Head and Neck Flashcards
What are some methods of diagnosis (5)
- Core biopsy
- Incisional biopsy
- FNABX (fine needle aspiration biopsy)
- histology
- excision biopsy
What is the purpose of staging investigations
- Assess primary tumour and define the extent of spread
- See suitability for a particular treatment
- Exclude co-morbidities
What may be some considerations/investigations prior to RT for head and neck patients
- cytology/ histology, radiology, biochem and haematology.
- Pandescopy (biopsy)
- OPG and dental assessment
- Social worker
- Speech pathology
What are some Tx options for Head and Neck Cancer?
- Surgery
- RT (preserves structure and function)
- Surgery + Post op RT +/- Chemo
- Chemo-radiation +- surgery for residual disease.
What are the indications for post-op RT?
- Close or +ve margins
- > = 3 nodes involved
- extra capsular spread
- locally advanced disease
- lymph-vascular or perineurial spread
Indications for post-op RT/CT
- Extra-capsular spread
- Positive margins
Dose fractionations head and neck?
T1/2 disease: 60-66Gy in 30-33# T2/4 disease: 70Gy in 35# N0 Neck: 50 Gy in 30# N1 Neck: 60Gy in 30# Post op neck: 60 in 30#
What would you expect to happen in the ‘follow up’ stage?
- Assess recurrence and if found options for salvage therapy
- Speech pathology
- Assess need for rehab
- Adress the side effects of therapy.
How long should you wait post op to start RT
How long do you need to allow for dental extractions
Post op - 6 weeks
Dental Extractions - 2 Weeks
What are some planning considerations for H&N
- Outline the CTV and GTV or HRTV if post op
- Add expansion on the CTV of 5-10mm (consider what the impact would be if it was ill defined, need to cover BOT)
- CTV - PTV - add another 5mm
- Volume QA is ideal.
What are the acute side effects of RT for head and neck ca patients? (7)
- change in salivary consistency
- Dysphagia
- Odonophagia
- fatigue
- skin reactions
- mucositis
- alteration in taste
What are the late side effects of RT for head and neck cancer patients? (10)
- xerostomia
- alopecia
- endocrine abnormalities
- radiation caries
- atrophy of the SC tissue
- reduced ability to sweat
- 2nd malignancy
- mucosal fragility
- trismus
- osteoradionecrosis
What are the considerations of chemo RT for H/N ca patients?
- Gives an increased survival advantage but is associated with increased morbidity so not for everyone
- Use 5FU or cisplatin given concurrently with RT.
What are the risk factors for H&N cancer?
- Smoking
- Alcohol
- Marijuana
- Male
What is the aim for the primary tumour site?
- Optimise tumour control
- Preserve structure and function
What comprises the oral cavity?
- Buccal cavity
- Hard palate
- Floor of mouth
- Tongue
- Alveolus
What is the main treatment for Oral Cavity ca?
- Surgery is the mainstay because want to preserve salivary function.
What is the function of the larynx
- Protects airway
- Vocalisation
What are the symptoms of Larynx ca? (6)
- Horse/ husky voice
- odonophagia/ oltagia/ localised pain
- palpable mass
- aspiration
- airway compromise
- weight loss
How is early glottic cancer characterised and how is it managed?
- Low incidence of nodes
- Treated using: conservative surgery or RT, possibly LASER but still being investigated.
What are the planning considerations for early glottic cancers?
- Volume the glottis with a margin
- Usually encompassed by a 5x5, 6x6cm field
- need overshoot anteriorly
- Field arrangement - opposed laterals (may need obliques if short neck)
What is the dose fractionation for EGC? (T1 and T2)
T1 - 63Gy in 28#
T2 - 66Gy in 33#
What is the treatment preferred for T3 Glottic cancer, when would RT be offered (6)?
- Surgery is preferred because increases local control.
- RT may be offered to select patients who understand
1. they will have increased recurrence risk
2. a laryngectomy may not be advised due to suspicion that recurrence may not be confirmed histologically.
