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OB2 > Head/Neck > Flashcards

Head/Neck Flashcards

1
Q

General H/N Clinical N2a

A

single ipsilateral node 3-6cm and ENE(-)

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2
Q

Head and Neck: constraints for parotids and submandibular glands

A

Mean parotid <26 Gy

50% of each parotid<30 Gy

Mean submandibular <39 Gy

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3
Q

Tonsil cancer: 2yr OS and LC for T1N0 and T2N0

A

2yr OS 95%

2yr LC:

T1 90%

T2 80%

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4
Q

Glottic larynx T1a

A

involves one vocal cord (normal mobility)

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5
Q

Oropharynx (p16+) Pathological N1

A

1-4 nodes

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6
Q

Supraglottic larynx T3

A

vocal cord fixation, postcricoid area, pre-epiglottic tissues, paraglottic space, inner cortex of thyroid cartilage

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7
Q

Nasal Cavity and Ethmoid Sinus T2

A

two subsites or extending to an adjacent region

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8
Q

Merkel stage III

A

N+

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9
Q

Nasopharyngeal carcinoma: WHO types

A

WHO type now is simply keratinized or nonkeratinized. Asian types are nearly all nonkeratinized

Old WHO classification:

WHO I: squamous

WHO II: nonkeratinizing

WHO III: undifferentiated, lymphoepithelioma

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10
Q

Nasopharyngeal cancer: anatomy

A

learn special nerves (Jacobs, Villaret etc…) and skull base anatomy

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11
Q

Mucosal melanoma T3

A

limited to mucosa and immediately underlying soft tissue

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12
Q

Lip and oral cavity T1

A

<2cm, DOI <5mm

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13
Q

General H/N Clinical N2c

A

bilateral or contralateral nodes <6cm and ENE(-)

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14
Q

Nasal Cavity and Ethmoid Sinus T1

A

one subsite with or without bone invasion

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15
Q

Glottic larynx T2

A

impaired vocal cord mobility or involving supraglottic or subglottic larynx

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16
Q

Head and Neck: follow up

A

PET at 3 months if nodes were treated (salvage neck dissection if SUV remains elevated)

post-treatment baseline imaging of primary then every 3-6 mo, TSH every 6-12 mo, speech/hearing/swallowing continued f/u, smoking cessation/alcohol counseling, dental f/u

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17
Q

Esthesioneuroblastoma: treatment paradigm

A

Kadish A: surgery alone

Kadish B/C: surgery then adjuvant xrt to 60Gy (with ENI)

Unresectable: pre-op 50 Gy with chemo followed by surgery

Not surgical candidate: 70Gy +/- chemo

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18
Q

Oral cavity cancer: indications for post-op xrt

A

T2 with greater than 5 mm, T3-4, N+, LVSI, PNI, close/positive margins

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19
Q

Hypopharynx T1

A

<2cm and one subsite

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20
Q

Melanoma stage II

A

T2b-4bN0

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21
Q

Merkel cell: target volumes

A

5 cm margins around the primary site. Smaller margins are accetptable in head and neck, at least 2 cm

If treating nodes, include in between intransit lymphatics (connect primary and lymph nodes)

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22
Q

General H/N Pathological N1

A

single ipsilateral node <3cm and ENE(-)

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23
Q

Mucosal melanoma N1

A

positive node(s)

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24
Q

General H/N Pathological N3a

A

node >6cm and ENE(-)

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25
Q

Melanoma N2a-c

A

N2a 2-3 occult nodes

N2b 2-3 clinical nodes

N2c one node and in-transit metastases

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26
Q

T2 Larynx: 5yr LC and OS

A

5yr LC 75%

5yr OS 60%

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27
Q

Oropharynx (p16+) Pathological Stage II

A

T0-2N2 or T3-4N0-1

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28
Q

Glottic larynx T3

A

vocal cord fixation, inner cortex of thyroid cartilage, paraglottic space

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29
Q

General H/N Stage I

A

T1N0

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30
Q

Nasopharynx T4

A

intracranial extension, cranial nerves, hypopharynx, orbit, parotid gland, or extension lateral to lateral pterygoid muscle

