H&N

Question 1

Oropharynx: 2 most important prognostic factors apart from smoking

Answer 1

• HPV, other I would say id TNM?

Question 2

Health care professionals / Assessments prior to treatment

Answer 2

DON’T FORGET SMOKING CESSATION, social work
SANDS-OE
Speech/swallow, Audiology, Nutrition, Dental, Smoking cessation - Ophthalmology, Endocrine as indicated

Question 3

H&N: 8 OARs

Answer 3

Globe, lens, optic nerve, chiasm, brainstem, spinal cord, parotid, submandibular, mandible, brachial plexus, cochlea, pharyngeal constrictors

Question 4

oropharynx: 4 treatment options and what are the volumes:

Answer 4

GTVP + N -> CTV70 + 5mm; CTV 56 + 1cm total
CTVn electives: 2-4 bilaterally if node negative, add 1B/V/VIIa (retropharyngeal) to involved sides

1) Definitive CRT
2) RT alone (altered fractionation)
3) RT + Cetux
4) TORS +/- adjuvant RT/chemo

Question 5

H&N indications for post op chemo, PORT

Answer 5

Chemo: margin positive (attempt re-excision first), ECE

PORT: pT3 or T4, N2+ (upstaging to Stage III+), >1LN, close margins (<2-3mm), nodal disease in levels IV or V, PNI, vascular embolism

Question 6

H&N radiation: 4 long term outcomes that can affect QOL

Answer 6

xerostomia, neck fibrosis, trismus, dysphagia

Question 7

Outcomes for oropharynx SCC:

Answer 7

Note: they often ask 3yr LC/OS based on paper.
HPV+ vs -:
3yrOS: 80% vs 60%
3yr LC: 85% vs 65%
3yr DM: 10% vs 15%

NOTE: for non-smoker HPV w/ unilateral neck nodes (“good risk”), would quote 90% OS (and probably LC) <3

THINK: LIAM CUSHING: T2N1 right palatine tonsil tumor with one small ipsilateral node. HPV positive, less than 10 pack year smoking history: OS 93%; LC definitely at least 90% (probably say 90% for exam).

Question 8

Unknown primary: What are the volumes :

Answer 8

CTV70: GTVn + 5mm
CTV56 = GTV + 1cm AND THEN:
o Ipsi neck: levels IB-V and retropharyngeal nodes
o Contralat neck: II-IV and RP (54 Gy)
o Mucosa of NPX, bilat tonsillar fossa + lateral pharyngeal wall, BOT, pyriform sinus

If multiple nodes, including nodes in levels IV/5, add larynx

NOTE: I would treat bilateral neck because the only reason you wouldn’t is if it is like high risk skin cancer (fitzpatrick 1 patient with parotid node and previous hx of SCC skin for example lol)

Question 9

What are three systemic agents that can be used concurrently with XRT in H&N cancer?

Answer 9

Cisplatin, cetuximab, carboplatin other: nimorazole

Question 10

Q: what is most likely primary for
- parotid
- Q: what else can this region drain into?

Answer 10

A: skin.
- Skin from posterior neck and scalp can also go to level V.

Question 11

Unknown primary: Staging and what makes high risk for Oropharynx, Nasopharynx primaries?

Answer 11

If EBV+ or p16+ stage as NPC or p16+ OPC, respectively.

If no primary found, assign T0 and stage based on nodal disease:
o Stage III: N1
o Stage Iva: N2
o Stage Ivb: N3
o Stage Ivc: M1

Question 12

In SCC of unknown primary, what makes patients high risk for either Oropharynx or nasopharynx cancer? (not an RC question haha)

Answer 12

-High risk for NPX (in addition to EBV+)
o Clinical: Younger cohort (<40 years), non-smoker, EBV+, Asian, Inuit, Polynesia, Mediterranean, including North Africa
o Radiological: Isolated or dominant level 5 disease; RPN lymph node disease
o Pathological: Lymphoepithelioma/unddx ca

High risk group for OPX ca (in addition to HPV+)
o Clinical: Non-smoker/no history of excess alcohol consumption, marijuana use
o Radiological: Cystic nodal disease
o Pathological: basaloid subtype SCC

Question 13

For oropharynx and other cancers, when do we give chemo?

Answer 13

For everyone but T1-2N0 (trials gave chemo for stage III and IV). (ie if T3+ or node positive). EXCEPT: when cancer of unkown primary, give radiation alone if T0N1.

Question 14

What is removed in a neck dissection: selective and radical. Which do we do for T1-2N0-1 for oropharynx cancer?

Answer 14

For surgery, say transoral robotic surgery with SELECTIVE neck dissection (not radical):
- This means selective dissection levels II-IV for oropharynx, hypopharynx, and larynx. For oral cavity, at least levels I-III.

Radical neck dissection:
 Levels IB-V, jugular vein, SCM, CN11, and submandibular gland (remember CN11 innervates trapezius and sternocleidomastoid musculature).

Question 15

what are causes of fixed vocal cords: EXAM q:

Answer 15

• Tumor invasion of thyroid cartilage
• Invasion of vocalis muscle and paralaryngeal space
• Invasion of crico-arytenoid joint
• Interference of cord mobility by bulky tumor
• Subglottic extension and fixation of the vocal cord to the cricoid cartilage
• Involvement of recurrent laryngeal nerve (can be in the lower neck, mediastinum AP WINDOW!!!!)

Question 16

4 structures removed in radical neck dissection?

Answer 16

Submandibular gland
Internal jugular vein
Sternocleidomastoid muscle
Spinal accessory nerve
Lymph nodes level I-V

Question 17

What 6th nerve runs through the Cavernous sinus?

Answer 17

The sympathetic plexus around the internal carotid artery!