Head and Neck Flashcards
Most common histology
squamous cell (alternate etiology suggest salivary or thyroid origin)
Incidence of new diagnosis,
Sex,
Age
3%,
M>F (3:1),
>60 (except HPV: 40-60)
Enviornmental Risk Factors
- Alcohol or Tobacco (if combine 100 fold increase)
- EBV (nasopharyngeal: endemic in southern China and Hong Kong)
- HPV (70% oropharyngeal)
Premalignant Lesions
Leukoplakia: fixed white patches
Erythroplakia: red patches; often with epithelial dysplasia
Key Molecular Abnormalities
p53 (poor prognosis, usually w/ Alcohol & Tobacco)
p16 inactivation
EGFR overexpression
CCND1 over expression
HPV: E6, E7 viral protein: inhibits tumor suppressors ie. p53, Rb
EBV: LMP1 protein
Big Picture:
multimodality approach allows for cure even in locally advanced
In addition to cure we strive for:
organ preservation
Treatment baskets:
- Early Stage (stage I-II; not high risk): single modality: surgery or RT
- Locally Advanced (stage III-IVB): surgery with adjuvant radiation +/- chemo or definitive chemoradiation
- Metastatic: combination chemo (ECOG1)
What are high risk features in early stage that warrant adjuvant therapy?
- extracapsular extension
- vascular embolism
- perineural invasion
When is adjuvant radiation + chemo preferred?
> 2 positive nodes
+ surgical margins (consider re-surgery first)
+ extracapsular extension
When is definitive chemoradiation preferred?
nonsurgical disease (Adelstein JCO 2003) larynx preservation (Forastiere NEJM 2003)
What are 6 primary sites of origin for SCC of Head and Neck?
Oral Cavity Oropharynx Nasal Cavity Nasopharynx Hypophaynx Larynx
Components of oral cavity?
lips, alveolar ridge, hard palate, buccal mucosa, anterior 2/3 tongue, floor of mouth, retromolar trigone (7)
Components of Oropharynx?
palatine tonsils, posterior 1/3 of tongue, vallecula, lingual tonsil, midportion of posterior pharyngeal wall, interior surface of soft palate, uvula (7)
Components of Nasal Cavity?
Nasal septum, mucosa of nasal cavity; superior, middle and inferior turbinates (3)
Components of Nasopharynx?
superior surface of soft palate, upper portion of posterior pharyngeal wall above level of uvula (2)
Components of Hypopharynx?
Postcricoid area, pyriform sinus (2)
Components of Larynx?
Supraglottis: supra and infrahyoid epiglottis, aryeepiglottic folds, arytenoids, falso crods
Glottis: tru vocal cords, anterior and posterior commissures, region 1cm below true vocal cords
Subglottis: from 1cm below true vocal cords to cervical trachea
Overview of stages in SCC in H&N?
- early (I-II)
- locally advanced but potentially curable (III-IVB)
- uncurable (IVC)
Features of early stage H&N cancer?
Tumor
Features of locally advanced disease in H&N cancer?
extensive local involvement and/or lymph node involvement
Features of incurable
distant metastasis
Preffered surgical margins in H&N cancer?
> 5mm
Preffered XRT modality (why?) and standard?
IMRT (reduced xerostomia and optimize targeting), standard id EBRT 66-70 Gy
Short and long term side effects of XRT in H&N?
fatigue, xerostomia, 2ndary malignancies (sarcomas)
Preffered agent in locally advanced H&N cancer for concurrent chemoXRT or adjuvant chemo if margins + or extracapsular extension (?
Cisplatin
- CRT: (RTOG 91-11 JCO 2013)
- adjuvant: increase DFS & OS (Bernier NEJM 2004, Cooper NEJM 2004)
Alternatives to cisplatin in advanced H&N disease?
- Carbo + 5FU for chemoXRT (JCO 2004)
- Cetuximab for chemoXRT (Bonner, NEJM 2006)
Recommended regimen for metastatic H&N cancer? (associated trial?)
Platinum doublet + cetuximab (EXTREME NEJM 2008)
- cis or carbo + taxanxe or 5FU
Is there a role for induction therapy in H&N cancer? (common regimen, evidence?)
No
- TPF: docetaxel, cisplatin and 5-Fu
- Paradigm (Lancet 2013) and Decide trials (JCO 2012)
Is there a role for reirradiation?
yes
