Head and neck Flashcards
What are the 3 structures and 3 levels for LN anatomy
How are the nodal levels defined using them
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
What nodal levels does the nasopharynx drain to
Level 2
7A
Upper level 5 (posterior triangle)
Where does the oral cavity drain to
Lateral tongue and hard palate to level 1b
Tongue and floor of mouth to levels 2-4
Tip of the tongue to 1A, and directly to 3
Soft palate - level 2 or retropharyngeal (7A)
Where does the oropharynx drain to
Level 2-4
7A&B
What are the 3 subsites of the hypopharynx (3 Ps)?
Pyriform sinus
Posterior pharyngeal wall
Post-cricoid region
What levels does the hypopharynx drain to
Pyriform sinus - Levels 2-5 & 7A
Posterior pharyngeal wall - 2-3 & 7A
Post-cricoid - 3 & 5. Inferiorly to paratracheal and para-oesophageal LNs
What levels does the larynx drain to
Levels 2-3
What are the three levels of the glottis and what are the boundaries / levels
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
Which inherited condition increases the risk of head and neck SCC, and what is the treatment consequence
Fanconi anaemia
They do not tolerate cisplatin and have severe toxicity with RT
When is a PET CT indicated in H&N cancer
SCC neck node of unknown primary
T3-4 disease
N3 cancer
What are the investigations for an SCC neck node of unknown primary
PET-CT
HPV / p16 status
If negative, then: EUA, panendoscopy, biopsies from base of tongue, piriform fossa, and consider bilateral tonsillectomy
For oral cavity, HPV- oropharynx, hypopharynx and larynx, how is stage 3 disease defined
T3N0 or T1-3 N1
ie presence of T3 disease or node positive (N1)
For oral cavity, HPV- oropharynx, hypopharynx and larynx, how is stage 4A disease defined
T4a N0-1 or T1-4a N2
ie the presence of T4a disease or N2 status
For oral cavity, HPV- oropharynx, hypopharynx and larynx, how is stage 4B disease defined
T4b Any N or Any T N3
ie the presence of T4b disease or N3 status
What is the management for a stage I-II oral cavity cancer and what is the TNM stage for this
Stage I-II = up to T2N0
WLE +/- PORT
For a p16-positive oropharyngeal tumour, how is stage 3 defined
T1-3 N3 or T4 N0-3
ie the presence of T4 or N3 disease
For a p16-positive oropharyngeal tumour, how is stage 2 defined
T1-2 N2 or T3 N0-2
ie the presence of T3 or N2 disease
What is the management for a stage III-IV oral cavity cancer and what is the TNM stage for this
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)
What is the management for a stage I-II oropharyngeal cancer and how is this TNM defined
If HPV negative: stage I-II = up to T2N0
If HPV positive: stage I-II = up to T3 or N2
SOC is RT (HPV negative), or chemoRT (HPV+)
What is the management for a stage III-IV oropharyngeal cancer and how is this TNM defined
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
Indications for neoadjuvant chemotherapy in H&N
And what regimen
Quick response needed due to tumour bulk
To facilitate organ preserving treatment
Where tumour shrinkage on treatment might require replanning
TPF
What is the treatment for a stage I laryngeal cancer, and what is the TNM staging
Stage I = T1N0
Treat with laser, surgery, or RT
What is the treatment for a stage II laryngeal cancer, and what is the TNM staging
stage 2 = T2N0
Treat with laser, surgery or RT
What is the treatment for a stage III laryngeal cancer, and what is the TNM staging
Stage III = T3 or N1 disease
Treat with CRT
What is the treatment for a stage IV laryngeal cancer, and what is the TNM staging
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
What is the treatment for a stage I-II hypopharyngeal tumour and what is the TNM staging
Stage I-II = up to T2N0
Treat with RT
What is the treatment for a stage III hypopharyngeal tumour and what is the TNM staging
stage III = T3 or N2 disease
Treat with CRT
What is the treatment for a stage IV hypopharyngeal tumour and what is the TNM staging
stage IV (non-metastatic) = T4b or N3
Treat with surgery (laryngectomy + partial pharyngectomy) + b/l neck dissection + PO RT/CRT
What is the preferred treatment modality for nasopharyngeal cancers?
