Head and Neck Flashcards
1
Q
What is the DDx for a HN mass?
A
SCC
Melanoma
Lymphoma
Sarcoma
Plasmacytoma
Angioma
Benign (abscess, inflammatory)
2
Q
Initial workup for HN cancer
A
Detailed H&P
- History
- Dysphagia
- Odynophagia
- Otalgia
- CN deficits
- Smoking/drinking/sexual habits
- Physical exam
- HEENT - oral exam
- CN exam
- Neuro exam
- Nasopharyngoscopy
- LN exam of neck
3
Q
Labwork to order for HN SCC
A
CBC
CMP
TSH
EBV (if nasopharynx)
4
Q
Imaging to order for HN
A
CT w contrast
MRI to assess for BOS invasion
PET/CT to assess nodes and distant mets
5
Q
What to check on HN Biopsy
A
HPV status
p16
6
Q
All HN patients should be referred for which services
A
Dental evaluation
Speech/Swallow
Nutrition
Audiology
7
Q
Indications for PEG tube placement
A
Severe weight loss prior to treatment (10% in 6 months)
Severe dysphagia
High aspiration risk
8
Q
Level 1A nodes
A
Submental
Lateral borders are anterior belly of digastric muscles
9
Q
Level 1B nodes
A
Submandibular nodes
Lateral to submandibular gland, behind mandible
10
Q
Level II lymph nodes
A
Upper cervical
- Superior edge is transverse process of C1, retrostyloid space
- Inferior: hyoid bone
- Posterior: post edge of SCM
- Anterior: post edge of submandib gland
- Medial: ICA
- Lateral: SCM muscle
11
Q
Level IIA
A
Anterior to internal jugular vein
12
Q
Level IIB
A
posterior to IJ vein
13
Q
Level III nodes
A
Mid cervical
Superior border: hyoid
Inferior border: inferior cricoid cartilage
Other borders same as level II
14
Q
Level IV neck
A
Inferior cervical
- Superior: inferior edge of cricoid cartilage
- Inferior: Depends on nodal status
- If N0 - 2 cm above manubrium
- If N+ - manubrium
- Lateral: SCM
- Medial: ICA
- Anterior: anterior edge of SCM
- Posterior: posterior edge of SCM
15
Q
Inferior edge of Level IV nodes if N+
A
manubrium
16
Q
Level V neck
A
Posterior triangle
- Superior: superior edge of hyoid
- Inferior: posterior to level II/III
- Anterior: posterior edge of SCM
- Posterior: Anterior edge of trapezius
17
Q
Level VIa nodes
A
Anterior central compartment
Below level 1A but between SCM
18
Q
Level VIb nodes
A
Central compartment nodes
19
Q
Retropharyngeal nodes
A
20
Q
What is removed in radical neck dissection?
A
- Levels I-V
- SCM
- Omohyoid muscle
- IJ and EJ veins
- CN XI
- Submandibular gland
21
Q
What is the difference with a modified radical neck dissection?
A
Leaves at least one of SCM, Int Jugular, CN XI
22
Q
What is comprehensive neck dissection
A
Removes all of LN I-V
(generally appropriate for N+ disease)
23
Q
What is a selective neck dissection?
A
Removes select nodal levels depending on sites and cN status
24
Q
What nodal dissection is required for N0 OC
A
Selective I-III
25
What nodal dissection is required for N0 OPX
Selective II-IV
26
What nodal dissection is required for N0 Hypopharynx or Larynx
Selective neck dissection of II-IV
Include level VI if subglottic extension
27
What nodal dissection is required for N1
Selective or comprehensive pending situation
28
What nodal dissection is required for N2
Selective or comprehensive pending situation
29
What nodal dissection is required for N3
Comprehensive neck dissection
30
RT coverage of N0 NPX
Cover levels II-III-IV-V
RP bilaterally (including medial)
31
RT coverage of N0 OC
Level Ib, II, III bilaterally
Top of level IV bilaterally
Include 1a for lip, oral tongue, alveolar ridge and FOM
32
Which N0 OC patients can get ipsilateral neck treatment
T1N0, T2N0 or T1N1 well-lateralized
buccal, alveolar, RMT
33
RT coverage of N0 OPX
Level II-III-IV bilaterally
Ipsilateral RP node
Bilateral RP nodes if posterior pharyngeal wall involved
34
Which N0 OPX patients can get ipsilateral neck treatment
well lateralized small tonsil
35
RT coverage of N0 Larynx cancer
II, III, IV bilaterally
Consider VI if thyroid cartilage, posterior cricoid cartilage or subglottis involved
36
RT coverage of N0 supraglottic larynx
II - III - IV bilaterally
37
RT coverage of N0 Hypopharynx
II - III - IV bilaterally
RP bilaterally
VI if thyroid cartilage, posterior edge of cricoid cartilage or subglottis involved
38
RT coverage of N0 thyroid
III - IV, VI bilaterally
Consider V
Cover II and mediastinum if anaplastic histology
39
When to cover medial RP nodes?
