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Neck Node& Contouring Guidelines
Prof Manoj Gupta
Shimla 26th April, 201416th ICRO Teaching Course, Shimla
Location & Pattern of Involvement.
Why is it needed ??
• Cancer treatment does not mean only cure but also to
provide good...
Location & Pattern of Involvement.
Why is it needed ??
• Depending upon the primary site and stage of the
disease, Surgeon...
Classification of neck nodes - levels
• Robbins Classification:- Surgeons usually
follow this system.
• For Radiation Onco...
Changes in Robbins classification
• Based on surgical boundaries like muscles, nerves
and vessels.
• But these structures ...
Changes in Robbins classification
• Similarly, Robbins defined the caudal limit of
level III as the point at which the omo...
Changes in Robbins classification
• Robbins used the spinal accessory nerve (SAN)
to sub-divide level II into IIa (anterio...
Classification of Neck
Nodes and Contouring
Guidelines
Classification of the Neck Nodes
Myelohyoid
Post. Belly of digastric
Sterno-cleido
mastoid
Omohyoid
Trpezius
Ant. Belly of digastric
Hyoid bone
Thyroid Car...
Boundaries
Cranial
Caudal
Lateral
Medial
Posterior
Anterior
Axial
CoronalSagittal
Lymph Node Regions
• Level I
Submental Nodes (Ia)
Submental triangle:
–Bounded by two anterior belly of digastric
Primary for Ia
• Floor of the mouth.
• Anterior oral tongue.
• Anterior mandibular alveolar ridge.
• lower lip.
Lateral-> Medial edge
of ant belly of two
digastric muscles
Anterior-> Platysma
muscle and the symphysis
menti,
Level Ia
P...
Medial-> region
continues into the
contralateral level Ia
Level Ia
Cranial-> Geniohyoid muscle or a plane tangent to
the basilar edge of the mandible.
Caudal-> hyoid bone
Level Ia
RTOG Atlas
Contouring
Lymph Node Regions
• Level Ib:
Submandibular Triangle
–Formed by the anterior and posterior belly
of the digastric muscle ...
Primary for Ib
• cancers of the oral cavity,
• anterior nasal cavity,
• soft tissue structures of the mid-face and
• the s...
Anteriorly -> Platysma muscle
Level Ib
Posterior-> Posterior edge of the submandibular gland,
Level Ib
Medial-> lateral edge of the ant belly of digastric
muscle
Level Ib
Lateral-> Inner side of the mandible, Platysma and skin.
Level Ib
Cranial-> Mylohyoid muscle and cranial edge of the
submandibular gland.
Level Ib
Caudal-> Plane crossing the central part of
Hyoid bone
Level Ib
Contouring
Level Ib
Most of the jugular nodes(lev. II-IV) present ant., post., and lateral
to the IJV.
So medial boundary is medial edge of ...
Level II
• Cranial limit for level II was defined by
surgeons at insertion of post belly of digastric
muscle at mastoid.
•...
How consensus was made for cranial border for level II Nodes?
• Clips cluster
around caudal
border of
transverse
process o...
Usually the cranial
limit of level II is
caudal border of
transverse process of
C1 vertebrae.
But few nodes also
present...
When to treat Retro Styloid Region
• Ca Nasopharynx.
Bilateral
• In +ve level II node
Ipsilateral
Caudal-> Carotid Bifurcation (Surgical Boundry)
Caudal edge of body of the hyoid bone.
Level II
• anteriorly by the
– the anterior edge
of the carotid
artery
– posterior edge of
the submandibular
gland,
– the posterior...
Anterior-> Anterior edge of the carotid artery
Level II
Anterior->Posterior edge of the submandibular gland,
Level II
Anterior->posterior belly of the digastric muscle,
Level II
Posterior-> Posterior edge of the sternocleidomastoid
(SCM) muscle,
Level II
Medial-> Medial edge of the carotid artery and the
paraspinal muscles (levator scapulae and splenius
capitis)
Level II
Lateral-> Medial edge of the SCM
Level II
Contouring
Level II
Primary for II
• Nasal cavity.
• Oral cavity.
• Oropharynx.
• Hypopharynx.
• Larynx.
• Major salivary glands.
• Nasopharyn...
IIa IIb
• Level II is further
subdivided into two
compartments.
– IIa
– IIb
• Surgeons demarcate
between the two by
spinal...
IIa
IIb
Level III
• contains the middle jugular lymph nodes located
around the middle third of the IJV.
• It is the caudal extensi...
Cranial-> caudal edge of body of the hyoid bone.
Level III
Caudal-> Caudal edge of the cricoid cartilage.