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31
Q

Lip and oral cavity T2

A

2-4cm, DOI 5-10mm

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32
Q

Salivary gland T4a

A

skin, mandible, ear canal, facial nerve

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33
Q

Nasopharynx N1

A

unilateral node(s) <6cm above the caudal edge of the cricoid

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34
Q

Postop Larynx: fields

A

Postop bed, levels II-VI to bilateral neck

When discussing borders don’t forget that the hyoid and cricoid are removed after larygectomy

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35
Q

H/N Cutaneous SCCa T4b

A

skull base or skull base foramen

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36
Q

Nasopharyngeal cancer: constraints for brainstem, spinal cord, chiasm, optic nerves, mandible, brachial plexus, temporal lobes

A

true brainstem: max 54Gy

brainstem PRV: V60 < 1%

spinal cord: max 45Gy

true chiasm/optic nerve: max 50 Gy

chiasm/optic nerve PRV: max 54Gy

mandible: max 70Gy, V75 < 1cc

brachial plexus: max 66Gy

temporal lobes: max 60Gy

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37
Q

Melanoma T4

A

>4mm

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38
Q

Mucosal melanoma T4b

A

brain, dura, skull base, cranial nerves 9-12, masticator space, carotid artery, prevertebral space, mediastinal structures

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39
Q

Nasopharynx N3

A

node >6cm or below the caudal edge of the cricoid

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40
Q

Nasopharynx Stage IVB

A

M1

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41
Q

Cutaneous SCCa: target volumes

A

2cm margin around tumor, can reduce to 1 cm around eye, use appositional electrons with custom bolus and custom lead blocking, minimal field size 4x4 cm, ENI if large invasive tumor or poorly differentiated

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42
Q

Salivary gland T3

A

>4cm or clinical extraparenchymal extension

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43
Q

Supraglottic cancer: 5yr OS stage I-IV

A

5yr OS

stage I 50%

stage II 50%

stage III 45%

stage IV 30%

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44
Q

Lip and oral cavity T3

A

>4cm, DOI >10mm

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45
Q

Hypopharynx T2

A

2-4cm or multiple subsites

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46
Q

Oropharynx (p16+) Pathological Stage I

A

T0-2N0-1

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47
Q

General H/N Stage IVB

A

T4b or N3

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48
Q

Merkel N1-3

A

N1 positive nodes without in-transit mets

N2 in-transit mets and negative nodes

N3 in-transit mets and positive nodes

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49
Q

Hypopharynx T4a

A

thyroid/cricoid cartilage, hyoid bone, thyroid gland, esophageal muscle, pre-laryngeal soft tissue

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50
Q

Oropharynx (p16+) Pathological N2

A

5+ nodes

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51
Q

Unilateral tonsil: doses

A

70/63/56 (2/1.8/1.6) 35 fx

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52
Q

General H/N Pathological N2c

A

bilateral or contralateral nodes <6cm and ENE(-)

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53
Q

Subglottic larynx T2

A

extends to vocal cords with normal or impaired vocal cord mobility

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54
Q

Merkel stage II

A

T2-4N0

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55
Q

Hypopharynx T4b

A

prevertebral fascia, mediastinal structures, encasing carotid

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56
Q

Subglottic larynx T4a

A

cricoid cartilage, thyroid cartilage, tissues beyond larynx

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57
Q

Nasal Cavity and Ethmoid Sinus T4a

A

anterior orbit, skin, anterior cranial fossa, pterygoid plates, sphenoid sinus, frontal sinus

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58
Q

Oropharynx (p16-) T4b

A

lateral pterygoid, pterygoid plates, lateral nasopharynx, skull base, encasing carotid

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59
Q

Supraglottic larynx T2

A

more than one supraglottic subsite, glottis, region outside the supraglottis (mucosa of base of tongue, vallecula, medial wall of pyriform sinus)

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60
Q

T2 Larynx: dose and field

A

(only if confined to glottis)

65.25 in 29 fx, finish in <44 days

Sup border: hyoid

Inf border: 1st tracheal ring

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61
Q

Mucosal melanoma T4a

A

deep soft tissue, cartilage, bone, skin

62
Q

Nasal Cavity and Ethmoid Sinus T4b

A

orbital apex, dura, brain, middle cranial fossa, cranial nerves (excluding V2), nasopharynx, clivus

63
Q

Subglottic larynx T4b

A

prevertebral space, mediastinal structures, encasing carotid

64
Q

Head/neck: postop doses

A

66 Gy: positive margin or ECE

60 Gy: node positive neck, dissected neck, and intermediate risk (PNI, LVI, T4, close margin)

54Gy: low risk areas, elective neck

65
Q

T1 Larynx: 5yr LC and OS

A

5yr LC 90%

5yr OS 80%

66
Q

Maxillary sinus T2

A

bone invasion (excluding posterior wall)