* Always for NPX
* If lateral RP nodes are positive
40
Other situations to consider covering level 1b
* NPX involving nasal cavity
* Oral cavity extension of OPX
* Level II with bulky disease or ECE
41
When to consider covering level V
NPX
Bulky or multiple levels II-IV
42
What are the only lesions which drain directly to level V
NPX
Scalp
Lymphoma!
43
What is the management by T stage
T1N0: surgery or RT alone
T2N0: surgery or RT alone
T3 or N+ : CRT
44
What is the preferred concurrent chemo regimen for HN SCC?
Bolus cisplatin
100 mg/m2 q3 weeks, for 3 infusions during RT
45
Other systemic therapy options if bolus cis is not possible
* Weekly cisplatin 40 mg/m2
* Cetuximab
* Weekly carbo-taxol
* Carbo AUC 2
* Taxol 80 mg/m2
46
Doses of cetuximab
400 mg/m2 loading week before RT
250 mg/m2 weekly
47
Indications for contralateral neck dissection
N+ disease on that side
Midline structures (oral tongue, FOM)
48
Indications for postop RT to primary
* pT3/T4
* PNI
* LVI
* Close margins
* OC primary with level IV or V LN involvement
49
What is considered close margin for HN
5 mm
50
What are indications for postop RT to neck?
N2 or N3
51
Indications for post op CRT
ECE
positive margins
52
If treating primary or nodes postop, do you always treat both?
Most of time yes
Consider separating if parotid or skin primary
53
When should reimaging occur after definitive CRT?
12 weeks with PET
54
What to do if residual disease at 12 week PET?
Consider referral to surgeon for neck dissection
55
Goal is to finish all treatment for HN SCC within X weeks
11 weeks
so RT should start \< 6 weeks after surgery
56
What are situations where an ipsilateral neck can be treated
* All T1-T2N0 or maybe T1N1
* Well-lateralized TBARS
* Tonsil with \<1cm involvement of BOT or soft palate
* Buccal
* Alveolar Ridge
* RMT
* Salivary
57
OPX situations where ipsilateral neck is ok
Well-lateralized tonsil
T1N0, T2N0, T1N1 (1 node only)
\<1 cm involvement of BOT or soft palate
58
What would be the benefit of hyperfractionation for patients?
Improved LC about 5-6%
But no benefit when chemo added so better to stick to RT alone
59
What is the advantage of CRT for patients with +ECE or +margin
10% improvement in OS, DFS, LRC
60
What is the improvement in outcomes if CRT used instead of definitive RT
5% OS if sequential chemo --\> RT
8% OS benefit if concurrent CRT
61
Simulation for Head and Neck Cancer
* Simulate supine with a 5 point aquaplast mask, neck hyperextended, shoulders down
* CT with IV contrast, if possible PET simulation or fusion with diagnostic PET and MRI
* Isocenter at the areytnoids
* Daily CBCT and KV
62
Dose levels for definitive CRT or RT alone for stage I-II
* IMRT using 3 dose levels
* Dose painting
* 1.8 x 30 to 54 Gy to low risk nodes (2nd eschelon and contralateral 1st echelon)
* 2 x 30 to 60 Gy to high risk nodal areas
* Boost of 2 Gy x 5 to total dose of 70 Gy to gross disease
63
How to contour CTV 70
Gross primary disease + 5 mm
Gross nodes + 5 mm
64
How to contour CTV 60
CTV 70 + 0.5 cm
High risk nodes (1st echelon)
65
What is PTV expansion for HN SCC
3 mm
66
How to contour CTV 54
Low risk nodes - 2nd echelon and contralateral 1st echelon if not involved
67
Dose levels utilized for postop HN cases
* 60 Gy (tumor bed and high risk nodes)
* 54 Gy (elective nodes)
* 66 Gy if ECE or +margin
68
How to contour CTV66 for postop case
Areas of positive margin or ECE + 0.5 cm
69
How to contour CTV 60 for post op case
Pre-op GTV + tumor bed + 1 cm
High risk nodal regions
70
How to contour CTV 54
Low risk nodes (2nd echelon and contralateral if indicated)
71
PTV expansion for postop cases
3 mm
72
If doing RT alone, what is a reasonable hyperfractionation schedule
6 fractions per week per DAHANCA or MARCH-HN
BID on Friday
Showed LC benefit, most pts T1-T2N0
73
Script for contouring intact cases
I would contour out my primary and nodal GTVs defined by preoperative physical exam, operative reports and imaging
These will be expanded by 5 mm to make the CTV70 and then by 3mm to make a PTV70
I will then make an additional 5 mm expansion on the CTV 70 to make a high risk CTV60 which is also expanded to include adjacent areas of potential spread. The involved nodal areas would also be included in the CTV60.