Level III
Anterior-> Posterolateral edge of the sternohyoid muscle
and the anterior edge of the SCM muscle,
Level III
Posterior-> Posterior edge of the SCM muscle
Level III
Lateral-> Medial edge of the SCM muscle
Level III
Medial-> Medial edge of the internal carotid artery
and the paraspinal muscles (scalenius).
Level III
Level III
Contouring
includes the lower
jugular lymph nodes
located around the
inferior third of the IJV.
According to Robbins, it
extends fr...
Caudal->2cm cranial to the
cranial edge of sterno-
clavicular joint.
Cranial-> Caudal edge of the cricoid cartilage.
Level IV
Anterior
Posterior
Lateral.
Level IV
Anterior edge , posterior edge and medial
edge of the SCM muscle, respectively
Medial-> Medial edge of the internal carotid artery
and the paraspinal muscles (scalenius)
Level IV
Level IV
Contouring
2 cm
Primary for level IV
• Hypopharynx.
• Larynx
• Oropharynx.
• Skip metastasis from ant tongue.
• Cervical esophagus
Level V
Clavicle
SCM
Trapezius
The uppermost part of
level V contains superficial
occipital lymph node(s),
which are not involved in
head and neck ca ex...
Cranial -> Horizontal plane crossing the cranial edge of
the body of the hyoid bone Level V
• For the caudal limit of level V, it appears from
critical examination of neck dissection
procedure, that surgeons never ...
Caudal -> CT slices at the level of transverse Cervical vessels
Level V
Lateral-> Platysma muscle and the skin,
Level V
Medial -> Paraspinal muscles (splenius capitis, levator
scapulae and scaleni (posterior, medial and anterior) muscles)
Lev...
Anterior-> Posterior edge of the SCM muscle
Level V
Posterior -> Antero-lateral border of the trapezius muscles
.Practically, a virtual line joining the antero-lateral border...
Level V
Contouring
Primary for Level V
• Nasopharynx.
• Oropharynx.
• Subglottic larynx.
• Apex of the pyriform sinus.
• Cervical esophagus.
...
Va
Vb
Level V is
divided into Va
and Vb by
omohyoid muscle
where it crosses
the internal
jugular vein.
But this
crossing...
Hyoid
Thyroid
Cricoid
For practical
purpose, use of the
plane between levels
III and IV extended
posteriorly is
recommend...
Located in anterior
neck compartment
They are pre- and
para tracheal nodes
including the pre-
cricoid (Delphian)
node an...
Cranial -> Caudal edge of the body of the thyroid cartilage,
Level VI
Caudal -> Cranial edge of the sternum manubrium
Level VI
Anterior-> Platysma and the skin
Level VI
Posterior -> Separation between the trachea and
the esophagus.
Level VI
.
Lateral -> Medial edge of the thyroid gland and
the antero-medial edge of the SCM muscle
Level VI
Para-tracheal
Pre-tracheal
Contouring
Level VI
Primary for Level VI
• cancers of the thyroid gland,
• the Trans glottic and subglottic larynx,
• the apex of the piriform...
Typically, retropharyngeal
nodes are divided into
Medial Group
Lateral Group.
The medial group is an
inconsistent grou...
Cranial-> Base of the skull
Mastoid Process RP nodes
Caudal -> Cranial edge of the body of the hyoid bone
RP nodes
Anterior-> Levator Veli palatini muscle.
RP nodes
Posterior-> Pre-vertebral Muscles. .
RP nodes
Lateral-> Medial edge of the carotid vessel.
RP nodes
Medial-> Midline
RP nodes
RP nodes
Contouring
Node Positive
Neck
Node positive Neck
• With N+ve, one adjacent extra nodal level is
also at high risk of occult metastasis, for eg.
the leve...
Retrostyloid
Region
S/C fossa Till
Sternum
Point No 1
In level II node positive include retro styloid region and in level ...
Retro Styloid Region
S/C Fossa
Point No 2
In fact, this recommendation will only apply to patients with
a single involved lymph node (pN1) for whom post-...
When an involved lymph node abuts a muscle (e.g. sterno-cleido-
mastoid or para-spinal) it is recommended to include this ...
Extra Capsular Extension(ECE)
Incidence of ECE is 20 to 40% in metastatic node <1cm size while
goes up to 75% if size is ...
Magnitude of ECE
The majority of the ECE extend
<5mm from the capsule of node.
None extend >10mm
Margins of 1 cm from
the nodal GTV to the CTV
would be sufficient to
fully cover any subclinical
nodal extension for lymp...
