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Oral Boards > Head and Neck > Flashcards

Head and Neck Flashcards

1
Q

What is the DDx for a HN mass?

A

SCC

Melanoma

Lymphoma

Sarcoma

Plasmacytoma

Angioma

Benign (abscess, inflammatory)

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2
Q

Initial workup for HN cancer

A

Detailed H&P

  • History
    • Dysphagia
    • Odynophagia
    • Otalgia
    • CN deficits
    • Smoking/drinking/sexual habits
  • Physical exam
    • HEENT - oral exam
    • CN exam
    • Neuro exam
    • Nasopharyngoscopy
    • LN exam of neck
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3
Q

Labwork to order for HN SCC

A

CBC

CMP

TSH

EBV (if nasopharynx)

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4
Q

Imaging to order for HN

A

CT w contrast

MRI to assess for BOS invasion

PET/CT to assess nodes and distant mets

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5
Q

What to check on HN Biopsy

A

HPV status

p16

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6
Q

All HN patients should be referred for which services

A

Dental evaluation

Speech/Swallow

Nutrition

Audiology

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7
Q

Indications for PEG tube placement

A

Severe weight loss prior to treatment (10% in 6 months)

Severe dysphagia

High aspiration risk

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8
Q

Level 1A nodes

A

Submental

Lateral borders are anterior belly of digastric muscles

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9
Q

Level 1B nodes

A

Submandibular nodes

Lateral to submandibular gland, behind mandible

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10
Q

Level II lymph nodes

A

Upper cervical

  • Superior edge is transverse process of C1, retrostyloid space
  • Inferior: hyoid bone
  • Posterior: post edge of SCM
  • Anterior: post edge of submandib gland
  • Medial: ICA
  • Lateral: SCM muscle
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11
Q

Level IIA

A

Anterior to internal jugular vein

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12
Q

Level IIB

A

posterior to IJ vein

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13
Q

Level III nodes

A

Mid cervical

Superior border: hyoid

Inferior border: inferior cricoid cartilage

Other borders same as level II

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14
Q

Level IV neck

A

Inferior cervical

  • Superior: inferior edge of cricoid cartilage
  • Inferior: Depends on nodal status
    • If N0 - 2 cm above manubrium
    • If N+ - manubrium
  • Lateral: SCM
  • Medial: ICA
  • Anterior: anterior edge of SCM
  • Posterior: posterior edge of SCM
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15
Q

Inferior edge of Level IV nodes if N+

A

manubrium

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16
Q

Level V neck

A

Posterior triangle

  • Superior: superior edge of hyoid
  • Inferior: posterior to level II/III
  • Anterior: posterior edge of SCM
  • Posterior: Anterior edge of trapezius
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17
Q

Level VIa nodes

A

Anterior central compartment

Below level 1A but between SCM

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18
Q

Level VIb nodes

A

Central compartment nodes

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19
Q

Retropharyngeal nodes

A
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20
Q

What is removed in radical neck dissection?

A
  • Levels I-V
  • SCM
  • Omohyoid muscle
  • IJ and EJ veins
  • CN XI
  • Submandibular gland
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21
Q

What is the difference with a modified radical neck dissection?

A

Leaves at least one of SCM, Int Jugular, CN XI

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22
Q

What is comprehensive neck dissection

A

Removes all of LN I-V

(generally appropriate for N+ disease)

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23
Q

What is a selective neck dissection?

A

Removes select nodal levels depending on sites and cN status

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24
Q

What nodal dissection is required for N0 OC

A

Selective I-III

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25
Q

What nodal dissection is required for N0 OPX

A

Selective II-IV

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26
Q

What nodal dissection is required for N0 Hypopharynx or Larynx

A

Selective neck dissection of II-IV

Include level VI if subglottic extension

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27
Q

What nodal dissection is required for N1

A

Selective or comprehensive pending situation

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28
Q

What nodal dissection is required for N2

A

Selective or comprehensive pending situation

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29
Q

What nodal dissection is required for N3

A

Comprehensive neck dissection

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30
Q

RT coverage of N0 NPX

A

Cover levels II-III-IV-V

RP bilaterally (including medial)

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31
Q

RT coverage of N0 OC

A

Level Ib, II, III bilaterally

Top of level IV bilaterally

Include 1a for lip, oral tongue, alveolar ridge and FOM

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32
Q

Which N0 OC patients can get ipsilateral neck treatment

A

T1N0, T2N0 or T1N1 well-lateralized

buccal, alveolar, RMT

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33
Q

RT coverage of N0 OPX

A

Level II-III-IV bilaterally

Ipsilateral RP node

Bilateral RP nodes if posterior pharyngeal wall involved

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34
Q

Which N0 OPX patients can get ipsilateral neck treatment

A

well lateralized small tonsil

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35
Q

RT coverage of N0 Larynx cancer

A

II, III, IV bilaterally

Consider VI if thyroid cartilage, posterior cricoid cartilage or subglottis involved

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36
Q

RT coverage of N0 supraglottic larynx

A

II - III - IV bilaterally

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37
Q

RT coverage of N0 Hypopharynx

A

II - III - IV bilaterally

RP bilaterally

VI if thyroid cartilage, posterior edge of cricoid cartilage or subglottis involved

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38
Q

RT coverage of N0 thyroid

A

III - IV, VI bilaterally

Consider V

Cover II and mediastinum if anaplastic histology

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39
Q

When to cover medial RP nodes?

