HN Flashcards
1
Q
LVL IA boundaries
A
submental - Lat: ant. belly digastric, Inf: inf hyoid
2
Q
LVL II boundaries
A
sup. cervical -
Sup: trans. process of C1
Inf: hyoid,
Post: SCM,
Medial: ICA,
Lat: SCM,
Ant: SCM
3
Q
LVL III boundaries
A
III: mid-cervical -
Sup: inf. hyoid,
inf: inf. cricoid,
same other borders as II:
Post: SCM,
Medial: ICA,
Lat: SCM,
Ant: SCM
4
Q
LVL IV boundaries
A
IV: inf. cervical –
Sup: inf. edge of cricoid,
Inf: 2 cm above manubrium
same other borders as II:
Post: SCM,
Medial: ICA,
Lat: SCM,
Ant: SCM
5
Q
PNI definition
A
PNI – nerve >0.1 mm
6
Q
H/P
A
History: dysphagia, odynophagia, otalgia, CN deficits
Physical: HEENT, CN, fiberoptic NPL, LN
7
Q
H/N Workup
A
Imaging: CT head/neck + C, PET/CT, MRI if BOS invasion (or any NPC)
Biopsy:
- EUA w/ bx (oropx, larynx, hypopx)
- Panendoscopy – includes nasopharyngoscopy, laryngo, bronch (larynx, hypopx)
- get HPV status
Other: SANDS
Speech and swallow eval
Audiology
Nutrition
Dental eval
Smoking Cessation
8
Q
Indications for PEG tube placement:
A
Indications for PEG tube placement:
- severe weight loss prior to tx (5% in 1 month, 10% in 6 months)
- severe dysphagia
- high aspiration risk
9
Q
Radical neck dissection
A
Radical – removes I-V, SCM, omohyoid, internal and external jug veins, CN XI, submandibular gland
10
Q
MR neck dissection
A
Modified radical – leaves >= 1 of SCM, internal jug, or CN XI
11
Q
Selected neck dissection
A
Selected neck dissection – leaves >= 1 lymph node level
12
Q
Supraomohyoid dissection
A
Supraomohyoid dissection – removes I-III
13
Q
Lateral neck dissection
A
Lateral neck dissection – removes II-IV
14
Q
New classification (NCCN) of neck dissection
Comprehensive
Selective
Neck dissection
N0: Selective
OC
OPX
HPX/LX
N1-N2:
N3:
A
New classification (NCCN) Comprehensive – removes all LN groups I-V (generally done for N+ disease) Selective – site specific depending on nodes at risk (OC I-III or upper IV, pharynx/larynx II-IV and VI for subglottic
Neck dissection
N0: Selective
OC I-III
OPX II-IV
HPX/LX II-IV, VI if subglottic ext
N1-N2: Selective or comprehensive
N3: Comprehensive
15
Q
General treatment paradigm
A
T1-T2: surgery or RT alone
T3 or N+: CRT
16
Q
Concurrent Chemo
A
Cisplatin 100 mg/m2 q 3 weeks x 3 cycles
17
Q
Post-op RT to primary:
A
Post-op RT to primary:
pT3/4
PNI
LVI
Close Margins (<5 mm)
OC primary w level IV/V LN
18
Q
Post-op RT to neck:
A
Post-op RT to neck: N2 or N3 (single large node or multiple nodes)
19
Q
Post-op CRT:
A
Post-op CRT: ECE, +margins
20
Q
When can treat only ipsilateral neck
A
Can treat ipsilateral neck for well-lateralized TBARS:
-tonsil – 1 cm involvement of BOT and 1 cm involvement of soft palate, 1 node
Maybe:
- buccal
- alveolar ridge
- RMT
- salivary
21
Q
package time
A
package time < 11 weeks (means should start RT < 6 weeks after surgery)
22
Q
Post-op RT: volumes
A
Post-op RT:
30 fractions: 60/2, 54/1.8
For ECE or + margins (or close!), 66/2 (59.4/1.8 int, and 54/1.64 low risk)
CTV\_66= (areas of pos margin or ECE) + 0.5-1 cm CTV\_60= (pre-op GTV + tumor bed + 1 cm) and high-risk nodes (1st echelon) CTV\_54= low risk nodes (2nd echelon and contralat if indicated)
23
Q
Treatment volumes script
A
Script:
- IMRT will be used for parotid-sparing
- Contour the primary and nodal GTV’s defined by preoperative physical examination, operative reports (e.g. exam under anesthesia) and imaging. These will be expanded by 5 mm to make the CTV70
- I will then make an additional 5 mm margin on CTV70 and include areas of potential spread, to make the CTV63. The involved lymph node level will also be CTV63. The remainder of nodal groups will be delineated as CTV56
-an additional 3 mm will be added to create the PTVs
24
Q
Constraints
- Brainstem/Optic Nerve
- Cord
- Mandible (– PTV)
- Oral cavity (uninvolved)
- Brachial plexus
- Constrictors
- Larynx – PTV
- Submandibular
- Parotid
- Esophagus
For nasal cavity/NPX:
- Pituitary
- Retina/cornea/cochlea
- Lens
- Temporal lobe
A
- Brainstem/Optic Nerve max 54 Gy
- Cord max 45 Gy
- Mandible (– PTV) max 70