The remaining nodal areas I wish to cover will be called CTV54
74
Plan evaluation coverage goal for HN cases
* 95% of PTV getting 100% of dose
* 99% of PTV getting 93% of dose
* Hot spot \< 107%
75
Brainstem max dose
54 Gy
Consider 60 Gy for NPX
76
Cord constraint
45 Gy
77
Mandible constraint
70 Gy MPD
78
Oral cavity constraint
Mean uninvolved \< 30 Gy if achievable
79
Brachial plexus constraint
66 Gy MPD
80
Larynx constraint
\<35-45 if not involved
81
Submandibular constraint
Mean \< 39 Gy
82
Parotid constraint
Mean \< 26 Gy or ALARA
83
Esophagus constraint
Mean dose \< 34 Gy
84
Lips constraint
Mean \< 20 Gy (MPD 30-50)
85
Retina constraint
MPD \< 45
86
Cornea constraint
MPD \< 45
87
Lens constraint
\<8 Gy
88
Temporal lobe constraint
MPD \< 70 Gy bilateral
89
Strategies to address is cannot meet DVH constraints
* Resim at 40 Gy and adaptive planning
* Induction chemotherapy
* Smaller margins on PTV 70
* Proton therapy
90
Follow-up imaging for HN cases
PET CT at 3 months post
Then as indicated (not routine)
91
FU exam scheduling
H&P with scople q3-6 months for 5 years then annually
Thyroid eval q6-12 months
Regular follow-up with dental
Speech, Nutrition, Audiology PRN
Carotid evaluation for long term survivors
92
When do most recurrences occurs
90% within first 3 years post treatment
93
WHO class I nasopharynx cancer
Keratinizing
Associated with EtOH and Tobacco
Worse LC and OS
94
WHO class II NPX cancer
Non-keratinizing
Associated with EBV and Asian demographic
A- differentiated
B- undifferentiated
95
WHO class III NPX cancer
Basaloid
96
Where is most common location for NPX cancer
Fossa of Rosenmuller
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97
Where is fossa of Rosenmuller
Posterior to Torus Tubarius
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98
Additional workup needed for NPX cancer
H&P with attention to Epistaxis, CN palsy, trismus, otalgia
Labs; EBV DNA level
99
What is trismus suggestive of for NPX cancer
invasion of masticator space
100
T1 nasopharynx
Confined to nasopharynx and/or adjacent orophaynx/nasal cavity
101
T2 nasopharynx
Parapharyngeal extension
Pterygoid muscles
Prevertebral muscles
102
T3 nasopharynx
Bony skull involvement, spine, pterygoid or bony sinus
103
T4 nasopharynx
Intracranial extension, CN palsy, hypopharynx, parotid, orbit or soft tissue beyond lateral pterygoid muscle
104
N1 nasopharynx
Unilateral Ib to III or Va Nodes
OR
**Unilateral or Bilateral RP**
All \< 6 cm
105
N2 NPX
Bilateral Ib to III or Va \< 6 cm
NOTE\*\* BILATERAL RP is still N1
106
N3 NPX
Any level IV or V (below cricoid cartilage)
Any node \> 6 cm
107
Treatment of T1 NPX
If T1N0 - RT alone
If N1+ then CRT
108
Treatment of T2+ NPX
Definitive CRT
Concurrent chemoRT with bolus cisplatin 100 mg/m2 q3 weeks x 3 infusions
Followed by adjuvant cis-5-FU for 3 cycles
109
Dose of adjuvant cis-5FU for NPX
cis 80 mg/m2 on D1
5FU 1000 mg/m2 (D-4)
q4 weeks for 3 cycles
110
What is the dose levels for NPX
2. 12 x 33 = 69.96 to gross disease
1. 8 x 33 = 59.40 to high risk CTV
1. 64 x 33 = 54 to elective CTV
111
What is CTV 69.96 for NPX
Primary and involved nodes + 5mm
Ok to reduce margin to 1mm at critical structures like brainstem
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112
What is CTV 59.40 for NPX
* Entire nasopharynx
* Superior: inferior half of sphenoid sinus, posterior and inferior ethmoid sinus, bilateral foramen ovale, rotundum and lacerum
* Anterior: posterior 1/4 of nasal cavity and max sinus, bilateral PPF
* Lateral: parapharyngeal space, pterygoid fossa
* Posterior: anterior 1/3 of clivus (or whole if involved)
* Nodes
* RP
* Level II, III, Va
113
What is CTV 54 for NPX
Level IV nodes
114
How do contours change if T3/T4 NPX
Treat entire sphenoid sinus
Ipsilateral cavernous sinus
Full clivus if T3 due to bone involvement
115
What is OS for locally advanced NPX
60-80%
116
Acute toxicities of NPX treatment
Mucositis
Dermatitis
Xerostomia
117
Late toxicities of NPX treatment
Cranial neuropathies
Trismus
Soft tissue fibrosis
Xerostomia
Hearing Loss
ORN
TLN
Hypothyroidism
Vasculopathy
118
Special follow-up considerations for NPX
MRI at 12 weeks plus PET
119
What are the oral cavity subsites?