A
  • Always for NPX
  • If lateral RP nodes are positive
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40
Q

Other situations to consider covering level 1b

A
  • NPX involving nasal cavity
  • Oral cavity extension of OPX
  • Level II with bulky disease or ECE
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41
Q

When to consider covering level V

A

NPX

Bulky or multiple levels II-IV

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42
Q

What are the only lesions which drain directly to level V

A

NPX

Scalp

Lymphoma!

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43
Q

What is the management by T stage

A

T1N0: surgery or RT alone

T2N0: surgery or RT alone

T3 or N+ : CRT

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44
Q

What is the preferred concurrent chemo regimen for HN SCC?

A

Bolus cisplatin

100 mg/m2 q3 weeks, for 3 infusions during RT

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45
Q

Other systemic therapy options if bolus cis is not possible

A
  • Weekly cisplatin 40 mg/m2
  • Cetuximab
  • Weekly carbo-taxol
    • Carbo AUC 2
    • Taxol 80 mg/m2
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46
Q

Doses of cetuximab

A

400 mg/m2 loading week before RT

250 mg/m2 weekly

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47
Q

Indications for contralateral neck dissection

A

N+ disease on that side

Midline structures (oral tongue, FOM)

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48
Q

Indications for postop RT to primary

A
  • pT3/T4
  • PNI
  • LVI
  • Close margins
  • OC primary with level IV or V LN involvement
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49
Q

What is considered close margin for HN

A

5 mm

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50
Q

What are indications for postop RT to neck?

A

N2 or N3

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51
Q

Indications for post op CRT

A

ECE

positive margins

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52
Q

If treating primary or nodes postop, do you always treat both?

A

Most of time yes

Consider separating if parotid or skin primary

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53
Q

When should reimaging occur after definitive CRT?

A

12 weeks with PET

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54
Q

What to do if residual disease at 12 week PET?

A

Consider referral to surgeon for neck dissection

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55
Q

Goal is to finish all treatment for HN SCC within X weeks

A

11 weeks

so RT should start < 6 weeks after surgery

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56
Q

What are situations where an ipsilateral neck can be treated

A
  • All T1-T2N0 or maybe T1N1
  • Well-lateralized TBARS
    • Tonsil with <1cm involvement of BOT or soft palate
    • Buccal
    • Alveolar Ridge
    • RMT
    • Salivary
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57
Q

OPX situations where ipsilateral neck is ok

A

Well-lateralized tonsil

T1N0, T2N0, T1N1 (1 node only)

<1 cm involvement of BOT or soft palate

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58
Q

What would be the benefit of hyperfractionation for patients?

A

Improved LC about 5-6%

But no benefit when chemo added so better to stick to RT alone

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59
Q

What is the advantage of CRT for patients with +ECE or +margin

A

10% improvement in OS, DFS, LRC

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60
Q

What is the improvement in outcomes if CRT used instead of definitive RT

A

5% OS if sequential chemo –> RT

8% OS benefit if concurrent CRT

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61
Q

Simulation for Head and Neck Cancer

A
  • Simulate supine with a 5 point aquaplast mask, neck hyperextended, shoulders down
  • CT with IV contrast, if possible PET simulation or fusion with diagnostic PET and MRI
  • Isocenter at the areytnoids
  • Daily CBCT and KV
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62
Q

Dose levels for definitive CRT or RT alone for stage I-II

A
  • IMRT using 3 dose levels
  • Dose painting
    • 1.8 x 30 to 54 Gy to low risk nodes (2nd eschelon and contralateral 1st echelon)
    • 2 x 30 to 60 Gy to high risk nodal areas
  • Boost of 2 Gy x 5 to total dose of 70 Gy to gross disease
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63
Q

How to contour CTV 70

A

Gross primary disease + 5 mm

Gross nodes + 5 mm

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64
Q

How to contour CTV 60

A

CTV 70 + 0.5 cm

High risk nodes (1st echelon)

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65
Q

What is PTV expansion for HN SCC

A

3 mm

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66
Q

How to contour CTV 54

A

Low risk nodes - 2nd echelon and contralateral 1st echelon if not involved

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67
Q

Dose levels utilized for postop HN cases

A
  • 60 Gy (tumor bed and high risk nodes)
  • 54 Gy (elective nodes)
  • 66 Gy if ECE or +margin
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68
Q

How to contour CTV66 for postop case

A

Areas of positive margin or ECE + 0.5 cm

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69
Q

How to contour CTV 60 for post op case

A

Pre-op GTV + tumor bed + 1 cm

High risk nodal regions

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70
Q

How to contour CTV 54

A

Low risk nodes (2nd echelon and contralateral if indicated)

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71
Q

PTV expansion for postop cases

A

3 mm

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72
Q

If doing RT alone, what is a reasonable hyperfractionation schedule

A

6 fractions per week per DAHANCA or MARCH-HN

BID on Friday

Showed LC benefit, most pts T1-T2N0

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73
Q

Script for contouring intact cases

A

I would contour out my primary and nodal GTVs defined by preoperative physical exam, operative reports and imaging

These will be expanded by 5 mm to make the CTV70 and then by 3mm to make a PTV70

I will then make an additional 5 mm expansion on the CTV 70 to make a high risk CTV60 which is also expanded to include adjacent areas of potential spread. The involved nodal areas would also be included in the CTV60.