- Oral cavity (uninvolved) mean < 30 (if achievable)
- Brachial plexus max 66 Gy
- Constrictors mean < 55 Gy (as low as possible)
- Larynx – PTV mean < 20 Gy
- Submandibular mean < 39 Gy
- Parotid mean < 26 Gy; ALARA if neck involved
- Esophagus mean < 35 Gy (when achievable)
For nasal cavity/NPX:
- Pituitary mean dose < 40 Gy
- Retina/cornea/cochlea max 45 Gy (cornea max 45)
- Lens max 10 Gy
- Temporal lobe (bilat) max < 60-70 Gy
25
Follow-up:
Follow-up:
- F/u imaging within 6 months of tx (PET/CT at 3 months if definitive), then as indicated (not routine)
- H&P (w/ NLscope) Q3-6mo for 5yrs, then annually
- Thyroid eval (TSH) q 6-12 months. 25% develop hypothyroidsim
- Carotid eval
- Dental
- Speech and swallow as needed
- Audiology
26
Nasopharynx T and N stage
T1 –confined to nasopharynx and/or adj oropharynx/nasal cavity
T2 – "soft stuff" parapharyngeal extension, pterygoid muscles, prevertebral muscles
T3 – "hard stuff" bony skull base/spine/pterygoid or bony sinus
T4 – "bad stuff" intracranial, CN palsy, hypopharynx, parotid, orbit, or soft tissue beyond lateral pterygoid muscle
N1 – unilateral, RP (uni/bi) \< 6 cm
N2 – bilateral \< 6 cm (bilat RP only still N1)
N3 – any level below cricoid(IV, low V) or \>6cm
27
Nasopharynx Overall stage
Overall: T or N+1:
I – T1 N0
II – T2 and/or N1
III – T3 and/or N2
IVA – T4 and/or N3
IVB – M1
28
NPX WHO types
WHO
I – tobacco/EtOH (US) – keratinizing SCC (worse LC and OS)
II – non keratinizing
A – differentiated
B – undifferentiated (EBV, Asia)
III – basaloid
29
NPX borders
Nasopharynx borders:
sup – sphenoid bone/base of skull
inf – roof of soft palate
ant – nasal chonae
post – clivus, C1 (C2)
Rosenmuller’s fossa – posterior to torus tubaris, most common cancer location
30
NPX extra workup
Extra work-up:
H&P with attn to epistaxis, CN palsy, trismus, otalgia
Labs: EBV IgA/DNA titers
Imaging:
MRI primary and base of skull
PET/CT for all
- if initially elevated, follow EBV titers during surveillance (consider first follow-up 1-4 weeks post-CRT)
31
Trismus indicates
Trismus – masticator space (pterygoids) invasion
32
NPX T1N0 treatment
T1N0 – RT alone
33
NPX T2 N0
Concurrent cis-RT
-concurrent q3week Cis 100 mg/m2
34
NPX T3 or N1
induction cis 80 mg/m2 + gem 1000 mg d1/d8 q3 weeks x 3 cycles -\>
Concurrent cis-RT
-concurrent q3week Cis 100 mg/m2
35
NPX high risk factors
Bulky tumor, high EBV levels
36
NPX volumes
IMRT – 33 fx
70/2.12, 59.4/1.8, 54/1.64
CTV\_70 – (primary + involved nodes) + 5 mm (1mm at critical structures like brainstem)
CTV\_59.4: GTV + 10 mm and
- entire NP
- superiorly: inf half of sphenoid sinus; entire vomer and post/inf ethmoid sinus (bony nasal septum); B/L foramen ovale, rotunda, lacera,
- ant: post 1/4 nasal cavity and max sinus, bilat PPF
- lat: parapharyngeal space, pterygoid muscles
- post: anterior 1/3 of clivus (whole if involved)
- 1st echelon nodes (RP, II, III, Va)
- If T3/T4 – entire sphenoid sinus, I/L cavernous sinus; consider jugular foramen, hypoglossal canal for posterolateral infiltration by primary
Level IV can get 54 – all other levels 59.4
37
NPX OS 3 yr
I – 85%
II – 75%
III – 65%
IV – 55%
38
NPX late side effects and followup
Late:
- cranial neuropathy
- trismus
- soft tissue fibrosis
- xerostomia
- hearing loss
- osteoradionecrosis
- temporal lobe necrosis
- hypothyroidism
- vasculopathy
Follow-up:
-Can add MRI to general paradigm (PET) at 12 weeks
39
OC regions
Lip
Gingiva/Alveolar Ridge
Buccal mucosa
Retromolar trigone
Hard palate
Oral tongue (ant 2/3)
Floor of mouth
Lower lip numbness = inf alveolar nerve involvement
40
OC H/P
History: non-healing ulcer, pain, bleeding, loose teeth, ill-fitting dentures, bad breath, neck mass
Physical: attn. to tongue mobility, floor of mouth, neck exam
15% skip mets to level IV for oral tongue (not addressed in supraomohyoid LN dissection I-III)
41
OC T stage
T1 - ≤ 2cm and DOI ≤ 5mm
T2 – 2.1-4 cm and/or DOI \>5-10mm
T3 - \>4cm and/or DOI \>10-20mm
T4a –
Lip: through bone, inf alv nerve, FOM, face skin
OC: bone, maxillary sinus, face skin, DOI \>20mm
