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Oral Boards > Head/Neck > Flashcards

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
Q

Oropharynx cancer: 3yr OS for low/intermediate/high risk groups

A

3-yr OS:

Low risk 90%

Int risk 70%

High risk 50%

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26
Q

Oral cavity cancer: doses

A

6996/5940/5412 (2.12/1.8/1.64) 33 fx

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27
Q

Oral cavity cancer: indications for post-op xrt

A

T2 with greater than 5 mm, T3-4, N+, LVSI, PNI, close/positive margins

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28
Q

Head/neck: postop doses

A

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

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29
Q

Head/neck cancer: 5yr OS with adjuvant chemoradiation on Cooper/Bernier

A

5yr OS 50%

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30
Q

Nasopharyngeal cancer: workup

A

typical head/neck workup plus:

MRI, audiology consult, ophthalmoloty consult, check EBV

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31
Q

Nasopharyngeal cancer: usage of EBV

A

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)

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32
Q

Nasopharyngeal cancer: volumes and dose

A

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)

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33
Q

Nasopharyngeal cancer: intermediate risk CTV structures

A

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

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34
Q

Nasopharyngeal cancer: chemo dose and schedule

A

(chemo for T2-4 or N+)

concurrent cisplatin 100mg/m2 q3wk

adjuvant cisplatin 80 and continuous infusion 5FU 1000 x 3 cycles

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35
Q

Nasopharyngeal cancer: constraints for brainstem, spinal cord, chiasm, optic nerves, mandible, brachial plexus, temporal lobes

A

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

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36
Q

Nasopharyngeal carcinoma: WHO types

A

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

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37
Q

Nasopharyngeal carcinoma: 5yr OS for T2-4 or N+

A

5yr OS 70%

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38
Q

Nasopharyngeal cancer: anatomy

A

learn special nerves (Jacobs, Villaret etc…) and skull base anatomy

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39
Q

Esthesioneuroblastoma: Kadish staging

A

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

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40
Q

Esthesioneuroblastoma: long term OS for Kadish A/B/C

A

A 70%

B 60%

C 50%

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41
Q

Esthesioneuroblastoma: treatment paradigm

A

yeah it’s empty, fill it and add a card with xrt volumes

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42
Q

Hard palate salivary tumor: treatment volume

A

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

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43
Q

Melanoma: volumes for nodal sites

A

Axilla: classic field includes axilla plus SCV. Some omit supraclavicle

Neck: level II down to supraclavicle

Inguinal: inguinal plus ipsilateral pelvic nodes

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44
Q

Merkel cell: target volumes

A

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)

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45
Q

Cutaneous SCCa: target volumes

A

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

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46
Q

Lip and oral cavity T1

A

<2cm, DOI <5mm

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47
Q

Lip and oral cavity T2

A

2-4cm, DOI 5-10mm

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48
Q

Lip and oral cavity T3

A

>4cm, DOI >10mm

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49
Q

Lip and oral cavity T4a

A

Lip: invades bone, inferior alveolar nerve, floor of mouth, skin Oral cavity: cortical bone of maxilla or mandible, maxillary sinus, skin

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50
Q

Lip and oral cavity T4b

A

invades masticator space, pterygoid plates, skull base, or encasing carotid

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51
Q

General H/N Clinical N1

A

single ipsilateral node <3cm and ENE(-)

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52
Q

General H/N Clinical N2a

A

single ipsilateral node 3-6cm and ENE(-)

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53
Q

General H/N Clinical N2b

A

multiple ipsilateral nodes <6cm and ENE(-)

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54
Q

General H/N Clinical N2c

A

bilateral or contralateral nodes <6cm and ENE(-)

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55
Q

General H/N Clinical N3a

A

node >6cm and ENE(-)

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56
Q

General H/N Clinical N3b

A

clinically overt ENE(+)

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57
Q

General H/N Pathological N1

A

single ipsilateral node <3cm and ENE(-)

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58
Q

General H/N Pathological N2a

A

single ipsilateral node 3-6cm and ENE(-) OR single ipsilateral node <3cm and ENE(+)

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59
Q

General H/N Pathological N2b

A

multiple ipsilateral nodes <6cm and ENE(-)

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60
Q

General H/N Pathological N2c

A

bilateral or contralateral nodes <6cm and ENE(-)

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61
Q

General H/N Pathological N3a

A

node >6cm and ENE(-)

