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Management of neck: A radiation oncologist's perspective

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Management of neck: A radiation oncologist's perspective

  1. 1. Management of Neck Nodes in Head and Neck Malignancies: A Radiation Oncologist’s Perspective Dr Suman Mallik Radiation Oncologist Westbank Cancer Centre Westbank Health and Wellness Institute
  2. 2. Issues • Where ? • When ? • How much ? (Risk stratification)
  3. 3. Aims • Radical • Prophylactic
  4. 4. • Radical • Adjuvant
  5. 5. Situations • Known Primary • Unknown Primary
  6. 6. Imaging • USG • CECT • MRI • PET-CT
  7. 7. Sources of information • Anatomy • Clinical and surgical data • Pattern of failure data
  8. 8. Modified Robbin’s nodal levels Gregoire V, Radiotherapy Oncol 2013
  9. 9. Oral Cavity 3.5% 91% 3.9% 4.8% Pantvaidya G 2013 698 Neck Dissection 566 oral cancer patient 434 unilateral, 132 bilateral Tongue(255), Buccal Mucosa(233) 698 Neck Dissection 566 oral cancer patient 434 unilateral, 132 bilateral Tongue(255), Buccal Mucosa(233) Level I to III 91% Skip metastasis to level III 13.8% Skip Metastasis for tongue primary 19% Level I to III 91% Skip metastasis to level III 13.8% Skip Metastasis for tongue primary 19%
  10. 10. Oral Cavity: determinants for nodal irradiation • Primary site • T stage • Depth (4 mm Vs 9mm) • N stage • Perinodal extension • LVE, PNI
  11. 11. CTV node (oral cavity) Gregoire V et al R&O 2000, 2006
  12. 12. Nasopharynx Ipsilateral 3% 70% 45% 1% 11% 0% 27% 3% Skip Metastasis 0.5 to 7.9%
  13. 13. CTV node (nasopharynx) Gregoire V et al R&O 2000, 2006
  14. 14. Oropharyngeal Tumor (clinical examn) Ipsilateral Contralateral 13% 82% 23% 2% 9% 0% 13% 1% 2% 24% 5% 3% 2% 0% Bataini and Lindberg
  15. 15. Oropharyngeal (Pathological) Clinical N0 Ipsilateral Clinical N+ Ipsilateral 2% 25% 19% 8% 0% 2% 15% 71% 42% 27% 0% 9% Candela 1990
  16. 16. T1-T2 Tonsil, clinical N0 or N+ (N=228) • Contralateral Neck failure 8/228 (3.5%) • For a well lateralized tumor it is safe to treat neck unilaterally O’Sullivan B IJROBP 2001
  17. 17. CTV node (oropharynx) Gregoire V et al R&O 2000, 2006
  18. 18. Hypopharynx (Pharyngeal wall) 0% 9% 0% 18% 0% 0% 11% 84% 0% 72% 40% 20% Clinical N0 Ipsilateral Clinical N+ Ipsilateral Chao KS IJROBP 2002
  19. 19. Hypopharynx (Pyriform sinus) 0% 15% 0% 8% 0% 0% 2% 77% 4% 57% 23% 22% Clinical N0 Ipsilateral Clinical N+ Ipsilateral Chao KS IJROBP 2002
  20. 20. CTV node (Hypopharynx) Gregoire V et al R&O 2000, 2006
  21. 21. Larynx (Supraglottic) 6% 18% 18% 9% 2% 2% 70% 48% 17% 16% Chao KS IJROBP 2002 Clinical N0 Ipsilateral Clinical N+ Ipsilateral
  22. 22. Larynx (Glottic) 0% 21% 29% 7% 7% 9% 42% 71% 24% 2% Chao KS IJROBP 2002 Clinical N0 Ipsilateral Clinical N+ Ipsilateral
  23. 23. CTV node (larynx) Gregoire V et al R&O 2000, 2006
  24. 24. Contralateral Neck Node cN+ Bilat cN+ Contralat cN-, pN+ bilat Oral Tongue 12 33 FOM 27 21 BOT 37 55 Tonsil 16 2 Pharyngeal wall 50 37 Pyriform Sinus 49 6 59 Supraglottic 39 2 26 Glottic 15 Chao KS IJROBP 2002
  25. 25. Unilateral Neck treatment • Cheek • Alveolus • Retromolar trigone • Early lateralised Tonsil
  26. 26. Retropharyngeal Node Nasopharynx 40% Oropharynx 4% Hypopharynx 16% Larynx 0% Nasopharynx 86% Oropharynx 12% Hypopharynx 21% Larynx 4% N0N0 N+N+ Pharyngeal wall N0= 16%, N+=21% Soft Palate N0= 5%, N+=19% Tonsillar Fossa N0= 4%, N+=12% Base of Tongue N0= 0%, N+=6% Chao KS, McLaughlin, Chua, Chong
  27. 27. Gregoire V et al R&O 2000, 2006
