Kathmandu
Cancer Center
Kathmandu
Cancer Center
Complete head and neck cancer care — parotid-sparing IMRT chemoradiation, interstitial brachytherapy for oral cavity tumours, oncological surgery (glossectomy, laryngectomy, neck dissection), cetuximab targeted therapy, and pembrolizumab immunotherapy.
For most locally advanced head and neck cancers, concurrent chemoradiation is the primary treatment — offering organ preservation (larynx, tongue, swallowing function) without compromising cure. KCC's LINAC delivers parotid-sparing IMRT, dramatically reducing dry mouth compared to older radiation techniques.
The head and neck is the most challenging region to irradiate safely. The spinal cord, brainstem, parotid glands, cochlea, mandible, and swallowing muscles all sit within millimetres of the tumour. IMRT shapes multiple radiation beams so that their combined dose is concentrated on the tumour while simultaneously staying below safe limits for each adjacent critical structure. At KCC, every head & neck IMRT plan is reviewed by the radiation oncologist and physicist before treatment begins.
Dry mouth from parotid gland damage was near-universal with older 2D/3D radiotherapy — affecting ~70% of patients severely. Parotid-sparing IMRT reduces severe xerostomia to <20% in most series. This is not a cosmetic issue — it affects eating, speaking, sleep, and dental health for life. KCC treats all head & neck patients with parotid-sparing IMRT as standard.
HPV-positive oropharyngeal cancer (base of tongue, tonsil) is a distinct disease — younger patients, non-smokers, highly radiosensitive. The same IMRT + cisplatin treatment produces 80–90% 5-year survival in HPV+ vs 40–50% in HPV-negative. KCC tests every oropharyngeal biopsy for p16 (HPV surrogate marker) — the result significantly changes prognosis counselling.
HPV types 16 and 18 cause the majority of oropharyngeal cancers. HPV vaccination — ideally given to adolescent girls and boys before sexual debut — prevents these infections and their downstream cancer risk. KCC can provide information about HPV vaccination programmes for your family members. Unlike tobacco-related cancers, HPV oropharyngeal cancer is not associated with field cancerisation — so second primary cancers in the mouth are less common.
For selected oral cavity cancers — oral tongue, floor of mouth, lip, buccal mucosa — interstitial HDR brachytherapy delivers radiation from the inside: directly into the tumour from implanted needles. The extremely high tumour dose is confined very close to the source, protecting the mandible and surrounding mucosa far better than external beam alone.
Under general or spinal anaesthesia, hollow catheters or needles are implanted into and around the tumour. The number and arrangement of catheters is designed based on tumour dimensions.
CT imaging of the implant is used for 3D dose planning — the radiation oncologist and physicist calculate an optimised distribution delivering the tumour dose while keeping mandible and mucosal doses within safe limits.
The HDR Iridium-192 source travels through each catheter sequentially. Treatment is delivered in multiple fractions (typically twice daily × 3–5 days). After completion, the catheters are removed and the patient recovers. Total implant duration: approximately one week.
For early oral tongue cancer (T1–T2), interstitial brachytherapy achieves 5-year local control of 85–95% — comparable to surgery — while preserving tongue mobility and speech. It avoids the trismus and dry mouth that prolonged IMRT can cause. For the patient, the implant week is a short, intensive period after which they return home — avoiding months of daily hospital visits for IMRT.
Surgery is the primary treatment for many oral cavity cancers and salivary gland tumours, and is used for salvage when chemoradiation fails. All procedures at KCC are performed via open approach. Organ preservation through chemoradiation is always considered first for laryngeal and oropharyngeal cancers.
Removal of the primary tumour with clear surgical margins (target ≥1cm). For tongue, buccal mucosa, floor of mouth, hard palate, and retromolar trigone. When mandible is involved — marginal or segmental mandibulectomy. Reconstruction for defects affecting swallowing or speech is planned with the surgical team pre-operatively.
Partial glossectomy for accessible tongue cancers preserves speech and swallowing. Hemiglossectomy for larger tumours. Total glossectomy is rarely required. Speech-language therapy begins pre-operatively and continues throughout recovery. For base of tongue (oropharynx), chemoradiation is preferred over surgery at KCC.
Total laryngectomy removes the entire larynx, creating a permanent tracheostomy. Reserved for tumours not amenable to organ-preservation chemoradiation, or recurrence after radiotherapy. Partial laryngectomy may preserve some voice in selected early cases. Voice rehabilitation with tracheoesophageal prosthesis (TEP) is offered post-operatively at KCC.
Selective neck dissection (levels I–IV or II–IV) removes highest-risk nodal levels while preserving the sternocleidomastoid muscle, internal jugular vein, and accessory nerve. Modified radical when nodes are more extensively involved. Radical neck dissection for massive fixed nodal disease. Bilateral when both sides are at risk.
Superficial or total parotidectomy for parotid tumours — with facial nerve dissection and preservation when oncologically safe. Facial nerve monitoring during parotidectomy reduces permanent facial palsy risk. Post-operative IMRT for high-grade histology, close margins, or nodal involvement.
KCC's head & neck tumour board prioritises concurrent IMRT + cisplatin for laryngeal and oropharyngeal cancers — preserving the larynx, voice, and swallowing. Laryngectomy is considered when: the cancer does not respond to chemoradiation, or the tumour is too advanced even for organ preservation attempts. This decision is always made after full discussion with the patient about functional outcomes — voice, swallowing, and airway — alongside cancer outcomes.
Chemotherapy in head & neck cancer primarily functions as a radiation sensitiser. For recurrent or metastatic disease, cetuximab targeted therapy and checkpoint immunotherapy have changed outcomes significantly.