* Lip
* Gingiva or alveolar ridge
* Buccal mucosa
* Retromolar trigone
* Hard palate
* Oral tongue (anterior 2/3)
* Floor of mouth
120
What does lower lip numbness suggest
Inferior alveolar nerve involvement
Part of V3 (mandibular branch of trigeminal nerve)
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121
History for OC cancers
Non-healing ulcers
Oral pain
Bleeding
Loose teeth
Ill fitting dentures
Halitosis
Neck masses
122
How often is IV involved for oral tongue
15% there are skip mets to level IV for oral tongue which are not addressed in typical selective neck dissection level I-III
123
T1 OC
\<2 cm
DOI = 5mm
124
T2 OC
2.1-4 cm AND/OR
DOI 5-10 mm
125
T3 OC
\>4 cm OR
DOI \> 1 cm
126
T4a lip
Through bone, inferior alveolar nerve involvement, FOM, facial skin
127
T4a oral cavity
Through bone, maxillary sinus, facial skin OR DOI \> 2 cm
128
T4b oral cavity
Masticator space
Pterygoid plates
Skull base
Carotid encasement
129
cN1 oral cavity
single ipsi node \<3 cm
130
cN2a oral cavity
single ipsilateral node between 3-6 cm
131
cN2b oral cavity
multiple ipsi nodes \<6 cm
132
cN2c oral cavity
bilateral or contralateral nodes \< 6 cm
133
cN3a oral cavity
any nodes \> 6 cm
134
cN3b oral cavity
clinically apparent ECE
135
How does path staging change for oral cavity vs. clinical staging?
pN2a includes single ipsi node 3-6 cm
BUT ALSO INCLUDES
single ipsi node \<3 cm with pathological ECE
136
How to classify ECE using path staging for oral cavity?
If single IPSI node \< 3 cm with path ECE --\> pN2a
If other ECE --\> pN3b
137
What is stage III oral cavity
T3 or N1
138
stage IVA oral cavity
T4a or N2
139
stage IVB oral cavity
T4b or N3
140
What is preferred management for oral cavity cancers?
* Surgery is preferred
* Do a neck dissection for
* cN+
* DOI \> 2 mm and definitely if \>4 mm
141
Indications for postop RT for oral cavity cancers
* pT3/T4 (consider for T2 tongue with DOI \> 5 mm)
* Close margin (\<5 mm)
* LVSI
* PNI
* 2+ nodes
* Level IV or V nodes
* Consider if DOI \> 4 mm
142
What is Quad Shot Dose
370 x 4 = 1480
143
What is the DOI suggestive of needing post op RT
4 mm
144
Indications for postop CRT for oral cavity
+ECE
+margin
145
Are there situations where RT is preferred for oral cavity?
Lip commissure tumors
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146
If an OC tumor is unresectable, how to approach
stage I - T1N0 --\> RT alone
stage II - T2N0 --\> RT alone
stage III+ --\> CRT
147
Surgery for oral tongue cancer
* If small and lateralized --\> partial glossectomy
* If T2 and lateralized --\> hemiglossectomy
* If midline --\> total glossectomy
148
Special considerations for lip primary for coverage
if commisure involved --\> cover Ib and II to 54 Gy
If upper lip, consider covering facial nodes
Do a lead shield for the mouth
149
Is cetuximab ok for oral cavity cancers?
Not included on Bonner trial so no
150
Sim considerations for oral cavity
IMRT
5 pt mask, arms down
IV contrast
Neck hyperextended, shoulders down
BITE BLOCK
151
What is the purpose of a bite block
To minimize dose to hard palate and immobilize tongue
152
CTV 66 for oral cavity
Areas of positive margin or ECE
3-5 mm expansion
Keep as small as possible per RTOG
153
CTV 60 for oral cavity
* Surgical bed
* Consider entire oral tongue/FOM
* Cover all clips and entire myocutaneous flap
* 1st echelon nodes
* Level IB, II, III bilaterally, top of IV
* If well lateralized buccal, gingival, RMT,
* Cover IA for FOM, oral tongue, inferior alveolar ridge, lip
* **_DO NOT NEED RP_**
154
What is CTV 54 for postop oral cavity?