T4b – masticator space, pterygoid plates, skull base, carotid encasement
42
OC overall stage
T or N+2
I – T1N0
II – T2N0
III – T3 or N1
IVA – T4a or N2
IVB – T4b or N3
IVC – M1
43
N stage
cN1 – single ipsi node ≤ 3 cm
cN2a – single I/L node 3 - 6 cm
cN2b – multiple ipsi nodes ≤ 6 cm
cN2c – bilat or contralat nodes ≤ 6 cm
cN3a – \> 6cm
cN3b – clinically overt ECE
Same as above except:
pN2a – includes single I/L node \<3cm with pathologic ECE
44
OC post op Indications for RT
Indications for RT
1. T3/T4
2. DOI \> 5mm
2. Close margin (\< 5 mm)
3. LVSI
4. PNI
5. N2+
6. Level IV/V LN
=\> for boards, irradiate primary and nodes together always
Post-op CRT:
+ margin, + ECE
45
Lip volumes
commissure involved
upper lip
Lip:
some say Definitive RT favored for lip commissure but not in NCCN
If commissure involved, cover Ib and II to 54 Gy (low risk)
If upper lip, cover facial nodes
-lead shield
46
Lip
1. inf alveolar nerve involvement
2. Skin involvement
3. bone invasion
\*\* if inf alveolar nerve involvement, cover through to mandible (high risk CTV)
\*\* if skin involvement, cover facial nodes (Moustache field)
\*\* remember: if bone invasion upfront, do surgery because RT has risk of radionecrosis
47
OC general treatment paradigm
Resectable: Surgery
-Neck dissection for N+, DOI \> 2 mm
Unresectable –
Stage I-II: definitive RT alone (EBRT + brachy)
Stage III-IV: CRT
48
Sim, dont forget
tongue depressor/bite block
49
Time between surgery and PORT
Time between surgery and PORT \< 6 weeks
50
OC 1st echelon nodes
1st echelon nodes – bilateral Ib-III, top of IV
-can consider ipsilateral for buccal, RMT, possibly alveolar ridge if ipsi neck N0
-Cover Ia for FOM, oral tongue, inf alveolar ridge, lip
\*don’t need RP nodes\*
51
OC LC
RT and surgery equal LC for T1-T2N0 (75-80%)
Much worse with RT alone for T3/T4
III-IV LC 60%; OS 70%
Lip:
T1-2: LC and OS 95%
T3-4: LC 80%
52
Oral cavity 5yr OS
Oral cavity 5yr OS
Stage I – 90%
Stage II – 85%
Stage III – 75%
Stage IV – 55%
53
OPX sites
Sites:
soft palate,
tonsils,
BOT,
posterior pharyngeal wall
vallecula
54
OPX borders
Soft Palate
Oral Tongue Pharyngeal wall
Hyoid
55
Hot potato voice
Hot potato voice – BOT involvement
56
OPX additional workup
Additional Workup:
H&P with attn to dysphagia, odynophagia, trismus, otalgia, HPV history, smoking, tobacco
HPV testing – either p16 IHC or HPV DNA FISH
\*if not p16 tested, treat as HPV-
57
OPX T stage
HPV negative
T1 – ≤ 2cm
T2 – 2.1-4 cm
T3 – \>4cm or lingual epiglottis ext
T4a – larynx, medial pytergoid, mandible, muscle tongue extrinsic, hard palate
T4b – lateral nasopharynx, lateral pterygoid muscles, pterygoid plates, skull base, carotid encasement
HPV positive
T4a and T4b collapsed into T4
58
OPX Trismus
Trismus suggests pterygoid involvement: T4b
59
OPX overall stage
p16+ stage
Overall Clinical Stage greater of T-1 or N, only M1 is stage IV
Pathologic: same except T4N0-1 = II
P16-: T or N+2 (if N+)
T1N0 – I
T2N0 – II
T3, N1 – III
T4a, N2-3a – IVA
T4b, N3b – IVB
60
OPX treatment Low risk (T1-2N0 or 1 small node (\<3cm):
Low risk (T1-2N0 or 1 small node (\<3cm):
1. Surgery (TORS) -\> chemo/RT as indicated
2. Definitive RT alone
\* do not do TORS + neck dissection if you suspect ECE because then they’ll get all 3 modalities
\*\* for T2N1 tonsil, can treat ipsilateral neck but give chemo, but bilateral neck tx not wrong
61
OPX treatment Int-High risk (T3-4, \>1 node):
Int-High risk (T3-4, \>1 node):
Concurrent chemoRT
-def chemoRT: cis 100mg/m2 q 3 wks + 70 Gy IMRT SIB
(if not chemo candidate) -RT+Cetuximab 400 mg/m2 loading dose, then 250 mg/m2 weekly w RT
-If not a candidate for chemo or cexutimab, but chemoRT indicated: RT 70 Gy in 35 fx, use 6 fx/week
TORS: not eligible if T3-4, more than minimal soft tissue palate extension, central BOT, trismus/other difficulties with exposure, radiographic or clinical ECE
62
P16+ N stage
Clinical N
cN1 – one or more I/L ≤ 6 cm
cN2 – bilat or contralat nodes ≤ 6 cm
cN3 – \> 6cm
Path N
pN1 – ≤ 4 LNs
pN2 – \> 5 LNs
63
OPX volumes
\*\* CTV70 = GTV + 5mm, edited anatomically off skin, bone, air, etc.