Post Operative
Neck
Point No 1
Retrostyloid
Region
S/C fossa
Till
Sternum
Point No 2
Point No 3
Point No 4
Pattern of Spread
•Prophylactic neck node
irradiation is required if
the incidence of occult
metastasis is >5%.
• Typically, nasopharyngeal and hypopharyngeal
tumors have the highest propensity of nodal
involvement which occurs in 80 ...
Incidence and distribution of regional metastasis for
Levels I–V for clinically N0 neck
• Tumor site Levels involved (%)
I...
Non Nasopharyngeal N0 Neck
• Oral Cavity Ca
• Oro pharynx
• Hypo pharynx
• larynx
Level I, II, III and in
ca tongue level ...
Incidence and distribution of regional metastasis for
Levels I–V for clinically N+ve neck
• Tumor site Levels involved (%)...
Primary site for RP Nodes inclusion
N0 Neck  Nasopharynx and Pharyngeal Wall
N+ Neck  All sites except larynx
In non nas...
Thanks
Questions???
Neck node & Contouring Guidelines
Neck node & Contouring Guidelines
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Neck node & Contouring Guidelines

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Normal Neck Node anatomical boundaries on CT scan and contouring guidelines for in N0 neck for Head and Neck IMRT

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Neck node & Contouring Guidelines

  1. 1. Neck Node& Contouring Guidelines Prof Manoj Gupta Shimla 26th April, 201416th ICRO Teaching Course, Shimla
  2. 2. Location & Pattern of Involvement. Why is it needed ?? • Cancer treatment does not mean only cure but also to provide good quality of life. • Therapeutic gain can be accomplished either by increasing the control rate or by decreasing the side effect of treatment. • That is what modern radiotherapy like IMRT has done so far. • Not all the neck nodes are involved in all sites. • Gone are the days when with 2-D radiation every thing between the radiation portal are treated irrespective of need.
  3. 3. Location & Pattern of Involvement. Why is it needed ?? • Depending upon the primary site and stage of the disease, Surgeons practice selective neck dissection. • If location and pattern of spread are known, then Radiation Oncologist can also plan selective neck irradiation thus avoiding many normal structures like parotid and swallowing muscles leading to better quality of life. • With high precision radiotherapy, the goal of providing better quality of life is further achieved.
  4. 4. Classification of neck nodes - levels • Robbins Classification:- Surgeons usually follow this system. • For Radiation Oncologists 2 systems of classifications are commonly used - Brussels system -Rotterdam system • Due to discrepancies in different systems , a consensus guidelines was derived (RTOG Consensus guidelines).
  5. 5. Changes in Robbins classification • Based on surgical boundaries like muscles, nerves and vessels. • But these structures may not be identifiable on CT. • Cranial limit for level II was defined by surgeons at insertion of post belley of digastric muscle at mastoid. • But this point may not be identifiable on CT. • So cranial limit was modified to bony land mark like cervical vertibrae.
  6. 6. Changes in Robbins classification • Similarly, Robbins defined the caudal limit of level III as the point at which the omohyoid muscle crossed the internal jugular vein (IJV); again not clearly identifiable on CT. • Again easily identifiable landmark is choosen like lower border of cricoid cartilage.
  7. 7. Changes in Robbins classification • Robbins used the spinal accessory nerve (SAN) to sub-divide level II into IIa (anterior to a vertical plane defined by the nerve) and IIb (posterior to that plane). • SAN cannot be identified on CT scans, • So, posterior edge of the IJV for the subdivision between levels IIa and IIb
  8. 8. Classification of Neck Nodes and Contouring Guidelines
  9. 9. Classification of the Neck Nodes
  10. 10. Myelohyoid Post. Belly of digastric Sterno-cleido mastoid Omohyoid Trpezius Ant. Belly of digastric Hyoid bone Thyroid Cartilage Cricoid Cartilage Jugular vein Submandibular gland
  11. 11. Boundaries Cranial Caudal
  12. 12. Lateral Medial
  13. 13. Posterior Anterior
  14. 14. Axial CoronalSagittal
  15. 15. Lymph Node Regions • Level I Submental Nodes (Ia) Submental triangle: –Bounded by two anterior belly of digastric
  16. 16. Primary for Ia • Floor of the mouth. • Anterior oral tongue. • Anterior mandibular alveolar ridge. • lower lip.
  17. 17. Lateral-> Medial edge of ant belly of two digastric muscles Anterior-> Platysma muscle and the symphysis menti, Level Ia Posterior -> body of the hyoid bone,
  18. 18. Medial-> region continues into the contralateral level Ia Level Ia
  19. 19. Cranial-> Geniohyoid muscle or a plane tangent to the basilar edge of the mandible.