Lower risk nodal levels - level IV, elective contralateral neck
Full oral tongue or FOM if involved
155
Optimal time between surgery and PORT for OC cancer
\<6 weeks
156
How do surgery and RT compare for LC for oral cavity
For T1-T2, similar (75-80%)
For advanced, much worse with RT alone
157
OS for stage III OC
75%
158
OS for stage IV OC
55%
159
Specific considerations for sim for lip tumor
Need lead shielding and in mouth
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160
What is the location of the hypopharynx
Pharynx from hyoid to cricoid cartilage
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161
What are the subsites of the hypopharynx cancer
* 3Ps
* Posterior pharyngeal wall
* Postcricoid area
* Piriform sinuses
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162
Location of pirform sinus
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163
What is typical clinical history for hypopharynx ca
Globus sensation
164
T1 hypopharynx
\<2 cm, one subsite
165
T2 hypopharynx
2-4 cm or
adjacent subsite or larynx
166
T3 hypopharynx
\>4 cm or
Hemilarynx fixation OR
esophageal involvement
167
T4a hypopharynx
Thyroid/cricoid cartilage
Hyoid bone
Thyroid gland
Central soft tissue (strap muscles or subQ fat)
168
T4b hypopharynx
Prevertebral fascia
Carotid artery
Mediastinum
169
Nodal staging for hypopharynx
cN1 – single ipsi node ≤ 3 cm
cN2a – single I/L node \> 3 cm, ≤ 6 cm
cN2b – multiple ipsi nodes ≤ 6 cm
cN2c – bilat or contralat nodes ≤ 6 cm
cN3a – \> 6cm
cN3b – clinically overt ECE
170
Treatment for T1 hypopharynx
* Two options
* Partial pharyngectomy (larynx preserving) with LND including pretracheal and IPSI paratracheal dissection
* Definitive RT to 70 Gy
171
Options for T2N0 hypopharynx
* Two options
* Partial pharyngectomy (larynx preserving) with LND including pretracheal and IPSI paratracheal dissection
* Definitive RT to 70 Gy
172
Options for T3/T4 or N+ hypopharynx which is resectable
* Options include
* Definitive CRT
* TL with LND (preferred for T4a or non-functional larynx with high aspiration risk) --\> RT or CRT as indicated by path findings
173
Options for T3 or T4 or N+ hypopharynx which is unresectable
Definitive CRT
174
Doses for hypopharynx
* Depends on definitive CRT or postop
* Definitive
* CTV70
* CTV60
* CTV54
* Postop
* CTV66 (+margin or ECE)
* CTV60
* CTV54
175
CTV70 for hypopharynx ca
GTV using scope, PET, MRI, CT expand by 5 mm
176
First eschelon nodes for hypoharynx
* Bilateral RP nodes
* Level II, III, IV
* Consider level VI if thyroid cartilage, cricoid cartilage or subglottis is involved
177
CTV 60 primary for hypopharynx
* T2+: should includ part of thyroid cartilage, part of cricoid cartilage, part of hyoid and maybe esophagus
* T3-4 should include at least hemi-larynx
178
Which subsite has worst prognosis in HN
hypopharynx
179
Rates of larynx preservation with hypopharynx
60-80%
180
OS at 5 years for hypopharynx
40-50%
181
What is the rate of pharyngocutaneous fistula after salvage laryngectomy
30%
182
OPX sites
Soft palate
Tonsil
BOT
Posterior pharyngeal wall
Glossotonsilar sulcus
Uvula
Vallecula - space anterior to epiglottis
183
Borders of the OPX
Superior = soft palatte
Inferior = hyoid
Anterior = oral tongue
Posterior - pharyngeal wall
184
What does trismus suggest for OPX cancer
pterygoid involvement
185
What does hot potato voice suggest
BOT involvement
186
What are the options for HPV testing
p16 IHC
HPV DNA FISH
187
How is OPX staging different than other sites
Divided into HPV+ and HPV-
188
HPV negative T1
\<2 cm
189
HPV negative T2
2.1 - 4 cm
190
HPV negative T3 OPX
\> 4cm OR
lingual epigottic extension
191
HPV negative T4a OPX
Larynx
Medial Pterygoid
Mandible
Extrinsic tongue muscles
Hard palate
192
HPV negative T4b OPX
lateral nasopharynx
lateral pterygoid muscles
Pterygoid plates
Skull base
Carotid encasement
193
N System for HPV negative OPX
same as oral cavity
194
How is T staging different for HPV+
T4a and T4b is collapsed into T4
195
What are the nuances of nodal staging for HPV+
Different clinical and path staging
196
cN1 HPV+
one or more ipsi LN \<6 cm
197
cN2 HPV+ OPX
bilateral or contralateral nodes \< 6 cm
198
cN3 HPV+ OPX
nodes \> 6 cm
199
What is path nodal staging for HPV+ OPX
pN1 = \<5 nodes
pN2 = 5 or greater LN
200
Clin stage I OPX
T0-2
N0-1
201
Clin stage II OPX
T3 or N2
202
Clinical stage III OPX
T4 and/or N3
203
Treatment of T1-2N0
1. Surgery (TORS) with adjuvant chemo/RT as indicated
2. Definitive RT alone
204
Any nodal patients candidate for TORS?
One Small node (\<3 cm)
\*\*Can also do RT alone for these patients
205
Which tonsils can you consider treating ipsi neck
T1N1
T2N1
206
Who is not eligible for TORS?
T3/T4
More than minimal soft tissue palate extension
Central BOT involvement
Trismus or other difficulties with exposure
Radiographic or clinical ECE
207
Treatment for T3/T4 OPX cancers or OPX cancers with \> 1 node
Definitive CRT to 70 Gy in 35 fx with concurrent cisplatin
208
CTV70 for OPX
GTV + 5 mm edited off skin, bone, air
209
GTV 60 for OPX
GTV + 10 mm and expanded to include areas of potential spread
210
1st eschelon nodes for OPX
Levels II-IV, I/L or Bilateral RP
If N+ neck, cover ipsi nodes to BOS and low level IV
211
CTV 54 for opx
Likely contralateral neck
212
Conditions for T2N1 to have ipsilateral neck RT
T1-T2 N0-1 tonsil
At most minimal superficial BOT involvement
At most 1 cm soft palate extension
No posterior wall involvement
At most 1 ipsi level II node, \< 3 cm, no ECE
213
What is long term PEG dependency with CRT
15-20% with CRT
5% with IMRT
214
What are the major salivary glands?
