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Rad Onc Oral Boards > HN > Flashcards

HN Flashcards

1
Q

LVL IA boundaries

A

submental - Lat: ant. belly digastric, Inf: inf hyoid

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2
Q

LVL II boundaries

A

sup. cervical -
Sup: trans. process of C1
Inf: hyoid,
Post: SCM,
Medial: ICA,
Lat: SCM,
Ant: SCM

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3
Q

LVL III boundaries

A

III: mid-cervical -
Sup: inf. hyoid,
inf: inf. cricoid,
same other borders as II:
Post: SCM,
Medial: ICA,
Lat: SCM,
Ant: SCM

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4
Q

LVL IV boundaries

A

IV: inf. cervical –
Sup: inf. edge of cricoid,
Inf: 2 cm above manubrium
same other borders as II:
Post: SCM,
Medial: ICA,
Lat: SCM,
Ant: SCM

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5
Q

PNI definition

A

PNI – nerve >0.1 mm

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6
Q

H/P

A

History: dysphagia, odynophagia, otalgia, CN deficits

Physical: HEENT, CN, fiberoptic NPL, LN

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7
Q

H/N Workup

A

Imaging: CT head/neck + C, PET/CT, MRI if BOS invasion (or any NPC)

Biopsy:

  • EUA w/ bx (oropx, larynx, hypopx)
  • Panendoscopy – includes nasopharyngoscopy, laryngo, bronch (larynx, hypopx)
  • get HPV status

Other: SANDS
Speech and swallow eval
Audiology
Nutrition
Dental eval

Smoking Cessation

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8
Q

Indications for PEG tube placement:

A

Indications for PEG tube placement:

  • severe weight loss prior to tx (5% in 1 month, 10% in 6 months)
  • severe dysphagia
  • high aspiration risk
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9
Q

Radical neck dissection

A

Radical – removes I-V, SCM, omohyoid, internal and external jug veins, CN XI, submandibular gland

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10
Q

MR neck dissection

A

Modified radical – leaves >= 1 of SCM, internal jug, or CN XI

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11
Q

Selected neck dissection

A

Selected neck dissection – leaves >= 1 lymph node level

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12
Q

Supraomohyoid dissection

A

Supraomohyoid dissection – removes I-III

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13
Q

Lateral neck dissection

A

Lateral neck dissection – removes II-IV

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14
Q

New classification (NCCN) of neck dissection
Comprehensive
Selective

Neck dissection
N0: Selective
OC
OPX
HPX/LX
N1-N2:
N3:

A 
New classification (NCCN) 
Comprehensive – removes all LN groups I-V (generally done for N+ disease) 
Selective – site specific depending on nodes at risk (OC I-III or upper IV, pharynx/larynx II-IV and VI for subglottic

Neck dissection
N0: Selective
OC I-III
OPX II-IV
HPX/LX II-IV, VI if subglottic ext
N1-N2: Selective or comprehensive
N3: Comprehensive

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15
Q

General treatment paradigm

A

T1-T2: surgery or RT alone
T3 or N+: CRT

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16
Q

Concurrent Chemo

A

Cisplatin 100 mg/m2 q 3 weeks x 3 cycles

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17
Q

Post-op RT to primary:

A

Post-op RT to primary:
pT3/4
PNI
LVI
Close Margins (<5 mm)
OC primary w level IV/V LN

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18
Q

Post-op RT to neck:

A

Post-op RT to neck: N2 or N3 (single large node or multiple nodes)

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19
Q

Post-op CRT:

A

Post-op CRT: ECE, +margins

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20
Q

When can treat only ipsilateral neck

A

Can treat ipsilateral neck for well-lateralized TBARS:
-tonsil – 1 cm involvement of BOT and 1 cm involvement of soft palate, 1 node

Maybe:

  • buccal
  • alveolar ridge
  • RMT
  • salivary
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21
Q

package time

A

package time < 11 weeks (means should start RT < 6 weeks after surgery)

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22
Q

Post-op RT: volumes

A

Post-op RT:
30 fractions: 60/2, 54/1.8
For ECE or + margins (or close!), 66/2 (59.4/1.8 int, and 54/1.64 low risk)

CTV\_66= (areas of pos margin or ECE) + 0.5-1 cm 
CTV\_60= (pre-op GTV + tumor bed + 1 cm) and high-risk nodes (1st echelon) 
CTV\_54= low risk nodes (2nd echelon and contralat if indicated)
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23
Q

Treatment volumes script

A

Script:

  • IMRT will be used for parotid-sparing
  • Contour the primary and nodal GTV’s defined by preoperative physical examination, operative reports (e.g. exam under anesthesia) and imaging. These will be expanded by 5 mm to make the CTV70
  • I will then make an additional 5 mm margin on CTV70 and include areas of potential spread, to make the CTV63. The involved lymph node level will also be CTV63. The remainder of nodal groups will be delineated as CTV56

-an additional 3 mm will be added to create the PTVs

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24
Q

Constraints

  • Brainstem/Optic Nerve
  • Cord
  • Mandible (– PTV)
  • Oral cavity (uninvolved)
  • Brachial plexus
  • Constrictors
  • Larynx – PTV
  • Submandibular
  • Parotid
  • Esophagus