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62
Q

General H/N Pathological N3b

A

ENE(+) that doesn’t meet criteria for N2a

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63
Q

General H/N Stage I

A

T1N0

64
Q

General H/N Stage II

A

T2N0

65
Q

General H/N Stage III

A

T3 or N1

66
Q

General H/N Stage IVA

A

T4a or N2

67
Q

General H/N Stage IVB

A

T4b or N3

68
Q

General H/N Stage IVC

A

M1

69
Q

Nasopharynx T0

A

no tumor identified but EBV(+) cervical nodes

70
Q

Nasopharynx T2

A

parapharyngeal space, medial/lateral pterygoids, prevertebral muscles

71
Q

Nasopharynx T3

A

skull base, pterygoid plates, cervical vertebra, paranasal sinuses

72
Q

Nasopharynx T4

A

intracranial extension, cranial nerves, hypopharynx, orbit, parotid gland, or extension lateral to lateral pterygoid muscle

73
Q

Nasopharynx N1

A

unilateral node(s) <6cm above the caudal edge of the cricoid

74
Q

Nasopharynx N2

A

bilateral nodes <6cm above the caudal edge of the cricoid

75
Q

Nasopharynx N3

A

node >6cm or below the caudal edge of the cricoid

76
Q

Nasopharynx Stage II

A

T0-1N1 or T2N0-1

77
Q

Nasopharynx Stage III

A

T0-2N2 or T3N0-2

78
Q

Nasopharynx Stage IVA

A

any T4 or N3

79
Q

Nasopharynx Stage IVB

A

M1

80
Q

Oropharynx (p16-) T1

A

<2cm

81
Q

Oropharynx (p16-) T2

A

2-4cm

82
Q

Oropharynx (p16-) T3

A

>4cm or extension to lingual surface of epiglottis

83
Q

Oropharynx (p16-) T4a

A

larynx, extrinsic tongue muscles, medial pterygoid, hard palate, mandible

84
Q

Oropharynx (p16-) T4b

A

lateral pterygoid, pterygoid plates, lateral nasopharynx, skull base, encasing carotid

85
Q

Hypopharynx T1

A

<2cm and one subsite

86
Q

Hypopharynx T2

A

2-4cm or multiple subsites

87
Q

Hypopharynx T3

A

>4cm,fixation of hemilarynx, extension to esophagus

88
Q

Hypopharynx T4a

A

thyroid/cricoid cartilage, hyoid bone, thyroid gland, esophageal muscle, pre-laryngeal soft tissue

89
Q

Hypopharynx T4b

A

prevertebral fascia, mediastinal structures, encasing carotid

90
Q

Oropharynx (p16+) T1

A

<2cm

91
Q

Oropharynx (p16+) T2

A

2-4cm

92
Q

Oropharynx (p16+) T3

A

>4cm or extension to lingual surface of epiglottis

93
Q

Oropharynx (p16+) T4

A

larynx, extrinsic tongue muscles, medial pterygoid, hard palate, mandible, or beyond

94
Q

Oropharynx (p16+) Clinical N1

A

ipsilateral node(s) <6cm

95
Q

Oropharynx (p16+) Clinical N2

A

bilateral or contralateral nodes <6cm

96
Q

Oropharynx (p16+) Clinical N3

A

node >6cm

97
Q

Oropharynx (p16+) Pathological N1

A

1-4 nodes

98
Q

Oropharynx (p16+) Pathological N2

A

5+ nodes

99
Q

Oropharynx (p16+) Clinical Stage I

A

T0-2N0-1

100
Q

Oropharynx (p16+) Clinical Stage II

A

T0-2N2 or T3N0-2

101
Q

Oropharynx (p16+) Clinical Stage III

A

any T4 or N3

102
Q

Oropharynx (p16+) Clinical Stage IV

A

M1

103
Q

Oropharynx (p16+) Pathological Stage I

A

T0-2N0-1

104
Q

Oropharynx (p16+) Pathological Stage II

A

T0-2N2 or T3-4N0-1

105
Q

Oropharynx (p16+) Pathological Stage III

A

T3-4N2

106
Q

Oropharynx (p16+) Pathological Stage IV

A

M1

107
Q

5 subsites of supraglottic larynx

A

false vocal cords, arytenoids, suprahyoid epiglottis, infrahyoid epiglottis, aryepiglottic folds

108
Q

Supraglottic larynx T1

A

one supraglottic subsite

109
Q

Supraglottic larynx T2

A

more than one supraglottic subsite, glottis, region outside the supraglottis (mucosa of base of tongue, vallecula, medial wall of pyriform sinus)

110
Q

Supraglottic larynx T3

A

vocal cord fixation, postcricoid area, pre-epiglottic tissues, paraglottic space, inner cortex of thyroid cartilage

