Doctor notes

Question 1

What are the four stages of Head and neck cancer treatment?

Answer 1

• Diagnosis
• Therapy
• Follow-up
• Rehabilitation

Question 2

What does smoking during RT effect?

Answer 2

LRC
OS
DFS
-Patients with high Hb do better, presumably because there is less hypoxia induced radio-resistance

Question 3

Effect of drinking alcohol during RT?

Answer 3

• synergistic with smoking

- there is also a dose response with alcohol

Question 4

Why is the Worldwide incidence of oro-pharyngeal cancer is going up despite reduction in smoking rates?

Answer 4

HPV associated H&N Ca

-increased incidence is secondary to changing lifestyle and changing sexual behaviour.

Question 5

Characteristics of HPV associated H&N cancer?

Answer 5

1) non-keratinizing SCC
2) now-intermediate T stage
3) middle-aged white men, high socio-economic status
4) little/ no tobacco history
5) responds well to therapy (5 year OS Stage III & IV HPV
positive >80% compared with 40% for non HPV positive
disease)
P16 is a surrogate for HPV status

Question 6

What is the natural history of head and neck cancer?

Answer 6

Clinical behavior depends on site of primary

Tend to recur locally, as opposed to metastasize, which dictates aggressive therapy to achieve local control.

Question 7

Natural history of Head and neck cancer?

Answer 7

-Clinical behavior depends on site of primary
-Tend to recur locally, as opposed to metastasize, which dictates
aggressive therapy to achieve local control.

Question 8

Diagnosis of head and neck cancer?

Answer 8

• Fine needle aspiration biopsy (cytology)
• Core Biopsy (histology)
• Incisional biopsy
• Excisional biopsy (to be avoided)

Question 9

Staging investigations?

Answer 9

1) Investigations to assess the primary lesion and nodal spread
2) Investigations to confirm suitability for therapy
3) Investigations to exclude co-morbidity

Question 10

How is CT utilised?

Answer 10

-Used to define the primary lesion, may give information about
the operability
-Information about nodal involvement
-Excludes distant metastase

Question 11

How is MRI used?

Answer 11

-Good for soft tissue assessment (e.g BOT)
-PNI
-Base of skull involvement
-Intracranial extension
(useful sequences include non-contrasted T, contrasted T1 fat
suppressed and T2 with fat suppression)

Question 12

How is PET used?

Answer 12

-May detect involved nodes that are morphologically normal
(which don’t meet CT criteria for pathological involvement)
-Excludes distant metastases

Question 13

Pre treatment assessment?

Answer 13

• Pan-endoscopy & EUA
Allows biopsy
Can use to define primary lesion extent
Exclude second primary (2.4-4.5%, more common with
laryngeal or hypo-haryngeal primaries)
• Dental assessment
• OPG
• Speech pathology
• Social worker

Question 14

Follow up?

Answer 14

• To detect salvageable recurrence or new H&N primary
• Side-effects of treatment
• Speech therapy
• Try to get them to STOP SMOKING!
• HPV epidemic means an increasing number of survivors.
• Emphasize regular dental care, therapy for dysphagia and
lymphedema

Question 15

Histology types?

Answer 15

• SCC
• Adeno-carcinoma
• Adenoid cystic
• Muco-epidermoid

Question 16

How would you treat a low risk T1-2 NOMO head and neck cancer?

Answer 16

Sole modality

• Wide local excision
• Radical resection +/- vascularised flap repair
• Transoral Robotic surgery (TORS) (currently investigational)
• Transoral LASER surgery (TLS)

Question 17

When would you use sole modality RT and which types can be used?

Answer 17

1) elderly
2) those with poor performance status

IMRT, brachytherapy and altered fractionation

Question 18

When would you used combined treatment modalities?

Answer 18

1) Medically inoperable
2) Un-resectable disease
3) Preservation of function

Question 19

When would you use neoadjuvant therapy?

Answer 19

CT/RT +/- surgery for residual disease

Question 20

Side-effects of radiation in the Head & Neck region: acute

Answer 20

• Lethargy
• Nausea and vomiting
• Skin erythema, initially dry desquamation, proceeding to
moist desquamation
• mucousitis, initially patchy, proceeding to confluent
• Alteration in taste
• Dysphagia
• Odynophagia
• Alteration in saliva consistency

Question 21

Side-effects of radiation in the Head & Neck region: Late

Answer 21

• Xerostomia (if can keep parotid dose <25Gy, at 18 months,
saliva is back to baseline).
• Radiation caries
• Second malignancy
• Mucosal atrophy and fragility
• Alopecia
• Loss of sweating
• Trismus
• Atrophy of subcutaneous tissues
• Endocrine abnormalities (hypothyroidism, hypo-pituitarism)
• Osteoradionecrosis

Question 22

IMRT voluming for head and neck cancer?

Answer 22

GTV = gross tumour identified clinically in conjunction with
radiological information (from CT, MRI and PET imaging,
which are often fused to help with voluming)

• CTV = GTV + 0.5mm is the margin to allow for microscopic
spread (this is “shaved” to remove structures which do not
need to be treated, e.g. bone)

• HRTV (in post-operative setting) = gross disease present preoperatively
+ 1 cm margin = HRCTV

• PTV = CTV + set-up error, which includes patient movement
and allows for beam characteristics (e.g. penumbra). PTV is a
geometrical construct. The more effective the immobilization,
the smaller the set-up error. For H&N tumours, 3-5mm CTV
to PTV margin is appropriate

Question 23

Biological agents used for treatment of head and neck cancer?

Answer 23

• Cetuximab (EGFR inhibitor) monoclonal antibody.

single RCT Cetuximab/RT versus RT alone, with survival
advantage (10%) and local control advantage to
Cetuximab (but may actually be associated with more
toxicity). Still under investigation.

Question 24

Indications for PORT?

Answer 24

1) Close margins ( < 5mm),
2) ≥ 2 nodes involved
3) pT3-pT4 tumours with negative margins
4) oral cavity lesion or oropharynx with level IV-V nodes
involved
5) peri-neural or LVI