For nasal cavity/NPX:

  • Pituitary
  • Retina/cornea/cochlea
  • Lens
  • Temporal lobe
A
  • Brainstem/Optic Nerve max 54 Gy
  • Cord max 45 Gy
  • Mandible (– PTV) max 70
  • Oral cavity (uninvolved) mean < 30 (if achievable)
  • Brachial plexus max 66 Gy
  • Constrictors mean < 55 Gy (as low as possible)
  • Larynx – PTV mean < 20 Gy
  • Submandibular mean < 39 Gy
  • Parotid mean < 26 Gy; ALARA if neck involved
  • Esophagus mean < 35 Gy (when achievable)

For nasal cavity/NPX:

  • Pituitary mean dose < 40 Gy
  • Retina/cornea/cochlea max 45 Gy (cornea max 45)
  • Lens max 10 Gy
  • Temporal lobe (bilat) max < 60-70 Gy
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25
Q

Follow-up:

A

Follow-up:

  • F/u imaging within 6 months of tx (PET/CT at 3 months if definitive), then as indicated (not routine)
  • H&P (w/ NLscope) Q3-6mo for 5yrs, then annually
  • Thyroid eval (TSH) q 6-12 months. 25% develop hypothyroidsim
  • Carotid eval
  • Dental
  • Speech and swallow as needed
  • Audiology
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26
Q

Nasopharynx T and N stage

A

T1 –confined to nasopharynx and/or adj oropharynx/nasal cavity
T2 – “soft stuff” parapharyngeal extension, pterygoid muscles, prevertebral muscles
T3 – “hard stuff” bony skull base/spine/pterygoid or bony sinus
T4 – “bad stuff” intracranial, CN palsy, hypopharynx, parotid, orbit, or soft tissue beyond lateral pterygoid muscle

N1 – unilateral, RP (uni/bi) < 6 cm
N2 – bilateral < 6 cm (bilat RP only still N1)
N3 – any level below cricoid(IV, low V) or >6cm

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27
Q

Nasopharynx Overall stage

A

Overall: T or N+1:

I – T1 N0
II – T2 and/or N1
III – T3 and/or N2
IVA – T4 and/or N3
IVB – M1

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28
Q

NPX WHO types

A

WHO
I – tobacco/EtOH (US) – keratinizing SCC (worse LC and OS)
II – non keratinizing
A – differentiated
B – undifferentiated (EBV, Asia)
III – basaloid

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29
Q

NPX borders

A

Nasopharynx borders:
sup – sphenoid bone/base of skull
inf – roof of soft palate
ant – nasal chonae
post – clivus, C1 (C2)

Rosenmuller’s fossa – posterior to torus tubaris, most common cancer location

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30
Q

NPX extra workup

A

Extra work-up:
H&P with attn to epistaxis, CN palsy, trismus, otalgia

Labs: EBV IgA/DNA titers

Imaging:
MRI primary and base of skull
PET/CT for all

  • if initially elevated, follow EBV titers during surveillance (consider first follow-up 1-4 weeks post-CRT)
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31
Q

Trismus indicates

A

Trismus – masticator space (pterygoids) invasion

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32
Q

NPX T1N0 treatment

A

T1N0 – RT alone

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33
Q

NPX T2 N0

A

Concurrent cis-RT
-concurrent q3week Cis 100 mg/m2

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34
Q

NPX T3 or N1

A

induction cis 80 mg/m2 + gem 1000 mg d1/d8 q3 weeks x 3 cycles ->

Concurrent cis-RT
-concurrent q3week Cis 100 mg/m2

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35
Q

NPX high risk factors

A

Bulky tumor, high EBV levels

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36
Q

NPX volumes

A

IMRT – 33 fx
70/2.12, 59.4/1.8, 54/1.64

CTV_70 – (primary + involved nodes) + 5 mm (1mm at critical structures like brainstem)

CTV_59.4: GTV + 10 mm and

  • entire NP
  • superiorly: inf half of sphenoid sinus; entire vomer and post/inf ethmoid sinus (bony nasal septum); B/L foramen ovale, rotunda, lacera,
  • ant: post 1/4 nasal cavity and max sinus, bilat PPF
  • lat: parapharyngeal space, pterygoid muscles
  • post: anterior 1/3 of clivus (whole if involved)
  • 1st echelon nodes (RP, II, III, Va)
  • If T3/T4 – entire sphenoid sinus, I/L cavernous sinus; consider jugular foramen, hypoglossal canal for posterolateral infiltration by primary

Level IV can get 54 – all other levels 59.4

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37
Q

NPX OS 3 yr

A

I – 85%
II – 75%
III – 65%
IV – 55%

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38
Q

NPX late side effects and followup

A

Late:

  • cranial neuropathy
  • trismus
  • soft tissue fibrosis
  • xerostomia
  • hearing loss
  • osteoradionecrosis
  • temporal lobe necrosis
  • hypothyroidism
  • vasculopathy

