H&N cancer in general Flashcards
nodal levels 1-7
Level I: submental and submandibular = submaxillary
Level II: superior spinal accessory and superior jugular = upper deep cervical
Level III: mid jugular = middle deep cervical
Level IV: inferior jugular = lower deep cervical
Level V: inferior spinal accessory = posterior cervical, transverse cervical = supraclavicular chain
Level VI: prelaryngeal = delphian
Level VII: contains lymph nodes inf to the SSN
what contrast is used for H&N CT scans
IV contrast is use to delineate the LN and blood vessels
GFR is calculated before giving IV contrast, ensure the GFR is >60 css/min
CT scanning limits for H&N cancer
SUP: top of skull
INF: to carina
RINGS IMRT
As many rings as needed
Target volume would have a max dose of the needed dose ex. 70 Gy
**if you aren’t achieving proper coverage, bump the max up to 105% to allow the target to be covered
5-7% of dose can be dropped per mm for IMRT and VMAT planning
The strongest weighting will be set on objectives for PTV coverage in order to achieve an ideal distribution around the volumes of interest. Medium weighting will be set on objectives to spare organs at risk, and lighter weighting will be set on Rings in order to help shape the overall distribution
XRT DOSES
60 Gy/25 60 Gy/30 POST-OP 66 Gy/33 POST-OP 70 Gy/30 in 6wks 70 Gy/35 in 7wks
Dysphagia/ odonophagia
Begins 2-3 weeks
Resolves 2-4 weeks post XRT
Increase fluid intake to avoid dehydration
Eat food high in protein and calories
Eat foods that are easy to chew and swallow
what are the IMRT matches after CBCT
Bony match for image matching: use the vertebral bodies near the PTV
Verify coverage of target volume *generally anatomy within 95%
what happens when there is gas in the patients shell
Assess for gaps in shell on a daily basis
Consult a planner when gap in shell occurs especially under bolus placement
If there is a discrepancy great than 2 mm between the RT and LT TP0+ during laser alignment, verify set-up and reposition the mask on the patient if necessary
If AP+ does not align with LAT+ in the SUP/INF direction, ensure patient’s chin and forehead are well positioned in the shell
mucositis
Begins week 1
Resolves 3 weeks post XRT
Increase fluid intake and mouth care routine
Clean mouth after meals and use soft toothbrush
Avoid alcohol, smoking, spicy food and citrus
Try to eat high protein and high calorie foods
xerostomia
Begins week 1
Resolves 6 months or later (variable)
Use mouthwashes regularly and frequent sips of water
Avoid alcohol, smoking, spicy food and dry food
Avoid coarse foods and add moisture to solid foods (gravies, etc.)
Use foods and drinks that promote salivary production
dysgeusia
Begins week 1-2
Resolves 2-4 months post XRT
Eat small frequent meals that are high protein and calorie foods
Try a nutritional supplement
Try fresh fruit, sugarless candies, tart flavours and other citrus food
Try marinating food and experiment with spices
Erythema/ moist/ dry desquamation
gentle cleansing, avoid sun exposure, lotion without irritants should be applied
Hydrocortisone cream for red/itchy- unopened skin
Those with moist desquamation: wound dressing with nonstick bandaging, Silvadene (silver sulfadiazine) is often prescribed to promote healing and avoid infection
Flamazine may also be used for
chronic side effects of XRT
Permanent xerostomia
Soft tissue fibrosis
Hyper and hypo pigmentation
Hair loss (whiskers) back of skull
OTC medications for Side effects
Aspirin (acetylsalicylic acid)- analgesic antipyretic, anti-inflammatory
used only if not on chemo
Tylenol (acetaminophen)- analgesic, antipyretic
used only if not on chemo
Biotene- relief of xerostomia and saliva substitute
Liquid Lidocaine - topical anaesthetic
Maalox- Antacid, used to coat the throat and ease swallowing
Magic Mouthwash- liquid lidocaine, Benadryl and Maalox
prescription for side effects
Salagen (pilocarpine HCl)- cholinomimetic agent; used for xerostomia
Mycostatin (Nystatin) - treatment of candidal infection of the mouth, related to XRT; anti-fungal
Xylocaine viscous 2% - topical anaesthetic
H&N CT sim scan parameters
from top of th head to carina
who s/b consulted when there is a gap in the shell
consult planners
what happens when there is discrepancy in TPO of the shell… how much discrepancy warrants action?
