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FRCR2 > Head and neck > Flashcards

Head and neck Flashcards

1
Q

What nodal levels does the nasopharynx drain to

A

Retropharyngeal nodes (7A)
Level 2
Upper level 5 (posterior triangle)

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2
Q

What are the 3 structures and 3 levels for LN anatomy

How are the nodal levels defined using them

A

3 structures: SCM, submandibular glands, parotids

3 levels: C2 (lateral process), hyoid, cricoid

Hyoid – division between levels II & III
Cricoid - division between levels III & IV
SCM – behind is level V

Level II – upper deep cervical, underneath SCM and above hyoid, and behind posterior border of submandibular gland. Anterior to this is level I

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3
Q

Where does the oropharynx drain to

A

Level 2 and inferiorly to 3 & 4
Or superiorly from level 2 to levels 7A&B

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4
Q

Where does the oral cavity drain to

A

Lateral tongue to level 1b
Tongue and floor of mouth to levels 2-4
Tip of the tongue to 1A, and directly to 3
Hard palate to 1B
Soft palate - level 2 or retropharyngeal (7A)

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5
Q

What levels does the hypopharynx drain to

A

Pyriform sinus - Levels 2-5 & 7A
Posterior pharyngeal wall - 2-3 & 7A
Post-cricoid - 3 & 5. Inferiorly to paratracheal and para-oesophageal LNs

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6
Q

What levels does the larynx drain to

A

Levels 2-3

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7
Q

What are the boundaries of nodal level xxx

A
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8
Q

What are the 3 subsites of the hypopharynx (3 Ps)?

A

Pyriform sinus
Posterior pharyngeal wall
Post-cricoid region

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9
Q

What are the three levels of the glottis and what are the boundaries / levels

A

Supraglottis, glottis, subglottis

Supraglottis - from epiglottis to upper border of arytenoids
Glottis - level of vocal cords
Subglottis - from 1cm below true cords, to lower border of cricoid

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10
Q

If level 2 nodes are involved, which levels must also be included

A

1b & 7b

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11
Q

If level 4a and or 5 is involved, what levels must also be included

A

4b and 5c

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12
Q

If level 4A or 5b is involved, what levels must also be included

A

4B & 5C

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13
Q

If any nodes are positive in the neck, what level must also be included

A

5a&b

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14
Q

Which inherited condition increases the risk of head and neck SCC, and what is the treatment consequence

A

Fanconi anaemia
They do not tolerate cisplatin and have severe toxicity with RT

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15
Q

When is a PET CT indicated in H&N cancer

A

SCC neck node of unknown primary
T3-4 disease
N3 cancer

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16
Q

What are the investigations for an SCC neck node of unknown primary

A

PET-CT
HPV / p16 status
If negative, then: EUA, panendoscopy, biopsies from base of tongue, piriform fossa, and consider bilateral tonsillectomy

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17
Q

For oral cavity, HPV- oropharynx, hypopharynx and larynx, how is stage 3 disease defined

A

T3N0 or T1-3 N1
ie presence of T3 disease or node positive (N1)

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18
Q

For oral cavity, HPV- oropharynx, hypopharynx and larynx, how is stage 4A disease defined

A

T4a N0-1 or T1-4a N2
ie the presence of T4a disease or N2 status

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19
Q

For oral cavity, HPV- oropharynx, hypopharynx and larynx, how is stage 4B disease defined

A

T4b Any N or Any T N3
ie the presence of T4b disease or N3 status

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20
Q

For a p16-positive oropharyngeal tumour, how is stage 2 defined

A

T1-2 N2 or T3 N0-2
ie the presence of T3 or N2 disease

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21
Q

For a p16-positive oropharyngeal tumour, how is stage 3 defined

A

T1-3 N3 or T4 N0-3
ie the presence of T4 or N3 disease

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22
Q

What is the management for a stage I-II oral cavity cancer and what is the TNM stage for this

A

Stage I-II = up to T2N0
WLE +/- PORT

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23
Q

What is the management for a stage III-IV oral cavity cancer and what is the TNM stage for this

A

stage III = T3N0 or T1-2N1
Up to stage IVb = T4b Any N or T1-4b N3
Mx would be surgery with reconstruction if possible & PORT (+/- neoadjuvant TPF chemotherapy)

