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Head/Neck Flashcards

1
Q

Head and Neck: Workup

A

H&P: Site specific symptoms, weight. Assess social support, smoking, alcohol. Head and neck exam, noting teeth condition, cranial nerves, mirror and flex laryngoscopy (esp for larynx), palpation of mass in mouth

FNA biopsy of node if possible

Labs: CBC, CMP, TSH

Primary Imaging: CT of the neck, possible MRI

Staging Imaging: CT chest, PET for stage III-IV (i.e. T3 or N1 or above)

Special imaging: direct laryngoscopy with biopsies, consider videostrobe

Special workup: dental, port, PEG tube, nutrition, audiology, speech and swallowing evaluation, smoking cessation / alcohol counseling

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2
Q

Head and Neck: Sim

A

supine with chin extended, long mask, wire scar.

Consider: bite block, bolus scar for ECE, contrast

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3
Q

Head/Neck: nodal drainage for oropharynx, larynx, hypopharynx, nasopharynx, and oral cavity

A

Oropharynx: II-IV

Larynx: II-IV

Hypopharynx: II-V and RP

Nasopharynx: II-deep V and RP, ipsi level IB for N+

Oral cavity: IA-IV

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4
Q

Head and Neck: constraints for parotids and submandibular glands

A

Mean parotid <26 Gy

50% of each parotid<30 Gy

Mean submandibular <39 Gy

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5
Q

Head and Neck: constraints for larynx, pharyngeal constrictors, and cervical esophagus

A

larynx mean 44Gy, max 66Gy

constrictors 50Gy

cervical esophagus V45 < 33%

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6
Q

Head and Neck: constraints for lips and oral cavity

A

oral cavity <39

Lips mean <20 Gy, max 50 Gy

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7
Q

Head and Neck: constraints for brachial plexus, temporal lobes, and brainstem/chiasm/optic nerves

A

Brachial plexus <66 Gy

Temporal lobes <60 Gy

brainstem/chiasm/optic nerves<54 Gy (1cc brainstem to 60 Gy)

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8
Q

Head and Neck: follow up

A

PET at 3 months if nodes were treated (salvage neck dissection if SUV remains elevated)

post-treatment baseline imaging of primary then every 3-6 mo, TSH every 6-12 mo, speech/hearing/swallowing continued f/u, smoking cessation/alcohol counseling, dental f/u

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9
Q

T1 Larynx: dose and field

A

63Gy/28fxs (complete within 44 days)

3D: Opposed laterals, bolus if lesion is anterior

sup: thyroid notch
inf: bottom of cricoid
ant: flash
post: ant vertebral bodies

Some rotate gantry to make posterior border non-divergent or place isocenter at anterior edge of vertebral body

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10
Q

T1 Larynx: dosimetry

A

wedges with heel anteriorly (15-30 degrees), 6MV photons, 95% isodose line to cover the entire cords, no hotspot over 110%

IMRT carotid sparing for young age

Carotid mean <25 Gy, V35<20%

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11
Q

T1 Larynx: 5yr LC and OS

A

5yr LC 90%

5yr OS 80%

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12
Q

T2 Larynx: dose and field

A

(only if confined to glottis)

65.25 in 29 fx, finish in <44 days

Sup border: hyoid

Inf border: 1st tracheal ring

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13
Q

T2 Larynx: 5yr LC and OS

A

5yr LC 75%

5yr OS 60%

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14
Q

contraindications to laryngeal preservation

A

T4

extension of 1 cm to BOT

Bulky tumor: 3.5 cm3 for glottic and 6cm3 for supraglottic

Poor swallowing or speech

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15
Q

Larynx: 5yr larynx preservation and OS for stage III and IV

A

5yr larynx preservation:

80% for stage III

60% for stage IV

5yr OS:

45% for stage III

35% for stage IV

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16
Q

Postop Larynx: fields

A

Postop bed, levels II-VI to bilateral neck

When discussing borders don’t forget that the hyoid and cricoid are removed after larygectomy

