Head/Neck Flashcards
1
Q
General H/N Clinical N2a
A
single ipsilateral node 3-6cm and ENE(-)
2
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
3
Q
Tonsil cancer: 2yr OS and LC for T1N0 and T2N0
A
2yr OS 95%
2yr LC:
T1 90%
T2 80%
4
Q
Glottic larynx T1a
A
involves one vocal cord (normal mobility)
5
Q
Oropharynx (p16+) Pathological N1
A
1-4 nodes
6
Q
Supraglottic larynx T3
A
vocal cord fixation, postcricoid area, pre-epiglottic tissues, paraglottic space, inner cortex of thyroid cartilage
7
Q
Nasal Cavity and Ethmoid Sinus T2
A
two subsites or extending to an adjacent region
8
Q
Merkel stage III
A
N+
9
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
10
Q
Nasopharyngeal cancer: anatomy
A
learn special nerves (Jacobs, Villaret etc…) and skull base anatomy
11
Q
Mucosal melanoma T3
A
limited to mucosa and immediately underlying soft tissue
12
Q
Lip and oral cavity T1
A
<2cm, DOI <5mm
13
Q
General H/N Clinical N2c
A
bilateral or contralateral nodes <6cm and ENE(-)
14
Q
Nasal Cavity and Ethmoid Sinus T1
A
one subsite with or without bone invasion
15
Q
Glottic larynx T2
A
impaired vocal cord mobility or involving supraglottic or subglottic larynx
16
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
17
Q
Esthesioneuroblastoma: treatment paradigm
A
Kadish A: surgery alone
Kadish B/C: surgery then adjuvant xrt to 60Gy (with ENI)
Unresectable: pre-op 50 Gy with chemo followed by surgery
Not surgical candidate: 70Gy +/- chemo
18
Q
Oral cavity cancer: indications for post-op xrt
A
T2 with greater than 5 mm, T3-4, N+, LVSI, PNI, close/positive margins
19
Q
Hypopharynx T1
A
<2cm and one subsite
20
Q
Melanoma stage II
A
T2b-4bN0
21
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)
22
Q
General H/N Pathological N1
A
single ipsilateral node <3cm and ENE(-)
23
Q
Mucosal melanoma N1
A
positive node(s)
24
Q
General H/N Pathological N3a
A
node >6cm and ENE(-)
25
Melanoma N2a-c
N2a 2-3 occult nodes
N2b 2-3 clinical nodes
N2c one node and in-transit metastases
26
T2 Larynx: 5yr LC and OS
5yr LC 75%
5yr OS 60%
27
Oropharynx (p16+) Pathological Stage II
T0-2N2 or T3-4N0-1
28
Glottic larynx T3
vocal cord fixation, inner cortex of thyroid cartilage, paraglottic space
29
General H/N Stage I
T1N0
30
Nasopharynx T4
intracranial extension, cranial nerves, hypopharynx, orbit, parotid gland, or extension lateral to lateral pterygoid muscle
31
Lip and oral cavity T2
2-4cm, DOI 5-10mm
32
Salivary gland T4a
skin, mandible, ear canal, facial nerve
33
Nasopharynx N1
unilateral node(s) \<6cm above the caudal edge of the cricoid
34
Postop Larynx: fields
Postop bed, levels II-VI to bilateral neck
When discussing borders don't forget that the hyoid and cricoid are removed after larygectomy
35
H/N Cutaneous SCCa T4b
skull base or skull base foramen
36
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
37
Melanoma T4
\>4mm
38
Mucosal melanoma T4b
brain, dura, skull base, cranial nerves 9-12, masticator space, carotid artery, prevertebral space, mediastinal structures
39
Nasopharynx N3
node \>6cm or below the caudal edge of the cricoid
40
Nasopharynx Stage IVB
M1
41
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
42
Salivary gland T3
\>4cm or clinical extraparenchymal extension
43
Supraglottic cancer: 5yr OS stage I-IV
5yr OS
stage I 50%
stage II 50%
stage III 45%
stage IV 30%
44
Lip and oral cavity T3
\>4cm, DOI \>10mm
45
Hypopharynx T2
2-4cm or multiple subsites
46
Oropharynx (p16+) Pathological Stage I
T0-2N0-1
47
General H/N Stage IVB
T4b or N3
48
Merkel N1-3
N1 positive nodes without in-transit mets
N2 in-transit mets and negative nodes
N3 in-transit mets and positive nodes
49
Hypopharynx T4a
thyroid/cricoid cartilage, hyoid bone, thyroid gland, esophageal muscle, pre-laryngeal soft tissue
50
Oropharynx (p16+) Pathological N2
5+ nodes
51
Unilateral tonsil: doses
70/63/56 (2/1.8/1.6) 35 fx
52
General H/N Pathological N2c
bilateral or contralateral nodes \<6cm and ENE(-)
53
Subglottic larynx T2
extends to vocal cords with normal or impaired vocal cord mobility
54
Merkel stage II
T2-4N0
55
Hypopharynx T4b
prevertebral fascia, mediastinal structures, encasing carotid
56
Subglottic larynx T4a
cricoid cartilage, thyroid cartilage, tissues beyond larynx
57
Nasal Cavity and Ethmoid Sinus T4a