67
Q

Nasopharyngeal cancer: workup

A

H&P, family history, assess social support, smoking, alcohol, head and neck exam, noting teeth condition, cranial nerves, flex nasolaryngoscopy

FNA biopsy of node if possible

Labs: CBC, CMP, TSH, EBV

Imaging: MRI skull base, CT neck/chest, PET

dental, port, PEG tube, nutrition, audiology, ophthalmology, speech and swallowing evaluation, smoking cessation / alcohol counseling

68
Q

Esthesioneuroblastoma: long term OS for Kadish A/B/C

A

A 70%

B 60%

C 50%

69
Q

5 subsites of supraglottic larynx

A

false vocal cords, arytenoids, suprahyoid epiglottis, infrahyoid epiglottis, aryepiglottic folds

70
Q

contraindications to laryngeal preservation

A

T4

extension of 1 cm to BOT

Bulky tumor: 3.5 cm3 for glottic and 6cm3 for supraglottic

Poor swallowing or speech

71
Q

Glottic larynx T1b

A

involves both vocal cords (normal mobility)

72
Q

Head and Neck: constraints for larynx, pharyngeal constrictors, and cervical esophagus

A

larynx mean 44Gy, max 66Gy

constrictors 50Gy

cervical esophagus V45 < 33%

73
Q

Oropharynx (p16+) Clinical N3

A

node >6cm

74
Q

Oropharynx (p16+) Pathological Stage III

A

T3-4N2

75
Q

Supraglottic cancer: radiation dose and volumes

A

70/63/56 (2/1.8/1.6) 35 fx

always treat bilateral neck II-IV

76
Q

Melanoma: indications for adjuvant xrt

A

ECE

parotid: 1+ node
cervical: 2+ nodes or node>3cm
axillary: 2+ nodes or node >3cm
inguinal: 3+ nodes or node >4cm

77
Q

Nasopharynx Stage III

A

T3 or N2

78
Q

Glottic larynx T4a

A

outer cortex of thyroid cartilage, tissues beyond the larynx

79
Q

General H/N Clinical N3b

A

clinically overt ENE(+)

80
Q

Nasopharyngeal cancer: chemo dose and schedule

A

(chemo for T2-4 or N+)

concurrent cisplatin 100mg/m2 q3wk

adjuvant cisplatin 80 and continuous infusion 5FU 1000 x 3 cycles

81
Q

Head and Neck: constraints for lips and oral cavity

A

oral cavity <39

Lips mean <20 Gy, max 50 Gy

82
Q

Nasopharyngeal cancer: usage of EBV

A

EBV DNA quantitative PCR: used to give surival and distant met prognosis, and monitor treatment response and recurrence. Can get before and after treatment (<1500 copies before treatment is good and undectable after tx is good)

83
Q

Merkel cell T2

A

diameter 2-5cm

84
Q

Merkel cell T4

A

invades fascia, muscle, cartilage, or bone

85
Q

Lip and oral cavity T4a

A

Lip: invades bone, inferior alveolar nerve, floor of mouth, skin Oral cavity: cortical bone of maxilla or mandible, maxillary sinus, skin

86
Q

Oropharynx (p16-) T4a

A

larynx, extrinsic tongue muscles, medial pterygoid, hard palate, mandible

87
Q

Oropharynx (p16+) Clinical Stage IV

A

M1

88
Q

General H/N Pathological N2a

A

single ipsilateral node 3-6cm and ENE(-) OR single ipsilateral node <3cm and ENE(+)

89
Q

Oropharynx (p16+) Clinical Stage III

A

T4 or N3

90
Q

Head and Neck: constraints for brachial plexus, temporal lobes, and brainstem/chiasm/optic nerves

A

Brachial plexus <66 Gy

Temporal lobes <60 Gy

brainstem/chiasm/optic nerves<54 Gy (1cc brainstem to 60 Gy)

