FRCR2 > Head and neck > Flashcards

Head and neck Flashcards

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1
Q

What are the 3 structures and 3 levels for LN anatomy

How are the nodal levels defined using them

A

3 structures: SCM, submandibular glands, parotids

3 levels: C2 (lateral process), hyoid, cricoid

Hyoid – division between levels II & III
Cricoid - division between levels III & IV
SCM – behind is level V

Level II – upper deep cervical, underneath SCM and above hyoid, and behind posterior border of submandibular gland. Anterior to this is level I

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2
Q

What nodal levels does the nasopharynx drain to

A

Level 2
7A
Upper level 5 (posterior triangle)

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3
Q

Where does the oral cavity drain to

A

Lateral tongue and hard palate to level 1b
Tongue and floor of mouth to levels 2-4
Tip of the tongue to 1A, and directly to 3
Soft palate - level 2 or retropharyngeal (7A)

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4
Q

Where does the oropharynx drain to

A

Level 2-4
7A&B

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5
Q

What are the 3 subsites of the hypopharynx (3 Ps)?

A

Pyriform sinus
Posterior pharyngeal wall
Post-cricoid region

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6
Q

What levels does the hypopharynx drain to

A

Pyriform sinus - Levels 2-5 & 7A
Posterior pharyngeal wall - 2-3 & 7A
Post-cricoid - 3 & 5. Inferiorly to paratracheal and para-oesophageal LNs

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7
Q

What levels does the larynx drain to

A

Levels 2-3

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8
Q

What are the three levels of the glottis and what are the boundaries / levels

A

Supraglottis, glottis, subglottis

Supraglottis - from epiglottis to upper border of arytenoids
Glottis - level of vocal cords
Subglottis - from 1cm below true cords, to lower border of cricoid

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9
Q

Which inherited condition increases the risk of head and neck SCC, and what is the treatment consequence

A

Fanconi anaemia
They do not tolerate cisplatin and have severe toxicity with RT

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10
Q

When is a PET CT indicated in H&N cancer

A

SCC neck node of unknown primary
T3-4 disease
N3 cancer

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11
Q

What are the investigations for an SCC neck node of unknown primary

A

PET-CT
HPV / p16 status
If negative, then: EUA, panendoscopy, biopsies from base of tongue, piriform fossa, and consider bilateral tonsillectomy

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12
Q

For oral cavity, HPV- oropharynx, hypopharynx and larynx, how is stage 3 disease defined

A

T3N0 or T1-3 N1
ie presence of T3 disease or node positive (N1)

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13
Q

For oral cavity, HPV- oropharynx, hypopharynx and larynx, how is stage 4A disease defined

A

T4a N0-1 or T1-4a N2
ie the presence of T4a disease or N2 status

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14
Q

For oral cavity, HPV- oropharynx, hypopharynx and larynx, how is stage 4B disease defined

A

T4b Any N or Any T N3
ie the presence of T4b disease or N3 status

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15
Q

What is the management for a stage I-II oral cavity cancer and what is the TNM stage for this

A

Stage I-II = up to T2N0
WLE +/- PORT

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16
Q

For a p16-positive oropharyngeal tumour, how is stage 3 defined

A

T1-3 N3 or T4 N0-3
ie the presence of T4 or N3 disease

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17
Q

For a p16-positive oropharyngeal tumour, how is stage 2 defined

A

T1-2 N2 or T3 N0-2
ie the presence of T3 or N2 disease

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18
Q

What is the management for a stage III-IV oral cavity cancer and what is the TNM stage for this

A

stage III = T3N0 or T1-2N1
Up to stage IVb = T4b Any N or T1-4b N3

Mx would be surgery with reconstruction if possible & PORT (+/- neoadjuvant TPF chemotherapy)

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19
Q

What is the management for a stage I-II oropharyngeal cancer and how is this TNM defined

A

If HPV negative: stage I-II = up to T2N0
If HPV positive: stage I-II = up to T3 or N2

SOC is RT (HPV negative), or chemoRT (HPV+)

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20
Q

What is the management for a stage III-IV oropharyngeal cancer and how is this TNM defined

A

If HPV negative: stage III-IVb (not metastatic) = up to T4b or N3
If HPV positive: stage III (stage IV = metastatic) = up to T4 or N3

Tx with chemo-RT

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21
Q

Indications for neoadjuvant chemotherapy in H&N
And what regimen

A

Quick response needed due to tumour bulk
To facilitate organ preserving treatment
Where tumour shrinkage on treatment might require replanning

TPF

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22
Q

What is the treatment for a stage I laryngeal cancer, and what is the TNM staging

A

Stage I = T1N0
Treat with laser, surgery, or RT

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23
Q

What is the treatment for a stage II laryngeal cancer, and what is the TNM staging