anterior orbit, skin, anterior cranial fossa, pterygoid plates, sphenoid sinus, frontal sinus
58
Oropharynx (p16-) T4b
lateral pterygoid, pterygoid plates, lateral nasopharynx, skull base, encasing carotid
59
Supraglottic larynx T2
more than one supraglottic subsite, glottis, region outside the supraglottis (mucosa of base of tongue, vallecula, medial wall of pyriform sinus)
60
T2 Larynx: dose and field
(only if confined to glottis)
65.25 in 29 fx, finish in \<44 days
Sup border: hyoid
Inf border: 1st tracheal ring
61
Mucosal melanoma T4a
deep soft tissue, cartilage, bone, skin
62
Nasal Cavity and Ethmoid Sinus T4b
orbital apex, dura, brain, middle cranial fossa, cranial nerves (excluding V2), nasopharynx, clivus
63
Subglottic larynx T4b
prevertebral space, mediastinal structures, encasing carotid
64
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
65
T1 Larynx: 5yr LC and OS
5yr LC 90%
5yr OS 80%
66
Maxillary sinus T2
bone invasion (excluding posterior wall)
67
Nasopharyngeal cancer: workup
H&P, family history, assess social support, smoking, alcohol, head and neck exam, noting teeth condition, cranial nerves, flex nasolaryngoscopy
FNA biopsy of node if possible
Labs: CBC, CMP, TSH, EBV
Imaging: MRI skull base, CT neck/chest, PET
dental, port, PEG tube, nutrition, audiology, **ophthalmology**, speech and swallowing evaluation, smoking cessation / alcohol counseling
68
Esthesioneuroblastoma: long term OS for Kadish A/B/C
A 70%
B 60%
C 50%
69
5 subsites of supraglottic larynx
false vocal cords, arytenoids, suprahyoid epiglottis, infrahyoid epiglottis, aryepiglottic folds
70
contraindications to laryngeal preservation
T4
extension of 1 cm to BOT
Bulky tumor: 3.5 cm3 for glottic and 6cm3 for supraglottic
Poor swallowing or speech
71
Glottic larynx T1b
involves both vocal cords (normal mobility)
72
Head and Neck: constraints for larynx, pharyngeal constrictors, and cervical esophagus
larynx mean 44Gy, max 66Gy
constrictors 50Gy
cervical esophagus V45 \< 33%
73
Oropharynx (p16+) Clinical N3
node \>6cm
74
Oropharynx (p16+) Pathological Stage III
T3-4N2
75
Supraglottic cancer: radiation dose and volumes
70/63/56 (2/1.8/1.6) 35 fx
always treat bilateral neck II-IV
76
Melanoma: indications for adjuvant xrt
ECE
parotid: 1+ node
cervical: 2+ nodes or node\>3cm
axillary: 2+ nodes or node \>3cm
inguinal: 3+ nodes or node \>4cm
77
Nasopharynx Stage III
T3 or N2
78
Glottic larynx T4a
outer cortex of thyroid cartilage, tissues beyond the larynx
79
General H/N Clinical N3b
clinically overt ENE(+)
80
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
81
Head and Neck: constraints for lips and oral cavity
oral cavity \<39
Lips mean \<20 Gy, max 50 Gy
82
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)
83
Merkel cell T2
diameter 2-5cm
84
Merkel cell T4
invades fascia, muscle, cartilage, or bone
85
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
86
Oropharynx (p16-) T4a
larynx, extrinsic tongue muscles, medial pterygoid, hard palate, mandible
87
Oropharynx (p16+) Clinical Stage IV
M1
88
General H/N Pathological N2a
single ipsilateral node 3-6cm and ENE(-) OR single ipsilateral node \<3cm and ENE(+)
89
Oropharynx (p16+) Clinical Stage III
T4 or N3
90
Head and Neck: constraints for brachial plexus, temporal lobes, and brainstem/chiasm/optic nerves
Brachial plexus \<66 Gy
Temporal lobes \<60 Gy
brainstem/chiasm/optic nerves\<54 Gy (1cc brainstem to 60 Gy)
91
H/N Cutaneous SCCa T2
2-4cm
92
Oropharynx T3
\>4cm or extension to lingual surface of epiglottis
93
Oropharynx (p16+) Clinical Stage I
T2 or N1
94
Subglottic larynx T3
vocal cord fixation, inner cortex of thyroid cartilage, paraglottic space
95
H/N Cutaneous SCCa T3
\>4cm, minor bone erosion, perineural invasion, subcutaneous fat
96
Nasopharynx T0
no tumor identified but EBV(+) cervical nodes
97
Lip and oral cavity T4b
invades masticator space, pterygoid plates, skull base, or encasing carotid
98
Oropharynx (p16+) Clinical N1
ipsilateral node(s) \<6cm
99
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
100
General H/N Pathological N2b
multiple ipsilateral nodes \<6cm and ENE(-)
101
T1 Larynx: dose and field
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
102
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
