Head and Neck

Question 1

HPV positive with multiple ipsilateral lymph nodes measuring up to 6 cm in neck level 2 and 4, what is the N staging?

Answer 1

N1

Question 2

HPV positive with multiple ipsilateral lymph nodes measuring up to 6.1 cm in neck level 2 and 4, what is the N staging?

Answer 2

N3

Question 3

HPV negative with multiple ipsilateral lymph nodes measuring up to 6 cm in neck level 2 and 4, what is the N staging?

Answer 3

N2b

Question 4

Discuss the study for Intergroup 0099 (Al-Sarraf et al. JCO 1998) study.

Answer 4

Phase III randomized study of 147 stage III-IV nasopharyngeal cancer pts randomized to definitive RT vs concurrent cisplatin/RT + adjuvant cisplatin.

The total dose was 70 Gy in 1.8 - 2 Gy/fx, 66 Gy for involved nodes, and 50 Gy for elective nodes.

Only 63% of patients received all 3 cycles of concurrent cisplatin and 55% received all 3 cycles of adjuvant cisplatin/5-FU.

3-year PFS was 24% vs 69% (P < 0.001) and OS of 46% vs 78% (P=0.005) in favor of chemoRT

Question 5

Based on the AJCC 8th edition what is the difference between T3 and T4 for nasopharyngeal cancer staging?

Answer 5

T3: Infiltrates bony structures of skull base, cervical vertebra, pterygoid structures, and/or paranasal sinuses

T4: Intracranial extension; involvement of cranial nerves, hypopharynx, orbit, and parotid gland and/or soft tissue involvement beyond the lateral surface of lateral pterygoid

Question 6

Risk of occult nodal disease for pts with early stage T1-T2 squamous cell carcinoma of the hypopharynx?

Answer 6

60%

Question 7

Hurthle cell carcinoma if a variant of which of the following types of thyroid carcinomas?

Answer 7

Follicular (when more than 75% of cells in follicular thyroid carcinoma exhibit Hurthle cell features, the tumor is classified as Hurthle cell carcinoma)

Question 8

Pt presents with multiple previously excised squamous cell skin cancers of the face and progressive numbness along the right medial cheek. Perineural spread to which structure explains the findings?

Answer 8

This pt has isolated infraorbital nerve dysfunction.

The infraorbital nerve is a branch of the maxillary nerve, itself a branch of the trigeminal nerve (CN V).

Question 9

What is Vidian nerve?

Answer 9

the Vidian nerve carries preganglionic, sensory and taste fibers from the greater petrosal, and postganglionic sympathetic fibers from the internal carotid plexus via the deep petrosal nerve. The Vidian nerve continues anteriorly within the pterygoid canal to the pterygopalatine fossa

Question 10

What is supraorbital nerve?

Answer 10

The supratrochlear nerve is a branch of the frontal nerve, itself a branch of the ophthalmic nerve (CN V1) from the trigeminal nerve (CN V)

The supraorbital nerve provides sensory innervation to the skin of the lateral forehead and upper eyelid, as well as the conjunctiva of the upper eyelid and mucosa of the frontal sinus.

Question 11

Gasserian ganglion what is that?

Answer 11

It’s another name for trigeminal gangilon.

The three major branches of the trigeminal nerve—the ophthalmic nerve (V1), the maxillary nerve (V2) and the mandibular nerve (V3)—converge on the trigeminal ganglion (also called the semilunar ganglion or gasserian ganglion), located within Meckel’s cave and containing the cell bodies of incoming sensory-nerve fibers. The trigeminal ganglion is analogous to the dorsal root ganglia of the spinal cord, which contain the cell bodies of incoming sensory fibers from the rest of the body.

Question 12

In nasopharyngeal cancer, bilateral cervical lymphadenopathy is automatically put you on which nodal stage?

Answer 12

N2

Question 13

Per AJCC 8th edition, what is the difference between T1 and T2 in nasopharyngeal cancer?

Answer 13

T1: Confined to nasopharynx or extends to oropharynx and/or nasal cavity without parapharyngeal involvement

T2: Extends to parapharyngeal space and/or adjacent soft tissue (eg, medial/lateral pterygoid, prevertebral muscle)

Question 14

What two tumor markers are found in neuroendocrine tumors such as esthesioneuroblastoma?

Answer 14

Synaptophysin and chromogranin

Question 15

Explain the RTOG 00-22 trial design

Answer 15

RTOG 0022 was a phase II trial that treated early stage oropharyngeal cancers with 66 Gy in 30 fractions.