Cycles 1, 4, and 7 of radiation. Meta-analysis shows 6.5% absolute survival benefit at 5 years vs radiation alone. Requires good renal function and hearing. Pre-hydration given at KCC day ward. Ototoxicity and nephrotoxicity monitoring throughout.
Weekly low-dose cisplatin for patients less tolerant of high-dose. Carboplatin + 5-FU for impaired renal function. Cetuximab + IMRT (BONNER trial) as alternative to any cisplatin in selected cases — less efficacious than high-dose cisplatin but better tolerated.
Anti-EGFR antibody. Concurrent with IMRT (BONNER trial) when cisplatin contraindicated. Recurrent/metastatic: EXTREME regimen (cetuximab + platinum + 5-FU — 36% response rate). Also combined with pembrolizumab. Weekly IV infusion. Available at KCC.
For recurrent/metastatic HNSCC: pembrolizumab monotherapy for CPS ≥1 (superior OS vs EXTREME); pembrolizumab + platinum + 5-FU for all comers. PD-L1 CPS testing arranged at KCC. Now standard first-line for recurrent/metastatic HNSCC.
For platinum-refractory recurrent/metastatic HNSCC. Significant OS benefit vs investigator-choice chemotherapy. Used at KCC for patients who have progressed after platinum therapy. Available at KCC.
3 cycles before definitive chemoradiation — for borderline cases to reduce bulk before radiation or assess chemo-responsiveness for larynx preservation decisions. Not used universally — KCC tumour board discusses each case individually.
Tongue, floor of mouth, buccal mucosa, lip, hard palate, retromolar trigone. Primary surgery ± post-op IMRT. Brachytherapy for tongue/floor of mouth. Tobacco + betel nut main cause.
Base of tongue, tonsil, soft palate. Definitive IMRT + cisplatin. HPV p16 status tested on every biopsy. Excellent prognosis if HPV+. Post-chemoradiation PET-CT at 12 weeks guides node management.
Glottis, supraglottis, subglottis. Early T1–T2 glottic: IMRT alone (voice preserved). Advanced T3–T4: IMRT + cisplatin for organ preservation. Laryngectomy (open) for failure or very advanced disease. Voice rehabilitation post-surgery.
Pyriform sinus, posterior pharyngeal wall, postcricoid. Poorest prognosis subsite. Definitive IMRT + cisplatin for organ preservation attempted. Total laryngopharyngectomy (open) for selected cases. Dysphagia rehabilitation essential.
Linked to EBV in Nepali / South Asian patients. Excellent IMRT response. Standard: IMRT 70 Gy + concurrent cisplatin + 3 cycles adjuvant cisplatin/5-FU. EBV DNA monitoring post-treatment. Not surgically accessible — radiation primary.
Primary surgery (parotidectomy / excision). Post-op IMRT for high-grade histology, close margins, node involvement. Histologies: mucoepidermoid, adenoid cystic, carcinoma ex pleomorphic adenoma.
| Stage | Description | KCC Treatment Approach |
|---|---|---|
| T1–T2 N0 Early | Small primary, no nodes | Surgery (oral cavity, salivary gland) · OR · Definitive IMRT alone (larynx T1–T2, nasopharynx) · Brachytherapy for oral tongue/floor of mouth T1–T2 |
| T1–T2 N+ Node-positive | Small primary with nodal involvement | Surgery + post-op IMRT ± cisplatin · OR · Definitive IMRT + cisplatin · Post-chemoradiation PET-CT at 12 weeks; neck dissection if residual PET-positive nodes |
| T3–T4 N0–N2 Locally advanced | Large/invasive tumour ± nodes | Concurrent IMRT 70 Gy + cisplatin (organ preservation priority) · OR · Surgery + post-op IMRT ± cisplatin for oral cavity primary · TPF induction for selected cases |
| T4b / N3 Very advanced | Massive primary or large fixed nodes | Definitive IMRT + cisplatin · Induction TPF to assess responsiveness · Cetuximab if cisplatin contraindicated · Palliative IMRT if unfit for aggressive approach |
| Recurrent / M1 Metastatic | Relapse or distant spread | Pembrolizumab ± platinum + 5-FU (KEYNOTE-048) · Nivolumab 2nd line (CheckMate-141) · Cetuximab + platinum + 5-FU (EXTREME) · Palliative IMRT for local symptoms |
Head and neck cancer symptoms are often dismissed as "infections" or "ulcers" for months before diagnosis. The rule: any mouth ulcer, neck lump, or throat change lasting more than 3 weeks needs assessment.
Any oral ulcer or sore not healed in 3 weeks requires biopsy regardless of pain. White patches (leukoplakia) and red patches (erythroplakia) are pre-cancerous and must be evaluated — they can be treated before becoming cancer.
A painless, firm neck lump for more than 3 weeks in an adult is head and neck cancer until proven otherwise. Often the first sign of an HPV-positive oropharyngeal cancer — even before a throat symptom appears.
Persistent hoarseness lasting over 3 weeks in a smoker is laryngeal cancer until proven otherwise. Flexible laryngoscopy at KCC takes minutes to visualise the vocal cords.
Progressive difficulty swallowing solids then liquids — common in hypopharyngeal, oropharyngeal, and advanced tongue cancer. Often associated with weight loss. Requires urgent assessment.
Betel nut and pan masala with tobacco create a chronic carcinogenic environment in the oral cavity. Khaini (smokeless tobacco) placed in the buccal sulcus directly causes buccal mucosa cancer. Oral submucous fibrosis — from betel nut — is itself a pre-malignant condition with progressive difficulty opening the mouth.
Stopping all tobacco and betel nut at any stage reduces further cancer risk. KCC can refer to cessation support services.
City Clinic — New Baneshwor · Main Campus — Bhaktapur · brachy.kccrc.org