A

stage 2 = T2N0
Treat with laser, surgery or RT

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24
Q

What is the treatment for a stage III laryngeal cancer, and what is the TNM staging

A

Stage III = T3 or N1 disease
Treat with CRT

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25
What is the treatment for a stage IV laryngeal cancer, and what is the TNM staging
stage IV non-metastatic disease = T4b or N3 disease Treat with total laryngotomy & neck dissection with PORT/PO-CRT Or consider downstaging with neoadjuvant chemo
26
What is the treatment for a stage I-II hypopharyngeal tumour and what is the TNM staging
Stage I-II = up to T2N0 Treat with RT
27
What is the treatment for a stage III hypopharyngeal tumour and what is the TNM staging
stage III = T3 or N2 disease Treat with CRT
28
What is the treatment for a stage IV hypopharyngeal tumour and what is the TNM staging
stage IV (non-metastatic) = T4b or N3 Treat with surgery (laryngectomy + partial pharyngectomy) + b/l neck dissection + PO RT/CRT
29
What is the preferred treatment modality for nasopharyngeal cancers?
RT or CRT Surgery reserved for residual or recurrent disease
30
When is chemotherapy indicated in addition to radical RT What is the benefit What are the scheduling options
Age <70 and stage III-IV disease Based on Pignon meta-analysis, 6-8% benefit in overall survival 3wkly cisplatin at 100mg/m2 - D1, 22, 43 - higher mucosal toxicity (82% vs 61%) Weekly cisplatin (min 5wks) at 40mg/m2 In theory can consider cetuximab for oropharynx, larynx and hypopharynx only, if cisplatin contraindicated
31
What is the RT dose to a T1 N0 (stage I) or T2N0 (stage II) larynx
55Gy/20#/4wks
32
What are the radical RT dose levels for primary RT What are the margins
GTV-T - 65Gy/30# GTV-N - 65Gy/30# Involved nodal level - 60Gy/30# Elective nodal levels - 54Gy/30# Tumour GTV-CTV margin - 65Gy to GTV +5mm, 60Gy to GTV +10mm Nodal GTV - CTV margin - 5mm, or 10mm if node >3cm
33
What is the benefit of adjuvant RT in H&N cancer
Improvement in local control by 38%, if treatment completed within 11wks of surgery
34
What are the indications for adjuvant RT following H&N cancer surgery (3 categories)
Tumour - related: Locally advanced tumours - T3-4 High grade tumours Surgery related: Positive or close margins (<1mm) and no further resection possible (-> chemoRT) Perineural or vascular invasion Node related: >2 nodes positive (N2b) Extracapsular extension (N3) (-> chemoRT) Any single node >3cm (N2)
35
What are the indications for adjuvant chemoRT following H&N cancer surgery What is the benefit of adding cisplatin to adjuvant RT
Positive margins (<1mm) Extracapsular extension Cisplatin (if <70yrs) adds 2% to locoregional control (12% vs 10%) and also improved OS
36
What is the adjuvant RT dose for H&N cancer
65Gy/30# if macroscopic residual disease or ECE 60Gy/30# otherwise If poor PS: 55Gy/20# for positive margins/ECE, 50Gy/20# otherwise
37
What is the adjuvant RT dose for cervical LNs for melanoma
48Gy/20#
38
What is the CTV margin for adjuvant H&N treatment?
GTVp & GTVn - recreate GTV based on pre-operative imaging CTV-P - GTVp+10mm CTV-N - GTVn+5mm & & pathologically involved nodal levels
39
What is the CTV-PTV margin for H&N
3-5mm
40
what was the outcome of the PET-neck study
That post RT for oropharyngeal cancers, PET-CT (and salvage neck dissection if necessary) is non-inferior to neck dissection for all
41
When are LNs treated electively (in a node negative neck)
When risk of involvement is >15-20%, which is usually the case in most sites except early larynx (T1-2), lip and lower alveolar ridge
42
What are the systemic treatment options for a metastatic SCC of H&N?
If PDL1 CPS >1, and not of skin origin, pembrolizumab 1st line If CPS <1, chemotherapy. Cisplatin/5FU 25-30% RR PFS 5-7 months with chemo - Doesn’t prolong survival, but can improve symptoms If progression within 6mths of Pt-containing chemotherapy -> nivolumab, independent of PDL1 status. Checkmate 141 - improves OS to 7.5mths
43
For a T2 oral cavity tumour, node positive, and >1cm lateral to the midline, what nodal levels should be treated Which additional level should be included dependent on which nodal level being positive
Ipsilateral levels 1a-4a None Contralateral 4a only included if anterior tongue or oropharynx involvement 9 if buccal mucosa involved Include level 5 if 4 or 1b involved
44
What is the management of a stage III-IV oral cavity tumour
Surgery with flap reconstruction & neck dissection +/- adj RT/CRT Or radical RT/CRT + unilateral or bilateral neck RT