91
Q

H/N Cutaneous SCCa T2

A

2-4cm

92
Q

Oropharynx T3

A

>4cm or extension to lingual surface of epiglottis

93
Q

Oropharynx (p16+) Clinical Stage I

A

T2 or N1

94
Q

Subglottic larynx T3

A

vocal cord fixation, inner cortex of thyroid cartilage, paraglottic space

95
Q

H/N Cutaneous SCCa T3

A

>4cm, minor bone erosion, perineural invasion, subcutaneous fat

96
Q

Nasopharynx T0

A

no tumor identified but EBV(+) cervical nodes

97
Q

Lip and oral cavity T4b

A

invades masticator space, pterygoid plates, skull base, or encasing carotid

98
Q

Oropharynx (p16+) Clinical N1

A

ipsilateral node(s) <6cm

99
Q

Melanoma: volumes for nodal sites

A

Axilla: classic field includes axilla plus SCV. Some omit supraclavicle

Neck: level II down to supraclavicle

Inguinal: inguinal plus ipsilateral pelvic nodes

100
Q

General H/N Pathological N2b

A

multiple ipsilateral nodes <6cm and ENE(-)

101
Q

T1 Larynx: dose and field

A

63Gy/28fxs (complete within 44 days)

3D: Opposed laterals, bolus if lesion is anterior

sup: thyroid notch
inf: bottom of cricoid
ant: flash
post: ant vertebral bodies

Some rotate gantry to make posterior border non-divergent or place isocenter at anterior edge of vertebral body

102
Q

Esthesioneuroblastoma: Kadish staging

A

Kadish Staging:

A: confined to nasal cavity

B: extends to paranasal sinuses

C: beyond nasal cavity or paranasal sinuses

D: lymph nodes or distant mets

103
Q

H/N Cutaneous SCCa T4a

A

gross cortical bone invasion

104
Q

General H/N Clinical N1

A

single ipsilateral node <3cm and ENE(-)

105
Q

Oropharynx cancer: options for HPV testing

A

first test p16

if negative but suspicious then test HPV PCR

106
Q

Melanoma T2

A

>1.0-2.0mm

107
Q

Supraglottic larynx T4b

A

prevertebral space, mediastinal structures, encasing carotid

108
Q

Oropharynx cancer: 3yr OS for low/intermediate/high risk groups

A

3-yr OS:

Low risk 90%

Int risk 70%

High risk 50%

109
Q

Maxillary sinus T3

A

posterior wall of maxillary sinus, subcutaneous tissues, floor or medial wall of orbit, pterygod fossa, ethmoid sinuses

110
Q

Supraglottic larynx T4a

A

outer cortex of thyroid cartilage, tissues beyond the larynx

111
Q

Maxillary sinus T1

A

tumor limited to mucosa of maxillary sinus WITHOUT bone invasion

112
Q

Supraglottic larynx T1

A

one supraglottic subsite

113
Q

Oropharynx (p16+) T4

A

larynx, extrinsic tongue muscles, medial pterygoid, hard palate, mandible, or beyond

114
Q

General H/N Pathological N3b

A

ENE(+) that doesn’t meet criteria for N2a

115
Q

Nasopharyngeal carcinoma: 5yr OS for T2-4 or N+

A

5yr OS 70%

116
Q

ACR approriateness criteria for unilateral tonsil treatment

A

T1-2N0-1 oropharynx, less than 1 cm extension to soft palate, and no BOT involvement

On PE make sure to note BOT or soft palate extension, trismus (pterygoid involvement), inability to protrude tongue (T4 deep tongue muscles)

117
Q

General H/N Stage II

A

T2N0

118
Q

Salivary gland T2

A

2-4cm without clinical extraparenchymal extension

119
Q

Oropharynx (p16+) Clinical Stage II

A

T3 or N2

120
Q

Head and Neck: Sim

A

supine with chin extended, long mask, wire scar.

Consider: bite block, bolus scar for ECE, contrast

121
Q

Oral cavity cancer: doses

A

6996/5940/5412 (2.12/1.8/1.64) 33 fx

122
Q

Nasopharynx T3

A

skull base, pterygoid plates, cervical vertebra, paranasal sinuses

123
Q

General H/N Stage IVC

A

M1

124
Q

Nasopharyngeal cancer: intermediate risk CTV structures

A

nasopharynx

anterior 1/3 of clivus

foramen rotundum and ovale

pterygoid fossa

parapharyngeal space

inferior sphenoid sinus

cavernous sinus

posterior nasal cavity

posterior maxillary sinus

inferior soft palate

retropharyngeal lymph nodes

retrostyloid space

Ib-V neck

125
Q

Glottic larynx T4b

A

prevertebral space, mediastinal structures, encasing carotid

126
Q

Subglottic larynx T1

A

limited to subglottis

127
Q

Hypopharynx T3

A

>4cm,fixation of hemilarynx, extension to esophagus

128
Q

Nasopharynx Stage II

A

T2 or N1

129
Q

Head/neck cancer: 5yr OS with adjuvant chemoradiation on Cooper/Bernier

A

5yr OS 50%

130
Q

General H/N Clinical N2b

A

multiple ipsilateral nodes <6cm and ENE(-)

