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26 Cards in this Set

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H&N - Is T or N stage more important with regard to distant mets?

N - 10% with N0-1, 30% N3

H&N general T staging

I- T1 II T2 III T3 or N1


IV - T4aN0/1

H&N general N stagin

N1 single ipsi 3m


N2 single ipsi 3-6, or multiple, or bilat <6cm max


N3 >6cm

H&N - when can you do selective neck dissection?

cN0, selected N1

H&N ENI vs elective neck dissection?


Also, in ENI to whom must you radiate bilat?

ENI = elective neck dissection


Bilat - extensive tongue or soft palate, all T3-4

H&N - when do you add RT after modified neck dissection?


When do you add surgery after neck RT?

RT after surgery - N2b, N3, ECE, multiple positive nodes


Surgery after RT - residula >1.5cm, calcifications

H&N - after open biopsy of the neck - what's the initial treatment?

RT!

H&N - recurrent or metastatic disease, whats' the benefit with combo chemo?

only RR and QOL. maybe OS with TPF (still uncofirmed in the book)/

H&N - EXTREME trial

Cis/Carbo+5FU +/- cetuximab


PFS 3.3-->5.6m, OS 7.5-->10m

H&N - indications for preop RT

fixed nodes, postop RT will be delayed >8w, gastric pull-up, s/p open biopsy

H&N - indications for post-op RT

Close or positive margins, ECE, multiple nodes, T4, LVI, PNI, >5mm subglottic invasion.


Note 60-66Gy unless close or positive margins and then 70-74.4Gy

MACH-NC addition of chemo to RT adds what?> whats the sequence?


In what instances can you use induction chemo?

Only concomitant proven. 4% in 5y added OS


Induction - for quick palliation to avoid PEG/tracheostomy, in organ-preservation when degree of response helps decide management, in patients with advanced neck disease at high risk for distant mets

MACH-NC data regarding combo chemo for definitive or adjuvant/neoadjuvant ChemoRT

Combos do not impact survival.


Most data for cisplatin, unclear if carbo equivalent

Results of Cetuximab as part of chemoRT

RT vs concurrent cetuximab-RT - mOS 29-->49m for cetuximab, also improved PFS

H&N - Int0099

Advanced NPC (stage III/IV) to defnitive RT(70Gy) or conccurent CRT(cis) + 3 cycles maintenance cis-5fu.


Improved local control, distant control, PFS, OS.


Note only 50-60% completion in CRT arm.

H&N - Veterans organ preservation study

CRT improved larynx preservation to 60%, better QOL. Note this study is induction chemo-->assessment-->responders go to definitive RT and non responders to salvage surgery

H&N - organ preservation RTOG91-11

larynx preservation study - RT alone, CRT induction(cis-5fU), CRT concomittant(cis) = better locoregional control and more larynx preservation with concomittant CRT.


No OS difference.

H&N - Adjuvant RT vs CRT , and to whom?

CRT better in terms of locoregional control, DFS, one study (EORTC) showed also improved OS.


Final conclusion CRT for ECE or positive margins.


RT is probably 60-66Gy with cis

H&N - follow up

q1-3m y1, q2-4m y2, q4-6 y3-5, q6-12m thereafter

Larynx - treatment T1-2, T3-4

T1-2 - usually RT alone\


T3-4 - low volume disease (3.5cc) CRT, higher volume total laryngectomy with neck dissection and adjuvant CRT

H&N - RT dose to larynx(glottic)

T1-2a 63Gy in 2.25Gy, T2b 65.25Gy


T3-T4 74.4Gy (cone down after 45.6Gy)

H&N - treatment to supraglottic T1-T2, T3-4

T1-2 or low volume T3 <6cc - RT or partial laryngectomy. >6cm partial laryngectomy.


stage III-III CRT.

NPC WHO types

Type 1 SCC, type 2 nonkeratinzing, Type III - undifferentitated or lymphoepithelioma

NPC lympathic spread incidence

80-90%, 50% bilat

NPC T stage, N stage

T2 - parapharyngeal, T3 - bony structure, T4-intracranial


N1-unilat <6cm, N2 bilat <6cm, N3 >6cm or supraclav

NPC treatment?

RT/CR definitive, RT is to 74.4Gy at 1.2Gy bid