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49 Cards in this Set

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What are the six major head and neck sites for cancer?
1 Oral cavity
2 Pharynx
- Nasopharynx
- Oropharynx
- Hypopharynx
3 Larynx
4 Paranasal sinuses
5 Salivary glands
6 Thyroid gland
List the seven levels of lymph nodes in H&N cancer.
I: Submental, submandibular
II: Upper jugular
III: Mid jugular
IV: Lower jugular
V: Posterior triangle
VI: Prelaryngeal, pretracheal, paratracheal
VII: Upper mediastinal
List other groups of lymph nodes in H&N cancer.
1 Sub-occipital
2 Retropharyngeal
3 Parapharyngeal
4 Buccinator (facial)
5 Preauricular
6 Periparotid and intraparotid
What are the boundaries of Level I?
Contains the submental and submandibular triangles
Bounded
-Anterior and posterior bellies of the digastric muscle
-Inferiorly hyoid bone
-Superiorly body of the mandible
What are the boundaries of Level II?
Contains the upper jugular nodes
-Superiorly level of the skull base
-Inferiorly hyoid bone
What are the boundaries of Level III?
Contains the middle jugular lymph nodes
-Superiorly hyoid bone
-Inferiorly lower border of the cricoid cartilage
What are the boundaries of Level IV?
Contains the lower jugular lymph nodes
-Superiorly cricoid cartilage
-Inferiorly clavicle
What are the boundaries of Level V?
Contains the lymph nodes in the posterior triangle
- Posteriorly - anterior border of the trapezius
- Anteriorly - posterior border of SCM
- Inferiorly - clavicle
What are the boundaries of Level VI?
Contains lymph nodes of the anterior central compartment
-Superiorly hyoid bone
-Inferiorly suprasternal notch
- Laterally medial border of carotid sheath
What are the boundaries of Level VII?
Contains lymph nodes inferior to the suprasternal notch in the superior mediastinum
What is the definition of N1?
N1 - A single ≤ 3 cm ipsilateral lymph node
What is the definition of N2a?
N2a - A single 3 < X ≤ 6 cm ipsilateral lymph node
What is the definition of N2b?
N2b - Mets in multiple ipsilateral lymph nodes ≤ 6 cm
What is the definition of N2c?
Bilateral or contralateral lymph nodes ≤ 6 cm
What is the definition of N3?
Metastasis in a lymph node > 6 cm in greatest dimension
What is the definition of M1?
Distant metastasis
Nasopharynx staging: T stage
Nasopharynx staging: T stage

T1: Confined to nasopharynx
T2: Extends to soft tissues
T2a: Oropharynx +/- NC without parapharyngeal extension
T2b: Parapharyngeal extension
T3: Bony structures +/- paranasal sinuses
T4: Intracranial extension, CN involvement, infratemporal fossa, orbit, hypopharynx, or masticator space
Nasopharynx staging: N stage
Nasopharynx staging: N stage
N1: Unilateral met(s) ≤ 6 cm above supraclavicular fossa
N2: Bilat mets ≤ 6 cm above supraclavicular fossa
N3a: Mets > 6 cm
N3b: Extension to supraclavicular fossa
Nasopharynx staging: M stage
Nasopharynx staging: M stage
M1: No distant mets
M2: Distant mets
Oropharynx subsites
Oropharynx subsites
- Extends from superior soft palate to superior hyoid
1 Base of tongue
2 Soft palate and uvula
3 Tonsillar pillars
4 Glossotonsillar sulci
5 Pharyngeal tonsils
6 Lat and post pharyngeal walls
Hypopharynx subsites
Hypopharynx subsites
- Extends from superior border of hyoid to lower cricoid
1 Piriform sinuses
2 Lateral and posterior hypophyarngeal walls
3 Postcricoid region
Larynx sites
1
2
3
Larynx sites
1 Supraglottis
2 Glottis
3 Subglottis
Supraglottis subsites
1
2
3
4
5
Supraglottis subsites
1 Supraglottic epiglottis
2 Infrahyoid epiglottis
3 AE folds (laryngeal aspect)
4 Arytenoids
5 FVCs
Glottis subsites
1
2
3
Glottis subsites
1 TVCs
2 AC
3 PC
Subglottis subsites
Subglottis subsites: Subglottis
Esthesioneuroblastoma staging
Esthesioneuroblastoma staging

