcome. The technique had a very low complication rate and cost analysis suggests a saving when compared to standard treatment by elective neck dissection.

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Organs at risk - reviewing the evidence: salivary glands, oral cavity and swallowing structures Dr Andrew Hartley Despite technical advances in radiation oncology, chemoradiotherapy to the head and neck remains a morbid treatment. When deciding which structures to spare during the planning process, the following factors require consideration: the significance to the patient of a particular acute or late side-effect; the most appropriate endpoint for this side-effect; the most practical way of measuring this endpoint; the identity of the organ at risk associated with this endpoint; the evidence for a dose response to this endpoint; the influence of non-dosimetric parameters on this endpoint.

The examples of late xerostomia, acute and late mucosal reaction and late dysphagia will be used to illustrate the consideration of these factors. In addition, new modelling which questions the classical radiobiological determinants of acute and late side effects will be presented using the examples of late mucosal reaction and long term feeding tube dependence.

Organs at risk - defining muscles of mastication, salivary glands and brachial plexus Dr Guy Burkill The neck is anatomically complex. It can be understood in different ways. Neck levels is a well-established road map for lymph node division allowing both staging and inter-disciplinary communication. Fascia and spaces provide barriers and pathways for disease spread. Organs become relevant in defining likely pathologies as well as preservation of function. Although modified by disease and interventions anatomy is static. However our ability to represent it in vivo has improved greatly in recent decades. Furthermore hybrid imaging more accurately defines disease extent whilst available therapeutic options continue to evolve. Collaboration between specialties to harness this knowledge is our best opportunity for treatment optimisation, which becomes ever more pertinent with improved survival.

New organs at risk - reviewing the evidence: carotids and cochleas Dr Dorothy Gujral This talk discusses the carotid arteries and cochleas in radiotherapy planning as organs at risk and reviews the literature for evidence of radiation damage, discussing likely dose constraints and the use of intensity modulated radiotherapy to reduce radiation dose to these structures.

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PET fusion in radiotherapy planning Miss Lucy Pike PET is increasingly used for disease staging, therapy monitoring and follow up for a range of tumour types in routine clinical management. In many tumour types PET can provide greater sensitivity and specificity for nodal staging than CT or MR and can detect functional changes much earlier than anatomical changes. The additional functional information from PET can complement the anatomical data provided by CT and there is much interest in incorporating this into radiotherapy planning to help more accurately define treatment volumes and potentially reduce radiation doses to healthy tissue. There is an increasing case to support the inclusion of FDG-PET in radiotherapy planning for some tumour types, but inappropriate use of PET to reduce treatment volumes could impair rather than improve patient outcomes. It is important therefore that a solid evidence base is established through clinical trials to determine how PET imaging is best utilised in radiotherapy planning.

Evaluation of volume delineation techniques incorporating PET versus conventional contouring techniques in radiotherapy should be carefully planned and executed through clinical trials incorporating rigorous and consistent quality control and imaging protocols. This talk aims to outline the processes involved in incorporating PET into radiotherapy planning and discusses some of the technical challenges that may be encountered. In particular this draws on our own experience of developing PET-CT protocols and the patient pathway for a phase I FDG-guided dose escalation study.

Educational aims and learning outcomes: • To gain an understanding of the requirements for incorporating PET-CT into radiotherapy planning • To gain an appreciation of the practical issues of incorporating PET-CT into radiotherapy planning Auto-contouring software - an end user evaluation.

Dr Keith Langmack Auto-contouring software is used to segment a new patient’s anatomy using previous examples. The contours produced are then manually edited. In Nottingham we have two such systems in clinical use (ABAS, Elekta, for head and neck and prostate; MIM, MIM Software, for lung SABR). The methodology used by each of these systems for auto-contouring will be explained, and some guidance given on atlas building.

The motivation for using such software is that IMRT requires more contouring than traditional radiotherapy. This is very time consuming. In this talk the evidence for times savings of the order of 50% being achieved by using auto-contouring will be reviewed. This requires the editing time for contours to be less than the time for them to be produced from scratch. Some evidence will be presented to show that this is not always the case and, where there is great inter-observer variability in contouring, unaided contouring is more efficient.

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Another proposed advantage of auto-contouring is that delineation uncertainty will be reduced. The evidence for this is reviewed along with the metrics used to measure contouring agreement. Finally there will be a short discussion of the clinical impact of delineation uncertainty.

Educational aims and learning outcomes • Be aware of auto-outlining and how 2 particular systems work • Know that use of such systems can save time • State the conditions in which significant time savings can be achieved • Be aware of delineation agreement metrics and their limitations • Be aware of delineation uncertainty and some of its impact on treatment planning Volume definition after neo-adjuvant chemotherapy Dr Tom Roques The potential benefits of neo-adjuvant chemotherapy in head and neck cancer remain hotly debated but there is not doubt that many tumours shrink when chemotherapy is given before curative radiation. This presents a challenge as target volumes have to be defined at a time when the primary site and involved nodes may be smaller than at diagnosis or even not visible at all. This talk will explore the evidence base for deciding how to contour after neo-adjuvant chemotherapy and will suggest methods for ensuring that any potential benefits of neo-adjuvant chemotherapy are maximized whilst ensuring that the radiotherapy is not compromised.

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