2 mm or greater warrants action, you reposition and set up the patient and ensure pt position and reposition the mask
if AP TP0 is off but the lats are on what action is taken?
issue in SUP/INF position ensure patient chin and forehead are in the mask correctly
what is the most common salivary gland tumour
parotid followed by submandibular
many H&N cancers are associated with smoking and or alcohol, this is not the case for this subtype….
salivary gland cancer
which H&N cancer is diagnosed at the youngest age?
sailvay gland tumours
45 yo for benign tumours
54 for malignant tumours
a 50 year old female patient with prior H&N lymphoma presents to the XRT department with a painless mass, what is her most likely primary?
a salivary gland tumour
-female gender could be an indication of a benign parotid tumour
70% of saliva is made by this structure….
submandibular glands
how long does it take for xerostomia to occur
after 1 week of tx 10 GY
what H&N cancer may use bulls eye technique
salivaRY GLAND cancer- specifically parotid gland
also paranasal sinus/ nasal cavity
what type of tumour is mucoepidermoid carcinoma
1 malignant parotid gland tumour
what type of tumour is adenoid cystic
malignant salivary gland tumours (except parotid gland)
what cancer type is often associated with occupational exposures?
paranasal sinus and nasal cavity
assoc with sawmill dust and nickel exposure
the septum divides me into left and right halves… what am I?
Nasal Cavity
i am the largest paranasal sinus? Who am I?
maxillary sinus
I am the most posterior sinus? Who am I?
i am the sphenoid sinus
A 62 year old man who is a retired nickel mine worker presents to the XRT department with facial swelling and pain, what is his diagnosis?
He has a paranasal sinus tumour-> maxillary sinus tumour SCC
SCC is associated with nickel exposure
Maxillary sinus presents with facial swelling and pain in late stages
A 61 y.o. man with a 30 pack year history presents to the radiation department with a crusty, scaly asymptomatic plaque, What is his primary?
This patient probably has a Nasal vestibule SCC
- nasal vestibule presents with asymptomatic plaque
- SCC is associated with smoking
A 64 y.o. male who is a retired Sawmill worker presents to the radiation department with epistaxis and nasal discharge, what is his primary?
this patient has an adenocarcinoma of the nasal cavity
- Adenocarcinoma is associated with working in a sawmill
- The presenting symptoms of epistaxis and nasal discharge (nasal polyp like S&S) are associated with nasal cavity tumours
Cancer most common in Japan and South Africa?
paranasal Sinuses
Cancer common in China, Saudia Arabia, north Africa
nASOPHARYNX
What is trismus
lock jaw can be SE or symptom of H&N cancer
What H&N cancer has different staging system than all other H&N ca?
NASOPHARYNX IS DIFFERENT THAN ALL OTHER H&N CA
cranial nerve 3-6 is most commonly involved in which H&N cancer
NPC
A 55 year old patient with a 35 pack year history, who drinks 4 drinks/ day, and has a diet high in salted meats presents with cold like symptoms. What is his most likely primary?
NPC
this cancer is diagnosed late because it manifests with cold like S&S
NASOPHARYNX
What cancer has more superior IMRT borders than other H&N cancer?
nasopharynx
what H&N cancer is associated with HPV
OROPHARYNX
a 32 y.o. female with a history of HPV presents at the cancer centre with a neck mass, what is her primary?