\*\* CTV63 = GTV + 10mm, edited anatomically and consider expand to include areas of potential spread
1st echelon nodes: cover bilateral II-IV, I/L vs. B/L RP
\*\* in N+ neck, generally cover level V too
\*\* if N+, cover ipsi nodes to BOS and low level IV
-ipsilateral 63, contra 56
64
OPX tonsil when ipsi neck only okay
I/L neck RT for T1-2 N0-1 tonsil w/
at most 1 cm soft palate or BOT extension,
no post. wall involvement;
and at most I/L level II LN(s) involved, \<3cm, no ECE
65
OPX OS
OS3 by risk (Ang, NEJM 2010):
Low (HPV+, \<10 pk-yr; HPV+, \>10 pk-yr N1/2a): 90%
Intermediate (HPV+, \>10 pk-yr N2b+): 70%
High: (HPV- \>10 pk year or T4): 50%
66
HPX borders and subsites
Pharynx from hyoid to cricoid
Subsites (3Ps):
Piriform sinuses (#1)
Posterior pharyngeal wall
Postcricoid area
67
HPX staging
Generally same as larynx+
T1 – ≤ 2cm, one subsite
T2 – 2.1-4cm, or adj subsite or larynx
T3 - \> 4cm, or hemilarynx fixation, or esophagus
T4a – thyroid/cricoid, hyoid bone, thyroid, central soft tissue (strap muscles, subQ fat)
T4b – prevertebral fascia, carotid artery, mediastinal structures
N stage =\> same as oral cavity
Overall Stage =\> same as oral cavity: T or N+2
68
HPX T1, select T2, N0 treatment
T1/T2 N0:
1) Partial pharyngectomy (larynx preserving) w/ LND (with pretracheal and I/L paratracheal LN dissection)
- CI: inadequate PFTs (aspiration, want FEV1\>70% predicted)
2) Definitive RT
69
HPX T3-4 or N+
T3-4 or N+, resectable:
1) ChemoRT
2) TL w LND (preferred for T4a or non-functional larynx w high aspiration risk) -\> RT or CRT as indicated
3) Induction chemo -\> RT or surgery
- TPF q 3W x3c -\> if CR -\> RT alone
- if PR at primary or less, TL with LND -\> RT or CRT
T3-4 or N+, unresectable:
ChemoRT
70
HPX dose and volumes
Post-op RT:
30 fractions: 60/2, 54/1.8
for ECE of + margins, 66/2 (59.4/1.8 int, and 54/1.64 low risk)
1st echelon nodes: bilateral RP, II-IV; VI if thyroid cartilage, post-cricoid cartilage, or subglottis involved
CTV\_63
- old recs: should include entire HPX subsite, entire larynx, and high risk neck
- new recs: for T2 and above, CTV\_63 passes through part of thyroid cartilage, part of cricoid, part of hyoid, and may extend into the esophagus. CTV\_63 may be extended 15 mm vertically, T1-2 incl at least ipsi arytenoid/post paraglottic space, T3-4 at least ipsi hemi-larynx
71
HPX OS
Worst prognosis in H&N
Overall outcomes:
Larynx preservation: 60- 80% depending on method
OS5: 40 – 50%
LRR: 30%
DM: 25%
30% risk of pharyngocutaneous fistula formation after salvage total laryngectomy
72
Supraglottis subsites and borders
FAVEA:
•False cords
•Arytenoids
Ventricles
Epiglottis
•Aryepiglottic folds
Borders:
Epiglottis
Petiole(epiglottis) Arytenoids
TVC
73
Larynx Workup imaging
MRI w/ thin cuts
74
Glottic T stage
General:
T1 – confined to site, nl mobility
T2 – adj site or impaired mobility
T3 – fixed or invasion into paraglottic space, inner cortex thyroid cart, pre-epiglottic space, postcricoid
T4a (same for all larynx)
* O-TESTES
•Outer Thyroid Cartilage
Trachea (inf. to cricoid)
* Extrinsic tongue muscles
* Strap muscles
* Thyroid
* Esophagus
* Soft tissue neck
T4b (same for all larynx)
* •prevertebral fascia
* •encases ICA
* •invades mediastinal structures
*
Glottic
T1a – one cord
T1b – both cords
75
_Early (T1-T2N0) Glottic treatment_
_Early (T1-T2N0) Glottic - surgery vs def RT_
1. Def RT
T1- **63 Gy (2.25x28)**