3. people who are compliant with follow up
4. Pts with a good airway
5. easy to examine
6. Cords fixed because bulk of tumour
What is the dose fractionation for T3 Glottic Cancer
66-70Gy in 33-35#
What are the tx options for locally advanced Glottic cancer?
1) Laryngectomy +/- PORT +/- Chemotherapy
2) RT (rare)
3) Chemoradiation
- Treat stoma if subglottic extension or if emergency tracheostomy.
How is the supra glottis characterised?
- Increased nodes at presentation and increased subclinical nodal involvement.
Note: Because it is a midline structure it requires the bilateral tx of the neck.
What are the Tx options for Supraglottis (Early)
- Radical RT
- Laryngectomy – this requires pts to have a good airway reserve as they are at risk of aspiration and need to learn to swallow again.
What are the tx options for Advanced supra glottis cancer?
- Surgery +- port +- Chemo
- chemo-radiation
- RT alone if pt refuses or has co-morbidites that prevent them from having surgery.
Supra glottis dose #
- 63-66Gy in 30-33#
- Bulk disease 70Gy in 35#, consider surgery for residual disease.
What are the risks associated with surgery of the glottis? (5)
- death
- flap necrosis
- infection
- carotid rupture
- DVT +- PE
What are the risks associated with RT for the glottis? (5)
- virtually no risk of death
- oedema
- chronditis
- osteoradionecrosis
- chrondronecrosis
What are the three regions of the hypopharynx?
- post pharyngeal wall
- piriform fossae
- post-cricoid space
What are the signs and symptoms of hypopharnx cancer? (6)
- hot potato voice
- stridor
- referred otalgia
- weight loss
- dysphagia
- sore throat
Do piriform hypo pharynx patients present early or late? How does this affect their tx?
What would be the management for an early stage hypo pharynx?
Most present late, therefore are rarely treated with RT or Surgery alone.
A partial pharyngo-laryngectomy may be an option for early stage disease.
What are the treatment options for advanced pf patients?
- Pharngolaryngectomy +- PORT +- Chemo
- RT alone (rare)
- CT/ RT
What are the three types of salivary glands?
- parotid
- submandibular
- sublingual
What benign/malignant salivary gland tumours
Benign
- Warthins tumours
- pleomorphic adenoma
- oncocytoma
Malignant
- Adenocarcinoma
- SCC
- muco-epidermal
- adenoid cystic
- acinic cell ca
- plasmacytoma
- secondary SCC, melanoma, NHL.
What is the primary tx option for salivary glad tumours? And what are some considerations ?
surgery +- PORT
- usually need to conserve facial nerve
- volume the parotid bed +-ipsilateral neck nodes.
What group is at risk of getting nasal tumours?
- Wood workers
What is the clinical presentation of nasal cancer?
- Nasal orbs & epistaxis
What is the mainstay of treatment for nasal cancer
surgery +- RT
Who is the at risk group for nasopharyngeal cancers and what are the characteristics of this disease?
- Chinese/ males
- usually bilateral disease
- well supplied with lymphatics
- high incidence of occult nodal groups
- incl. spinal mets
Signs and symptoms of nasopharyngeal tumours (7)
- painless neck lump
- proptosis
- sore throat
- nasal obstruction
- facial pain
- cranial nerve defects
- unilateral ottis media (in adult)
what are the tx options for NPC?
- RT is the standard
- highly chemo sensitive so increased survival advantage when chemo is given to this area. (concomitant rt/ ct)
What do you volume for NPC? and what is the #?
NPX + bilateral neck nodes (including the sp nodes)
63-70Gy to primary lesion (may use brachy).
What does the choice of therapy for the neck depend on?
- Extent of nodal involvement
2. management of the primary lesion
What is the fractionation for a node negative neck pt
50Gy in 25#
What does extra capsular neck spread indicate
indicates that there is increased risk of local recurrence, therefore PORT is considered and higher doses will be used. Consider PORT and chemotherapy.
What are the types of neck directions?
- radical
- modified radical
- functional
- supra-omohyoid
What are the complications of a neck dissection (8)
- nerves
- vascular
- death
- pulmonary
- lymphatic
- infection
- flap necrosis
- lymphoma