Parotid
Submandibular
Sublingual
215
Most common location for minor salivary gland tumors
hard palate
216
What is most common location for minor salivary gland tumors
Hard palate
217
Epidemiology of salivary gland tumors
75% are parotid and of them 75% are benign
75% of minor salivary gland tumors are malignant
218
Most common presentation of salivary gland tumor
Painless mass
CN VII (Bell) Palsy
Trismus is possible but suggestive of parapharyngeal involvement
219
What imaging workup needed for salivary gland tumor
CT neck
MRI neck which does help to clarify PNI and possibly grade
CT chest
220
DDx of salivary gland tumor
Rule out skin cancer with parotid nodes
Cysts
Sarcoid
Lymphoma
Sjogren's
Sialadenitis
Bell palsy
221
T1 salivary
\<2 cm
222
T2 salivary
2.1-4 cm
223
T3 salivary
\>4 cm or extraparenchymal extension
224
T4a salivary gland
FEMS
* Facial nerve
* Ear canal involvement
* Mandible
* Skin
225
T4b salivary
skull base, pterygoid plates, carotid encasement
226
What are low grade salivary histologies?
* acinic
* mucoepidermoid
227
What are the high grade salivary histologies?
* Adenoid cystic
* Adeno
* Squamous
228
What is the management of salivary gland tumors?
* Start with surgery (parotidectomy)
* Total if deep lobe is involved
* Ipsilateral level II-V dissection if high grade or cN+
* Consider RT for most, unless small and low grade
229
What should be asked about on the parotid path specimen?
Grade
PNI
Margins
230
What are the indications for post op RT to primary alone for salivary?
Close or positive margins (especially deep lobe)
PNI/LVSI
Capsule rupture or spillage
Recurrence
231
Indications for postop RT to primary and neck for salivary
N+
High grade
T3-T4
232
What neck levels are involved for parotid?
If elective: IB-III
If involved: IB-V
233
What is one of the objectives of surgery for parotid?
avoid damaging facial nerve
otherwise need nerve graft or plastic surgery
234
How to manage the neck surgically for parotid tumor
Only need ipsi neck dissection
Treat the contralateral neck if there is multilevel nodal involvement and \>50% of removed nodes +
235
Sim for salivary gland tumor
Supine
Hyperextended neck
IV contrast
5 pt mask
Iso behind cricoid cartilage
Fuse MRI for skull base or CN involvement
236
What is the contours for salivary gland tumor
CTV Post-op = tumor bed
PTV = CTV + 2 cm
CTV intact = tumor + normal parotid gland
Neck = Ib to IV, V if involved
237
Doses for salivary gland tumors
Intact or R2 - 70 Gy in 35 fx
R1 or ECE - 66 Gy in 33 fx
R0 - 60 Gy in 30 fx
Elective neck - 54 Gy in 30 fx
238
How to address PNI in volumes for salivary gland
Cover 7th nerve back through stylomastoid foramen back to 2nd genu unless gross disease in BOS
239
At what dose is loss of salivary function permanent
35 Gy
240
Goal parotid dose
Mean \< 26 but ALARA
241
Supraomohyoid dissection
removes I-III
242
Is chemo used for salivary gland?
Controversial, at this point no
243
Most common benign histology of parotid gland
pleomorphic adenoma.
244
Most common malignant histology of parotid gland
mucoepidermoid
245
Most common malignant histology of submandibular and minor salivary glands
ACC
246
What are the subsites for larynx
* Supraglottic larynx
* Glottic larynx
* Subglottic larynx
247
If the disease is glottic larynx what subsites?
True cords, anterior or posterior commissures
248
What are the potential subsites of supraglottic larynx?
* Suprahyoid epiglottis
* Infrahyoid epiglottis
* Aryepiglottic folds
* Aryenoids
* False vocal cords
249
Physical exam for larynx cancer
History of hoarseness
Swallowing issues
Flexible nasopharyngoscopy to identify disease laterality, involvement of commisures, extension to adjacent sites, VC mobility
250
What imaging should be obtained for suspected larynx ca
CT larynx with thin slices through larynx
MR neck
PET
251
What other referrals should be made for patients with suspected larynx ca
speech swallow
nutrition
dental
smoking cessation
252
T1 larynx
Confined to one subsite with normal cord mobility
253
T2 larynx - general
involvement of adjacent site or impaired VC mobility
254
T3 larynx - general
* Fixed VC
* Invasion into
* the paraglottic space
* inner cortex of the thyroid cartilage
* pre-epiglottic space
* post cricoid
255
T4a larynx - general
* Invasion into
* outer thyroid cartilage
* outside larynx
* trachea (inferior to cricoid)
* soft tissue of the neck
* extrinsic tongue muscles
* strap muscles
* thyroid
* esophagus
256
T4b larynx - general
prevertebral fascia
encasement of ICA
mediastinum
257
Special T stage considerations for glottic larynx
Remember only true cords
T1a = one cord
T1b = both cords
258
What are treatment options for Tis glottic larynx?