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17
Q

Supraglottic cancer: radiation dose and volumes

A

70/63/56 (2/1.8/1.6) 35 fx

always treat bilateral neck II-IV

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18
Q

Supraglottic cancer: 5yr OS stage I-IV

A

5yr OS

stage I 50%

stage II 50%

stage III 45%

stage IV 30%

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19
Q

Hypopharynx cancer: dose and volumes for stage III-IV

A

Three volume: 6996/5940/5412 (2.12/1.8/1.64) 33 fx with chemo

Two volume: 70/56 SIB

Treat bilateral II-VII and RP

If gross nodes were treated, perform PET at 3 months. If disease is still active, recommend neck dissection

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20
Q

Hypopharynx cancer: 5yr OS and laryngeal preservation for stage III-IV

A

5yr OS 35%

5ry laryngeal preservation 35%

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21
Q

ACR approriateness criteria for unilateral tonsil treatment

A

T1-2N0-1 oropharynx, less than 1 cm extension to soft palate, and no BOT involvement

On PE make sure to note BOT or soft palate extension, trismus (pterygoid involvement), inability to protrude tongue (T4 deep tongue muscles)

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22
Q

Unilateral tonsil: doses

A

70/63/56 (2/1.8/1.6) 35 fx

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23
Q

Tonsil cancer: 2yr OS and LC for T1N0 and T2N0

A

2yr OS 95%

2yr LC:

T1 90%

T2 80%

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24
Q

Oropharynx cancer: options for HPV testing

A

first test p16

if negative but suspicious then test HPV PCR

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25
Oropharynx cancer: 3yr OS for low/intermediate/high risk groups
3-yr OS: Low risk 90% Int risk 70% High risk 50%
26
Oral cavity cancer: doses
6996/5940/5412 (2.12/1.8/1.64) 33 fx
27
Oral cavity cancer: indications for post-op xrt
T2 with greater than 5 mm, T3-4, N+, LVSI, PNI, close/positive margins
28
Head/neck: postop doses
66 Gy: positive margin or ECE 60 Gy: node positive neck, dissected neck, and intermediate risk (PNI, LVI, T4, close margin) 54Gy: low risk areas, elective neck
29
Head/neck cancer: 5yr OS with adjuvant chemoradiation on Cooper/Bernier
5yr OS 50%
30
Nasopharyngeal cancer: workup
typical head/neck workup plus: MRI, audiology consult, ophthalmoloty consult, check EBV
31
Nasopharyngeal cancer: usage of EBV
EBV DNA quantitative PCR: used to give surival and distant met prognosis, and monitor treatment response and recurrence. Can get before and after treatment (\<1500 copies before treatment is good and undectable after tx is good)
32
Nasopharyngeal cancer: volumes and dose
6996/5940/5412 (2.12/1.8/1.64) 33 fx (FUSE MRI!!!) CTV 6996: GTV and gross nodes with 0.5cm expansion CTV 5940: GTV +1cm, entire nasopharynx, node positive and dissected neck Ib-Vb/RP/RS, special NPX CTV structures known from heavy pimpin CTV 5412: node negative neck (may exlcude level IV and Vb)
33
Nasopharyngeal cancer: intermediate risk CTV structures
nasopharynx anterior 1/3 of clivus foramen rotundum and ovale pterygoid fossa parapharyngeal space inferior sphenoid sinus cavernous sinus posterior nasal cavity posterior maxillary sinus inferior soft palate retropharyngeal lymph nodes retrostyloid space Ib-V neck
34
Nasopharyngeal cancer: chemo dose and schedule
(chemo for T2-4 or N+) concurrent cisplatin 100mg/m2 q3wk adjuvant cisplatin 80 and continuous infusion 5FU 1000 x 3 cycles
35
Nasopharyngeal cancer: constraints for brainstem, spinal cord, chiasm, optic nerves, mandible, brachial plexus, temporal lobes
true brainstem: max 54Gy brainstem PRV: V60 \< 1% spinal cord: max 45Gy true chiasm/optic nerve: max 50 Gy chiasm/optic nerve PRV: max 54Gy mandible: max 70Gy, V75 \< 1cc brachial plexus: max 66Gy temporal lobes: max 60Gy
36
Nasopharyngeal carcinoma: WHO types
WHO type now is simply keratinized or nonkeratinized. Asian types are nearly all nonkeratinized Old WHO classification: WHO I: squamous WHO II: nonkeratinizing WHO III: undifferentiated, lymphoepithelioma
37
Nasopharyngeal carcinoma: 5yr OS for T2-4 or N+
5yr OS 70%
38
Nasopharyngeal cancer: anatomy
learn special nerves (Jacobs, Villaret etc…) and skull base anatomy
39
Esthesioneuroblastoma: Kadish staging
Kadish Staging: A: confined to nasal cavity B: extends to paranasal sinuses C: beyond nasal cavity or paranasal sinuses D: lymph nodes or distant mets
40
Esthesioneuroblastoma: long term OS for Kadish A/B/C
A 70% B 60% C 50%
41
Esthesioneuroblastoma: treatment paradigm
yeah it's empty, fill it and add a card with xrt volumes
42
Hard palate salivary tumor: treatment volume
For adenoid cystic hard palate tumor, if tracing PNI cover hard palate, greater and lesser palatine foramen up PPF and at least some of V2 to foramen rotundum and probably vidian canal. For extensive PNI consider covering VII via greater petrosal nerve and more of V2
43
Melanoma: volumes for nodal sites
Axilla: classic field includes axilla plus SCV. Some omit supraclavicle Neck: level II down to supraclavicle Inguinal: inguinal plus ipsilateral pelvic nodes
44
Merkel cell: target volumes
5 cm margins around the primary site. Smaller margins are accetptable in head and neck, at least 2 cm If treating nodes, include in between intransit lymphatics (connect primary and lymph nodes)
45
Cutaneous SCCa: target volumes