The remaining nodal areas I wish to cover will be called CTV54

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74
Q

Plan evaluation coverage goal for HN cases

A
  • 95% of PTV getting 100% of dose
  • 99% of PTV getting 93% of dose
  • Hot spot < 107%
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75
Q

Brainstem max dose

A

54 Gy

Consider 60 Gy for NPX

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76
Q

Cord constraint

A

45 Gy

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77
Q

Mandible constraint

A

70 Gy MPD

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78
Q

Oral cavity constraint

A

Mean uninvolved < 30 Gy if achievable

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79
Q

Brachial plexus constraint

A

66 Gy MPD

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80
Q

Larynx constraint

A

<35-45 if not involved

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81
Q

Submandibular constraint

A

Mean < 39 Gy

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82
Q

Parotid constraint

A

Mean < 26 Gy or ALARA

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83
Q

Esophagus constraint

A

Mean dose < 34 Gy

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84
Q

Lips constraint

A

Mean < 20 Gy (MPD 30-50)

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85
Q

Retina constraint

A

MPD < 45

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86
Q

Cornea constraint

A

MPD < 45

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87
Q

Lens constraint

A

<8 Gy

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88
Q

Temporal lobe constraint

A

MPD < 70 Gy bilateral

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89
Q

Strategies to address is cannot meet DVH constraints

A
  • Resim at 40 Gy and adaptive planning
  • Induction chemotherapy
  • Smaller margins on PTV 70
  • Proton therapy
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90
Q

Follow-up imaging for HN cases

A

PET CT at 3 months post

Then as indicated (not routine)

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91
Q

FU exam scheduling

A

H&P with scople q3-6 months for 5 years then annually

Thyroid eval q6-12 months

Regular follow-up with dental

Speech, Nutrition, Audiology PRN

Carotid evaluation for long term survivors

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92
Q

When do most recurrences occurs

A

90% within first 3 years post treatment

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93
Q

WHO class I nasopharynx cancer

A

Keratinizing

Associated with EtOH and Tobacco

Worse LC and OS

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94
Q

WHO class II NPX cancer

A

Non-keratinizing

Associated with EBV and Asian demographic

A- differentiated

B- undifferentiated

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95
Q

WHO class III NPX cancer

A

Basaloid

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96
Q

Where is most common location for NPX cancer

A

Fossa of Rosenmuller

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97
Q

Where is fossa of Rosenmuller

A

Posterior to Torus Tubarius

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98
Q

Additional workup needed for NPX cancer

A

H&P with attention to Epistaxis, CN palsy, trismus, otalgia

Labs; EBV DNA level

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99
Q

What is trismus suggestive of for NPX cancer

A

invasion of masticator space

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100
Q

T1 nasopharynx

A

Confined to nasopharynx and/or adjacent orophaynx/nasal cavity

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101
Q

T2 nasopharynx

A

Parapharyngeal extension

Pterygoid muscles

Prevertebral muscles

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102
Q

T3 nasopharynx

A

Bony skull involvement, spine, pterygoid or bony sinus

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103
Q

T4 nasopharynx

A

Intracranial extension, CN palsy, hypopharynx, parotid, orbit or soft tissue beyond lateral pterygoid muscle

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104
Q

N1 nasopharynx

A

Unilateral Ib to III or Va Nodes

OR

Unilateral or Bilateral RP

All < 6 cm

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105
Q

N2 NPX

A

Bilateral Ib to III or Va < 6 cm

NOTE** BILATERAL RP is still N1

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106
Q

N3 NPX

A

Any level IV or V (below cricoid cartilage)

Any node > 6 cm

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107
Q

Treatment of T1 NPX

A

If T1N0 - RT alone

If N1+ then CRT

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108
Q

Treatment of T2+ NPX

A

Definitive CRT

Concurrent chemoRT with bolus cisplatin 100 mg/m2 q3 weeks x 3 infusions

Followed by adjuvant cis-5-FU for 3 cycles

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109
Q

Dose of adjuvant cis-5FU for NPX

A

cis 80 mg/m2 on D1

5FU 1000 mg/m2 (D-4)

q4 weeks for 3 cycles

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110
Q

What is the dose levels for NPX

A
  1. 12 x 33 = 69.96 to gross disease
  2. 8 x 33 = 59.40 to high risk CTV
  3. 64 x 33 = 54 to elective CTV
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111
Q

What is CTV 69.96 for NPX

A

Primary and involved nodes + 5mm

Ok to reduce margin to 1mm at critical structures like brainstem

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112
Q

What is CTV 59.40 for NPX

A
  • Entire nasopharynx
  • Superior: inferior half of sphenoid sinus, posterior and inferior ethmoid sinus, bilateral foramen ovale, rotundum and lacerum
  • Anterior: posterior 1/4 of nasal cavity and max sinus, bilateral PPF
  • Lateral: parapharyngeal space, pterygoid fossa
  • Posterior: anterior 1/3 of clivus (or whole if involved)
  • Nodes
    • RP
    • Level II, III, Va
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113
Q

What is CTV 54 for NPX

A

Level IV nodes

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114
Q

How do contours change if T3/T4 NPX

A

Treat entire sphenoid sinus

Ipsilateral cavernous sinus

Full clivus if T3 due to bone involvement

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115
Q

What is OS for locally advanced NPX

A

60-80%

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116
Q

Acute toxicities of NPX treatment

A

Mucositis

Dermatitis

Xerostomia

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117
Q

Late toxicities of NPX treatment

A

Cranial neuropathies

Trismus

Soft tissue fibrosis

Xerostomia

Hearing Loss

ORN

TLN

Hypothyroidism

Vasculopathy

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118
Q

Special follow-up considerations for NPX

A

MRI at 12 weeks plus PET

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119
Q

What are the oral cavity subsites?