111
Q

Supraglottic larynx T4a

A

outer cortex of thyroid cartilage, tissues beyond the larynx

112
Q

Supraglottic larynx T4b

A

prevertebral space, mediastinal structures, encasing carotid

113
Q

Glottic larynx T1a

A

involves one vocal cord (normal mobility)

114
Q

Glottic larynx T1b

A

involves both vocal cords (normal mobility)

115
Q

Glottic larynx T2

A

impaired vocal cord mobility or involving supraglottic or subglottic larynx

116
Q

Glottic larynx T3

A

vocal cord fixation, inner cortex of thyroid cartilage, paraglottic space

117
Q

Glottic larynx T4a

A

outer cortex of thyroid cartilage, tissues beyond the larynx

118
Q

Glottic larynx T4b

A

prevertebral space, mediastinal structures, encasing carotid

119
Q

Subglottic larynx T1

A

limited to subglottis

120
Q

Subglottic larynx T2

A

extends to vocal cords with normal or impaired vocal cord mobility

121
Q

Subglottic larynx T3

A

vocal cord fixation, inner cortex of thyroid cartilage, paraglottic space

122
Q

Subglottic larynx T4a

A

cricoid cartilage, thyroid cartilage, tissues beyond larynx

123
Q

Subglottic larynx T4b

A

prevertebral space, mediastinal structures, encasing carotid

124
Q

Maxillary sinus T1

A

tumor limited to mucosa of maxillary sinus WITHOUT bone invasion

125
Q

Maxillary sinus T2

A

bone invasion (excluding posterior wall)

126
Q

Maxillary sinus T3

A

posterior wall of maxillary sinus, subcutaneous tissues, floor or medial wall of orbit, pterygod fossa, ethmoid sinuses

127
Q

Maxillary sinus T4a

A

anterior orbit, skin, pterygoid plates, infratemporal fossa, cribriform plate, sphenoid sinus, frontal sinus

128
Q

Maxillary sinus T4b

A

orbital apex, dura, brain, middle cranial fossa, cranial nerves (excluding V2), nasopharynx, clivus

129
Q

Nasal Cavity and Ethmoid Sinus T1

A

one subsite with or without bone invasion

130
Q

Nasal Cavity and Ethmoid Sinus T2

A

two subsites or extending to an adjacent region

131
Q

Nasal Cavity and Ethmoid Sinus T3

A

floor or medial wall of orbit, maxillary sinus, palate, cribriform plate

132
Q

Nasal Cavity and Ethmoid Sinus T4a

A

anterior orbit, skin, anterior cranial fossa, pterygoid plates, sphenoid sinus, frontal sinus

133
Q

Nasal Cavity and Ethmoid Sinus T4b

A

orbital apex, dura, brain, middle cranial fossa, cranial nerves (excluding V2), nasopharynx, clivus

134
Q

Salivary gland T2

A

2-4cm without clinical extraparenchymal extension

135
Q

Salivary gland T3

A

>4cm or clinical extraparenchymal extension

136
Q

Salivary gland T4a

A

skin, mandible, ear canal, facial nerve

137
Q

Salivary gland T4b

A

skull base, pterygoid plates, encasing carotid

138
Q

Mucosal melanoma T3

A

limited to mucosa and immediately underlying soft tissue

139
Q

Mucosal melanoma T4a

A

deep soft tissue, cartilage, bone, skin

140
Q

Mucosal melanoma T4b

A

brain, dura, skull base, cranial nerves 9-12, masticator space, carotid artery, prevertebral space, mediastinal structures

141
Q

Mucosal melanoma N1

A

positive node(s)

142
Q

H/N Cutaneous SCCa T2

A

2-4cm

143
Q

H/N Cutaneous SCCa T3

A

>4cm, minor bone erosion, perineural invasion, subcutaneous fat

144
Q

H/N Cutaneous SCCa T4a

A

gross cortical bone invasion

145
Q

H/N Cutaneous SCCa T4b

A

skull base or skull base foramen

146
Q

Merkel cell T2

A

diameter 2-5cm

147
Q

Merkel cell T4

A

invades fascia, muscle, cartilage, or bone

148
Q

Merkel N1-3

A

N1 positive nodes without in-transit mets

N2 in-transit mets and negative nodes

N3 in-transit mets and positive nodes

149
Q

Merkel stage II

A

T2-4N0

150
Q

Merkel stage III

A

N+

151
Q

Melanoma T2

A

>1.0-2.0mm

152
Q

Melanoma T4

A

>4mm

153
Q

Melanoma N2a-c

A

N2a 2-3 occult nodes

N2b 2-3 clinical nodes

N2c one node and in-transit metastases

154
Q

Melanoma stage II

A

T2b-4bN0

155
Q

Melanoma stage III

A

N+

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