RTOG 0022, Eisbruch (JROBP 2010, PMID 19540060): Initial RTOG multi-institutional trial demonstrating safety and efficacy of IMRT.

Prospective phase II trial of 69 T1–2 N0–1 OPC treated with RT
alone to 66 Gy/30 fx with IMRT; 2-year LRF was 9%. LRF was increased in those with major deviations: 2/4 patients with deviations (50%) vs. 3/49 without (6%, p = .04).

Conclusion: IMRT is feasible with encouraging acute and late toxicity. Quality of IMRT is important to avoid LRF.

Question 16

Explain the DAHANCA 6 study.

Answer 16

DAHANCA 6 compared 6 vs. 5 fractions per week for laryngeal cancer.

Overgaard, DAHANCA 6 and 7 Combined Analysis (Lancet 2003, PMID 14511925): Combined analysis of two trials performed from 1992 to 1999 including 1,485 patients with stage I to stage IV SCC; DAHANCA 6 of glottis carcinoma testing fractionation and DAHANCA 7 of supraglottic, pharynx, and oral cavity cancers testing fractionation and radiosensitizer nimorazole. RT given to 62 to 68Gy at 2 Gy/fx and randomized to either 5 or 6 fractions per week.

Overall 5-year LRC was improved with acceleration (70% vs. 60%, p = .0005).

Disease-specific survival but not OS was also improved
by acceleration. Conclusion: Six fractions weekly became standard in Denmark. This result was independent of p16 status

Question 17

Describe intergroup 0099 study

Answer 17

Intergroup 0099 study established chemoradiation as standard of care for advanced nasopharyngeal cancer.

Al-Sarraf, Intergroup 0099 (JCO 1998, PMID 9552031): PRT of 193 patients with biopsy proven stage III to IV (M0) NPC. Note that AJCC 4th edition included N1 patients in stage III (now stage II).

Randomized to RT alone vs. RT with concurrent cisplatin and adjuvant CHT with cisplatin and 5-FU (see Chemotherapy section). Study was closed early after interim analysis of 147 patients demonstrated OS benefit in experimental arm (see Table 13.4). Sixty-three percent completed all concurrent
CHT, 55% completed all cycles of adjuvant.

Conclusion: Concurrent and adjuvant CHT with RT improves OS for stage III to stage IV (and N1, 7/8th edition stage II) nasopharyngeal cancer.

Question 18

Describe EORTC 22791 study.

Answer 18

EORTC 22791 compared hyperfractionation (1.15 Gy BID) to conventional fractions (2 Gy daily).

Horiot, EORTC 22791 (Radiother Oncol 1992, PMID 1480768): PRT of 356 patients randomized to 70 Gy/35 to 40 fx or hyperfractionation of 80.5 Gy/70 fx. T2–3 oropharynx (excluding BOT) cancers, N0–1 were included from 1980 to 1987.

Hyperfractionation demonstrated LRC benefit and trend
toward OS in T3N0–1 patients but not T2.

Question 19

Describe RTOG 9501 study.

Answer 19

This was a study that showed ECE and + margins are the indications for chemotherapy and Postop-RT.

Cooper, RTOG 9501 (NEJM 2004, PMID 15128893, Update Cooper IJROBP 2012, PMID 2274963):

PRT of 416 patients (update 410 patients) w/ HNSCC (oral cavity, oropharynx, hypopharynx, or larynx) s/p macroscopic complete resection w/ high-risk features (any or all of: histologic invasion of ≥2 LNs, ECE or +margins) comparing RT alone (60–66 Gy/30–33 fx) vs. chemoRT (cisplatin 100
mg/m2 on days 1, 22, 43). Overall, 18% had positive margins, 82% had ≥2 LNs or ECE. MFU 6.1 yrs, update 9.4 yrs for survivors. See Table 17.5. Incidence of acute adverse effects ≥ grade 3 was 34% and 77% in RT and chemoRT arms, respectively (p < .001). In the first report, CHT improved LRF and DFS but not OS. With long-term follow-up CHT improved LRF in patients with ECE or +margins.

Conclusion: ECE and +margins remain indications for concurrent CHT and PORT

Question 20

Per AJCC 8th, what is the TNM stage for nasopharyngeal carcinoma involving the left orbit with left level II, III, Va lymphadenopathy? 6 cm and no evidence for DM?

Answer 20

T4N3M0, Stage IVA

Orbital involvement makes it T4.

Unilateral or bilateral cervical lymph nodes, larger than 6 cm (including 6 cm) makes it N3.