Follow-up:
-Can add MRI to general paradigm (PET) at 12 weeks

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39
Q

OC regions

A

Lip
Gingiva/Alveolar Ridge
Buccal mucosa
Retromolar trigone
Hard palate
Oral tongue (ant 2/3)
Floor of mouth

Lower lip numbness = inf alveolar nerve involvement

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40
Q

OC H/P

A

History: non-healing ulcer, pain, bleeding, loose teeth, ill-fitting dentures, bad breath, neck mass

Physical: attn. to tongue mobility, floor of mouth, neck exam

15% skip mets to level IV for oral tongue (not addressed in supraomohyoid LN dissection I-III)

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41
Q

OC T stage

A

T1 - ≤ 2cm and DOI ≤ 5mm
T2 – 2.1-4 cm and/or DOI >5-10mm
T3 - >4cm and/or DOI >10-20mm
T4a –
Lip: through bone, inf alv nerve, FOM, face skin
OC: bone, maxillary sinus, face skin, DOI >20mm
T4b – masticator space, pterygoid plates, skull base, carotid encasement

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42
Q

OC overall stage

A

T or N+2

I – T1N0
II – T2N0
III – T3 or N1
IVA – T4a or N2
IVB – T4b or N3
IVC – M1

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43
Q

N stage

A

cN1 – single ipsi node ≤ 3 cm
cN2a – single I/L node 3 - 6 cm
cN2b – multiple ipsi nodes ≤ 6 cm
cN2c – bilat or contralat nodes ≤ 6 cm
cN3a – > 6cm
cN3b – clinically overt ECE

Same as above except:
pN2a – includes single I/L node <3cm with pathologic ECE

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44
Q

OC post op Indications for RT

A

Indications for RT

  1. T3/T4
  2. DOI > 5mm
  3. Close margin (< 5 mm)
  4. LVSI
  5. PNI
  6. N2+
  7. Level IV/V LN

=> for boards, irradiate primary and nodes together always

Post-op CRT:
+ margin, + ECE

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45
Q

Lip volumes
commissure involved
upper lip

A

Lip:
some say Definitive RT favored for lip commissure but not in NCCN

If commissure involved, cover Ib and II to 54 Gy (low risk)
If upper lip, cover facial nodes
-lead shield

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46
Q

Lip

  1. inf alveolar nerve involvement
  2. Skin involvement
  3. bone invasion
A

** if inf alveolar nerve involvement, cover through to mandible (high risk CTV)

** if skin involvement, cover facial nodes (Moustache field)

** remember: if bone invasion upfront, do surgery because RT has risk of radionecrosis

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47
Q

OC general treatment paradigm

A

Resectable: Surgery
-Neck dissection for N+, DOI > 2 mm

Unresectable –
Stage I-II: definitive RT alone (EBRT + brachy)
Stage III-IV: CRT

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48
Q

Sim, dont forget

A

tongue depressor/bite block

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49
Q

Time between surgery and PORT

A

Time between surgery and PORT < 6 weeks

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50
Q

OC 1st echelon nodes

A

1st echelon nodes – bilateral Ib-III, top of IV

-can consider ipsilateral for buccal, RMT, possibly alveolar ridge if ipsi neck N0

-Cover Ia for FOM, oral tongue, inf alveolar ridge, lip
*don’t need RP nodes*

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51
Q

OC LC

A

RT and surgery equal LC for T1-T2N0 (75-80%)
Much worse with RT alone for T3/T4

III-IV LC 60%; OS 70%

Lip:
T1-2: LC and OS 95%
T3-4: LC 80%

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52
Q

Oral cavity 5yr OS

A

Oral cavity 5yr OS
Stage I – 90%
Stage II – 85%
Stage III – 75%
Stage IV – 55%

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53
Q

OPX sites

A

Sites:
soft palate,
tonsils,
BOT,
posterior pharyngeal wall
vallecula

54
Q

OPX borders

A

Soft Palate

Oral Tongue Pharyngeal wall

Hyoid

55
Q

Hot potato voice

A

Hot potato voice – BOT involvement

56
Q

OPX additional workup

A

Additional Workup:
H&P with attn to dysphagia, odynophagia, trismus, otalgia, HPV history, smoking, tobacco

HPV testing – either p16 IHC or HPV DNA FISH

*if not p16 tested, treat as HPV-

57
Q

OPX T stage

A

HPV negative
T1 – ≤ 2cm
T2 – 2.1-4 cm
T3 – >4cm or lingual epiglottis ext
T4a – larynx, medial pytergoid, mandible, muscle tongue extrinsic, hard palate
T4b – lateral nasopharynx, lateral pterygoid muscles, pterygoid plates, skull base, carotid encasement

HPV positive
T4a and T4b collapsed into T4

58
Q

OPX Trismus

A

Trismus suggests pterygoid involvement: T4b

59
Q

OPX overall stage

A

p16+ stage
Overall Clinical Stage greater of T-1 or N, only M1 is stage IV
Pathologic: same except T4N0-1 = II

P16-: T or N+2 (if N+)
T1N0 – I
T2N0 – II
T3, N1 – III
T4a, N2-3a – IVA
T4b, N3b – IVB