45
When is radical RT indicated for an oral cavity tumour
Pt declines surgery or is unfit for surgery Or stage III/IV
46
where do hypopharyngeal cancers commonly originate from
Pyriform fossa
47
For which head and neck cancer is bilateral neck treatment recommended
Hypopharynx
48
What is the management of stage I-II hypopharyngeal cancers (T1-2 N0)
Larynx-preserving surgery if possible, with bilateral neck dissection If not possible, primary chemoradiation with elective neck irradiation
49
What is the management of stage III - IV hypopharyngeal cancers (>T3 or N+)
If functioning larynx -> radical chemoRT If cartilage/bone invasion/large volume extra laryngeal disease -> surgery & adj RT/CRT +/- neoadjuvant TPF
50
What proportion of tumours arise from the different levels of the larynx
Supraglottis - 30% Glottis - 60-70% Subglottis - <5% Supra- and subglottis tend to present later
51
What is the treatment for a T1 laryngeal cancer (stage 1)
Transoral laser surgery or RT Dose: 55Gy/20# over 4 weeks Bolus (especially if anterior commissure involved) Volumes - CTV = Whole glottis
52
What is the treatment for a T2 laryngeal cancer (stage 2)
RT Dose: 55Gy/20# over 4 weeks Bolus (especially if anterior commissure involved) Volumes - CTV = Whole glottis
53
What is the treatment for a stage III (T3 or N1) laryngeal tumour
Primary CRT for larynx preservation Or surgery with adjuvant RT
54
What is the treatment for a stage 4 (T4 or N2-3) laryngeal tumour What are the RT volumes
Surgery - total laryngectomy, neck dissection, flap reconstruction and adjuvant RT/CRT Larynx-preserving primary CRT if there is a functioning larynx with no extra-laryngeal disease, and salvage laryngectomy if needed CTV-T - GTV + 1cm laterally + 1.5-2cm sup/inf Whole larynx (tip of epiglottis to bottom of cricoid) or lower depending on inferior extent of tumour and expansion. Include tracheostomy if present
55
What is the order of planning priorities?
OAR constraints PTV constraints PTV objective OAR objective
56
What are the predictors of improved loco-regional control after H&N RT re-treatment?
Decreased stage at time of recurrence Nasopharynx cancer No organ dysfunction (ie absence of feeding tube or tracheostomy) Surgery for recurrence Initial RT dose >50Gy Time interval since initial radiotherapy
57
When is a larger margin (10mm) included for an involved neck node, vs 5mm
Node >3cm or invasion ito adjacent structures
58
How are salivary gland carcinomas classified
Adenoid cystic vs non-adenoid cystic
59
How is adenoid cystic carcinoma treated
WLE and always adjuvant RT
60
How is an acinic cell carcinoma treated
Total parotidectomy with preservation of uninvolved nerves. No elective neck dissection No adjuvant RT (Not radiosensitive)
61
What are the indications for post-op RT for salivary gland tumours
All Adenoid Cystic High grade tumours T3/T4 - >4cm, extraparenchymal extension Close or Positive margins Positive Nodes PNI or LVI
62
What is the management of submandibular gland salivary tumours What are the indications and levels treated for adjuvant RT for submandibular gland tumours
N0 neck, small tumour & LG histology -> Levels I & IIa only High grade or suspicious MRI appearances – level I-III Node positive, T3/T4 - Levels I-IV Adj RT: All adenoid cystic carcinomas High grade tumours Residual neck disease or ECS Following surgery for recurrent disease Nodal treatment If node negative -> I & II only, even if adenoid cystic If node positive -> levels Ib-IV
63
What is the treatment for a metastatic salivary gland carcinoma
Adenoid cystic: 1st line - TKI - lenvatinib 2nd line - CAP (cisplatin, doxorubicin, paclitaxel) & whole genome sequencing (RET & NTRK) Non-adenoid cystic: Sequence earlier - RET, NTRK, B-raf Targeted treatment options if mutation present If mutation negative - chemotherapy
64
What is the OS benefit for Nivolumab 2nd line in metastatic H&N SCC
2.6mths
65
What is the OS benefit for pembrolizumab in metastatic H&N SCC
For PDL1 CPS >1 - 2mths
66
What is the rate of HPV positivity in oropharyngeal cancer
30%
67
What is the long term risk of osteoradionecrosis of the jaw after radical RT
5%
68
what are the key numbers for staging, HPV negative, non-nasopharyngeal H&N
2,4,5,10,3,6 2 & 5 4 & 10 T1 - <2cm or DOI <5mm T2 - size 2-4cm & DOI <10mm T3 - >4cm or DOI >10mm T4 - local invasion Clinical nodal staging - Nodes - 3, 6 N1 - ipsi, <3cm N2a - single ipsi node 3-6cm 2b - multiple ipsi node, <6cm 2c - bilateral nodes, all <6cm N3a - LN >6cm (ipsi or contra or bilat), ECE- N3b - Ln >6cm (ipsi or contra or bilat), ECE+
