Other Flashcards
Esthesio-neuroblastoma
“MRI max/fac
Surgery: transfacial combined with craniotomy. Indicated for all T1-T4a tumors.
Kadish Staging (esthesioneuroblastoma): A: confined to nasal cavity B: extends to paranasal sinuses C: extends beyond nasal cavity or paranasal sinuses D: Distant metastasis or LN originates from olfactory epithelium"
“Unresectable (T4b): induction 50 Gy with chemo followed by surgery for good responders. If unlikely to be operable, 70 Gy with concurrent chemoRT.
Surgery alone for T1. Definitive RT without chemo is another option.
For >T1, adjuvant RT and possibly chemo is recommended. Definitive chemoRT is another option.” “cisplatin based, possibly with etoposide
“CTV neck: For Kadish C, D or any node positive, include Ib-V, RP
“LN spread <10% if early stage, but 50% for Kadish C
Sinonasal undifferentiated (SNUC), sinonasal neuroendocrine tumors (SNEC)
Surgical management as in esthesio
Chemotherapy for all SNUC/SNEC, often induction
60-70 Gy RT with SIB to intermediate and low risk neck
MDACC method: induction chemo, then CRT if response. Surgery in those with poor response”
“Cisplatin and etoposide
“Lower threshold to treat nodes. More risk of local and distant recurrence
Paraglanglionoma / glomus tumor
“5% can produce catecholamines. Most common presentation is HTN. Can also have headache, sweating, palpatations.
MRI findings:
T1: hypointense, speckeled. Has enhancement with contrast
T2: Hyperintense. If 2cm or larger, the serpentine void pattern is often described as ““salt and pepper”””
“pre-op embolization and maximal safe resection (don’t do embolization alone. Embolization may help reduce bleeding during surgery/shrink tumor). Surgery is indicated for catecholamine secreting tumors. RT has not been shown to reduce levels
Post op RT to 45-50 Gy. For tympanic give 45 Gy
If no surgery: 54 Gy IMRT or SRS 15 Gy (linac 15-20 Gy or GK 12-18 Gy)”
Some give a CTV of 1-5 mm (Combs Head and Neck 2014)
alpha/beta blocker prior to surgery
“Most commonly found in abdomen (80%). Only 3% in H&N. Can be familial. Arise from glomus cells, chemoreceptors on blood vessels. Neuroendocrine tumors, highly vascular
"”LC and resolution of tinnitus 90%
30% will decrease in size “
Large tumor, cannot lie flat
“consider induction chemotherapy
Place trach if not already done, if already done then ask ENT to eval again, have suction device at sim, take lung history and consult pulm”
Thyroid
“for papillary, follicular, Hurthle
Labs: post op thyroglobin Ab, thyroid panel
LC with EBRT is superior to RAI”
“Remnant ablation for residual tissue: 30 mCi
Adjuvant therapy for microscopic tumor: 30-150 mCi
Gross disease, locoregional or metastatic: 100-200 mCi
EBRT indications: unresectable local disease, positive margin after surgery and no metastasis, progression with no iodine uptake, poor response, tracheal compression, or reaching RAI limit that could cause bone marrow toxicity (~800 mCi)”
“Elective treatment of neck may not be required. Recurrences there can be often be salvaged surgically.
If treating neck, consider coverage of levels III-V plus VI with extension of level VI down to carina. Some practicioners include level II”
Anaplastic thyroid
Option of standard H&N doses or hyperfractionate 1.5 Gy BID to total 60 Gy
level III-V to deep level VI to carina (some will also include level II)
“carbo/taxol
or weekly doxo 20mg/m2 with docetaxel 20mg/m2”
Mucosal Melanoma
“NCCN: treat similar to other head and neck regimens
For adjuvant:
High risk areas: >2 nodes, node > 3cm, ECE, recurrence after surgery to 60-66 Gy
Low to int risk areas treat with elective doses”
Reirradiation
Ideally over one year interval has passed, allowing for some tissue recovery. Assess long term effects of prior radiation and prior field overlap
“Gross disease: ≥66 Gy.
Elective neck, ECE: 50-66 Gy (ENI may have no benefit)
Gross disease, SBRT: ≥35 Gy/ 5 fx
Some use hyperfractionation with chemo: 60 Gy in 1.5 Gy BID. (Do not do split course as was done in some trials). But on the MIRI study, hyperfx and/or elective neck seems to increase toxicity and was not associated with any benefit.”
“Typically only gross disease, or possibly site of ECE
Inclusion of elective neck is an option. The risk to benefit ratio however may be high.”
“Concurrent cisplatin. Some use cisplatin and etoposide
Chemo alone:
Cis/5FU/cetuximab
carbo/taxol or cis/taxel
Or single agent platinum, taxol, or cetuximab.”
"Nasopharyhx reirradaition guidelines: Brainstem EQD2 <81 Gy Cord EQD2 <67.5 Gy Chiasm/optics EQD2 <81 Gy Carotid: no constraints known
Others favor cord EDQ2 < 135 Gy (or <98 Gy if <6 mos passed)
- Create composite plan
- Sum equivalent doses using EQD2 and α/β ratios
- Consider a discount to prior dose based on time interval”
Palliation of H&N
“Assess goals of care
Pain?
Airway?
Swallowing?
LC in advance of symptoms?”
"Dismal prognosis: QUAD shot 14.0-14.8 Gy /4 fx BID, repeat up to x3 24 Gy/ 3 fx 20 Gy/ 5 fx 30 Gy /10 fx
More favorable prognosis:
70 Gy/ 35 fx
50 Gy/ 20 fx
Or shorter courses if preferred”
Primary tracheal
Surgery then RT. However tumors are often not resectable, or would require a very extensive surgery
70 Gy
12 month OS
Verrucous carcinoma of larynx
“surgery is preferred
RT to 50-55 Gy in 20-25 fx”
with RT: 66% local control, 87% OS and 97% DSS
H&N recurrent or metastatic
“Nivolumab
If local then consider surgery or reirradiation (see its section)
Cis/5FU/cetuximab
carbo/taxol or cis/taxel
Or single agent platinum, taxol, or cetuximab.”