RT or CRT
Surgery reserved for residual or recurrent disease
When is chemotherapy indicated in addition to radical RT
What is the benefit
What are the scheduling options
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
What is the RT dose to a T1 N0 (stage I) or T2N0 (stage II) larynx
55Gy/20#/4wks
What are the radical RT dose levels for primary RT
What are the margins
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
What is the benefit of adjuvant RT in H&N cancer
Improvement in local control by 38%, if treatment completed within 11wks of surgery
What are the indications for adjuvant RT following H&N cancer surgery (3 categories)
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)
Extracapsular extension (N3) (-> chemoRT)
Any single node >3cm (N2)
What are the indications for adjuvant chemoRT following H&N cancer surgery
What is the benefit of adding cisplatin to adjuvant RT
Positive margins (<1mm)
Extracapsular extension
Cisplatin (if <70yrs) adds 2% to locoregional control (12% vs 10%) and also improved OS
What is the adjuvant RT dose for H&N cancer
65Gy/30# if macroscopic residual disease or ECE
60Gy/30# otherwise
If poor PS:
55Gy/20# for positive margins/ECE, 50Gy/20# otherwise
What is the adjuvant RT dose for cervical LNs for melanoma
48Gy/20#
What is the CTV margin for adjuvant H&N treatment?
GTVp & GTVn - recreate GTV based on pre-operative imaging
CTV-P - GTVp+10mm
CTV-N - GTVn+5mm & & pathologically involved nodal levels
What is the CTV-PTV margin for H&N
3-5mm
what was the outcome of the PET-neck study
That post RT for oropharyngeal cancers, PET-CT (and salvage neck dissection if necessary) is non-inferior to neck dissection for all
When are LNs treated electively (in a node negative neck)
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
What are the systemic treatment options for a metastatic SCC of H&N?
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
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
Ipsilateral levels 1a-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
What is the management of a stage III-IV oral cavity tumour
Surgery with flap reconstruction & neck dissection +/- adj RT/CRT
Or radical RT/CRT + unilateral or bilateral neck RT
When is radical RT indicated for an oral cavity tumour
Pt declines surgery or is unfit for surgery
Or stage III/IV
where do hypopharyngeal cancers commonly originate from
Pyriform fossa
For which head and neck cancer is bilateral neck treatment recommended
Hypopharynx
What is the management of stage I-II hypopharyngeal cancers (T1-2 N0)
Larynx-preserving surgery if possible, with bilateral neck dissection
If not possible, primary chemoradiation with elective neck irradiation
What is the management of stage III - IV hypopharyngeal cancers (>T3 or N+)
If functioning larynx -> radical chemoRT
If cartilage/bone invasion/large volume extra laryngeal disease -> surgery & adj RT/CRT
+/- neoadjuvant TPF
What proportion of tumours arise from the different levels of the larynx
Supraglottis - 30%
Glottis - 60-70%
Subglottis - <5%
Supra- and subglottis tend to present later
What is the treatment for a T1 laryngeal cancer (stage 1)
Transoral laser surgery or RT
Dose: 55Gy/20# over 4 weeks
Bolus (especially if anterior commissure involved)
Volumes - CTV = Whole glottis
What is the treatment for a T2 laryngeal cancer (stage 2)
RT
Dose: 55Gy/20# over 4 weeks
Bolus (especially if anterior commissure involved)
Volumes - CTV = Whole glottis
What is the treatment for a stage III (T3 or N1) laryngeal tumour
Primary CRT for larynx preservation
Or surgery with adjuvant RT
What is the treatment for a stage 4 (T4 or N2-3) laryngeal tumour
What are the RT volumes
Surgery - total laryngectomy, 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
What is the order of planning priorities?
OAR constraints
PTV constraints
PTV objective
OAR objective
What are the predictors of improved loco-regional control after H&N RT re-treatment?
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
When is a larger margin (10mm) included for an involved neck node, vs 5mm
Node >3cm or invasion ito adjacent structures
How are salivary gland carcinomas classified
Adenoid cystic vs non-adenoid cystic
How is adenoid cystic carcinoma treated
WLE and always adjuvant RT
How is an acinic cell carcinoma treated
Total parotidectomy with preservation of uninvolved nerves.