131
Q

Nasopharyngeal cancer: volumes and dose

A

6996/5940/5412 (2.12/1.8/1.64) 33 fx (FUSE MRI!!!)

CTV 6996: GTV and gross nodes with 0.5cm expansion

CTV 5940: GTV +1cm, entire nasopharynx, node positive and dissected neck Ib-Vb/RP/RS, special NPX CTV structures known from heavy pimpin

CTV 5412: node negative neck (may exlcude level IV and Vb)

132
Q

Nasal Cavity and Ethmoid Sinus T3

A

floor or medial wall of orbit, maxillary sinus, palate, cribriform plate

133
Q

Hypopharynx cancer: 5yr OS and laryngeal preservation for stage III-IV

A

5yr OS 35%

5ry laryngeal preservation 35%

134
Q

Oropharynx T2

A

2-4cm

135
Q

General H/N Stage IVA

A

T4a or N2

136
Q

Nasopharynx N2

A

bilateral nodes <6cm above the caudal edge of the cricoid

137
Q

Oropharynx (p16+) Pathological Stage IV

A

M1

138
Q

Head and Neck: Workup

A

H&P, family history, assess social support, smoking, alcohol, head and neck exam, noting teeth condition, cranial nerves, flex laryngoscopy (esp for larynx), palpation of mass in mouth

FNA biopsy of node if possible

Labs: CBC, CMP, TSH

Imaging: CT neck/chest, PET for stage III-IV

consider DL/biopsy and videostrobe

dental, port, PEG tube, nutrition, audiology, speech and swallowing evaluation, smoking cessation / alcohol counseling

139
Q

Nasopharynx Stage IVA

A

T4 or N3

140
Q

Maxillary sinus T4a

A

anterior orbit, skin, pterygoid plates, infratemporal fossa, cribriform plate, sphenoid sinus, frontal sinus

141
Q

Oropharynx T1

A

<2cm

142
Q

Maxillary sinus T4b

A

orbital apex, dura, brain, middle cranial fossa, cranial nerves (excluding V2), nasopharynx, clivus

143
Q

Nasopharynx T2

A

parapharyngeal space, medial/lateral pterygoids, prevertebral muscles

144
Q

Oropharynx (p16+) Clinical N2

A

bilateral or contralateral nodes <6cm

145
Q

Hypopharynx cancer: dose and volumes for stage III-IV

A

Three volume: 6996/5940/5412 (2.12/1.8/1.64) 33 fx with chemo

Two volume: 70/56 SIB

Treat bilateral II-VII and RP

If gross nodes were treated, perform PET at 3 months. If disease is still active, recommend neck dissection

146
Q

General H/N Clinical N3a

A

node >6cm and ENE(-)

147
Q

T1 Larynx: dosimetry

A

wedges with heel anteriorly (15-30 degrees), 6MV photons, 95% isodose line to cover the entire cords, no hotspot over 110%

IMRT carotid sparing for young age

Carotid mean <25 Gy, V35<20%

148
Q

General H/N Stage III

A

T3 or N1

149
Q

Larynx: 5yr larynx preservation and OS for stage III and IV

A

5yr larynx preservation:

80% for stage III

60% for stage IV

5yr OS:

45% for stage III

35% for stage IV

150
Q

Melanoma stage III

A

N+

151
Q

Salivary gland T4b

A

skull base, pterygoid plates, encasing carotid

152
Q

Head/Neck: nodal drainage for oropharynx, larynx, hypopharynx, nasopharynx, and oral cavity

A

Oropharynx: II-IV

Larynx: II-IV

Hypopharynx: II-V and RP

Nasopharynx: II-deep V and RP, ipsi level IB for N+

Oral cavity: IA-IV

OB2 (10 decks)

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