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24
Q

What is the management for a stage I-II oropharyngeal cancer and how is this TNM defined

A

If HPV negative: stage I-II = up to T2N0
If HPV positive: stage I-II = up to T3 or N2

Mx is surgery or chemoradiotherapy

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25
Q

What is the management for a stage III-IV oropharyngeal cancer and how is this TNM defined

A

If HPV negative: stage III-IVb (not metastatic) = up to T4b or N3
If HPV positive: stage III (stage IV = metastatic) = up to T4 or N3

Tx with chemo-RT

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26
Q

Indications for neoadjuvant chemotherapy in H&N
And what regime

A

x

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27
Q

What is the treatment for a stage I laryngeal cancer, and what is the TNM staging

A

Stage I = T1N0
Treat with laser, surgery, or RT

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28
Q

What is the treatment for a stage II laryngeal cancer, and what is the TNM staging

A

stage 2 = T2N0
Treat with laser, surgery or RT

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29
Q

What is the treatment for a stage III laryngeal cancer, and what is the TNM staging

A

Stage III = T3 or N1 disease
Treat with CRT

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30
Q

What is the treatment for a stage IV laryngeal cancer, and what is the TNM staging

A

stage IV non-metastatic disease = T4b or N3 disease
Treat with total laryngotomy & neck dissection with PORT/PO-CRT
Or consider downstaging with neoadjuvant chemo

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31
Q

What is the treatment for a stage I-II hypopharyngeal tumour and what is the TNM staging

A

Stage I-II = up to T2N0
Treat with RT or ?partial surgery

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32
Q

What is the treatment for a stage III hypopharyngeal tumour and what is the TNM staging

A

stage III = T3 or N2 disease
Treat with CRT + ?neck dissection

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33
Q

What is the treatment for a stage IV hypopharyngeal tumour and what is the TNM staging

A

stage IV (non-metastatic) = T4b or N3
Treat with surgery (laryngectomy + partial pharyngectomy) + b/l neck dissection + PO RT or PO CRT

34
Q

What is the preferred treatment modality for nasopharyngeal cancers?

A

RT or CRT
Surgery reserved for residual or recurrent disease

35
Q

When is chemotherapy indicated in addition to radical RT
What is the benefit
What are the scheduling options

A

Age <70 and stage III-IV disease
Based on Pignon meta-analysis, 6-8% benefit in overall survival

3wkly cisplatin at 100mg/m2 - D1, 22, 43 - higher mucosal toxicity (82% vs 61%)

Weekly cisplatin (min 5wks) at 40mg/m2

In theory can consider cetuximab for oropharynx, larynx and hypopharynx only, if cisplatin contraindicated

36
Q

What is the RT dose to a T1 N0 (stage I) or T2N0 (stage II) larynx

A

55Gy/20#/4wks

37
Q

What are the radical RT dose levels for primary RT
What are the margins

A

GTV-T - 65Gy/30#
GTV-N - 65Gy/30#

Involved nodal level - 60Gy/30#

Elective nodal levels - 54Gy/30#

Tumour GTV-CTV margin - 65Gy to GTV +5mm, 60Gy to GTV +10mm

Nodal GTV - CTV margin - 5mm, or 10mm if node >3cm

38
Q

What is the benefit of adjuvant RT in H&N cancer

A

Improvement in local control by 38%, if treatment completed within 11wks of surgery

39
Q

What are the indications for adjuvant RT following H&N cancer surgery (3 categories)

A

Tumour - related:
Locally advanced tumours - T3-4
High grade tumours

Surgery related:
Positive or close margins (<1mm) and no further resection possible (-> chemoRT)
Perineural or vascular invasion

Node related:
>2 nodes positive (N2b)
Macroscopic residual disease
Extracapsular extension (N3) (-> chemoRT)
Any single node >3cm (N2)

40
Q

What are the indications for adjuvant chemoRT following H&N cancer surgery

What is the benefit of adding cisplatin to adjuvant RT

A

Positive margins (<1mm)
Extracapsular extension

Cisplatin (if <70yrs) adds 2% to locoregional control (12% vs 10%) and also improved OS

41
Q

What is the adjuvant RT dose for H&N cancer

A

65Gy/30# if macroscopic residual disease or ECE
60Gy/30# otherwise

If poor P:
55Gy/20# for positive margins/ECE, 50Gy/20# otherwise

42
Q

What is the adjuvant RT dose for cervical LNs for melanoma

A

48Gy/20#

43
Q

What is the CTV margin for adjuvant H&N treatment?