60
Q

OPX treatment Low risk (T1-2N0 or 1 small node (<3cm):

A

Low risk (T1-2N0 or 1 small node (<3cm):

  1. Surgery (TORS) -> chemo/RT as indicated
  2. Definitive RT alone

* do not do TORS + neck dissection if you suspect ECE because then they’ll get all 3 modalities

** for T2N1 tonsil, can treat ipsilateral neck but give chemo, but bilateral neck tx not wrong

61
Q

OPX treatment Int-High risk (T3-4, >1 node):

A

Int-High risk (T3-4, >1 node):
Concurrent chemoRT

-def chemoRT: cis 100mg/m2 q 3 wks + 70 Gy IMRT SIB

(if not chemo candidate) -RT+Cetuximab 400 mg/m2 loading dose, then 250 mg/m2 weekly w RT

-If not a candidate for chemo or cexutimab, but chemoRT indicated: RT 70 Gy in 35 fx, use 6 fx/week

TORS: not eligible if T3-4, more than minimal soft tissue palate extension, central BOT, trismus/other difficulties with exposure, radiographic or clinical ECE

62
Q

P16+ N stage

A

Clinical N
cN1 – one or more I/L ≤ 6 cm
cN2 – bilat or contralat nodes ≤ 6 cm
cN3 – > 6cm

Path N
pN1 – ≤ 4 LNs
pN2 – > 5 LNs

63
Q

OPX volumes

A

** CTV70 = GTV + 5mm, edited anatomically off skin, bone, air, etc.

** CTV63 = GTV + 10mm, edited anatomically and consider expand to include areas of potential spread

1st echelon nodes: cover bilateral II-IV, I/L vs. B/L RP
** in N+ neck, generally cover level V too
** if N+, cover ipsi nodes to BOS and low level IV

-ipsilateral 63, contra 56

64
Q

OPX tonsil when ipsi neck only okay

A

I/L neck RT for T1-2 N0-1 tonsil w/
at most 1 cm soft palate or BOT extension,
no post. wall involvement;
and at most I/L level II LN(s) involved, <3cm, no ECE

65
Q

OPX OS

A

OS3 by risk (Ang, NEJM 2010):
Low (HPV+, <10 pk-yr; HPV+, >10 pk-yr N1/2a): 90%

Intermediate (HPV+, >10 pk-yr N2b+): 70%

High: (HPV- >10 pk year or T4): 50%

66
Q

HPX borders and subsites

A

Pharynx from hyoid to cricoid

Subsites (3Ps):
Piriform sinuses (#1)
Posterior pharyngeal wall
Postcricoid area

67
Q

HPX staging

A

Generally same as larynx+
T1 – ≤ 2cm, one subsite
T2 – 2.1-4cm, or adj subsite or larynx
T3 - > 4cm, or hemilarynx fixation, or esophagus
T4a – thyroid/cricoid, hyoid bone, thyroid, central soft tissue (strap muscles, subQ fat)
T4b – prevertebral fascia, carotid artery, mediastinal structures

N stage => same as oral cavity
Overall Stage => same as oral cavity: T or N+2

68
Q

HPX T1, select T2, N0 treatment

A

T1/T2 N0:

1) Partial pharyngectomy (larynx preserving) w/ LND (with pretracheal and I/L paratracheal LN dissection)
- CI: inadequate PFTs (aspiration, want FEV1>70% predicted)

2) Definitive RT

69
Q

HPX T3-4 or N+

A

T3-4 or N+, resectable:
1) ChemoRT

2) TL w LND (preferred for T4a or non-functional larynx w high aspiration risk) -> RT or CRT as indicated

3) Induction chemo -> RT or surgery
- TPF q 3W x3c -> if CR -> RT alone
- if PR at primary or less, TL with LND -> RT or CRT

T3-4 or N+, unresectable:
ChemoRT

70
Q

HPX dose and volumes

A

Post-op RT:
30 fractions: 60/2, 54/1.8
for ECE of + margins, 66/2 (59.4/1.8 int, and 54/1.64 low risk)

1st echelon nodes: bilateral RP, II-IV; VI if thyroid cartilage, post-cricoid cartilage, or subglottis involved

CTV_63

  • old recs: should include entire HPX subsite, entire larynx, and high risk neck
  • new recs: for T2 and above, CTV_63 passes through part of thyroid cartilage, part of cricoid, part of hyoid, and may extend into the esophagus. CTV_63 may be extended 15 mm vertically, T1-2 incl at least ipsi arytenoid/post paraglottic space, T3-4 at least ipsi hemi-larynx
71
Q

HPX OS

A

Worst prognosis in H&N

Overall outcomes:
Larynx preservation: 60- 80% depending on method
OS5: 40 – 50%
LRR: 30%
DM: 25%

30% risk of pharyngocutaneous fistula formation after salvage total laryngectomy

72
Q

Supraglottis subsites and borders

A

FAVEA:
•False cords
•Arytenoids
Ventricles
Epiglottis
•Aryepiglottic folds

Borders:

Epiglottis

Petiole(epiglottis) Arytenoids

TVC

73
Q

Larynx Workup imaging

A

MRI w/ thin cuts

74
Q

Glottic T stage

A

General:

T1 – confined to site, nl mobility

T2 – adj site or impaired mobility

T3 – fixed or invasion into paraglottic space, inner cortex thyroid cart, pre-epiglottic space, postcricoid

T4a (same for all larynx)

  • O-TESTES

•Outer Thyroid Cartilage

Trachea (inf. to cricoid)

  • Extrinsic tongue muscles
  • Strap muscles
  • Thyroid
  • Esophagus
  • Soft tissue neck

T4b (same for all larynx)

  • •prevertebral fascia
  • •encases ICA
  • •invades mediastinal structures

Glottic

T1a – one cord

T1b – both cords

75
Q

Early (T1-T2N0) Glottic treatment

A

Early (T1-T2N0) Glottic - surgery vs def RT

  1. Def RT

T1- 63 Gy (2.25x28)

T2 - 65.25 (2.25x29)

  1. Surgery –
    1) Cordectomy (T1)
    - CI: ant commissure involvement
    2) Vertical hemilaryngectomy (T1, select T2)– can take ipsi and 1/3 of contralat cord, ½ thyroid cartilage; leaves cricoid and hyoid intact
    - CI: T3/T4 (fixed cord), select T2 (bilateral arytenoid, epiglottis, subglottic involvement)

** LC, larynx pres, OS same w RT or surg. Voice quality better w RT; swallowing better w surgery

** if T2 has extension to supraglottis/subglottis, treat the nodes as well

76
Q

TVC T1-2 fields

A

T1-T2, N0 – contour larynx first

Don’t just say-> T1- 5x5 field; T2 – 6x6 field

Iso at TVC

sup – top of thyroid cartilage (T2 inf hyoid)

inf – bottom of cricoid (T2 first trach ring below cricoid)

*about C4-6*

ant – 1 cm flash

post – ant vertebral body

Nodes for T2: bulky or extending sub or supraglottic – cover II and III with IMRT

  • opposed laterals with 15 or 30 degree wedges (heel anterior)
  • underwedge or bolus if ant commissure involvement and plan is cold anteriorly
  • no elective nodes unless supraglottic/subglottic extension (then electively tx level II-III)
  • keep hot spot < 103%
77
Q

TVC Advanced (T3 or N+) treatment

A

Advanced (T3 or N+)

  1. CRT (RTOG 91-11)
  2. TL w LND à RT or CRT as indicated (preferred if T4a)
    - Removes hyoid, thyroid, cricoid cartilage, epiglottis, strap muscles
    - Pt left w permanent trach & pharynx reconstruction (by suturing to BOT)
    - most commonly fail at stoma, base of tongue, neck nodes
  3. Induction chemo -> RT or surgery
    * -* TPF q 3W x3c-> if > PR à RT
    * - if < PR, TL with LND*
78
Q

TVC T3-T4, N+ volumes

A

T3-T4, N+

Def IMRT: dose painting

35 fractions: 70/2, 63/1.8, 56/1.6

- CTV 70 =

  • 1st echelon nodes: bilateral II-IV, VI if thyroid cartilage, post-cricoid cartilage, or subglottis involved (no level V)
  • high risk CTV should include entire larynx
  • low risk CTV: contralateral 2-4
79
Q

Larynx when to boost stoma

A

Boost stoma for:

T4 post-op

  1. Emergent tracheostomy
  2. Subglottic extension (> 5 mm inferior to TVC)
  3. Tumor invasion to soft tissues of neck
  4. Close/+ tracheal margin
  5. Scar crosses stoma (?)

** note: leave trach in during RT

80
Q

Post-op glottic:

A

Post-op glottic:

  • Review op note, pre-op imaging, discuss with surgeon
  • HR CTV (60-66): tumor bed and pre-op disease extent with 1.5-2 cm margin, stoma boost if needed
  • LR CTV (54-56): uninvolved nodal levels

-post-bed to 60, if close margins or ECE then 66

-dissected neck 60, undissected 54

81
Q

Larynx 5 yr OS

A

5 yr OS

Larynx

I – 80%, RT LC 90%

II – 60%, RT LC 80%

III – 50%

IV – 35%

82
Q

Larynx preservation RT and CRT

A

Larynx preservation

RT alone – 65%

Concurrent chemoRT – 85%

83
Q

Supraglottis T stage

A

Supra-

T1 •one subsite, normal VC mobility

T2 •> 1 adjacent subsite or involvement in immediate surrounding regions (ie BOT or piriform sinus)

T3: PPP-TV

  • post-cricoid
  • pre-epiglottic space
  • paraglottic space
  • (inner cortex) thyroid cartilage erosion
  • VC fixation

Much higher rate of LN positivity than glottis

84
Q

Supraglottis T1-2 treatment

A

T1-T2:

  1. Definitive RT – cover 2-4 bilateral to 56, gtv 70, larynx 63 – no chemo – discuss 6 fractions
  2. Supraglottic laryngectomy + LND -> RT or CRT for high risk features
    - Supraglottic laryngectomy –takes epiglottis, AE fold, false cords, hyoid if preglottic ext, upper ½ thyroid cartilage. Preserves 1 or both arytenoids, both TVCs – NOT TL!
    - CI: true glottis, ant commissure, fixed cord, inadequate PFTs (aspiration), bilateral arytenoid
85
Q