A
  • Lip
  • Gingiva or alveolar ridge
  • Buccal mucosa
  • Retromolar trigone
  • Hard palate
  • Oral tongue (anterior 2/3)
  • Floor of mouth
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120
Q

What does lower lip numbness suggest

A

Inferior alveolar nerve involvement

Part of V3 (mandibular branch of trigeminal nerve)

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121
Q

History for OC cancers

A

Non-healing ulcers

Oral pain

Bleeding

Loose teeth

Ill fitting dentures

Halitosis

Neck masses

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122
Q

How often is IV involved for oral tongue

A

15% there are skip mets to level IV for oral tongue which are not addressed in typical selective neck dissection level I-III

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123
Q

T1 OC

A

<2 cm

DOI = 5mm

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124
Q

T2 OC

A

2.1-4 cm AND/OR

DOI 5-10 mm

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125
Q

T3 OC

A

>4 cm OR

DOI > 1 cm

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126
Q

T4a lip

A

Through bone, inferior alveolar nerve involvement, FOM, facial skin

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127
Q

T4a oral cavity

A

Through bone, maxillary sinus, facial skin OR DOI > 2 cm

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128
Q

T4b oral cavity

A

Masticator space

Pterygoid plates

Skull base

Carotid encasement

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129
Q

cN1 oral cavity

A

single ipsi node <3 cm

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130
Q

cN2a oral cavity

A

single ipsilateral node between 3-6 cm

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131
Q

cN2b oral cavity

A

multiple ipsi nodes <6 cm

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132
Q

cN2c oral cavity

A

bilateral or contralateral nodes < 6 cm

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133
Q

cN3a oral cavity

A

any nodes > 6 cm

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134
Q

cN3b oral cavity

A

clinically apparent ECE

135
Q

How does path staging change for oral cavity vs. clinical staging?

A

pN2a includes single ipsi node 3-6 cm

BUT ALSO INCLUDES

single ipsi node <3 cm with pathological ECE

136
Q

How to classify ECE using path staging for oral cavity?

A

If single IPSI node < 3 cm with path ECE –> pN2a

If other ECE –> pN3b

137
Q

What is stage III oral cavity

A

T3 or N1

138
Q

stage IVA oral cavity

A

T4a or N2

139
Q

stage IVB oral cavity

A

T4b or N3

140
Q

What is preferred management for oral cavity cancers?

A
  • Surgery is preferred
  • Do a neck dissection for
    • cN+
    • DOI > 2 mm and definitely if >4 mm
141
Q

Indications for postop RT for oral cavity cancers

A
  • pT3/T4 (consider for T2 tongue with DOI > 5 mm)
  • Close margin (<5 mm)
  • LVSI
  • PNI
  • 2+ nodes
  • Level IV or V nodes
  • Consider if DOI > 4 mm
142
Q

What is Quad Shot Dose

A

370 x 4 = 1480

143
Q

What is the DOI suggestive of needing post op RT

A

4 mm

144
Q

Indications for postop CRT for oral cavity

A

+ECE

+margin

145
Q

Are there situations where RT is preferred for oral cavity?

A

Lip commissure tumors

146
Q

If an OC tumor is unresectable, how to approach

A

stage I - T1N0 –> RT alone

stage II - T2N0 –> RT alone

stage III+ –> CRT

147
Q

Surgery for oral tongue cancer

A
  • If small and lateralized –> partial glossectomy
  • If T2 and lateralized –> hemiglossectomy
  • If midline –> total glossectomy
148
Q

Special considerations for lip primary for coverage

A

if commisure involved –> cover Ib and II to 54 Gy

If upper lip, consider covering facial nodes

Do a lead shield for the mouth

149
Q

Is cetuximab ok for oral cavity cancers?

A

Not included on Bonner trial so no

150
Q

Sim considerations for oral cavity

A

IMRT

5 pt mask, arms down

IV contrast

Neck hyperextended, shoulders down

BITE BLOCK

151
Q

What is the purpose of a bite block

A

To minimize dose to hard palate and immobilize tongue

152
Q

CTV 66 for oral cavity

A

Areas of positive margin or ECE

3-5 mm expansion

Keep as small as possible per RTOG

153
Q

CTV 60 for oral cavity

A
  • Surgical bed
    • Consider entire oral tongue/FOM
    • Cover all clips and entire myocutaneous flap
  • 1st echelon nodes
    • Level IB, II, III bilaterally, top of IV
    • If well lateralized buccal, gingival, RMT,
    • Cover IA for FOM, oral tongue, inferior alveolar ridge, lip
    • DO NOT NEED RP
154
Q

What is CTV 54 for postop oral cavity?

A

Lower risk nodal levels - level IV, elective contralateral neck

Full oral tongue or FOM if involved

155
Q

Optimal time between surgery and PORT for OC cancer

A

<6 weeks

156
Q

How do surgery and RT compare for LC for oral cavity

A

For T1-T2, similar (75-80%)

For advanced, much worse with RT alone

157
Q

OS for stage III OC

A

75%

158
Q

OS for stage IV OC

A

55%

159
Q

Specific considerations for sim for lip tumor

A

Need lead shielding and in mouth

160
Q

What is the location of the hypopharynx

A

Pharynx from hyoid to cricoid cartilage

161
Q

What are the subsites of the hypopharynx cancer

A
  • 3Ps
    • Posterior pharyngeal wall
    • Postcricoid area
    • Piriform sinuses
162
Q

Location of pirform sinus

A
163
Q

What is typical clinical history for hypopharynx ca

A

Globus sensation

164
Q

T1 hypopharynx

A

<2 cm, one subsite

165
Q

T2 hypopharynx

A

2-4 cm or

adjacent subsite or larynx

166
Q

T3 hypopharynx

A

>4 cm or

Hemilarynx fixation OR

esophageal involvement

167
Q

T4a hypopharynx

A

Thyroid/cricoid cartilage

Hyoid bone

Thyroid gland

Central soft tissue (strap muscles or subQ fat)