* Laser therapy to strip mucosa
* RT alone (60.75 Gy - 2.25 x 27)
259
Management options for T1 or T2 larynx glottic
* Definitive RT alone
* Surgery alone with risk adapted adjuvant therapy
260
What is the definitive RT dose for T1 larynx
2.25 x 28 = 63
No chemo
261
What is the definitive RT dose for T2 larynx
2.25 x 29 = 65.25
262
What are the surgical options for T1 or T2 larynx
* Cordectomy
* Vertical hemilaryngectomy - takes ipsi cord and 1/3 of contra cord and 1/2 of cricoid cartilage
* leaves the cricoid and hyoid intact
263
What patients are suitable for cordectomy
T1
264
What is a contraindication to cordectomy
anterior commissure involvement
265
What patients are suitable for vertical hemilaryngectomy
T1 and some T2
266
What are contraindications to hemilaryngectomy
T3 or T4, select T2 with bilateral arytenoid or epiglottic or subglottic involvement
267
How does OS differ between surgery and RT for early stage larynx
same
268
After surgery or RT for early stage larynx, what is better/worse
Swallowing better with surgery
Voice better with RT
269
When should nodes be treated with early stage glottic larynx?
If it is a T2 with extension into subglottis or supraglottic region
270
Treatment options for locally advanced glottic larynx (T3+ N+)
* Definitive CRT
* Total laryngectomy with bilateral LND --\> RT or CRT pending path findings
* Induction chemo --\> RT or surgery (less preferred)
271
What is removed with a total laryngectomy
Hyoid
Thyroid
Cricoid cartilage
Epiglottis
Strap muscles
Pt is left with a permanent trach and pharynx reconstruction (by suturing to BOT)
272
Most common location for failure after total laryngectomy
stoma
BOT
Neck nodes
273
When is total laryngectomy preferred
T4a disease
274
Supraglottic larynx T1 stage
One subsite, normal VC movement
275
T2 supraglottic larynx stage
More than one subsite
Involvement of immediate surrounding areas (BOT or piriform sinus)
Impaired VC movement
276
T3 supraglottic larynx stage
* PPP-TF
* Post cricoid space
* Pre-epiglottic space
* Paraglottic
* Inner cortex of thyroid cartilage
* **_VC fixation_**
277
How does nodal involvement compare between supraglottic and glottic larynx
Much higher with supraglottic
278
Treatment options for T1 or T2N0 supraglottic
* Definitive RT
* Supraglottic laryngectomy + BLND --\> RT or CRT as guided by path findings
279
Dose of definitive RT for supraglottic larynx
GTV to 70 Gy
CTV including full larynx to 60 Gy
Bilateral levels II-IV to 54 Gy
280
What is a definitive RT dosing option for supraglottic larynx?
Consider DAHANCA of 6 fractions per week
281
What is removed in supraglottic laryngectomy?
Epiglottis, AE fold, false cords, hyoid if preglottic extension, upper 1/2 of thyroid cartilage
**_Preserves one or both arytenoids and both TVCs_**
282
What are contraindications to supraglottic laryngectomy
T2 with true glottic involvement, anterior commisure involvement, fixed cord, inadequate PFTs or bilateral arytenoid involvement
283
Treatment options for T3, T4 or N+ supraglottic larynx
* CRT if functional larynx with low risk of aspiration
* TL + BLND --\> RT or CRT pending features (preferred if T4a)
284
Subglottic T1 stage
Confined to subglottis
285
Subglottic T2 stage
Extension to TVC (normal or impaired mobility)
286
T3 subglottic stage
limited to larynx with fixed VC
287
Management of T1 or T2 subglottic larynx
Definitive RT with treatment of the bilateral nodes
288
Treatment options for T3, T4 or N+ subglottic larynx
Definitive CRT if functional larynx and low risk of aspiration
TL + BLND --\> RT or CRT (preferred if T4a)
289
RT approach for T1N0 larynx
* CT simulation
* Contour the entire larynx setting iso at TVC
* Superior border is top of thyroid cartilage
* Inferior border is bottom of cricoid
* Treats roughly from C4 to C6
* Anterior is 1 cm flash on skin
* Posterior is anterior edge of vertebral body
* **DOSE IS 2.25 x 28 = 63**
290
RT approach for T2N0 larynx
* Contour the full larynx and GTV
* Set iso at TVC
* Superior edge is inferior edge of hyoid
* Inferior edge is first tracheal ring below cricoid
* Anterior: 1 cm flash
* Posterior: anterior edge of vertebral body
291
How to treat T1 or T2 larynx RT approach
Opp lats with 15 or 30 degree wedges (heel anterior)
292
How do fields change if anterior commissure involvement?
underwedge or give bolus to front of larynx
293
How do fields change if posterior commissure involvement?