Supraglottis T3-T4 or N+: treatment

A

T3-T4 or N+:

  1. CRT if functional larynx with low risk aspiration
  2. TL + LND -> RT or CRT for high risk features (preferred if T4a)
86
Q

Supraglottis Volumes

A

Def IMRT: dose painting

35 fractions: 70/2, 63/1.8, 56/1.6

HR CTV includes – entire larynx, high risk nodes

1st echelon nodes: II-IV bilaterally

RP if hypopx involvement

Ipsi IB if level II involved

Cover level VI if subglottic extension

87
Q

Subglottis T stage

A

Sub-

T1: subglottis only

T2: extension to TVC (normal or impaired mobility)

T3: limited to larynx with fixed VC

88
Q

Subglottis T1-2 treatment

A

T1-T2:

  1. Definitive RT
89
Q

Subglottis T3-T4 or N+: treatment

A

T3-T4 or N+:

  1. CRT if functional larynx with low risk aspiration
  2. TL + LND -> RT or CRT for high risk features (preferred if T4a)
90
Q

Subglottis Volumes

A

1st echelon nodes: RP, bilateral II – IV and V

Cover stoma in high risk CTV in all cases

91
Q

PS sites

A

Sinus: maxillary*, frontal, ethmoid, sphenoid

92
Q

NC sites

A

NC: vestibule, septum, floor, lateral wall

93
Q

Ohngren’s line

A

Ohngren’s line – medial canthus to angle of mandible – upper does worse

Nasal cavity

94
Q

NC PS workup

A

Additional work-up:

Nasal endoscopy

MRI H&N

CT c/a/p or PET

SCC most common

95
Q

Nasal Cavity/Ethmoid T stage

A

Nasal Cavity/Ethmoid

T1 = 1 subsite, no bone inv

T2 = 2 subsites or bone inv

T3 = Cribiform plate, medial wall or floor of Orbit, Max sinus, or Palate (COMP)

T4a = Skin of nose/cheek, anterior orbital contents, pterygoid plates, sphenoid or frontal sinus, minimal anterior cranial fossa

T4b = orbital apex, dura, brain, middle cranial fossa, CN (not V2), NPX,

clivus

96
Q

Maxillary T stage

A

Maxillary

T1 = maxillary sinus mucosa, no bone

T2 = +bone erosion or ext to hard palate, middle nasal meatus (excludes posterior extension, i.e. post max sinus, pterygoid plates)

T3 = post wall bone erosion, SubQ tissue, floor or medial wall of orbit, pterygoid fossa, ethmoid sinuses

T4a = Skin of cheek, anterior orbital

contents, sphenoid/frontal sinuses,

infratemporal fossa, cribriform plate

T4b = same as NC above,

orbital apex, dura, brain, middle cranial fossa, CN (not V2), NPX,

clivus

97
Q

Esthesioneuroblastoma Staging

A

Esthesioneuroblastoma

Kadish staging:

A: confined to NC

B: involves NC and para-nasal sinus

C: extends beyond NC and paranasal sinus (including LN, DM, orbit, intracranial etc)

98
Q

Wang staging for nasal vestibule

A

Wang staging for nasal vestibule

T1 – confined to skin

T2 – invades subcutaneous tissue or cartilage

T3 – invades bone

99
Q

Nasal cavity and ethmoid sinus

T1N0: treatment

A

Nasal cavity and ethmoid sinus

T1N0:

1) Surgery -> PORT
- no PORT for low grade & neg margin
2) RT (70 Gy)

100
Q

Nasal cavity T2+ or N+: treatment

A

T2+ or N+:

Surgery → PORT

  • cover neck (bilateral IB and II) for SCC N0
  • cover IB–IV for N+
  • cover RP for posterior 1/3 nasal cavity

T1 = 1 subsite, no bone inv

T2 = 2 subsites or bone inv

T3 = Cribiform plate, medial wall or floor of Orbit, Max sinus, or Palate (COMP)

T4a = Skin of nose/cheek, anterior orbital contents, pterygoid plates, sphenoid or frontal sinus, minimal anterior cranial fossa

T4b = orbital apex, dura, brain, middle cranial fossa, CN (not V2), NPX,

clivus

101
Q

Maxillary sinus

T1-T2 N0: treatment

A

Maxillary sinus

T1-T2 N0:

Surgery → PORT to primary site for + margins, PNI, LVI, or ACC above Ohngren’s line

*discuss re-resection for +SM

102
Q

Maxillary sinus

T3-T4 or N+: treatment

A

Maxillary sinus

T3-T4 or N+:

Surgery (ND for N+) → PORT

No need for elective neck RT unless SCC or undifferentiated (consider for ACC)

N0: cover ipsi IB and II

N+: cover ipsi IB-IV (consider RP, V)

Cover ipsi neck only, unless tumor crosses midline

103
Q

SNUC: treatment

A

SNUC:

Induction cis-based chemo (retrospective) → surgery → PORT with coverage of bilateral IB and II

104
Q

Esthesioneuroblastoma:treatment

A

B

C

A

Esthesioneuroblastoma:

Kadish A: surgery (preferred) or RT (70 Gy)

Kadish B: Surgery → PORT

Kadish C: Surgery → PORT

*Cover bilateral lateral RP, IB, and II for Kadish B and C

A: confined to NC

B: involves NC and para-nasal sinus

C: extends beyond NC and paranasal sinus (including LN, DM, orbit, intracranial etc)

105
Q

Nasal Vestibule

A

< 1.5 cm and well-diff: RT to primary + 2 cm (66Gy)

> 1.5 cm or poorly-diff: RT to primary and nodes

50 Gy to bilateral facial LN, IB-II

66 Gy to primary + 2 cm

If LN positive: RT to primary and nodes

50 Gy to bilateral facial, Ib – IV

66 Gy to primary + 2 cm

106
Q

General Sinus volumes

A

Volumes:

Entire tumor bed + pre-op GTV + 1.5 cm anatomically cropped + entire involved sinus + ipsi PPF and pterygoid space + cribriform plate

107
Q

Salivary gland anatomy

A

Major:

  • Parotid – drains into OC via Stenson’s duct near 2nd molar; mucoepidermoid (MEC)
  • Submandibular – drains into OC via Wharton’s duct
  • Sublingual – via Bartholin’s duct

Minor (MEC LN spread)

-Most common location is hard palate

75% parotid

75% of parotid masses are benign

75% of minor salivary are malignant

108
Q

Salivary gland T stage, high low grade histology

A

T1 – ≤ 2cm

T2 – 2.1-4cm

T3 - > 4cm or extraparenchymal extension

T4a – FEMS: Facial nerve, ear canal, mandible, skin

T4b – skull base, pterygoid plates, encase carotid

Low grade: acinic, mucoepidermoid

High grade: adenoid cystic, adeno, squam

109
Q

Salivary Gland Treatment

A

Surgery (parotidectomy)

  • total if deep lobe involved
  • ipsi II-V neck dissection if high grade or cN+

RT for all but very small, low grade

Parotid: ask about grade, PNI

Post-op RT to primary site only for:

1) T3 (EPE) or T4
2) close or + margins (deep lobe)
3) PNI/LVSI
4) Capsule rupture or tumor spillage
5) Recurrence

Post-op RT to primary and neck for:

1) N+
2) High grade

Unresectable: Definitive RT

** adenoid cystic – need to cover facial nerve

110
Q

Salivary Gland volumes

A

Post-op volume – tumor bed + 2 cm

For unresectable – tumor + normal gland

Neck – Ib-IV

R2 – 70 Gy

R1, ECE – 66 Gy

R0 – 60/2 Gy

Elective neck 54/1.8 Gy

Techniques: IMRT (favored if treating neck), wedge pair (ant/post obliques), electrons, electron/photon mix (4:1)

Cover PNI to base of skull (thru stylomastoid foramen, can stop at 2nd genu unless gross disease in BOS)

111
Q

Thyroid histology

A
  • Papillary (most common) – takes up RAI
  • Follicular, Hurtle – take up RAI
  • Medullary – associated w/ MEN; do not take up RAI
  • Anaplastic – do not take up RAI

Functioning thyroid nodules are rarely malignant

112
Q

Thyroid Workup

A

T3, T4, TSH, thyroglobulin, anti-thyroglobulin Ab

Thyroid u/s

Neck u/s or MRI for adenopathy

FNA

***No contrast with CT – because then thyroid will take up iodine, then RAI won’t work (if take up RAI)

If FNA + for medullary, serum calcitonin, CEA, Ca, urine catecholamines (screen for pheo), PTH for parathyroid (MEN)

If FNA+ for anaplastic, full body staging with PET/CT

113
Q

Thyroid Staging

A
  • T1 – ≤ 2cm, limited to thyroid
  • T2 – 2.1-4cm, limited to thyroid
  • T3a – > 4cm
  • T3b – Invading strap muscles
  • T4a – Larynx, trachea, esophagus, recurrent laryngeal nerve, subQ tissues
  • T4b – Pre-vertebral fascia, encase carotid, mediastinal vessels

* note: all anaplastics are T4 (T4a contained to thyroid; T4b outside thyroid)

  • N1a – level VI (pretrach, paratrach, delphian), or upper mediastinal
  • N1b: cervical or RP nodes

M1: distant mets

  • Stage I: age < 55, M0; age > 55, T1-2
  • Stage II: age < 55, M1; age > 55, N1 or T3
  • Stage III: T4a
  • Stage IVA: T4b; anaplastic T4a
  • Stage IVB: age > 55, M1; anaplastic N1 or T3b; anaplastic T4b
  • Stage IVC: anaplastic M1
114
Q

Thyroid treatment paradigm

A

Surgery -> RAI (for papillary/follicular) for T2+ or elevated post-op thyroglobulin (> 1 ng/ml), +LVI