69
stage grouping summary - non-HPV+ oropharynx or nasopharynx
1 - T1N0 2 - T2N0 3 - T3N0 or T1-3N1 4 - >T4a or N2
70
how is stage 3 defined
T1-3N0-1, or T3N0 where N1 (clinical or pathological staging), is 1 single ipsilateral node, <3cm
71
What is the follow up for nasopharyngeal cancer after CRT
PET at 3mths. if residual disease, rescan at 6wks. if persistent -> salvage surgery
72
What must always be treated for a hypopharyngeal tumour
bilateral neck nodes
73
When can unilateral RT be considered for a tonsillar tumour instead of bilateral
T1-2N0, well lateralised tumour (based on consensus recommendation): Consider for T1-2 N1, if well lateralised primary (>1cm from midline, not involving base of tongue, posterior pharyngeal wall or extension onto adjacent soft palate by >10mm) T1-2 N2b (multiple ipsilateral nodes, <6cm) - if no significant nodal burden, ie 1-2 nodes only, both <3cm and located only in levels 2 & 3
74
when should contralateral neck irradiation be offered following surgery to an oral cavity tumour when should it be considered
Offer following surgery to a primary oral tongue SCC and ipsilateral neck dissection, if any of: - T3-4 tumour (>4cm or locally invasive) - ≥2 nodes positive in ipsilateral neck - any ECE within the ipsilateral neck - primary <10mm from midline Consider if: -single ipsilateral LN and no ECE
75
When is the neck electively treated in oral cavity tumours
in all but the very earliest any depth >4mm for tongue, and >1.5mm for floor of mouth = elective neck treatment usually selective neck dissection, 1-3, or 1-4a Surgery is primary modality - tumour, neck dissection and reconstruction
76
when is adjuvant RT indicated following surgery to the oral cavity
T3 -4 disease >N2a (single ipsi node 3-6cm, or single ipsi node < 3cm but with ECE) close margins PNI
77
how is a lateralised tumour defined such that unilateral RT can be given
>1cm from midline and <1cm extension onto soft palate or BOT
78
what is the rate of feeding tube dependency at 1yr after chemoRT treatment
5%
79
what is the rate of osteoradionecrosis with chemoRT assuming good dentition
5%
80
how is an olfactory neuroblastoma treated
Resection and adjuvant RT, occasionally induction cisplatin/etoposide
81
is the infra temporal fossa high or low risk for nasopharyngeal cancer
low risk - separate from nasopharynx
82
what is the 5yr control rate for a T1a laryngeal cancer, treated with RT only and current smoker
80%
83
what is the local control rate for a T2N1 hypopharyngeal cancer treated with chemoRT?
70-80%
84
For a T1-2 oral cavity tumour, node negative, and >1cm lateral to the midline, what nodal levels should be treated
Ipsilateral levels 1a-4a (if no neck dissection) None contralaterally If 4a or 5b involved - include 4b & 5c If level 2 involved, include 7b 9 if buccal mucosa involved
85
For an T2 oral cavity tumour, node negative, and <1cm lateral to the midline, what nodal levels should be treated
Bilateral 1a-4a (if no neck dissection) If 4a or 5b involved - include 4b & 5c If level 2 involved, include 7b 9 if buccal mucosa involved
86
For a T2N1 (stage 3) oral cavity tumour, >1cm from midline, what levels should be included
1a-4a ipsilaterally none contralaterally If 4a or 5b involved - include 4b & 5c If level 2 involved, include 7b 9 if buccal mucosa involved
87
For a T2N1 (stage 3) oral cavity tumour, <1cm from midline, what levels should be included
1a-4a bilaterally If 4a or 5b involved - include 4b & 5c If level 2 involved, include 7b 9 if buccal mucosa involved
88
If level 4A or 5b is involved, what levels must also be included
4B & 5C
89
If level 2 nodes are involved, which levels must also be included
1b & 7b
90
What is the exception when a stage I-II oral cavity cancer can be treated with RT rather than surgery
Retromolar trigone
91
What is the management of a stage I-II oral cavity tumour
surgical WLE + neck dissection (level I-IV) (unilateral or bilateral depending on laterality of the lesion) for all but very early lesions
92
When should contralateral neck RT be offered for a lateralised oral cavity tumour, following surgery to the primary and ipsilateral neck dissection
When adjuvant ipsilateral neck RT is being given, and T3-4, primary <10mm from midline, or ≥2 positive nodes within ipsilateral neck or ECE present consider contralateral RT if only one node ipsilaterally
93
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