HN Flashcards
General treatment paradigm
T1-T2: surgery or RT alone
T3 or N+: CRT
Post-op RT to primary:
Post-op RT to primary:
pT3/4
PNI
LVI
Close Margins (<5 mm)
OC primary w level IV/V LN
Post-op RT to neck:
Post-op RT to neck: N2 or N3 (single large node or multiple nodes)
Post-op CRT:
Post-op CRT: ECE, +margins
Treatment volumes script
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
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
- 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
Nasopharynx T and N stage
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
Nasopharynx Overall stage
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
NPX T1N0 treatment
T1N0 – RT alone
NPX T2 N0
Concurrent cis-RT
-concurrent q3week Cis 100 mg/m2
NPX T3 or N1
induction cis 80 mg/m2 + gem 1000 mg d1/d8 q3 weeks x 3 cycles ->
Concurrent cis-RT
-concurrent q3week Cis 100 mg/m2
NPX volumes
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
OC T stage
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
OC overall stage
T or N+2
I – T1N0
II – T2N0
III – T3 or N1
IVA – T4a or N2
IVB – T4b or N3
IVC – M1
N stage
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
OC post op Indications for RT
Indications for RT
- T3/T4
- DOI > 5mm
- Close margin (< 5 mm)
- LVSI
- PNI
- N2+
- Level IV/V LN
=> for boards, irradiate primary and nodes together always
Post-op CRT:
+ margin, + ECE
OC general treatment paradigm
Resectable: Surgery
-Neck dissection for N+, DOI > 2 mm
Unresectable –
Stage I-II: definitive RT alone (EBRT + brachy)
Stage III-IV: CRT
OPX T stage
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
OPX overall stage
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
OPX treatment Low risk (T1-2N0 or 1 small node (<3cm):
Low risk (T1-2N0 or 1 small node (<3cm):
- Surgery (TORS) -> chemo/RT as indicated
- 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
OPX treatment Int-High risk (T3-4, >1 node):
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
P16+ N stage
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
HPX borders and subsites
Pharynx from hyoid to cricoid
Subsites (3Ps):
Piriform sinuses (#1)
Posterior pharyngeal wall
Postcricoid area
HPX staging
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
HPX T1, select T2, N0 treatment
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
HPX T3-4 or N+
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
HPX dose and volumes
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
Supraglottis subsites and borders
FAVEA:
•False cords
•Arytenoids
Ventricles
Epiglottis
•Aryepiglottic folds
Borders:
Epiglottis
Petiole(epiglottis) Arytenoids
TVC
Glottic T stage
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
Early (T1-T2N0) Glottic treatment
Early (T1-T2N0) Glottic - surgery vs def RT
- Def RT
T1- 63 Gy (2.25x28)
T2 - 65.25 (2.25x29)
- 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
TVC T1-2 fields
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%
TVC Advanced (T3 or N+) treatment
Advanced (T3 or N+)
- CRT (RTOG 91-11)
- 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 -
Induction chemo -> RT or surgery
* -* TPF q 3W x3c-> if > PR à RT
* - if < PR, TL with LND*
TVC T3-T4, N+ volumes
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
Post-op glottic:
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
Larynx preservation RT and CRT
Larynx preservation
RT alone – 65%
Concurrent chemoRT – 85%
Supraglottis T stage
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
Supraglottis T1-2 treatment
T1-T2:
- Definitive RT – cover 2-4 bilateral to 56, gtv 70, larynx 63 – no chemo – discuss 6 fractions
- 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
Supraglottis T3-T4 or N+: treatment
T3-T4 or N+:
- CRT if functional larynx with low risk aspiration
- TL + LND -> RT or CRT for high risk features (preferred if T4a)
Subglottis T stage
Sub-
T1: subglottis only
T2: extension to TVC (normal or impaired mobility)
T3: limited to larynx with fixed VC
Subglottis T1-2 treatment
T1-T2:
- Definitive RT
Subglottis T3-T4 or N+: treatment
T3-T4 or N+:
- CRT if functional larynx with low risk aspiration
- TL + LND -> RT or CRT for high risk features (preferred if T4a)
Nasal Cavity/Ethmoid T stage
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
Maxillary T stage
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
Esthesioneuroblastoma Staging
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)
Nasal cavity and ethmoid sinus
T1N0: treatment
Nasal cavity and ethmoid sinus
T1N0:
1) Surgery -> PORT
- no PORT for low grade & neg margin
2) RT (70 Gy)
Nasal cavity T2+ or N+: treatment
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
Maxillary sinus
T1-T2 N0: treatment
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
Maxillary sinus
T3-T4 or N+: treatment
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
SNUC: treatment
SNUC:
Induction cis-based chemo (retrospective) → surgery → PORT with coverage of bilateral IB and II
Esthesioneuroblastoma:treatment
A
B
C
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)
Salivary gland T stage, high low grade histology
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
Salivary Gland Treatment
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
Salivary Gland volumes
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)
Thyroid Staging
- 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
Thyroid treatment paradigm
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+
Indications for post-op EBRT for papillary, follicular/Hurthe cell:
Indications for post-op EBRT for papillary, follicular/Hurthe cell:
Consider for lesions w inadequate iodine uptake, and:
- R1 in papillary
- R2
- Extensive ETE
- Poor RAI response
Or pT4N1 and age > ~40 after RAI
Medullary and Anaplastic treatment
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)
RAI 1/2 life and side effects
RAI: ½ life 8 days
Acute: sialadenitis, cystitis, gastritis
Chronic: leukemia, pulmonary fibrosis, oligospermia
Unknown primary workup
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
Unknown primary treatment N1
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
Unknown Primary N2-3 Treatment
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
Unknown Primary RT volumes
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
T-1 or N
p16+
Overall Clinical Stage greater of T-1 or N, only M1 is stage IV
Pathologic: same except T4N0-1 = II
T or N+2
p16-, Larynx, Oral Cavity
T or N+1
Nasopharynx
Larynx T4a
O-TESTES
- •Outer Thyroid Cartilage
- Trachea (inf. to cricoid)
- •Extrinsic tongue muscles
- •Strap muscles
- •Thyroid
- •Esophagus
- •Soft tissue neck
Larynx T4b
MPE (molly pearl escott)
- mediastinal structures
- prevertebral fascia
- encases ICA