  28. 28. Risk Stratification Target Definitive RT PORT High risk PORT intermediate risk CTV1 Gross Tumor, node and adjacent nodal region 70 Gy equivalent Surgical bed with soft tissue involvement or nodal region with extracapsular spread 56-60 Gy eqv Surgical bed without soft tissue involvement or nodal region without extracapsular extension 56-60 Gy eqv CTV2 Elective nodal region. 50-60 Gy eqv Elective nodal region 50-54 Gy eqv Elective nodal region 50-54 Gy eqv CTV3 Elective nodal region 50-54 Gy eqv Elective nodal region 50 Gy eqv Elective nodal region 50 Gy eqv
  29. 29. Nodal treatment in N+ • Primary • Nodal staging • ECE
  30. 30. ECE and nodal size PIRUS GHADJAR IJROBP 2010
  31. 31. Extent of ECE • The mean and median extent values of ECE were 1.8 and 1 mm • ECE 5 mm in 97% and 3 mm in 91% of the 231 LN analyzed. • The largest percentage of LN had an ECE of 1 mm (58%) • In 17 (17%) patients, infiltration of the adjacent • muscular fascia was observed, with mean and median extension values of 2.8 and 2.0 mm, respectively (range, 1–9 mm). PIRUS GHADJAR IJROBP 2010
  32. 32. CTV in presence of ECE
  33. 33. ECE • For metastatic lymph node the risk of ECE is associated with lymph node size. • The extention of EC spread is not related to lymph node size. • In 96 % of all ECE, extension is less than 5 mm. • 1 cm margin over node will cover >99% ECE but also significantly increase the high dose volume
  34. 34. Delineation of nodal stations Harari et al 2004 Grégoire V et al Radiother Oncol 2000;56:135–50. Grégoire V et al, Radiother Oncol 2003;69:227–36. Grégoire V et al, Radiother Oncol 2013. RTOG contouring guideline www.dahanca.dk
  35. 35. Metastatic neck node from unknown primary
  36. 36. • Hist and Physical Examination • Triple scopy • FNAC/ Biopsy Biopsy to search primary (Blind biopsy from nasopharynx, base of the tongue, pyriform sinus + ipsilateral tonsillectomy) • HPV, P-16, EBV
  37. 37. Imaging • Local imaging (CECT, MRI, USG) • Metastatic workup • CXR/ CT Thorax • Whole body PET-CT
  38. 38. Importance of histology
  39. 39. Immunohistochemistry LCA CD-45
  40. 40. DAHANCA (Grau et al 2000)N=277
  41. 41. CUP • The five-year estimates of neck control, disease- specific survival and overall survival for radically treated patients were 51%, 48% and 36%, respectively. • Oropharynx, hypopharynx and oral cavity being the  most common sites. • Emerging primaries outside the head and neck region are primarily located in the lung and oesophagus . • The most important factor for neck control is nodal  stage (5-year estimates 69% [N1], 58% [N2] and 30% [N3]). • Conflicting results on surgery and radiotherapy. Grau 2000 Head and Neck
  42. 42. Post Neck Dissection N1 disease ECE(-) Level involved Target area Level 1 only RT to oral cavity, Waldeyer’s ring, oropharynx, bilateral neck Level 2,3 RT to oropharynx and bilateral neck Level 4 only RT to Waldeyer’s ring, larynx, hypopharynx, bilateral neck Level 5 RT to npx, larynx, hypopharynx, bilateral neck OR OBSERVATION
  43. 43. Post Neck Dissection N2-3 disease ECE(-) Level involved Target area Level 1 only RT to oral cavity, Waldeyer’s ring, oropharynx, bilateral neck Level 2,3, upper 5 RT to nasopharynx, oropharynx, hypopharynx, larynx and bilateral neck Level 4 only RT to Waldeyer’s ring, larynx, hypopharynx, bilateral neck Level 5 RT to npx, larynx, hypopharynx, bilateral neck + Chemotherapy
  44. 44. Post Neck Dissection ECE(+) Level involved Target area Level 1 only RT to oral cavity, Waldeyer’s ring, oropharynx, bilateral neck Level 2,3, upper 5 RT to nasopharynx, oropharynx, hypopharynx, larynx and bilateral neck Level 4 only RT to Waldeyer’s ring, larynx, hypopharynx, bilateral neck Level 5 RT to npx, larynx, hypopharynx, bilateral neck + Chemotherapy
  45. 45. Take home message • Optimal clinical examn and imaging modality • Evolution and evidences of nodal delineation • Optimal treatment approach • Multimodality approach

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