A

GTVp & GTVn - recreate GTV based on pre-operative imaging
CTV-P - GTVp+10mm
CTV-N - GTVn+5mm & & pathologically involved nodal levels

44
Q

What is the CTV-PTV margin for H&N

A

3-5mm

45
Q

When are LNs treated electively (in a node negative neck)

A

When risk of involvement is >15-20%, which is usually the case in most sites except early larynx (T1-2), lip and lower alveolar ridge

46
Q

Which nodal levels are typically included in the:
Node negative neck
Node positive neck

A

Node negative neck - levels 2-4a
Node positive neck - levels 1b-5

47
Q

what was the outcome of the PET-neck study

A

That post RT for oropharyngeal cancers, PET-CT (and salvage neck dissection if necessary) is non-inferior to neck dissection for all

48
Q

What are the systemic treatment options for a metastatic SCC of H&N?

A

If PDL1 CPS >1, and not of skin origin, pembrolizumab 1st line
If CPS <1, chemotherapy. Cisplatin/5FU
25-30% RR
PFS 5-7 months with chemo - Doesn’t prolong survival, but can improve symptoms
If progression within 6mths of Pt-containing chemotherapy -> nivolumab, independent of PDL1 status.
Checkmate 141 - improves OS to 7.5mths

49
Q

For a T1-2 oral cavity tumour, node negative, and >1cm lateral to the midline, what nodal levels should be treated

A

Ipsilateral levels 1a&b, 2-4a (if no neck dissection)
None contralaterally
4a only included if anterior tongue or oropharynx involvement
9 if buccal mucosa involved

50
Q

For an T2 oral cavity tumour, node negative, and <1cm lateral to the midline, what nodal levels should be treated

A

Ipsilateral levels 1a&b, 2-4a (if no neck dissection)
Contralateral 1a-4
4a only included if anterior tongue or oropharynx involvement
9 if buccal mucosa involved

51
Q

For a T2 oral cavity tumour, node positive, and >1cm lateral to the midline, what nodal levels should be treated

Which additional level should be included dependent on which nodal level being positive

A

Ipsilateral levels 1a&b, 2-4a
None Contralateral
4a only included if anterior tongue or oropharynx involvement
9 if buccal mucosa involved

Include level 5 if 4 or 1b involved

52
Q

For a T2 oral cavity tumour, node positive, and <1cm lateral to the midline, what nodal levels should be treated

A

Ipsilateral levels 1a&b, 2-4a
None Contralateral
4a only included if anterior tongue or oropharynx involvement
9 if buccal mucosa involved

Include level 5 if 4 or 1b involved

53
Q

What is the exception when a stage I-II oral cavity cancer can be treated with RT rather than surgery

A

Retromolar trigone

54
Q

What is the management of a stage I-II oral cavity tumour

A

surgical WLE + neck dissection (level I-IV) (unilateral or bilateral depending on laterality of the lesion) for all but very early lesions

55
Q

What is the management of a stage III-IV oral cavity tumour

A

Surgery with flap reconstruction & neck dissection +/- adj RT/CRT
Or radical RT/CRT + unilateral or bilateral neck RT

56
Q

When is radical RT indicated for an oral cavity tumour

A

Pt declines surgery or is unfit for surgery
Or stage III/IV

57
Q

where do hypopharyngeal cancers commonly originate from

A

Pyriform fossa

58
Q

For which head and neck cancer is bilateral neck treatment recommended

A

Hypopharynx

59
Q

What is the management of stage I-II hypopharyngeal cancers (T1-2 N0)

A

Larynx-preserving surgery if possible, with bilateral neck dissection
If not possible, primary chemoradiation with elective neck irradiation

60
Q

What is the management of stage III - IV hypopharyngeal cancers (>T3 or N+)

A

If functioning larynx -> radical chemoRT
If cartilage/bone invasion/large volume extra laryngeal disease -> surgery & adj RT/CRT