T2 - **65.25 (2.25x29)**
2. Surgery –
1) Cordectomy (T1)
- CI: ant commissure involvement
2) Vertical hemilaryngectomy (T1, select T2)– can take ipsi and 1/3 of contralat cord, ½ thyroid cartilage; leaves cricoid and hyoid intact
- CI: T3/T4 (**fixed cord)**, select T2 (bilateral arytenoid, epiglottis, subglottic involvement)
\*\* LC, larynx pres, OS same w RT or surg. Voice quality better w RT; swallowing better w surgery
\*\* if T2 has extension to supraglottis/subglottis, treat the nodes as well
76
TVC T1-2 fields
T1-T2, N0 – contour larynx first
Don’t just say-\> T1- 5x5 field; T2 – 6x6 field
Iso at TVC
sup – top of thyroid cartilage (T2 inf hyoid)
inf – bottom of cricoid (T2 first trach ring below cricoid)
\*about C4-6\*
ant – 1 cm flash
post – ant vertebral body
Nodes for T2: bulky or extending sub or supraglottic – cover II and III with IMRT
- opposed laterals with 15 or 30 degree wedges (heel anterior)
- underwedge or bolus if ant commissure involvement and plan is cold anteriorly
- no elective nodes unless supraglottic/subglottic extension (then electively tx level II-III)
- keep hot spot \< 103%
77
TVC _Advanced (T3 or N+) treatment_
_Advanced (T3 or N+)_
1. CRT (RTOG 91-11)
2. TL w LND à RT or CRT as indicated (preferred if T4a)
- Removes hyoid, thyroid, cricoid cartilage, epiglottis, strap muscles
- Pt left w permanent trach & pharynx reconstruction (by suturing to BOT)
- most commonly fail at stoma, base of tongue, neck nodes
3. *Induction chemo -\>* *RT or surgery*
* -* *TPF q 3W x3c-\>* *if _\>_ PR* *à* *RT*
* - if \< PR, TL with LND*
78
TVC T3-T4, N+ volumes
T3-T4, N+
Def IMRT: dose painting
35 fractions: **70/2, 63/1.8, 56/1.6**
**-** CTV 70 =
- 1st echelon nodes: bilateral II-IV, VI if thyroid cartilage, post-cricoid cartilage, or subglottis involved (no level V)
- high risk CTV should include entire larynx
- low risk CTV: contralateral 2-4
79
Larynx when to boost stoma
Boost stoma for:
T4 post-op
1. Emergent tracheostomy
2. Subglottic extension (\> 5 mm inferior to TVC)
3. Tumor invasion to soft tissues of neck
4. Close/+ tracheal margin
5. Scar crosses stoma (?)
\*\* note: leave trach in during RT
80
Post-op glottic:
Post-op glottic:
- Review op note, pre-op imaging, discuss with surgeon
- HR CTV (60-66): tumor bed and pre-op disease extent with 1.5-2 cm margin, stoma boost if needed
- LR CTV (54-56): uninvolved nodal levels
_-post-bed to 60, if close margins or ECE then 66_
_-dissected neck 60, undissected 54_
81
Larynx 5 yr OS
5 yr OS
Larynx
I – 80%, RT LC 90%
II – 60%, RT LC 80%
III – 50%
IV – 35%
82
Larynx preservation RT and CRT
Larynx preservation
RT alone – 65%
Concurrent chemoRT – 85%
83
Supraglottis T stage
Supra-
T1 •one subsite, normal VC mobility
T2 •\> 1 adjacent subsite or involvement in immediate surrounding regions (ie BOT or piriform sinus)
T3: PPP-TV
* post-cricoid
* pre-epiglottic space
* paraglottic space
* (inner cortex) thyroid cartilage erosion
* VC fixation
Much higher rate of LN positivity than glottis
84
Supraglottis T1-2 treatment
_T1-T2:_
1. Definitive RT – cover 2-4 bilateral to 56, gtv 70, larynx 63 – no chemo – discuss 6 fractions
2. Supraglottic laryngectomy + LND -\> RT or CRT for high risk features
- Supraglottic laryngectomy –takes epiglottis, AE fold, false cords, hyoid if preglottic ext, upper ½ thyroid cartilage. Preserves 1 or both arytenoids, both TVCs – NOT TL!