2cm margin around tumor, can reduce to 1 cm around eye, use appositional electrons with custom bolus and custom lead blocking, minimal field size 4x4 cm, ENI if large invasive tumor or poorly differentiated
46
Lip and oral cavity T1
\<2cm, DOI \<5mm
47
Lip and oral cavity T2
2-4cm, DOI 5-10mm
48
Lip and oral cavity T3
\>4cm, DOI \>10mm
49
Lip and oral cavity T4a
Lip: invades bone, inferior alveolar nerve, floor of mouth, skin Oral cavity: cortical bone of maxilla or mandible, maxillary sinus, skin
50
Lip and oral cavity T4b
invades masticator space, pterygoid plates, skull base, or encasing carotid
51
General H/N Clinical N1
single ipsilateral node \<3cm and ENE(-)
52
General H/N Clinical N2a
single ipsilateral node 3-6cm and ENE(-)
53
General H/N Clinical N2b
multiple ipsilateral nodes \<6cm and ENE(-)
54
General H/N Clinical N2c
bilateral or contralateral nodes \<6cm and ENE(-)
55
General H/N Clinical N3a
node \>6cm and ENE(-)
56
General H/N Clinical N3b
clinically overt ENE(+)
57
General H/N Pathological N1
single ipsilateral node \<3cm and ENE(-)
58
General H/N Pathological N2a
single ipsilateral node 3-6cm and ENE(-) OR single ipsilateral node \<3cm and ENE(+)
59
General H/N Pathological N2b
multiple ipsilateral nodes \<6cm and ENE(-)
60
General H/N Pathological N2c
bilateral or contralateral nodes \<6cm and ENE(-)
61
General H/N Pathological N3a
node \>6cm and ENE(-)
62
General H/N Pathological N3b
ENE(+) that doesn't meet criteria for N2a
63
General H/N Stage I
T1N0
64
General H/N Stage II
T2N0
65
General H/N Stage III
T3 or N1
66
General H/N Stage IVA
T4a or N2
67
General H/N Stage IVB
T4b or N3
68
General H/N Stage IVC
M1
69
Nasopharynx T0
no tumor identified but EBV(+) cervical nodes
70
Nasopharynx T2
parapharyngeal space, medial/lateral pterygoids, prevertebral muscles
71
Nasopharynx T3
skull base, pterygoid plates, cervical vertebra, paranasal sinuses
72
Nasopharynx T4
intracranial extension, cranial nerves, hypopharynx, orbit, parotid gland, or extension lateral to lateral pterygoid muscle
73
Nasopharynx N1
unilateral node(s) \<6cm above the caudal edge of the cricoid
74
Nasopharynx N2
bilateral nodes \<6cm above the caudal edge of the cricoid
75
Nasopharynx N3
node \>6cm or below the caudal edge of the cricoid
76
Nasopharynx Stage II
T0-1N1 or T2N0-1
77
Nasopharynx Stage III
T0-2N2 or T3N0-2
78
Nasopharynx Stage IVA
any T4 or N3
79
Nasopharynx Stage IVB
M1
80
Oropharynx (p16-) T1
\<2cm
81
Oropharynx (p16-) T2
2-4cm
82
Oropharynx (p16-) T3
\>4cm or extension to lingual surface of epiglottis
83
Oropharynx (p16-) T4a
larynx, extrinsic tongue muscles, medial pterygoid, hard palate, mandible
84
Oropharynx (p16-) T4b
lateral pterygoid, pterygoid plates, lateral nasopharynx, skull base, encasing carotid
85
Hypopharynx T1
\<2cm and one subsite
86
Hypopharynx T2
2-4cm or multiple subsites
87
Hypopharynx T3
\>4cm,fixation of hemilarynx, extension to esophagus
88
Hypopharynx T4a
thyroid/cricoid cartilage, hyoid bone, thyroid gland, esophageal muscle, pre-laryngeal soft tissue
89
Hypopharynx T4b
prevertebral fascia, mediastinal structures, encasing carotid
90
Oropharynx (p16+) T1
\<2cm
91
Oropharynx (p16+) T2
2-4cm
92
Oropharynx (p16+) T3
\>4cm or extension to lingual surface of epiglottis
93
Oropharynx (p16+) T4
larynx, extrinsic tongue muscles, medial pterygoid, hard palate, mandible, or beyond
94
Oropharynx (p16+) Clinical N1
ipsilateral node(s) \<6cm
95
Oropharynx (p16+) Clinical N2
bilateral or contralateral nodes \<6cm
96
Oropharynx (p16+) Clinical N3
node \>6cm
97
Oropharynx (p16+) Pathological N1
1-4 nodes
98
Oropharynx (p16+) Pathological N2
5+ nodes
99
Oropharynx (p16+) Clinical Stage I
T0-2N0-1
100
Oropharynx (p16+) Clinical Stage II
T0-2N2 or T3N0-2
101
Oropharynx (p16+) Clinical Stage III
any T4 or N3
102
Oropharynx (p16+) Clinical Stage IV
M1
103
Oropharynx (p16+) Pathological Stage I
T0-2N0-1
104
Oropharynx (p16+) Pathological Stage II
T0-2N2 or T3-4N0-1
105
Oropharynx (p16+) Pathological Stage III
T3-4N2
106
Oropharynx (p16+) Pathological Stage IV
M1
107
5 subsites of supraglottic larynx