1 cm into the vertebral body
294
Nodal coverage for T1-T2 larynx
None, unless supraglottic or subglottic extension and then consider covering II-III to 54 Gy
295
Coverage target for T1-T2N0 larynx
Hot spot \< 103%
296
Where is iso placed for early stage larynx
anterior to vertebral bodies midway between superior and inferior edge for posterior half beam block
297
Rough size of field for T1 larynx
5x5
COLLIMATE
298
Rough size of a T2 larynx field
6x6
COLLIMATE
299
What should be included in CTV60 for T3/T4 or N+ larynx
* Full larynx should be in CTV60
* Bilateral II-IV and VI if thyroid cartilage, post-cricoid cartilage or subglottis involved
* No Level V
300
What should happen to trach during RT
Should stay in place
301
How to approach contouring postop larynx
Discuss area at risk with surgeon
CTV60 is tumor bed and pre-op disease with 2 cm margin
Boost stoma is needed
CTV54 includes uninvolved nodal levels
302
Reasons to boost stoma for larynx
* T4 post-op
* Emergent tracheostomy
* Subglottic extension
* Tumor invasion into soft tissue of neck
* Close/tracheal margin
303
Dose for tracheostomy boost
66 Gy in 33 fx
304
Nodal levels for supraglottic larynx
**_II-IV bilaterally_**
* RP if hypopharynx involvement
* Ipsi level IB if II involved
* Consider VI
* ENSURE FULL LARYNX IN CTV60
305
Nodal levels for subglottic larynx
RP, II-IV, V, VI
306
5y OS for stage I larynx
80%
LC is 90%
307
5y OS for stage III larynx
50%
308
year OS for stage IV larynx
35%
309
Larynx preservation with RT alone for stage III/IV disease with RT alone
60-70%
310
Larynx preservation with CRT for stage III/IV disease
80\*85%
311
Rate of laryngeal edema with RT
\<5%
312
Rate of cartilage necrosis from definitive RT
5%
313
Most common thyroid ca
Papillary
314
Which subtypes take up RAI
Papillary and Follicular
Hurthle cell
315
Which subtypes do not take up RAI
medullary
anaplastic
316
What is a special feature of workup for thyroid cancer
no constrast with CT because thyroid will take up the iodine and then RAI won't work
317
What is the first approach for path for thyroid cancer
FNA
318
If FNA shows anaplastic what other staging needs to happen
PET CT
319
What is the preferred management of thyroid cancer
Thyroidectomy and central neck dissection
Levels VI and sample II through IV
320
Role of postop RT for thyroid
* Unresectable residual disease
* Multiple recurrences
* Non RAI avid residual
* Biocheical evidence of recurrent medullary thyroid (detectable calcitonin or CEA)
* All fully resected, non-metastatic anaplastic histologies
321
What is the surgical strategy for anaplastic thyroid
Only do surgery if GTR possible
Otherwise definitive RT with comprehensive nodal RT down to carina
Concurrent chemo (doxorubicin)
322
Nodal areas to treat for thyroid cancer
II through VI
323
H&P for unknown primary
Smoking history
Skin exam
Check thyroglobulin, calcitonin, EBV, HPV
324
Imaging for unknown primary
CT/MRI BOS and neck
PET CT
CT chest
325
Path approach for unknown primary
EUA with pan endoscopy with biopsies of
* NPX
* Tonsils
* BOT
* Pyriform sinus
* FNA any neck nodes
* If not revealing --\> bilateral tonsillectomy
326
How often is a primary located for unknown primary
75%+
327
How to approach N1 with unknown primary
Ipsilateral modified radical neck dissection
If just one node \<3 cm with no ECE --\> observe
If \>1 node --\> PORT
If ECE --\> CRT
328
Approach to unknown primary N2 or N3
Consider CRT
RT to NPX, OPX, bilateral neck
Or Bilateral neck dissection --\> CRT or RT
329
What is CTV60 for unknowne primary
NPX
OPX
Larynx
HPX
Ipsi neck (RP, IB-V)
330
How does viral status guide what should be covered for unknown primary
If EBV+ --\> cover NPX and neck
If p16+ --\> OPX and neck
If p16-: OPX, NPX, +/- hypopharynx and larynx
If level I or II node involved --\> exclude larynx and hypopharynx
331
What would be CTV54 for unknown primary
contralateral neck (II-IV, RP)
332
treatment options for T2+ nasopharynx
T2 or greater:
Concurrent cis-RT, adj Cis-5FU x 3 cycles
- concurrent q3week Cis 100 mg/m2
- adj Cis 80mg/m2 (D1) + CI 5FU 1000mg/m2 (D1-4) q4 wk x 3 cycles
333
Another treatment option for WHO type II NPX
Consider 3 cycles of induction gem-cis followed by cisRT to 70 Gy