- CI: true glottis, ant commissure, fixed cord, inadequate PFTs (aspiration), bilateral arytenoid
85
Supraglottis _T3-T4 or N+: treatment_
_T3-T4 or N+:_
1. CRT if functional larynx with low risk aspiration
2. TL + LND -\> RT or CRT for high risk features (preferred if T4a)
86
Supraglottis Volumes
Def IMRT: dose painting
35 fractions: **70/2, 63/1.8, 56/1.6**
HR CTV includes – entire larynx, high risk nodes
1st echelon nodes: II-IV bilaterally
RP if hypopx involvement
Ipsi IB if level II involved
Cover level VI if subglottic extension
87
Subglottis T stage
Sub-
T1: subglottis only
T2: extension to TVC (normal or impaired mobility)
T3: limited to larynx with fixed VC
88
Subglottis T1-2 treatment
_T1-T2:_
1. Definitive RT
89
Subglottis _T3-T4 or N+: treatment_
_T3-T4 or N+:_
1. CRT if functional larynx with low risk aspiration
2. TL + LND -\> RT or CRT for high risk features (preferred if T4a)
90
Subglottis Volumes
1st echelon nodes: RP, bilateral II – IV and V
Cover stoma in high risk CTV in all cases
91
PS sites
Sinus: maxillary\*, frontal, ethmoid, sphenoid
92
NC sites
NC: vestibule, septum, floor, lateral wall
93
Ohngren’s line
Ohngren’s line – medial canthus to angle of mandible – upper does worse
Nasal cavity
94
NC PS workup
Additional work-up:
Nasal endoscopy
MRI H&N
CT c/a/p or PET
SCC most common
95
_Nasal Cavity/Ethmoid T stage_
_Nasal Cavity/Ethmoid_
T1 = 1 subsite, no bone inv
T2 = 2 subsites or bone inv
T3 = Cribiform plate, medial wall or floor of Orbit, Max sinus, or Palate (COMP)
T4a = Skin of nose/cheek, anterior orbital contents, pterygoid plates, sphenoid or frontal sinus, minimal anterior cranial fossa
T4b = orbital apex, dura, brain, middle cranial fossa, CN (not V2), NPX,
clivus
96
_Maxillary T stage_
_Maxillary_
T1 = maxillary sinus mucosa, no bone
T2 = +bone erosion or ext to hard palate, middle nasal meatus (excludes posterior extension, i.e. post max sinus, pterygoid plates)
T3 = post wall bone erosion, SubQ tissue, floor or medial wall of orbit, pterygoid fossa, ethmoid sinuses
T4a = Skin of cheek, anterior orbital
contents, sphenoid/frontal sinuses,
infratemporal fossa, cribriform plate
T4b = same as NC above,
orbital apex, dura, brain, middle cranial fossa, CN (not V2), NPX,
clivus
97
_Esthesioneuroblastoma Staging_
_Esthesioneuroblastoma_
Kadish staging:
A: confined to NC
B: involves NC and para-nasal sinus
C: extends beyond NC and paranasal sinus (including LN, DM, orbit, intracranial etc)
98
_Wang staging for nasal vestibule_
_Wang staging for nasal vestibule_
T1 – confined to skin
T2 – invades subcutaneous tissue or cartilage
T3 – invades bone
99
_Nasal cavity and ethmoid sinus_
T1N0: treatment
_Nasal cavity and ethmoid sinus_
T1N0:
1) Surgery -\> PORT
- no PORT for low grade & neg margin
2) RT (70 Gy)
100
Nasal cavity T2+ or N+: treatment
T2+ or N+:
Surgery → PORT
- cover neck (bilateral IB and II) for SCC N0
- cover IB–IV for N+
- cover RP for posterior 1/3 nasal cavity
T1 = 1 subsite, no bone inv
T2 = 2 subsites or bone inv
T3 = Cribiform plate, medial wall or floor of Orbit, Max sinus, or Palate (COMP)
T4a = Skin of nose/cheek, anterior orbital contents, pterygoid plates, sphenoid or frontal sinus, minimal anterior cranial fossa
T4b = orbital apex, dura, brain, middle cranial fossa, CN (not V2), NPX,
clivus
101
_Maxillary sinus_
T1-T2 N0: treatment
_Maxillary sinus_
T1-T2 N0:
Surgery → PORT to primary site for + margins, PNI, LVI, or ACC above Ohngren’s line
\*discuss re-resection for +SM
102
_Maxillary sinus_
T3-T4 or N+: treatment
_Maxillary sinus_
T3-T4 or N+:
Surgery (ND for N+) → PORT
No need for elective neck RT unless SCC or undifferentiated (consider for ACC)
N0: cover ipsi IB and II
N+: cover ipsi IB-IV (consider RP, V)
Cover ipsi neck only, unless tumor crosses midline
103
_SNUC: treatment_
_SNUC:_