103
H/N Cutaneous SCCa T4a
gross cortical bone invasion
104
General H/N Clinical N1
single ipsilateral node \<3cm and ENE(-)
105
Oropharynx cancer: options for HPV testing
first test p16
if negative but suspicious then test HPV PCR
106
Melanoma T2
\>1.0-2.0mm
107
Supraglottic larynx T4b
prevertebral space, mediastinal structures, encasing carotid
108
Oropharynx cancer: 3yr OS for low/intermediate/high risk groups
3-yr OS:
Low risk 90%
Int risk 70%
High risk 50%
109
Maxillary sinus T3
posterior wall of maxillary sinus, subcutaneous tissues, floor or medial wall of orbit, pterygod fossa, ethmoid sinuses
110
Supraglottic larynx T4a
outer cortex of thyroid cartilage, tissues beyond the larynx
111
Maxillary sinus T1
tumor limited to mucosa of maxillary sinus WITHOUT bone invasion
112
Supraglottic larynx T1
one supraglottic subsite
113
Oropharynx (p16+) T4
larynx, extrinsic tongue muscles, medial pterygoid, hard palate, mandible, or beyond
114
General H/N Pathological N3b
ENE(+) that doesn't meet criteria for N2a
115
Nasopharyngeal carcinoma: 5yr OS for T2-4 or N+
5yr OS 70%
116
ACR approriateness criteria for unilateral tonsil treatment
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)
117
General H/N Stage II
T2N0
118
Salivary gland T2
2-4cm without clinical extraparenchymal extension
119
Oropharynx (p16+) Clinical Stage II
T3 or N2
120
Head and Neck: Sim
supine with chin extended, long mask, wire scar.
Consider: bite block, bolus scar for ECE, contrast
121
Oral cavity cancer: doses
6996/5940/5412 (2.12/1.8/1.64) 33 fx
122
Nasopharynx T3
skull base, pterygoid plates, cervical vertebra, paranasal sinuses
123
General H/N Stage IVC
M1
124
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
125
Glottic larynx T4b
prevertebral space, mediastinal structures, encasing carotid
126
Subglottic larynx T1
limited to subglottis
127
Hypopharynx T3
\>4cm,fixation of hemilarynx, extension to esophagus
128
Nasopharynx Stage II
T2 or N1
129
Head/neck cancer: 5yr OS with adjuvant chemoradiation on Cooper/Bernier
5yr OS 50%
130
General H/N Clinical N2b
multiple ipsilateral nodes \<6cm and ENE(-)
131
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)
132
Nasal Cavity and Ethmoid Sinus T3
floor or medial wall of orbit, maxillary sinus, palate, cribriform plate
133
Hypopharynx cancer: 5yr OS and laryngeal preservation for stage III-IV
5yr OS 35%
5ry laryngeal preservation 35%
134
Oropharynx T2
2-4cm
135
General H/N Stage IVA
T4a or N2
136
Nasopharynx N2
bilateral nodes \<6cm above the caudal edge of the cricoid
137
Oropharynx (p16+) Pathological Stage IV
M1
138
Head and Neck: Workup
H&P, family history, assess social support, smoking, alcohol, head and neck exam, noting teeth condition, cranial nerves, flex laryngoscopy (esp for larynx), palpation of mass in mouth
FNA biopsy of node if possible
Labs: CBC, CMP, TSH
Imaging: CT neck/chest, PET for stage III-IV
consider DL/biopsy and videostrobe
dental, port, PEG tube, nutrition, audiology, speech and swallowing evaluation, smoking cessation / alcohol counseling
139
Nasopharynx Stage IVA
T4 or N3
140
Maxillary sinus T4a
anterior orbit, skin, pterygoid plates, infratemporal fossa, cribriform plate, sphenoid sinus, frontal sinus
141
Oropharynx T1
\<2cm
142
Maxillary sinus T4b
orbital apex, dura, brain, middle cranial fossa, cranial nerves (excluding V2), nasopharynx, clivus
143
Nasopharynx T2
parapharyngeal space, medial/lateral pterygoids, prevertebral muscles
144
Oropharynx (p16+) Clinical N2
bilateral or contralateral nodes \<6cm
145
Hypopharynx cancer: dose and volumes for stage III-IV
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
146
General H/N Clinical N3a
node \>6cm and ENE(-)
147
T1 Larynx: dosimetry
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%
148
General H/N Stage III
T3 or N1
149
Larynx: 5yr larynx preservation and OS for stage III and IV
5yr larynx preservation:
80% for stage III
60% for stage IV
5yr OS:
45% for stage III
35% for stage IV
150
Melanoma stage III
N+
151
Salivary gland T4b
skull base, pterygoid plates, encasing carotid
152
Head/Neck: nodal drainage for oropharynx, larynx, hypopharynx, nasopharynx, and oral cavity
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