No elective neck dissection
No adjuvant RT (Not radiosensitive)
What are the indications for post-op RT for salivary gland tumours
All Adenoid Cystic
High grade tumours
T3/T4 - >4cm, extraparenchymal extension
Close or Positive margins
Positive Nodes
PNI or LVI
What is the management of submandibular gland salivary tumours
What are the indications and levels treated for adjuvant RT for submandibular gland tumours
N0 neck, small tumour & LG histology -> Levels I & IIa only
High grade or suspicious MRI appearances – level I-III
Node positive, T3/T4 - Levels I-IV
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
What is the treatment for a metastatic salivary gland carcinoma
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
What is the OS benefit for Nivolumab 2nd line in metastatic H&N SCC
2.6mths
What is the OS benefit for pembrolizumab in metastatic H&N SCC
For PDL1 CPS >1 - 2mths
What is the rate of HPV positivity in oropharyngeal cancer
30%
What is the long term risk of osteoradionecrosis of the jaw after radical RT
5%
what are the key numbers for staging, HPV negative, non-nasopharyngeal H&N
2,4,5,10,3,6
2 & 5
4 & 10
T1 - <2cm or DOI <5mm
T2 - size 2-4cm & DOI <10mm
T3 - >4cm or DOI >10mm
T4 - local invasion
Clinical nodal staging - Nodes - 3, 6
N1 - ipsi, <3cm
N2a - single ipsi node 3-6cm
2b - multiple ipsi node, <6cm
2c - bilateral nodes, all <6cm
N3a - LN >6cm (ipsi or contra or bilat), ECE-
N3b - Ln >6cm (ipsi or contra or bilat), ECE+
stage grouping summary - non-HPV+ oropharynx or nasopharynx
1 - T1N0
2 - T2N0
3 - T3N0 or T1-3N1
4 - >T4a or N2
how is stage 3 defined
T1-3N0-1, or T3N0
where N1 (clinical or pathological staging), is 1 single ipsilateral node, <3cm
What is the follow up for nasopharyngeal cancer after CRT
PET at 3mths. if residual disease, rescan at 6wks. if persistent -> salvage surgery
What must always be treated for a hypopharyngeal tumour
bilateral neck nodes
When can unilateral RT be considered for a tonsillar tumour instead of bilateral
T1-2N0, well lateralised tumour
(based on consensus recommendation):
Consider for T1-2 N1, if well lateralised primary
(>1cm from midline, not involving base of tongue, posterior pharyngeal wall or extension onto adjacent soft palate by >10mm)
T1-2 N2b (multiple ipsilateral nodes, <6cm) - if no significant nodal burden, ie 1-2 nodes only, both <3cm and located only in levels 2 & 3
when should contralateral neck irradiation be offered following surgery to an oral cavity tumour
when should it be considered
Offer following surgery to a primary oral tongue SCC and ipsilateral neck dissection, if any of:
- T3-4 tumour (>4cm or locally invasive)
- ≥2 nodes positive in ipsilateral neck
- any ECE within the ipsilateral neck
- primary <10mm from midline
Consider if:
-single ipsilateral LN and no ECE
When is the neck electively treated in oral cavity tumours
in all but the very earliest
any depth >4mm for tongue, and >1.5mm for floor of mouth = elective neck treatment
usually selective neck dissection, 1-3, or 1-4a
Surgery is primary modality - tumour, neck dissection and reconstruction
when is adjuvant RT indicated following surgery to the oral cavity
T3 -4 disease
>N2a (single ipsi node 3-6cm, or single ipsi node < 3cm but with ECE)
close margins
PNI
how is a lateralised tumour defined such that unilateral RT can be given
> 1cm from midline and <1cm extension onto soft palate or BOT
what is the rate of feeding tube dependency at 1yr after chemoRT treatment
5%
what is the rate of osteoradionecrosis with chemoRT assuming good dentition
5%
how is an olfactory neuroblastoma treated
Resection and adjuvant RT, occasionally induction cisplatin/etoposide
is the infra temporal fossa high or low risk for nasopharyngeal cancer
low risk - separate from nasopharynx
what is the 5yr control rate for a T1a laryngeal cancer, treated with RT only and current smoker
80%
what is the local control rate for a T2N1 hypopharyngeal cancer treated with chemoRT?
70-80%
For a T1-2 oral cavity tumour, node negative, and >1cm lateral to the midline, what nodal levels should be treated
Ipsilateral levels 1a-4a (if no neck dissection)
None contralaterally
If 4a or 5b involved - include 4b & 5c
If level 2 involved, include 7b
9 if buccal mucosa involved
For an T2 oral cavity tumour, node negative, and <1cm lateral to the midline, what nodal levels should be treated
Bilateral 1a-4a (if no neck dissection)
If 4a or 5b involved - include 4b & 5c
If level 2 involved, include 7b
9 if buccal mucosa involved
For a T2N1 (stage 3) oral cavity tumour, >1cm from midline, what levels should be included
1a-4a ipsilaterally
none contralaterally
If 4a or 5b involved - include 4b & 5c
If level 2 involved, include 7b
9 if buccal mucosa involved
For a T2N1 (stage 3) oral cavity tumour, <1cm from midline, what levels should be included
1a-4a bilaterally
If 4a or 5b involved - include 4b & 5c
If level 2 involved, include 7b
9 if buccal mucosa involved
If level 4A or 5b is involved, what levels must also be included
4B & 5C
If level 2 nodes are involved, which levels must also be included
1b & 7b
What is the exception when a stage I-II oral cavity cancer can be treated with RT rather than surgery
Retromolar trigone
What is the management of a stage I-II oral cavity tumour
surgical WLE + neck dissection (level I-IV) (unilateral or bilateral depending on laterality of the lesion) for all but very early lesions
When should contralateral neck RT be offered for a lateralised oral cavity tumour, following surgery to the primary and ipsilateral neck dissection
When adjuvant ipsilateral neck RT is being given, and T3-4, primary <10mm from midline, or ≥2 positive nodes within ipsilateral neck or ECE present
consider contralateral RT if only one node ipsilaterally