Induction cis-based chemo (retrospective) → surgery → PORT with coverage of bilateral IB and II
104
_Esthesioneuroblastoma_:treatment
A
B
C
_Esthesioneuroblastoma_:
Kadish A: surgery (preferred) or RT (70 Gy)
Kadish B: Surgery → PORT
Kadish C: Surgery → PORT
\*Cover bilateral lateral RP, IB, and II for Kadish B and C
A: confined to NC
B: involves NC and para-nasal sinus
C: extends beyond NC and paranasal sinus (including LN, DM, orbit, intracranial etc)
105
Nasal Vestibule
\< 1.5 cm and well-diff: RT to primary + 2 cm (66Gy)
\> 1.5 cm or poorly-diff: RT to primary and nodes
50 Gy to bilateral facial LN, IB-II
66 Gy to primary + 2 cm
If LN positive: RT to primary and nodes
50 Gy to bilateral facial, Ib – IV
66 Gy to primary + 2 cm
106
General Sinus volumes
Volumes:
Entire tumor bed + pre-op GTV + 1.5 cm anatomically cropped + entire involved sinus + ipsi PPF and pterygoid space + cribriform plate
107
Salivary gland anatomy
Major:
- Parotid – drains into OC via Stenson’s duct near 2nd molar; mucoepidermoid (MEC)
- Submandibular – drains into OC via Wharton’s duct
- Sublingual – via Bartholin’s duct
Minor (MEC LN spread)
-Most common location is hard palate
75% parotid
75% of parotid masses are benign
75% of minor salivary are malignant
108
Salivary gland T stage, high low grade histology
T1 – ≤ 2cm
T2 – 2.1-4cm
T3 - \> 4cm or extraparenchymal extension
T4a – FEMS: Facial nerve, ear canal, mandible, skin
T4b – skull base, pterygoid plates, encase carotid
Low grade: acinic, mucoepidermoid
High grade: adenoid cystic, adeno, squam
109
Salivary Gland Treatment
Surgery (parotidectomy)
- total if deep lobe involved
- ipsi II-V neck dissection if high grade or cN+
**RT for all but very small, low grade**
Parotid: ask about grade, PNI
Post-op RT to primary site only for:
1) T3 (EPE) or T4
2) close or + margins (deep lobe)
3) PNI/LVSI
4) Capsule rupture or tumor spillage
5) Recurrence
Post-op RT to primary and neck for:
1) N+
2) High grade
Unresectable: Definitive RT
\*\* adenoid cystic – need to cover facial nerve
110
Salivary Gland volumes
Post-op volume – tumor bed + 2 cm
For unresectable – tumor + normal gland
Neck – Ib-IV
R2 – 70 Gy
R1, ECE – 66 Gy
R0 – 60/2 Gy
Elective neck 54/1.8 Gy
Techniques: IMRT (favored if treating neck), wedge pair (ant/post obliques), electrons, electron/photon mix (4:1)
Cover PNI to base of skull (thru stylomastoid foramen, can stop at 2nd genu unless gross disease in BOS)
111
Thyroid histology
- Papillary (most common) – takes up RAI
- Follicular, Hurtle – take up RAI
- Medullary – associated w/ MEN; do not take up RAI
- Anaplastic – do not take up RAI
Functioning thyroid nodules are rarely malignant
112
Thyroid Workup
T3, T4, TSH, thyroglobulin, anti-thyroglobulin Ab
Thyroid u/s
Neck u/s or MRI for adenopathy
FNA
\*\*\*No contrast with CT – because then thyroid will take up iodine, then RAI won’t work (if take up RAI)
If FNA + for medullary, serum calcitonin, CEA, Ca, urine catecholamines (screen for pheo), PTH for parathyroid (MEN)
If FNA+ for anaplastic, full body staging with PET/CT
113
Thyroid Staging
* T1 – ≤ 2cm, limited to thyroid
* T2 – 2.1-4cm, limited to thyroid
* T3a – \> 4cm
* T3b – Invading strap muscles
* T4a – Larynx, trachea, esophagus, recurrent laryngeal nerve, subQ tissues
* T4b – Pre-vertebral fascia, encase carotid, mediastinal vessels
\* note: all anaplastics are T4 (T4a contained to thyroid; T4b outside thyroid)
* N1a – level VI (pretrach, paratrach, delphian), or upper mediastinal
* N1b: cervical or RP nodes
M1: distant mets
* Stage I: age \< 55, M0; age _\>_ 55, T1-2
* Stage II: age \< 55, M1; age _\>_ 55, N1 or T3
* Stage III: T4a
* Stage IVA: T4b; anaplastic T4a
* Stage IVB: age _\>_ 55, M1; anaplastic N1 or T3b; anaplastic T4b
* Stage IVC: anaplastic M1
114
Thyroid treatment paradigm
Surgery -\> RAI (for papillary/follicular) for T2+ or elevated post-op thyroglobulin (\> 1 ng/ml), +LVI
