Background and recommendations Flashcards
Stage I
T1 N0 M0
Stage II
T2 N0 M0
Stage III
T3 N0 M0 or T1-3 N1
Stage IVA
T4a N0-1 or T1-4 N2
Stage IVB
Any T N3 M0 or T4b N0
Stage IVC
Any T Any N and M1
T1
2 cm or less and without extraparenchymal extension.
T2
more than 2 cm in size but not more than 4 cm without extraparenchymal extension
T3
More than 4 cm and/or have extraparenchymal extension.
T4a
tumors that invade the skin, mandible, ear canal, and/or facial nerve.
T4b
tumors that invade the skull base and/or pterygoid plates and/or encases the carotid artery.
Benign salivary tumors
- Pleomorphic adenoma
- Myoepithelioma
- Warthins
- Basal cell adenoma
Low grade salivary tumors
- Acinic cell
2. Low grade mucoepidermoid
High grade salivary tumors
- High grade mucoepidermoid carcinoma
- Adenoid cystic
- Malignant mixed tumor
- Undifferentiated carcinoma NOS
- Mucinous adenocarcinoma
- Small cell carcinoma
- Clear cell carcinomas
- Adenocarcinoma
- Carcinoma ex-pleomorphc adenoma
N3
Nodes more than 6 cm in size
N2a
single node is positive that is more than 3 cm but 6 cm or less.
N2b
multiple ipsilateral nodes are positive but none are more than 6 cm.
N2c
metastasis to contralateral nodes has occurred but none more than 6 cm in size.
What is the most common malignant subtype of major salivary glands?
Mucoepidermoid
What are PORT indications for low grade malignant tumors?
- Positive margin
2. Multiply recurrence
When do you deliver elective nodal radiation with low grade malignancies?
- Never
Salivary gland tumors originate where most frequent?
- Parotid : 70%
- Submandibular: 8%
- Sublingual gland: 2%
In general, where are minor salivary glands found?
The epithelium of the upper aerodigestive tract
What is the purpose of major salivary glands?
Produce saliva along with enzymes to digest food. Specifically, it secretes amylase which breaks down starch.
What are the only tumors where surgery alone is adequate?
Low grade tumors and benign tumors, node negative, resected with negative margins.
What are the indications for PORT for benign tumors or the major salivary glands?
- Positive margins
2. Multiple recurrent tumors
What are the indications for PORT for malignant tumors?
- Multiple recurrent
- All high grade tumors
- Positive margins
- Positive lymph nodes
- PNI
What are the only situations where RT alone is indicated?
- Surgery would be too morbid
- A gross total resection is not possible
- Patient is a poor surgical candiate for medical reasons
How is the HR CTV defined? What dose?
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
How is the LR CTV defined? What dose?
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
How is the IR CTV defined? What dose?
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
CT Simulation
- Supine
- Arms at Side
- Qfix
- Neck extended
- Aquaplast mask
- IV contrast
- Barium paste over scars.
- 5 mm bolus over scar
UF constraints to protect the eye?
- Lens Dmax 12 Gy
- Retina Dmax 16 Gy
- Temporal lobe 1 cc 6 Gy
What are common cnventional techniques used? What is the downside of using convetional techniques?
- Unilateral photon wedge pair
2. Mixed photon and electron lateral beams, 15 MeV (estimate parotide depth is 4.5 cm)
What are indications to deliver ENI RT?
High grade tumors that were resected without node dissection
What are indications to provide PORT to the neck?
- Always provide atleast 50 Gy of RT to the neck
When is surgery appropriate?
A GTR should be the first step in nearly all nonmetastatic cases.
Push for GTR even when CN 7 must be sacrificed.
What imaging is needed?
- Diagnostic CT scan of the neck
- MR of head and neck
- CXR but if multiple positive nodes, CT scan of chest
What is the most common symptom experienced by patients with an enlarging parotid mass?
Painless palpable mass
Ipsilateral facial weakness
What is the proper method to getting a tissue diagnosis?
- Surgical resection
2. FNA biopsy