168
Q

T4b hypopharynx

A

Prevertebral fascia

Carotid artery

Mediastinum

169
Q

Nodal staging for hypopharynx

A

cN1 – single ipsi node ≤ 3 cm

cN2a – single I/L node > 3 cm, ≤ 6 cm

cN2b – multiple ipsi nodes ≤ 6 cm

cN2c – bilat or contralat nodes ≤ 6 cm

cN3a – > 6cm

cN3b – clinically overt ECE

170
Q

Treatment for T1 hypopharynx

A
  • Two options
    • Partial pharyngectomy (larynx preserving) with LND including pretracheal and IPSI paratracheal dissection
    • Definitive RT to 70 Gy
171
Q

Options for T2N0 hypopharynx

A
  • Two options
    • Partial pharyngectomy (larynx preserving) with LND including pretracheal and IPSI paratracheal dissection
    • Definitive RT to 70 Gy
172
Q

Options for T3/T4 or N+ hypopharynx which is resectable

A
  • Options include
    • Definitive CRT
    • TL with LND (preferred for T4a or non-functional larynx with high aspiration risk) –> RT or CRT as indicated by path findings
173
Q

Options for T3 or T4 or N+ hypopharynx which is unresectable

A

Definitive CRT

174
Q

Doses for hypopharynx

A
  • Depends on definitive CRT or postop
    • Definitive
      • CTV70
      • CTV60
      • CTV54
    • Postop
      • CTV66 (+margin or ECE)
      • CTV60
      • CTV54
175
Q

CTV70 for hypopharynx ca

A

GTV using scope, PET, MRI, CT expand by 5 mm

176
Q

First eschelon nodes for hypoharynx

A
  • Bilateral RP nodes
  • Level II, III, IV
  • Consider level VI if thyroid cartilage, cricoid cartilage or subglottis is involved
177
Q

CTV 60 primary for hypopharynx

A
  • T2+: should includ part of thyroid cartilage, part of cricoid cartilage, part of hyoid and maybe esophagus
  • T3-4 should include at least hemi-larynx
178
Q

Which subsite has worst prognosis in HN

A

hypopharynx

179
Q

Rates of larynx preservation with hypopharynx

A

60-80%

180
Q

OS at 5 years for hypopharynx

A

40-50%

181
Q

What is the rate of pharyngocutaneous fistula after salvage laryngectomy

A

30%

182
Q

OPX sites

A

Soft palate

Tonsil

BOT

Posterior pharyngeal wall

Glossotonsilar sulcus

Uvula

Vallecula - space anterior to epiglottis

183
Q

Borders of the OPX

A

Superior = soft palatte

Inferior = hyoid

Anterior = oral tongue

Posterior - pharyngeal wall

184
Q

What does trismus suggest for OPX cancer

A

pterygoid involvement

185
Q

What does hot potato voice suggest

A

BOT involvement

186
Q

What are the options for HPV testing

A

p16 IHC

HPV DNA FISH

187
Q

How is OPX staging different than other sites

A

Divided into HPV+ and HPV-

188
Q

HPV negative T1

A

<2 cm

189
Q

HPV negative T2

A

2.1 - 4 cm

190
Q

HPV negative T3 OPX

A

> 4cm OR

lingual epigottic extension

191
Q

HPV negative T4a OPX

A

Larynx

Medial Pterygoid

Mandible

Extrinsic tongue muscles

Hard palate

192
Q

HPV negative T4b OPX

A

lateral nasopharynx

lateral pterygoid muscles

Pterygoid plates

Skull base

Carotid encasement

193
Q

N System for HPV negative OPX

A

same as oral cavity

194
Q

How is T staging different for HPV+

A

T4a and T4b is collapsed into T4

195
Q

What are the nuances of nodal staging for HPV+

A

Different clinical and path staging

196
Q

cN1 HPV+

A

one or more ipsi LN <6 cm

197
Q

cN2 HPV+ OPX

A

bilateral or contralateral nodes < 6 cm

198
Q

cN3 HPV+ OPX

A

nodes > 6 cm

199
Q

What is path nodal staging for HPV+ OPX

A

pN1 = <5 nodes

pN2 = 5 or greater LN

200
Q

Clin stage I OPX

A

T0-2

N0-1

201
Q

Clin stage II OPX

A

T3 or N2

202
Q

Clinical stage III OPX

A

T4 and/or N3

203
Q

Treatment of T1-2N0

A
  1. Surgery (TORS) with adjuvant chemo/RT as indicated
  2. Definitive RT alone
204
Q

Any nodal patients candidate for TORS?

A

One Small node (<3 cm)

**Can also do RT alone for these patients

205
Q

Which tonsils can you consider treating ipsi neck

A

T1N1

T2N1

206
Q

Who is not eligible for TORS?

A

T3/T4

More than minimal soft tissue palate extension

Central BOT involvement

Trismus or other difficulties with exposure

Radiographic or clinical ECE

207
Q

Treatment for T3/T4 OPX cancers or OPX cancers with > 1 node

A

Definitive CRT to 70 Gy in 35 fx with concurrent cisplatin

208
Q

CTV70 for OPX

A

GTV + 5 mm edited off skin, bone, air

209
Q

GTV 60 for OPX

A

GTV + 10 mm and expanded to include areas of potential spread

210
Q

1st eschelon nodes for OPX

A

Levels II-IV, I/L or Bilateral RP

If N+ neck, cover ipsi nodes to BOS and low level IV

211
Q

CTV 54 for opx

A

Likely contralateral neck

212
Q

Conditions for T2N1 to have ipsilateral neck RT

A

T1-T2 N0-1 tonsil

At most minimal superficial BOT involvement

At most 1 cm soft palate extension

No posterior wall involvement

At most 1 ipsi level II node, < 3 cm, no ECE

213
Q

What is long term PEG dependency with CRT

A

15-20% with CRT

5% with IMRT

214
Q

What are the major salivary glands?

