Head and Neck Bullshit

Question 1

What is pentoclo protocol for osteoradionecrosis?

Answer 1

PENTOCLO protocol:
Pentoxifylline 400 mg, BD
Tocopherol 500 mg, BD
Clodronate BD
5 Days a week
Continue til “acceptable clinical response”

Question 2

Approach to PORT (or definitive) nodal irradiation for oral cavity SCC

Answer 2

1) Decide if unilateral or bilateral:
- Unilateral only if single ipsilateral node & tumour well lateralised - at least 1cm from midline, BOT or tip of tongue.
- Bilateral if >2 ipsi nodes, close to midline.

2) Which nodes?
IB, II and III always
Any tumour close to midline or into oropharynx then include level IV. Obviously also if III involved.

If bucal mucosae then level IX (buccal nodes) ipsilateral nodes.

Question 3

Approach to PORT (or definitive) nodal irradiation for Oropharynx SCC p16 negative.

Answer 3

Trick - p16+ may also be the same - unlear.
1) Decide if unilateral or bilateral (similar to oral cav):
Unilateral if NO-N2a (single ipsilateral node <6cm).
Tonsil fossa tumor NOT
infiltrating the soft palate OR
the BOT

2) Which nodes?
If ipsilateral then: II, III, IVa’,
+ 1B if oral cavity extension (e.g. into retromolar trigone)
+VIla for posterior pharyngeal wall tumor

If bilateral: Ib, II, III, IVa, Va,b, +VIla,
+VIIb* only do bilateral retropharygeal nodes if posterior paryngeal wall tumour.

Question 4

Definitive dose and volumes for a T1-T2 glottic larynx:

Answer 4

T1 = vocal cords (a = uni, b=bi)
T2= extension in supra/sub glottis.

60/25!!!
CTV= Entire larynx at level of GTV and 0.5-1.0 cm superiorly and inferiorly.

Question 5

Compare volumes for larynx and hypopharynx

Answer 5

CTV70 = GTV + 5-10mm both sites.
CTV63 = CTV70+ intermediate risk nodes +:
If Larynx SCC: consider entire larynx
If Hypopharynx: entire hypopharynx

CTV56=Bilateral nodal levels II, III and IV.
Consider levels Ib and/or V included on side(s) of lymphadenopathy.
Consider VIIb and level V for extensive level II lymph node involvement.

IF
Larynx: VI if subglottis

Hypopharynx: VI for apex of piriform sinus, post cricoid and/or oesophageal extension

Question 6

Primary Tx for a T2NOMO nasopharyngeal carcinoma:

What 2 factors may change volumes?

Answer 6

EBRT (VMAT partial arc 6MV photons) alone:
CTV_70Gy/35# = GTV+5mm

CTV_63/35 (EQD2 60Gy) = Entire nasopharynx +
Sup: Skull base w/ovale and rotundum, inf sphenoid sinus
if >=T3 - whole sphenoid and cavernous sinus
Inf: Soft palate
Ant: posterior 1/3 of max and nasal sinus
Post: Bilateral retropharynx nodes, ant 1/3 of clivus (whole clivus if involved - i.e. T3)
Lateral: Pterygoids and parapharyngeal space.

CTV 56 (EQD2 50): CTV 63+ Levels II-V.
If node +ve include 1B.

Question 7

The OARS of head and neck and Dmax

Answer 7

Brain stem/ optic chiasm = Dmax <54Gy

Optic nerve Spinal cord = Dmax <45Gy

Temporal lobe/Brain = Dmax< 60Gy, V40Gy<5cc

Brachial plexus= Dmax< 66Gy

Retina/ eye = Dmax< 50Gy
Lens = Dmax < 8Gy

Lacrima = Dmax < 30Gy

Manidble = Dmax < 70Gy

Carotid = Dmax <100Gy

Parodid is a mean dose = Dmean 26Gy

Question 8

For H&N cancers define:
Positive/involved margin:
Close margin
Clear margin.

Large-calibre and small-calibre nerves

Answer 8

Positive/involved margin: <1mm
Close margin: 1-5mm
Clear margin: >5mm

Large-calibre and small-calibre nerves: Large >0.1mm, small <0.1