Oropharynx cancer— can be associated with HPV in younger pts
a 57 y.o. male with a 43 pack year and 5 alcoholic drinks/ day presents at the radiation department with trismus and necrotic smell, what is his most likely primary?
Oropharynx
erythroplakia vs leukoplakia
leukoplakia is a white patch erythroplakia is a red patch
what cancers are preceeded by erythroplakia or leukoplakia
oral cavity cancers
snuff, betel nut chewing are etiological factors for what H&N cancer
oral cavity
more specifically the buccal mucosa, gingiva, lip and floor of mouth
a 54 y.o. man with a 30 pack year and 6 ounces of alcoholic drinks/ day presents to the radiation department with white patches in his mouth, what is his primary, what are the white patches?
the white patches are leukoplakia which is an indication of oral cavity cancer- this occurs more often in FOM. buccal mucosa tongue and retromolar trigone
salivary origin tumour is the primary histology for what H&N cancer
hard palate of the oral cavity
why are teeth removed before XRT
to avoid osteoradionecrosis
which subsite is surgery most important for?
surgery is primary treatment for oral cavity cancer - oral cavity cancers are harder to control with XRT
brachy and electrons may be used for what site?
oral cavity cancers
ill fitting dentures can cause what cancer?
oral cavity- the hard palate
What agent is used for H&N brachy
Ir-192
brachy is used LDR/HDR? remote or manual afterloading?
typically LDR and is remote afterloading
loose teeth could be an indication of what
late stage oral cavity cancer
what is the most common site of H&N cancer
larynx
endophytic tumour
tending to grow inward into tissues in fingerlike projections from a superficial site of origin —used of tumors
exophytic tumour
Exophytic tumors grow out from the mucosal surface in cauliflower-like clusters, and rapidly become symptomatic. Thus, these tumors are usually diagnosed earlier in the course of the disease
what tumour types present early?
most tumour type present late except for oral cavity and larynx cancers
what site most commonly gets mets?
the hypopharynx
this cancer is associated with voice changes?
supraglottic cancer
a 58 y.o. male patient with a history of smoking and drinking presents to the XRT department with voice changes, what is his primary?
larynx- more specifically the supraglottis, th epiglottis as its associated with voice changes
a 63 y.o. retired speaker of the house presents at the radiation department with hoarseness, what is their primary?
larynx- can be any part of the larynx as hoarseness is most common s&s however, most likely of the glottis as its the most common site
plummer vinison syndrome causes what H&N cancer
hypopharynx
EBV is associated with what subtpye?
nasopharynx—- STRONG ASSOCIATION
parotid drains from what ducts
stensons ducts
submandibular gland drains from what ducts
whartons ducts
subsites for larynx
glottis, subglottis and supraglottis
subsites for nasopharynx
Posterosuperior and lateral pharyngeal wall
Eustachian tube orifice
Adenoids
subsites nasal cavity and paranasal sinus
Maxillary, frontal, ethmoid and sphenoid
subsites orpopharynx
tonsil, BOT, soft palate and post pharyngeal walls
oral cavity subsites
buccal mucosa, gingiva, lips, ant 2/3 of tongue, hard palate, retromolar trigone, FOM
HYPOPHARYNX SUBSITES
POST CRICOID, POST PHARYNGEAL WALL AND PIRIFORM FOSSA
Nickel exposure is associated with what H&N cancer
sinuses- SCC- most commonly in maxillary sinus
wood dust is associated with what cancer subtype
adenocarcinomas of the paranasal sinuses- ethmoid sinus
presentation oral cavity
erythroplasia leukoplakia
presentation ooropharynx
painful swallowing and otalgia (ear pain)
presentation hypopharynx
dysphagia, painful neck Ln
presentation nasopharynx
bloody discharge, difficulty hearing
presentation larynx
hoarseness and stridor
presentation maxillary sinus
sinusitis, nasal obstruction and bloody discharge
what site is cranial nerves most commonly involved in?
nasopharynx