A

Parotid

Submandibular

Sublingual

215
Q

Most common location for minor salivary gland tumors

A

hard palate

216
Q

What is most common location for minor salivary gland tumors

A

Hard palate

217
Q

Epidemiology of salivary gland tumors

A

75% are parotid and of them 75% are benign

75% of minor salivary gland tumors are malignant

218
Q

Most common presentation of salivary gland tumor

A

Painless mass

CN VII (Bell) Palsy

Trismus is possible but suggestive of parapharyngeal involvement

219
Q

What imaging workup needed for salivary gland tumor

A

CT neck

MRI neck which does help to clarify PNI and possibly grade

CT chest

220
Q

DDx of salivary gland tumor

A

Rule out skin cancer with parotid nodes

Cysts

Sarcoid

Lymphoma

Sjogren’s

Sialadenitis

Bell palsy

221
Q

T1 salivary

A

<2 cm

222
Q

T2 salivary

A

2.1-4 cm

223
Q

T3 salivary

A

>4 cm or extraparenchymal extension

224
Q

T4a salivary gland

A

FEMS

  • Facial nerve
  • Ear canal involvement
  • Mandible
  • Skin
225
Q

T4b salivary

A

skull base, pterygoid plates, carotid encasement

226
Q

What are low grade salivary histologies?

A
  • acinic
  • mucoepidermoid
227
Q

What are the high grade salivary histologies?

A
  • Adenoid cystic
  • Adeno
  • Squamous
228
Q

What is the management of salivary gland tumors?

A
  • Start with surgery (parotidectomy)
    • Total if deep lobe is involved
  • Ipsilateral level II-V dissection if high grade or cN+
  • Consider RT for most, unless small and low grade
229
Q

What should be asked about on the parotid path specimen?

A

Grade

PNI

Margins

230
Q

What are the indications for post op RT to primary alone for salivary?

A

Close or positive margins (especially deep lobe)

PNI/LVSI

Capsule rupture or spillage

Recurrence

231
Q

Indications for postop RT to primary and neck for salivary

A

N+

High grade

T3-T4

232
Q

What neck levels are involved for parotid?

A

If elective: IB-III

If involved: IB-V

233
Q

What is one of the objectives of surgery for parotid?

A

avoid damaging facial nerve

otherwise need nerve graft or plastic surgery

234
Q

How to manage the neck surgically for parotid tumor

A

Only need ipsi neck dissection

Treat the contralateral neck if there is multilevel nodal involvement and >50% of removed nodes +

235
Q

Sim for salivary gland tumor

A

Supine

Hyperextended neck

IV contrast

5 pt mask

Iso behind cricoid cartilage

Fuse MRI for skull base or CN involvement

236
Q

What is the contours for salivary gland tumor

A

CTV Post-op = tumor bed

PTV = CTV + 2 cm

CTV intact = tumor + normal parotid gland

Neck = Ib to IV, V if involved

237
Q

Doses for salivary gland tumors

A

Intact or R2 - 70 Gy in 35 fx

R1 or ECE - 66 Gy in 33 fx

R0 - 60 Gy in 30 fx

Elective neck - 54 Gy in 30 fx

238
Q

How to address PNI in volumes for salivary gland

A

Cover 7th nerve back through stylomastoid foramen back to 2nd genu unless gross disease in BOS

239
Q

At what dose is loss of salivary function permanent

A

35 Gy

240
Q

Goal parotid dose

A

Mean < 26 but ALARA

241
Q

Supraomohyoid dissection

A

removes I-III

242
Q

Is chemo used for salivary gland?

A

Controversial, at this point no

243
Q

Most common benign histology of parotid gland

A

pleomorphic adenoma.

244
Q

Most common malignant histology of parotid gland

A

mucoepidermoid

245
Q

Most common malignant histology of submandibular and minor salivary glands

A

ACC

246
Q

What are the subsites for larynx

A
  • Supraglottic larynx
  • Glottic larynx
  • Subglottic larynx
247
Q

If the disease is glottic larynx what subsites?

A

True cords, anterior or posterior commissures

248
Q

What are the potential subsites of supraglottic larynx?

A
  • Suprahyoid epiglottis
  • Infrahyoid epiglottis
  • Aryepiglottic folds
  • Aryenoids
  • False vocal cords
249
Q

Physical exam for larynx cancer

A

History of hoarseness

Swallowing issues

Flexible nasopharyngoscopy to identify disease laterality, involvement of commisures, extension to adjacent sites, VC mobility

250
Q

What imaging should be obtained for suspected larynx ca

A

CT larynx with thin slices through larynx

MR neck

PET

251
Q

What other referrals should be made for patients with suspected larynx ca

A

speech swallow

nutrition

dental

smoking cessation

252
Q

T1 larynx

A

Confined to one subsite with normal cord mobility

253
Q

T2 larynx - general

A

involvement of adjacent site or impaired VC mobility

254
Q

T3 larynx - general

A
  • Fixed VC
  • Invasion into
    • the paraglottic space
    • inner cortex of the thyroid cartilage
    • pre-epiglottic space
    • post cricoid
255
Q

T4a larynx - general

A
  • Invasion into
    • outer thyroid cartilage
    • outside larynx
    • trachea (inferior to cricoid)
    • soft tissue of the neck
    • extrinsic tongue muscles
    • strap muscles
    • thyroid
    • esophagus
256
Q

T4b larynx - general

A

prevertebral fascia

encasement of ICA

mediastinum

257
Q

Special T stage considerations for glottic larynx

A

Remember only true cords

T1a = one cord

T1b = both cords

258
Q

What are treatment options for Tis glottic larynx?

