Treatment/Prognosis Flashcards
What is the general management paradigm for benign mixed/pleomorphic adenoma of the parotid?
Benign mixed/pleomorphic adenoma management paradigm: WLE, or superficial parotid lobectomy → observation (even if +margin or with extraglandular extension)
What is the management paradigm for low- to intermediate-grade tumors of the salivary gland?
Low- to intermediate-grade salivary gland tumor management paradigm: surgical resection with PORT for close (<2 mm) or +margin, unresectable Dz, pT3–4, PNI, capsule rupture, +nodes, or recurrent Dz
What is the management paradigm for high-grade tumors of the salivary gland?
High-grade salivary gland tumor management paradigm: surgical resection (facial nerve sparing if possible for parotid tumors), including LND if node+ → PORT
What is the role of concurrent CRT?
The level of evidence for CRT is weak. NCCN guidelines (2018) recommend consideration of definitive CRT for T4b Dz or PORT + chemo for pathologic adverse features including intermediate or high grade, inadequate margins, PNI, +LN, and LVI.
What is the management paradigm for ACC with pulmonary mets?
ACC (cribriform or tubular) with pulmonary mets (typically asymptomatic with low tumor burden) management paradigm: same local therapy as in pts without mets b/c pulmonary mets have a long natural Hx
What is the difference b/t superficial, total, and radical parotidectomy?
Superficial: en bloc resection of gland superficial to CN VII
Total: en bloc resection of entire gland with nerve sparing
Radical: en bloc resection of entire gland + CN VII + skin + fascia +/– muscle
What are the indications for LND with salivary gland tumors?
A clinically+ neck. LND is often done for high-grade and large tumors, but in the clinically negative neck, if the pt is to get PORT, the role of LND is questionable.
What are the indications for PORT in the management of salivary gland cancers?
Adj RT is indicated for the following: high grade (regardless of margin), close/+ margin, pT3–T4 Dz, PNI, capsule rupture, tumor spillage, ECE, N2–N3 Dz, unresectable tumor/gross residual Dz, and recurrent tumor
For which cN0 salivary gland tumors, by histology, does elective nodal RT significantly reduce the incidence of nodal relapse?
Elective nodal RT is more likely to reduce the incidence of nodal relapse in pts with squamous, undifferentiated, or adenocarcinoma histologies. (Chen AM et al., IJROBP 2007)
When should bilat neck coverage with RT be considered for salivary gland neoplasms?
Tx of the ipsi neck should be adequate for major salivary gland cancers. Bilat nodal Tx is considered for high-grade minor salivary gland cancers affecting midline structures.
What are some ways to deliver RT/set up the RT fields in the Tx of parotid gland tumors?
RT delivery and set up of RT fields:
AP/PA wedge pairs (120-degree hinge angle) but difficult setup, exit through OC
Sup/Inf wedge pair (with 90-degree couch kick), avoids exit through OC but exits through brain
Single direct field with mixed energy beam (80% 15 MeV electron: 20% 6 MV photon) with bolus, electron portal 1 cm larger than the photon field b/c of IDL constriction with depth, higher dose to bone, keep contralat parotid at <30 Gy
IMRT (most commonly utilized nowadays)
What are the PORT doses used in the management of salivary gland tumors?
60 Gy for –margin, 66 Gy for close/+margin, 70 Gy for gross residual, and 50–56 Gy to a low-risk neck
What RT techniques can be used in the management of the ipsi neck?
RT techniques for the ipsi neck:
- Single lat appositional electron field
- Mixed electron–photon beam technique
- Half beam block technique
- IMRT (most commonly utilized nowadays)
What key retrospective data demonstrated the importance of adding PORT for stages III–IV and high-grade salivary gland tumors?
MSKCC data (Armstrong JG et al., Arch Otolaryngol Head Neck Surg 1990; Harrison L et al., J Surg Oncol 1990) showed improved LC and survival. SEER data (Mahmood U et al., Arch Otolaryngol Head Neck Surg 2011) also showed improved survival.
What is the largest retrospective study demonstrating the benefit of adj RT for malignant salivary gland neoplasms?
Dutch NWHHT study (Terhaard CHJ et al., IJROBP 2005): 498 pts. Adj RT significantly improved LC in pts with T3–T4 Dz, a close margin, incomplete resection, bony invasion, and PNI.