  • surgery is thyroidectomy + LND (II-IV, VI) if cN+ or pN+
115
Q

Indications for post-op EBRT for papillary, follicular/Hurthe cell:

A

Indications for post-op EBRT for papillary, follicular/Hurthe cell:

Consider for lesions w inadequate iodine uptake, and:

  1. R1 in papillary
  2. R2
  3. Extensive ETE
  4. Poor RAI response

Or pT4N1 and age > ~40 after RAI

116
Q

Medullary and Anaplastic treatment

A

For Medullary ca:

Consider EBRT for incomplete resection, LN+, extensive ETE, or persistent incr calcitonin

** for anaplastic, only do surgery if GTR possible. Otherwise definitive RT with comprehensive nodal RT (down to carina) and concurrent chemo (weekly carbo/taxol or doxorubicin)

117
Q

RAI dose

A

RAI – 30-50 mCi for low risk disease (T1-2N0, remnant ablation), 50-100 mCi for high risk disease (T3+ or N+, thyroid bed uptake). 100-200 mCi for metastatic disease

  • CI during pregnancy or nursing
  • Max lifetime RAI dose: 800-1,000 mCi
118
Q

Thyroid Volumes and dose

A
  • Thyroid bed only if well-diff without ETE
  • Otherwise, thyroid + bilat neck (II-VI and sup mediastinum); sup mediastinum to carina (if N+ or anaplastic)
  • IMRT – post op dose painting
  • 30 fractions: 60/2, 54/1.8
  • for ECE or + margins, 66/2 (59.4/1.8 int, and 54/1.64 low risk)
  • CTV_66 = positive margins, ECE
  • CTV_60= high risk CTV (tumor bed, 1st echelon nodes II-VI)
  • CTV_54= low risk CTV (contralateral nodes, 1b if II involved)
  • Gross disease to 70 Gy
119
Q

Thyroid OS

A

10 yr OS

  • Papillary: 90%
  • Follicular: 85%
  • Hurthle cell: 75%
  • Medullary: 70%
  • Anaplastic: MS 6 months
120
Q

RAI 1/2 life and side effects

A

RAI: ½ life 8 days

Acute: sialadenitis, cystitis, gastritis

Chronic: leukemia, pulmonary fibrosis, oligospermia

121
Q

Unknown primary site %

A
  • Tonsil 45%
  • BOT 40%
  • Piriform sinus 10%

DDx:

  • Adenocarcinoma
  • Lymphoma
  • Thyroid
  • Melanoma
  • Salivary
  • Sarcoma
122
Q

Unknown primary workup

A

History: smoking history

Physical: skin exam

Labs:

  • -thyroglobulin/calcitonin for adeno, EBV, HPV

Imaging:

  • -CT/MRI BOS/neck
  • -PET/CT (can do before pan-endoscopy)
  • -CT chest

Biopsy:

  • -EUA and panendo w directed bx of NPX, tonsils, BOT, pyriform sinus
  • -FNA neck node (HPV and EBV testing)
  • -Bilateral tonsillectomy and directed biopsy

Other:

  • For level IV nodes, consider non-H&N primary:
  • -CT c/a/p
  • -triple endoscopy
123
Q

Unknown primary treatment N1

A

N1 – ipsilateral modified radical LND

  • -if no ECE, can observe but RT okay as well
  • -risk-stratified PORT
    • *if just 1 node < 3cm, can be cured with just ipsilateral neck dissection – if just 1 node, no ECE
124
Q

Unknown Primary N2-3 Treatment

A

N2-N3 – consider CRT

  • -RT to NPX, OPX, bilateral neck
  • -or bilateral neck dissection à CRT or RT

** If TG neg, calcitonin neg adenoCA of LN levels IB – III:

Ipsi parotidectomy and ND → PORT

** can add chemo for gross disease, ECE

125
Q

Unknown Primary RT volumes

A

Def IMRT: dose painting

35 fractions: 70/2, 63/1.8, 56/1.6

  • CTV_70= gross LN + 5 mm
  • CTV_63= NPX, OPX, larynx, HPX, and ipsi neck (RP, Ib-V)
    • can exclude larynx, hypopharynx (U of FL data) in non-smoker if level I-III node involved
    • OC not included unless Ia/b node present
  • CTV_56=low risk uninvolved and contralateral neck (II-IV, RP)

PORT:

  • -60 Gy to involved region (66 if ECE)
  • -54 to mucosa and uninvolved neck
126
Q

T-1 or N

A

p16+

Overall Clinical Stage greater of T-1 or N, only M1 is stage IV

Pathologic: same except T4N0-1 = II

127
Q

T or N+2

A

p16-, Larynx, Oral Cavity

128
Q

T or N+1

A

Nasopharynx

129
Q

Larynx T4a

A

O-TESTES

  • •Outer Thyroid Cartilage
  • Trachea (inf. to cricoid)
  • •Extrinsic tongue muscles
  • •Strap muscles
  • •Thyroid
  • •Esophagus
  • •Soft tissue neck
130
Q

Larynx T4b

A

MPE (molly pearl escott)

  • mediastinal structures
  • prevertebral fascia
  • encases ICA

Rad Onc Oral Boards (11 decks)

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