A
  • Laser therapy to strip mucosa
  • RT alone (60.75 Gy - 2.25 x 27)
259
Q

Management options for T1 or T2 larynx glottic

A
  • Definitive RT alone
  • Surgery alone with risk adapted adjuvant therapy
260
Q

What is the definitive RT dose for T1 larynx

A

2.25 x 28 = 63

No chemo

261
Q

What is the definitive RT dose for T2 larynx

A

2.25 x 29 = 65.25

262
Q

What are the surgical options for T1 or T2 larynx

A
  • Cordectomy
  • Vertical hemilaryngectomy - takes ipsi cord and 1/3 of contra cord and 1/2 of cricoid cartilage
    • leaves the cricoid and hyoid intact
263
Q

What patients are suitable for cordectomy

A

T1

264
Q

What is a contraindication to cordectomy

A

anterior commissure involvement

265
Q

What patients are suitable for vertical hemilaryngectomy

A

T1 and some T2

266
Q

What are contraindications to hemilaryngectomy

A

T3 or T4, select T2 with bilateral arytenoid or epiglottic or subglottic involvement

267
Q

How does OS differ between surgery and RT for early stage larynx

A

same

268
Q

After surgery or RT for early stage larynx, what is better/worse

A

Swallowing better with surgery

Voice better with RT

269
Q

When should nodes be treated with early stage glottic larynx?

A

If it is a T2 with extension into subglottis or supraglottic region

270
Q

Treatment options for locally advanced glottic larynx (T3+ N+)

A
  • Definitive CRT
  • Total laryngectomy with bilateral LND –> RT or CRT pending path findings
  • Induction chemo –> RT or surgery (less preferred)
271
Q

What is removed with a total laryngectomy

A

Hyoid

Thyroid

Cricoid cartilage

Epiglottis

Strap muscles

Pt is left with a permanent trach and pharynx reconstruction (by suturing to BOT)

272
Q

Most common location for failure after total laryngectomy

A

stoma

BOT

Neck nodes

273
Q

When is total laryngectomy preferred

A

T4a disease

274
Q

Supraglottic larynx T1 stage

A

One subsite, normal VC movement

275
Q

T2 supraglottic larynx stage

A

More than one subsite

Involvement of immediate surrounding areas (BOT or piriform sinus)

Impaired VC movement

276
Q

T3 supraglottic larynx stage

A
  • PPP-TF
    • Post cricoid space
    • Pre-epiglottic space
    • Paraglottic
    • Inner cortex of thyroid cartilage
    • VC fixation
277
Q

How does nodal involvement compare between supraglottic and glottic larynx

A

Much higher with supraglottic

278
Q

Treatment options for T1 or T2N0 supraglottic

A
  • Definitive RT
  • Supraglottic laryngectomy + BLND –> RT or CRT as guided by path findings
279
Q

Dose of definitive RT for supraglottic larynx

A

GTV to 70 Gy

CTV including full larynx to 60 Gy

Bilateral levels II-IV to 54 Gy

280
Q

What is a definitive RT dosing option for supraglottic larynx?

A

Consider DAHANCA of 6 fractions per week

281
Q

What is removed in supraglottic laryngectomy?

A

Epiglottis, AE fold, false cords, hyoid if preglottic extension, upper 1/2 of thyroid cartilage

Preserves one or both arytenoids and both TVCs

282
Q

What are contraindications to supraglottic laryngectomy

A

T2 with true glottic involvement, anterior commisure involvement, fixed cord, inadequate PFTs or bilateral arytenoid involvement

283
Q

Treatment options for T3, T4 or N+ supraglottic larynx

A
  • CRT if functional larynx with low risk of aspiration
  • TL + BLND –> RT or CRT pending features (preferred if T4a)
284
Q

Subglottic T1 stage

A

Confined to subglottis

285
Q

Subglottic T2 stage

A

Extension to TVC (normal or impaired mobility)

286
Q

T3 subglottic stage

A

limited to larynx with fixed VC

287
Q

Management of T1 or T2 subglottic larynx

A

Definitive RT with treatment of the bilateral nodes

288
Q

Treatment options for T3, T4 or N+ subglottic larynx

A

Definitive CRT if functional larynx and low risk of aspiration

TL + BLND –> RT or CRT (preferred if T4a)

289
Q

RT approach for T1N0 larynx

A
  • CT simulation
  • Contour the entire larynx setting iso at TVC
  • Superior border is top of thyroid cartilage
  • Inferior border is bottom of cricoid
  • Treats roughly from C4 to C6
  • Anterior is 1 cm flash on skin
  • Posterior is anterior edge of vertebral body
  • DOSE IS 2.25 x 28 = 63
290
Q

RT approach for T2N0 larynx

A
  • Contour the full larynx and GTV
  • Set iso at TVC
  • Superior edge is inferior edge of hyoid
  • Inferior edge is first tracheal ring below cricoid
  • Anterior: 1 cm flash
  • Posterior: anterior edge of vertebral body
291
Q

How to treat T1 or T2 larynx RT approach

A

Opp lats with 15 or 30 degree wedges (heel anterior)

292
Q

How do fields change if anterior commissure involvement?

