Head and Neck Cancer

Question 1

What is the treatment of Stage I HPV+ oral pharyngeal cancer?

Answer 1

Resection of primary tumor along with ipsilateral and bilateral select node dissection. OR you can do definitive RT. So definitive tx here is single modality.

Question 2

For HPV+ disease that is Stage I-III, what are the high risk features that for sure warrant additional tx and what is that?

Answer 2

So for tumors that have positive margins or extranodal extension these tumors will need adjuvant chemo/RT. It says for positive margins too if you can resect it, that’s an option too.

Question 3

What are other lower risk pathologic features that warrant additional treatment after surgery for HPV+ Stage 1 disease?

Answer 3

Close margins <3mm, pT3 or 4 primary tumor, one positive node >3cm, multiple positive nodes, nodal dx in level 4/5 station, lympho-vascular invasion, peri-neural invasion

Question 4

For HPV positive disease of the oropharynx that has one single node less than 3cm what is the tx? Stage I includes N1 disease
N1-one or more ipsilateral nodes, none larger than 6cm.
N2-contralateral or bilateral nodes, none larger than 6 cm
N3-nodes larger than 6cm

Answer 4

Here you have the option of doing a resection w/lymph node dissection or definitive RT. It also says concurrent chemo/RT is an option which is Cat 2B rec

Question 5

For HPV+ dx of the oropharynx with one single node greater than 3cm or 2 or more nodes less than or equal to 6cm what is the tx? (Also applies to T3, N0-2) Stage II

Answer 5

So here you can do concurrent chemo/RT or you still have the option for resection w/neck dissection

Question 6

What is the tx for HPV+ Oropharyngeal dx that is stage III? T0-3/N3 or T4/N0-3

Answer 6

So here chemo/RT is listed as the preferred option, but do you have the option of doing a resection with lymph node dissection

Question 7

What is the tx for T1,N0 or selected T2,N0 hypopharynx cancer?

Answer 7

Definitive RT, partial laryngopharyngectomy w/lymph node dissection +/- hemithryoidectomy w/pretracheal and paratracheal node dissection

Question 8

What is the tx for T2-3, N0-3 or T1, N+ tumors of the hypopharynx? Remember that N1 disease automatically indicates Stage III

Answer 8

Induction chemotherapy followed by RT if they had a good response, chemo/RT for partial response (Cat 2B for PR), or you can do surgery if they had a less than partial response. Other options are: surgery with partial or total laryngopharyngectomy w/lymph node dissection OR chemo/RT

Question 9

For those patients who received induction chemo for hypopharyngeal cancer (T2-3,N0-3 or T1,N+ tumors) what is the best next step if they had a CR, PR or stable disease, or less than PR?

Answer 9

CR-RT (Cat 1 rec)
PR/stable or improved dx-Surgery is preferred here, can consider chemo/RT but Cat 2B rec
Less than PR-surgery or treat as locally advanced/metastatic dx

Question 10

What is the tx of T4a, N0-3 cancer of the hypopharynx? Stage IVA. N2 also places a person in Stage IVA.

Answer 10

The preferred option here is total laryngopharyngectomy w/lymph node dissection. Induction and concurrent chemo/RT are both Cat 3 recs.

Question 11

What is the tx of T4a,N0-3 hypopharyngeal cancer after primary treatment when they have either a CR, PR or stable/improved disease, or less than PR?

Answer 11

CR-RT or chemo/RT, both are acceptable options
PR, stable/improved dx-Chemo/RT or surgery
Less than PR-treat as metastatic/locally advanced

Question 12

What is the tx for p16 neg T1-2,N0-1 oropharynx cancer?

Answer 12

The options are: resection w/lymph node dissection, RT, or you can consider chemo/RT for T1-2,N1 dx (this cat2B rec for the last option).

Question 13

For p16 neg T1-2,N0-1 oropharynx cancer that was tx w/surgery and has extranodal extension +/- positive margins, what do you do? What if it is positive margins only? Other lower risk features (everything but nodal extension and + margins)? This is for Stage I-III dx

Answer 13

Extranodal Ext w/+/-positive margin-Chemo/Rt
Positive Margin only-chemo/RT or RT both are okay, or re-resection
Lower risk-RT or chemo/RT

Question 14

What is the tx for p16 neg oropharyngeal cancer that is T3-4, N0-1 dx? Stage III and Stage IVA dx

Answer 14

Here your options are concurrent chemo/RT or resection of the tumor w/lymph node dissection. It lists induction chemo followed by chemo/RT as a Cat 3 rec.