Kadish system
A: Confined to nasal cavity
B: Extends more than one paranasal sinus
C: Extends beyond nasal cavity or paranasal sinuses
D: Regional mets (cervical nodes)
Distant metastases
Esthesioneuroblastoma treatment

Small, low-grade tumors confined to the ethmoids

Otherwise
Esthesioneuroblastoma treatment

Small, low-grade tumors confined to the ethmoids: Surgery +/- RT or RT (65-70 Gy if def)
--> Local control stage A: 70%
Otherwise: CMT
- Surgery then
-- PORT 50-60 Gy
-- Adj CCRT 50-60 Gy
-- PORT 45 Gy
--> LC stage B: 50-65%
LC stage C: 30-50%
Esthesioneuroblastoma pearls

Age on presentation

Symptoms at presentation

Lymph node spread
Esthesioneuroblastoma pearls

Age on presentation: 11-20 & 40-60

Symptoms at presentation
- Unilateral nasal blockage
- Epistaxis

Lymph node spread
- Early stage: <10%
- Stage C: up to 50%
Esthesioneuroblastoma Histology
1
2
3
4
Esthesioneuroblastoma Histology
1 Epithelial components provide supporting stroma
2 Nerve component corresponding to olfactory cells
3 Rosettes - Rows of columnar cells with radially oriented nuclei arranged around a central area
4 Pseudorosettes - Ring of blue cells around a tangle of neurofibrils
Esthesioneuroblastoma Imaging
Esthesioneuroblastoma Imaging
- MR for soft tissue and brain involvement
- CT for bone involvement
- Octreotide scan
-- Uses tagged somatostatin analog
-- Produces scintigraphic image of neuroendocrine tumors
Esthesioneuroblastoma prognosis

Local recurrence rate

Cervical metastatic rate
Esthesioneuroblastoma prognosis

Local recurrence rate: ~70%

Cervical metastatic rate: ~25%
H&N: PORT indications

1
2
3
4
5
6
7

Ref
H&N: PORT indications

1 Oral cavity site
2 PNI
3 Largest node > 3cm
4 Multiple positive nodes
5 Tx delay > 6 wks postop
6 Positive margins (= Adj CCRT)
7 ECE (= Adj CCRT)

