Background and recommendations

Question 1

Stage I

Answer 1

T1 N0 M0

Question 2

Stage II

Answer 2

T2 N0 M0

Question 3

Stage III

Answer 3

T3 N0 M0 or T1-3 N1

Question 4

Stage IVA

Answer 4

T4a N0-1 or T1-4 N2

Question 5

Stage IVB

Answer 5

Any T N3 M0 or T4b N0

Question 6

Stage IVC

Answer 6

Any T Any N and M1

Question 7

T1

Answer 7

2 cm or less and without extraparenchymal extension.

Question 8

T2

Answer 8

more than 2 cm in size but not more than 4 cm without extraparenchymal extension

Question 9

T3

Answer 9

More than 4 cm and/or have extraparenchymal extension.

Question 10

T4a

Answer 10

tumors that invade the skin, mandible, ear canal, and/or facial nerve.

Question 11

T4b

Answer 11

tumors that invade the skull base and/or pterygoid plates and/or encases the carotid artery.

Question 12

Benign salivary tumors

Answer 12

1. Pleomorphic adenoma
2. Myoepithelioma
3. Warthins
4. Basal cell adenoma

Question 13

Low grade salivary tumors

Answer 13

1. Acinic cell

2. Low grade mucoepidermoid

Question 14

High grade salivary tumors

Answer 14

1. High grade mucoepidermoid carcinoma
2. Adenoid cystic
3. Malignant mixed tumor
4. Undifferentiated carcinoma NOS
5. Mucinous adenocarcinoma
6. Small cell carcinoma
7. Clear cell carcinomas
8. Adenocarcinoma
9. Carcinoma ex-pleomorphc adenoma

Question 15

N3

Answer 15

Nodes more than 6 cm in size

Question 16

N2a

Answer 16

single node is positive that is more than 3 cm but 6 cm or less.

Question 17

N2b

Answer 17

multiple ipsilateral nodes are positive but none are more than 6 cm.

Question 18

N2c

Answer 18

metastasis to contralateral nodes has occurred but none more than 6 cm in size.

Question 19

What is the most common malignant subtype of major salivary glands?

Answer 19

Mucoepidermoid

Question 20

What are PORT indications for low grade malignant tumors?

Answer 20

1. Positive margin

2. Multiply recurrence

Question 21

When do you deliver elective nodal radiation with low grade malignancies?

Answer 21

1. Never

Question 22

Salivary gland tumors originate where most frequent?

Answer 22

1. Parotid : 70%
2. Submandibular: 8%
3. Sublingual gland: 2%

Question 23

In general, where are minor salivary glands found?

Answer 23

The epithelium of the upper aerodigestive tract

Question 24

What is the purpose of major salivary glands?

Answer 24

Produce saliva along with enzymes to digest food. Specifically, it secretes amylase which breaks down starch.

Question 25

What are the only tumors where surgery alone is adequate?

Answer 25

Low grade tumors and benign tumors, node negative, resected with negative margins.

Question 26

What are the indications for PORT for benign tumors or the major salivary glands?

Answer 26

1. Positive margins | 2. Multiple recurrent tumors

Question 27

What are the indications for PORT for malignant tumors?

Answer 27

1. Multiple recurrent 2. All high grade tumors 3. Positive margins 4. Positive lymph nodes 5. PNI

Question 28

What are the only situations where RT alone is indicated?

Answer 28

1. Surgery would be too morbid 2. A gross total resection is not possible 3. Patient is a poor surgical candiate for medical reasons

Question 29

How is the HR CTV defined? What dose?

Answer 29

Post-operative bed in the case of gross, disease, close or positive margin and any areas with clinical perineural invasion or ECE 70 Gy at 2 Gy/fx using DAHANCA

Question 30

How is the LR CTV defined? What dose?

Answer 30

Ipsilateral levels 2-3, and 5 if node negative and there are indications for ENI In case of neck is positive for nodes, then treat the ipsilateral RS space, IB, and right SCL In case of adenoid cystic include the main CN to the level of the ganglion. 56 Gy at 1.6 Gy/fx using DAHANCA

Question 31

How is the IR CTV defined? What dose?

Answer 31

Treat any areas that were involved with positive nodes or adjacent nodal stations to areas with positive nodes. Primary tumors resected with negative margins but those having indications to treat the neck 63 Gy at 1.8 Gy/fx using DAHANCA

Question 32

CT Simulation

Answer 32

1. Supine 2. Arms at Side 3. Qfix 4. Neck extended 5. Aquaplast mask 6. IV contrast 7. Barium paste over scars. 8. 5 mm bolus over scar

Question 33

UF constraints to protect the eye?

Answer 33

1. Lens Dmax 12 Gy 2. Retina Dmax 16 Gy 3. Temporal lobe 1 cc 6 Gy

Question 34

What are common cnventional techniques used? What is the downside of using convetional techniques?

Answer 34

1. Unilateral photon wedge pair | 2. Mixed photon and electron lateral beams, 15 MeV (estimate parotide depth is 4.5 cm)

Question 35

What are indications to deliver ENI RT?

Answer 35

High grade tumors that were resected without node dissection

Question 36

What are indications to provide PORT to the neck?

Answer 36

1. Always provide atleast 50 Gy of RT to the neck

Question 37

When is surgery appropriate?

Answer 37

A GTR should be the first step in nearly all nonmetastatic cases. Push for GTR even when CN 7 must be sacrificed.

Question 38

What imaging is needed?

Answer 38

1. Diagnostic CT scan of the neck 2. MR of head and neck 3. CXR but if multiple positive nodes, CT scan of chest

Question 39

What is the most common symptom experienced by patients with an enlarging parotid mass?

Answer 39

Painless palpable mass | Ipsilateral facial weakness

Question 40

What is the proper method to getting a tissue diagnosis?

Answer 40

1. Surgical resection | 2. FNA biopsy