- surgery is thyroidectomy + LND (II-IV, VI) if cN+ or pN+
115
_Indications for post-op EBRT for papillary, follicular/Hurthe cell:_
_Indications for post-op EBRT for papillary, follicular/Hurthe cell:_
Consider for lesions w **inadequate iodine uptake**, **and**:
1. R1 in papillary
2. R2
3. Extensive ETE
4. Poor RAI response
Or pT4N1 and age _\>_ ~40 after RAI
116
Medullary and Anaplastic treatment
For Medullary ca:
Consider EBRT for incomplete resection, LN+, extensive ETE, or persistent incr calcitonin
\*\* for anaplastic, only do surgery if GTR possible. Otherwise definitive RT with comprehensive nodal RT (down to carina) and concurrent chemo (weekly carbo/taxol or doxorubicin)
117
RAI dose
RAI – **30-50 mCi** for low risk disease (T1-2N0, remnant ablation), 50-**100 mCi** for high risk disease (T3+ or N+, thyroid bed uptake). 100-**200 mCi** for metastatic disease
- CI during pregnancy or nursing
- Max lifetime RAI dose: 800-1,000 mCi
118
Thyroid Volumes and dose
* Thyroid bed only if well-diff without ETE
* Otherwise, thyroid + bilat neck (II-VI and sup mediastinum); sup mediastinum to carina (if N+ or anaplastic)
* IMRT – post op dose painting
* 30 fractions: **60/2, 54/1.8**
* **for ECE or + margins, 66/2 (59.4/1.8 int, and 54/1.64 low risk)**
* CTV\_66 = positive margins, ECE
* CTV\_60= high risk CTV (tumor bed, 1st echelon nodes II-VI)
* CTV\_54= low risk CTV (contralateral nodes, 1b if II involved)
* Gross disease to 70 Gy
119
Thyroid OS
10 yr OS
* Papillary: 90%
* Follicular: 85%
* Hurthle cell: 75%
* Medullary: 70%
* Anaplastic: MS 6 months
120
RAI 1/2 life and side effects
RAI: ½ life 8 days
Acute: sialadenitis, cystitis, gastritis
Chronic: leukemia, pulmonary fibrosis, oligospermia
121
Unknown primary site %
* Tonsil 45%
* BOT 40%
* Piriform sinus 10%
DDx:
* Adenocarcinoma
* Lymphoma
* Thyroid
* Melanoma
* Salivary
* Sarcoma
122
Unknown primary workup
**History:** smoking history
**Physical:** skin exam
**Labs**:
* -thyroglobulin/calcitonin for adeno, EBV, HPV
**Imaging:**
* -CT/MRI BOS/neck
* -PET/CT (can do before pan-endoscopy)
* -CT chest
**Biopsy:**
* -EUA and panendo w directed bx of NPX, tonsils, BOT, pyriform sinus
* -FNA neck node (HPV and EBV testing)
* -Bilateral tonsillectomy and directed biopsy
**Other:**
* For level IV nodes, consider non-H&N primary:
* -CT c/a/p
* -triple endoscopy
123
Unknown primary treatment N1
_N1 – ipsilateral modified radical LND_
* -if no ECE, can observe but RT okay as well
* -risk-stratified PORT
* * \*if just 1 node \< 3cm, can be cured with just ipsilateral neck dissection – if just 1 node, no ECE
124
Unknown Primary N2-3 Treatment
_N2-N3 – consider CRT_
* -RT to NPX, OPX, bilateral neck
* -or bilateral neck dissection à CRT or RT
\*\* If TG neg, calcitonin neg **adenoCA** of LN levels IB – III:
Ipsi parotidectomy and ND → PORT
\*\* can add chemo for gross disease, ECE
125
Unknown Primary RT volumes
Def IMRT: dose painting
35 fractions: **70/2, 63/1.8, 56/1.6**
* CTV\_70= gross LN + 5 mm
* CTV\_63= NPX, OPX, larynx, HPX, and ipsi neck (RP, Ib-V)
* - _can exclude larynx, hypopharynx (U of FL data) in non-smoker_ if level I-III node involved
* - OC not included unless Ia/b node present
* CTV\_56=low risk uninvolved and contralateral neck (II-IV, RP)
*
PORT:
* -60 Gy to involved region (66 if ECE)
* -54 to mucosa and uninvolved neck
126
T-1 or N
p16+
## Footnote
Overall Clinical Stage greater of T-1 or N, only M1 is stage IV
Pathologic: same except T4N0-1 = II
127
T or N+2
p16-, Larynx, Oral Cavity
128
T or N+1
Nasopharynx
129
Larynx T4a
O-TESTES
* •Outer Thyroid Cartilage
* Trachea (inf. to cricoid)
* •Extrinsic tongue muscles
* •Strap muscles
* •Thyroid
* •Esophagus
* •Soft tissue neck
130
Larynx T4b
MPE (molly pearl escott)
* mediastinal structures
* prevertebral fascia
* encases ICA