Ref: Ang IJROBP 2001
H&N: Adj CCRT indications

1
2

Ref
H&N: Adj CCRT indications

1 Positive margins ("microscopically involved")
2 ECE

Ref
1 EORTC 22931 Bernier
2 RTOG 9511 Cooper
3 Comparison Bernier & Cooper
Oropharynx T staging
T1 ≤ 2 cm
T2 2 < X ≤ 4 cm
T3 > 4 cm
T4a invades larynx, deep tongue muscles, medial pterygoid, hard palate, or mandible
T4b invades lateral pterygoid, pterygoid plates, lateral nasopharynx, skull base, or encases cartoid
Hypopharynx T staging
T1 - One subsite ≤ 2 cm
T2
- More than one subsite OR
- 2 < X ≤ 4 cm
T3 > 4 cm
T4a Invades thyroid/cricoid cartilage, hyoid bone, thyroid gland, esophagus, or central compartment soft tissues
T4b invades prevertebral fascia, encases carotid, involves mediastinal structures
Oropharynx and Hypopharynx N staging
N1 Single ipsi node ≤ 3 cm
N2a Single ipsi node 3 < X ≤ 6 cm
N2b Multiple ipsi nodes ≤ 6 cm
N3 > 6 cm
Nasopharynx Stage Grouping
I: T1N0M0
IIA: T2aN0M0
IIB: T1-2bN1M0, T2bN0M0
III: T1-3N2M0, T3N0-1M0
IVA: T4N0-2M0
IVB: Any T N3M0
IVC: Any T Any N M1
Oro- / Hypopharynx Stage Grouping
I: T1N0M0
II: T2N0M0
III: T1-3N1M0, T3N0M0
IVA: T4aN0-1M0, T1-4aN2M0
IVB: T4b Any N M0, Any T N3M0
IVC: Any T Any N M1
Lip/OC T Staging
T1: ≤ 2 cm
T2: 2 < X ≤ 4 cm
T3: > 4 cm
Lip T4 invades through cortical bone, inferior alveolar nerve, floor of mouth, skin of face
OC T4a invades through cortical bone, deep tongue mesucles, maxillary sinus, skin of face
OC T4b invades masticator space, pterygoid plates, skull base, encases carotid
Lip/OC N Staging
N1: Single ipsi node ≤ 3 cm
N2a - Single ipsi node 3 < X ≤ 6 cm
N2b - Multiple ipsi nodes ≤ 6 cm
N2c - Bilat or contralateral nodes ≤ 6 cm
N3 > 6 cm
-
Supraglottis T Staging
T1: One subsite with normal cord mobility
T2: More than on subsite or region outside the glottis without fixation
T3
- Limited to larynx with cord fixation
- Invades postcricoid area, pre-epiglottic tissues, paraglottic space, minor thyroid cartilate erosion
T4a invades through thyroid cartilage, tissues beyond larynx
T4b invades prevertebral space or mediastinal structures, encases carotid
Glottis T Staging
T1a: Limited to one cord with normal mobility
T1b: Involves both cord with normal mobility
T2
- Extends to supraglottis +/- subglottis
- Impaired cord mobility
T3
- Limited to cord fixation
- Invades paraglottic space
- Minor cartilage erosion
T4a
- Invades through thyroid cartilage
- Invades tissues beyond larynx
T4b - Invades prevert space or med structures or encases carotid
Subglottis T Staging
T1: Limited to subglottis
T2: Extends to cords with normal or impaired mobility
T3: Limited to larynx with fixation
T4a - Invades cricoid or thyroid cartilage or tissue beyond larynx
T4b - Invades prevert space or med structures or encases cartoid
Larynx N Staging
N1: Single ipsi node ≤ 3 cm
N2a: Single ipsi node 3 < X ≤ 6 cm
N2b: Multiple ipsi nodes ≤ 6 cm
N2c: Bilat or contralateral nodes ≤ 6 cm
N3: > 6 cm
Larynx Stage Grouping
I: T1N0M0
II: T2N0M0
III: T3N0M0, T1-3N1M0
IVA: T4aN0-1M0, T1-4aN2M0
IVB: T4b Any NM0, Any T N3M0
IVC: Any T Any N M1
Major Salivary Gland T Staging
T1: ≤ 2 cm without extraparenchymal extension
T2: 2 < X ≤ 4 cm without extraparenchymal extension
T3: > 4 cm +/- extraparenchymal extension
T4a: Skin, mandible, ear canal, facial nerve
T4b: Skull base, pterygoid plates, encases carotid
Major Salivary Gland N Staging
N1: Single ipsi node ≤ 3 cm
N2a: Single ipsi node 3 < X ≤ 6 cm
N2b: Multiple ipsi nodes ≤ 6 cm
N2c: Bilat or contralateral nodes ≤ 6 cm
N3: > 6 cm
Thyroid T Staging
T1: ≤ 2 cm limited to thyroid
T2: 2 < X ≤ 4 cm limited to thyroid
T3: < 4 cm or minimal extrathyroi extension
T4a: Beyond thyroid capsule into subcu soft tissues, larynx, trachea, eso, or RLN
T4b: Invades prevert fascia or encases carotids or med vessels
Thyroid N Staging
N1a: Mets to level VI
N2b: Met to uni-, bi-, or contralateral cervical or superior med nodes