Question 15

What is the tx for p16 neg oropharyngeal cancer that is T1-T4a, N2-3? This is stage IVA or IVB

Answer 15

The main options are concurrent chemo/RT or resection with node dissection. It lists induction chemo followed by chemo/RT as Cat 3 rec.

Question 16

After patients undergo surgery in Stages III, IVA, IVB for HPV neg oropharyngeal cancer with no adverse prognostic features what is the best next step? For stages I-II?

Answer 16

They will need RT even still. HPV- is a higher risk disease than HPV+ dx. Remember that for Stage I and Stage II if they have no adverse features you can just observe these patients.

Question 17

What is the definitive treatment for T4a,N0-3 Laryngeal cancer? This is high yield! This is for stages IVA/B
T4a-Tumor invades through the outer cortex of the thyroid cartilage and/or invades trachea, soft tissues of neck e.g. deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus

Answer 17

Laryngectomy including w/nodal dissection and thyroidectomy. Please know this!

Question 18

For Laryngeal cancer T4a,N0-3, after they undergo surgery if they have no adverse features or if they do have adverse features, what do you do? What about for those with other lower risk features?

Answer 18

No adverse features-observe
Nodal extension or + margin-chemo/RT
Other lower risk features-RT or chemo/RT

Question 19

What is the tx for T3 N2/3 Laryngeal cancer, what is the tx? Stage IVA and B

Answer 19

So here you can do either chemo/RT (larynx preservation), surgery, or induction chemo followed by def RT (those w/CR OR PR), or chemo/RT (PR) Cat 2B. If after chemo they have less than a PR you take them for surgery. ASCO says that chemo/RT or induction chemo followed by RT is preferred.

Question 20

What is the tx for T3,N0-1 laryngeal cancer? This is Stage III dx.

Answer 20

Chemo/RT or RT alone if they aren’t a candidate for both. Or you have the option of resection w/node dissection and thyroidectomy if needed. OR induction chemo.

Question 21

What is the tx for T1-T2,N0 or select T3,N0 laryngeal cancer? Carcinoma in-situ?

Answer 21

RT or laryngeal surgery w/ node dissection as indicated. Carcinoma in-situ-endoscopic resection or RT. Remember if they have no poor prognostic features-observe. Nodal ext-chemo/RT. + margin-RT or resect, other low risk features-RT. pN1-RT.

Question 22

What is the first line option for locally advanced/metastatic HNSCC?

Answer 22

Pembro w/ Carboplatin or Cisplatin w/ 5-FU. If they have a CPS of 1 or higher you give Pembro alone. In GW video for the last subset of patients with high volume disease you can add a platinum agent.

Question 23

What therapy can you give for platinum resistant disease that progresses to locally advanced/metastatic disease?

Answer 23

Pembro or Nivolumab if not previously used.

Question 24

What is the tx for Stage I (T1,N0) nasopharyngeal cancer?

Answer 24

RT to nasopharynx and elective RT to the neck.

Question 25

What is the tx for Stage II nasopharyngeal cancer? (T2,N0)

Answer 25

So this depends on if high risk features are present: cervical nodes greater than or equal to 3cm, Level IV or VB nodes, nodal ext, EBV of 4,000 or higher. Higher risk-chemo/RT. Lower risk-RT alone.

Question 26

What is the tx for Stage III nasopharyngeal cancer? T0-1,N1 or T3,N0

Answer 26

Chemo/RT. You can consider induction or adjuvant chemotherapy if high risk features are present.

Question 27

What is the tx of Stage IVA nasopharyngeal cancer? T3-4,N1-3 or T2, N2-3

Answer 27

Induction chemo followed by chemo/RT (Cat 1 rec). Chemo/RT followed by adjuvant chemo (less patients able to do this due to toxicity from chemo/RT). Chemo/RT alone (Cat 2B).

Question 28

What are the induction regimens used for Nasopharyngeal cancer? What about concurrent chemo/RT followed by chemo?

Answer 28

Gemcitabine/Cisplatin and Docetaxel/Cisplatin/5-FU (TPF)
Concurrent regimen: Cisplatin+RT followed by Cisplatin+5-FU