A

underwedge or give bolus to front of larynx

293
Q

How do fields change if posterior commissure involvement?

A

1 cm into the vertebral body

294
Q

Nodal coverage for T1-T2 larynx

A

None, unless supraglottic or subglottic extension and then consider covering II-III to 54 Gy

295
Q

Coverage target for T1-T2N0 larynx

A

Hot spot < 103%

296
Q

Where is iso placed for early stage larynx

A

anterior to vertebral bodies midway between superior and inferior edge for posterior half beam block

297
Q

Rough size of field for T1 larynx

A

5x5

COLLIMATE

298
Q

Rough size of a T2 larynx field

A

6x6

COLLIMATE

299
Q

What should be included in CTV60 for T3/T4 or N+ larynx

A
  • Full larynx should be in CTV60
  • Bilateral II-IV and VI if thyroid cartilage, post-cricoid cartilage or subglottis involved
  • No Level V
300
Q

What should happen to trach during RT

A

Should stay in place

301
Q

How to approach contouring postop larynx

A

Discuss area at risk with surgeon

CTV60 is tumor bed and pre-op disease with 2 cm margin

Boost stoma is needed

CTV54 includes uninvolved nodal levels

302
Q

Reasons to boost stoma for larynx

A
  • T4 post-op
  • Emergent tracheostomy
  • Subglottic extension
  • Tumor invasion into soft tissue of neck
  • Close/tracheal margin
303
Q

Dose for tracheostomy boost

A

66 Gy in 33 fx

304
Q

Nodal levels for supraglottic larynx

A

II-IV bilaterally

  • RP if hypopharynx involvement
  • Ipsi level IB if II involved
  • Consider VI
  • ENSURE FULL LARYNX IN CTV60
305
Q

Nodal levels for subglottic larynx

A

RP, II-IV, V, VI

306
Q

5y OS for stage I larynx

A

80%

LC is 90%

307
Q

5y OS for stage III larynx

A

50%

308
Q

year OS for stage IV larynx

A

35%

309
Q

Larynx preservation with RT alone for stage III/IV disease with RT alone

A

60-70%

310
Q

Larynx preservation with CRT for stage III/IV disease

A

80*85%

311
Q

Rate of laryngeal edema with RT

A

<5%

312
Q

Rate of cartilage necrosis from definitive RT

A

5%

313
Q

Most common thyroid ca

A

Papillary

314
Q

Which subtypes take up RAI

A

Papillary and Follicular

Hurthle cell

315
Q

Which subtypes do not take up RAI

A

medullary

anaplastic

316
Q

What is a special feature of workup for thyroid cancer

A

no constrast with CT because thyroid will take up the iodine and then RAI won’t work

317
Q

What is the first approach for path for thyroid cancer

A

FNA

318
Q

If FNA shows anaplastic what other staging needs to happen

A

PET CT

319
Q

What is the preferred management of thyroid cancer

A

Thyroidectomy and central neck dissection

Levels VI and sample II through IV

320
Q

Role of postop RT for thyroid

A
  • Unresectable residual disease
  • Multiple recurrences
  • Non RAI avid residual
  • Biocheical evidence of recurrent medullary thyroid (detectable calcitonin or CEA)
  • All fully resected, non-metastatic anaplastic histologies
321
Q

What is the surgical strategy for anaplastic thyroid

A

Only do surgery if GTR possible

Otherwise definitive RT with comprehensive nodal RT down to carina

Concurrent chemo (doxorubicin)

322
Q

Nodal areas to treat for thyroid cancer

A

II through VI

323
Q

H&P for unknown primary

A

Smoking history

Skin exam

Check thyroglobulin, calcitonin, EBV, HPV

324
Q

Imaging for unknown primary

A

CT/MRI BOS and neck

PET CT

CT chest

325
Q

Path approach for unknown primary

A

EUA with pan endoscopy with biopsies of

  • NPX
  • Tonsils
  • BOT
  • Pyriform sinus
  • FNA any neck nodes
  • If not revealing –> bilateral tonsillectomy
326
Q

How often is a primary located for unknown primary

A

75%+

327
Q

How to approach N1 with unknown primary

A

Ipsilateral modified radical neck dissection

If just one node <3 cm with no ECE –> observe

If >1 node –> PORT

If ECE –> CRT

328
Q

Approach to unknown primary N2 or N3

A

Consider CRT

RT to NPX, OPX, bilateral neck

Or Bilateral neck dissection –> CRT or RT

329
Q

What is CTV60 for unknowne primary

A

NPX

OPX

Larynx

HPX

Ipsi neck (RP, IB-V)

330
Q

How does viral status guide what should be covered for unknown primary

A

If EBV+ –> cover NPX and neck

If p16+ –> OPX and neck

If p16-: OPX, NPX, +/- hypopharynx and larynx

If level I or II node involved –> exclude larynx and hypopharynx

331
Q

What would be CTV54 for unknown primary

A

contralateral neck (II-IV, RP)

332
Q

treatment options for T2+ nasopharynx

A

T2 or greater:

Concurrent cis-RT, adj Cis-5FU x 3 cycles

  • concurrent q3week Cis 100 mg/m2
  • adj Cis 80mg/m2 (D1) + CI 5FU 1000mg/m2 (D1-4) q4 wk x 3 cycles
333
Q

Another treatment option for WHO type II NPX

A

Consider 3 cycles of induction gem-cis followed by cisRT to 70 Gy

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