+/- neoadjuvant TPF

61
Q

What nodal levels are treated in hypopharyngeal cancers

A

Add table

62
Q

Diagnostic work up of new head and neck presentation

A

xx

63
Q

What proportion of tumours arise from the different levels of the larynx

A

Supraglottis - 30%
Glottis - 60-70%
Subglottis - <5%

Supra- and subglottis tend to present later

64
Q

What is the treatment for a T1 laryngeal cancer (stage 1)

A

Transoral laser surgery or RT

Dose: 55Gy/20# over 4 weeks
Bolus (especially if anterior commissure involved)
Volumes - CTV = Whole glottis

65
Q

What is the treatment for a T2 laryngeal cancer (stage 2)

A

RT
Dose: 55Gy/20# over 4 weeks
Bolus (especially if anterior commissure involved)
Volumes - CTV = Whole glottis

66
Q

What is the treatment for a stage III (T3 or N1) laryngeal tumour

A

Surgery with adjuvant RT
Or primary CRT

67
Q

What is the treatment for a stage 4 (T4 or N2-3) laryngeal tumour

What are the RT volumes

A

Surgery - total larryngectomy, neck dissection, flap reconstruction and adjuvant RT/CRT

Larynx-preserving primary CRT if there is a functioning larynx with no extra-laryngeal disease, and salvage laryngectomy if needed

CTV-T - GTV + 1cm laterally + 1.5-2cm sup/inf
Whole larynx (tip of epiglottis to bottom of cricoid) or lower depending on inferior extent of tumour and expansion.
Include tracheostomy if present

68
Q

What is the order of planning priorities?

A

OAR constraints
PTV constraints
PTV objective
OAR objective

69
Q

What are the predictors of improved loco-regional control after H&N RT re-treatment?

A

Decreased stage at time of recurrence
Nasopharynx cancer
No organ dysfunction (ie absence of feeding tube or tracheostomy)
Surgery for recurrence
Initial RT dose >50Gy
Time interval since initial radiotherapy

70
Q

When is a larger margin (10mm) included for an involved neck node, vs 5mm

A

Node >3cm or invasion ito adjacent structures

71
Q

How are salivary gland carcinomas classified

A

Adenoid cystic vs non-adenoid cystic

72
Q

How is adenoid cystic carcinoma treated

A

WLE and always adjuvant RT

73
Q

How is an acinic cell carcinoma treated

A

Total parotidectomy with preservation of uninvolved nerves.
No elective neck dissection
No adjuvant RT (Not radiosensitive)

74
Q

What are the indications for post-op RT for salivary gland tumours

A

All Adenoid Cystic
High grade tumours
T3/T4 - >4cm, extraparenchymal extension
Close or Positive margins
Positive Nodes
PNI or LVI

75
Q

What is the management of submandibular gland salivary tumours

What are the indications and levels treated for adjuvant RT for submandibular gland tumours

A

WLE + Neck dissection (for all)
N0 neck, small tumour & LG histology -> Levels I & IIa only
High grade or suspicious MRI appearances – level I-III
Levels I-IV - Node positive, T3/T4

Adj RT:
All adenoid cystic carcinomas
High grade tumours
Residual neck disease or ECS
Following surgery for recurrent disease

Nodal treatment
If node negative -> I & II only, even if adenoid cystic
If node positive -> levels Ib-IV

76
Q

What is the treatment for a metastatic salivary gland carcinoma

A

Adenoid cystic:
1st line - TKI - lenvatinib
2nd line - CAP (cisplatin, doxorubicin, paclitaxel) & whole genome sequencing (RET & NTRK)

Non-adenoid cystic:
Sequence earlier - RET, NTRK, B-raf
Targeted treatment options if mutation present
If mutation negative - chemotherapy

77
Q

What is the OS benefit for Nivolumab 2nd line in metastatic H&N SCC

A

2.6mths

78
Q

What is the OS benefit for pembrolizumab in metastatic H&N SCC

A

For PDL1 CPS >1 - 2mths

79
Q

What is the rate of HPV positivity in oropharyngeal cancer

A

30%

80
Q

What is the long term risk of osteoradionecrosis of the jaw after radical RT

A

5%

81
Q
A

FRCR2 (28 decks)

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