false vocal cords, arytenoids, suprahyoid epiglottis, infrahyoid epiglottis, aryepiglottic folds
108
Supraglottic larynx T1
one supraglottic subsite
109
Supraglottic larynx T2
more than one supraglottic subsite, glottis, region outside the supraglottis (mucosa of base of tongue, vallecula, medial wall of pyriform sinus)
110
Supraglottic larynx T3
vocal cord fixation, postcricoid area, pre-epiglottic tissues, paraglottic space, inner cortex of thyroid cartilage
111
Supraglottic larynx T4a
outer cortex of thyroid cartilage, tissues beyond the larynx
112
Supraglottic larynx T4b
prevertebral space, mediastinal structures, encasing carotid
113
Glottic larynx T1a
involves one vocal cord (normal mobility)
114
Glottic larynx T1b
involves both vocal cords (normal mobility)
115
Glottic larynx T2
impaired vocal cord mobility or involving supraglottic or subglottic larynx
116
Glottic larynx T3
vocal cord fixation, inner cortex of thyroid cartilage, paraglottic space
117
Glottic larynx T4a
outer cortex of thyroid cartilage, tissues beyond the larynx
118
Glottic larynx T4b
prevertebral space, mediastinal structures, encasing carotid
119
Subglottic larynx T1
limited to subglottis
120
Subglottic larynx T2
extends to vocal cords with normal or impaired vocal cord mobility
121
Subglottic larynx T3
vocal cord fixation, inner cortex of thyroid cartilage, paraglottic space
122
Subglottic larynx T4a
cricoid cartilage, thyroid cartilage, tissues beyond larynx
123
Subglottic larynx T4b
prevertebral space, mediastinal structures, encasing carotid
124
Maxillary sinus T1
tumor limited to mucosa of maxillary sinus WITHOUT bone invasion
125
Maxillary sinus T2
bone invasion (excluding posterior wall)
126
Maxillary sinus T3
posterior wall of maxillary sinus, subcutaneous tissues, floor or medial wall of orbit, pterygod fossa, ethmoid sinuses
127
Maxillary sinus T4a
anterior orbit, skin, pterygoid plates, infratemporal fossa, cribriform plate, sphenoid sinus, frontal sinus
128
Maxillary sinus T4b
orbital apex, dura, brain, middle cranial fossa, cranial nerves (excluding V2), nasopharynx, clivus
129
Nasal Cavity and Ethmoid Sinus T1
one subsite with or without bone invasion
130
Nasal Cavity and Ethmoid Sinus T2
two subsites or extending to an adjacent region
131
Nasal Cavity and Ethmoid Sinus T3
floor or medial wall of orbit, maxillary sinus, palate, cribriform plate
132
Nasal Cavity and Ethmoid Sinus T4a
anterior orbit, skin, anterior cranial fossa, pterygoid plates, sphenoid sinus, frontal sinus
133
Nasal Cavity and Ethmoid Sinus T4b
orbital apex, dura, brain, middle cranial fossa, cranial nerves (excluding V2), nasopharynx, clivus
134
Salivary gland T2
2-4cm without clinical extraparenchymal extension
135
Salivary gland T3
\>4cm or clinical extraparenchymal extension
136
Salivary gland T4a
skin, mandible, ear canal, facial nerve
137
Salivary gland T4b
skull base, pterygoid plates, encasing carotid
138
Mucosal melanoma T3
limited to mucosa and immediately underlying soft tissue
139
Mucosal melanoma T4a
deep soft tissue, cartilage, bone, skin
140
Mucosal melanoma T4b
brain, dura, skull base, cranial nerves 9-12, masticator space, carotid artery, prevertebral space, mediastinal structures
141
Mucosal melanoma N1
positive node(s)
142
H/N Cutaneous SCCa T2
2-4cm
143
H/N Cutaneous SCCa T3
\>4cm, minor bone erosion, perineural invasion, subcutaneous fat
144
H/N Cutaneous SCCa T4a
gross cortical bone invasion
145
H/N Cutaneous SCCa T4b
skull base or skull base foramen
146
Merkel cell T2
diameter 2-5cm
147
Merkel cell T4
invades fascia, muscle, cartilage, or bone
148
Merkel N1-3
N1 positive nodes without in-transit mets N2 in-transit mets and negative nodes N3 in-transit mets and positive nodes
149
Merkel stage II
T2-4N0
150
Merkel stage III
N+
151
Melanoma T2
\>1.0-2.0mm
152
Melanoma T4
\>4mm
153
Melanoma N2a-c
N2a 2-3 occult nodes N2b 2-3 clinical nodes N2c one node and in-transit metastases
154
Melanoma stage II
T2b-4bN0
155
Melanoma stage III
N+

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