  20. 20. Caudal-> hyoid bone Level Ia
  21. 21. RTOG Atlas Contouring
  22. 22. Lymph Node Regions • Level Ib: Submandibular Triangle –Formed by the anterior and posterior belly of the digastric muscle and the body of the mandible
  23. 23. Primary for Ib • cancers of the oral cavity, • anterior nasal cavity, • soft tissue structures of the mid-face and • the submandibular gland.
  24. 24. Anteriorly -> Platysma muscle Level Ib
  25. 25. Posterior-> Posterior edge of the submandibular gland, Level Ib
  26. 26. Medial-> lateral edge of the ant belly of digastric muscle Level Ib
  27. 27. Lateral-> Inner side of the mandible, Platysma and skin. Level Ib
  28. 28. Cranial-> Mylohyoid muscle and cranial edge of the submandibular gland. Level Ib
  29. 29. Caudal-> Plane crossing the central part of Hyoid bone Level Ib
  30. 30. Contouring Level Ib
  31. 31. Most of the jugular nodes(lev. II-IV) present ant., post., and lateral to the IJV. So medial boundary is medial edge of the vessel bundle. Jugular nodes
  32. 32. Level II • Cranial limit for level II was defined by surgeons at insertion of post belly of digastric muscle at mastoid. • But this point may not be identifiable on CT. • Surgeons were asked to put the clips at the upper level of dissection for level II nodes in node negative neck.
  33. 33. How consensus was made for cranial border for level II Nodes? • Clips cluster around caudal border of transverse process of vertebra C1. • So cranial border of level II is taken at caudal edge of transverse process of C1. Parotid projection so if cranial limit is taken at base of skull then more parotid will be irradiated.
  34. 34. Usually the cranial limit of level II is caudal border of transverse process of C1 vertebrae. But few nodes also present superior to this up to base of skull. This region cranial to cranial limit of Level II is called Retro Styloid region. Level II Retrostyloid Region
  35. 35. When to treat Retro Styloid Region • Ca Nasopharynx. Bilateral • In +ve level II node Ipsilateral
  36. 36. Caudal-> Carotid Bifurcation (Surgical Boundry) Caudal edge of body of the hyoid bone. Level II
  37. 37. • anteriorly by the – the anterior edge of the carotid artery – posterior edge of the submandibular gland, – the posterior belly of the digastric muscle, Level II Anterior Relation Cranial Caudal
  38. 38. Anterior-> Anterior edge of the carotid artery Level II
  39. 39. Anterior->Posterior edge of the submandibular gland, Level II
  40. 40. Anterior->posterior belly of the digastric muscle, Level II
  41. 41. Posterior-> Posterior edge of the sternocleidomastoid (SCM) muscle, Level II
  42. 42. Medial-> Medial edge of the carotid artery and the paraspinal muscles (levator scapulae and splenius capitis) Level II
  43. 43. Lateral-> Medial edge of the SCM Level II
  44. 44. Contouring Level II
  45. 45. Primary for II • Nasal cavity. • Oral cavity. • Oropharynx. • Hypopharynx. • Larynx. • Major salivary glands. • Nasopharynx,
  46. 46. IIa IIb • Level II is further subdivided into two compartments. – IIa – IIb • Surgeons demarcate between the two by spinal accessory nerve (SAN). • From a radiological point of view, the posterior edge of the IJV is taken as the boundary between levels IIa and IIb. Sub division of Level II
  47. 47. IIa IIb
  48. 48. Level III • contains the middle jugular lymph nodes located around the middle third of the IJV. • It is the caudal extension of level II • Primary. Oral cavity. Oropharynx. Hypopharynx. Larynx. Nasopharynx,
  49. 49. Cranial-> caudal edge of body of the hyoid bone. Level III
  50. 50. Caudal-> Caudal edge of the cricoid cartilage. Level III
  51. 51. Anterior-> Posterolateral edge of the sternohyoid muscle and the anterior edge of the SCM muscle, Level III
  52. 52. Posterior-> Posterior edge of the SCM muscle Level III
  53. 53. Lateral-> Medial edge of the SCM muscle Level III
  54. 54. Medial-> Medial edge of the internal carotid artery and the paraspinal muscles (scalenius). Level III
  55. 55. Level III Contouring
  56. 56. includes the lower jugular lymph nodes located around the inferior third of the IJV. According to Robbins, it extends from the caudal limit of level III to the clavicle. But since surgeons never dissect upto clavicle so consensus is that the caudal limit is 2cm cranial to the cranial edge of sterno-clavicular joint. 2 cm Level IV
  57. 57. Caudal->2cm cranial to the cranial edge of sterno- clavicular joint.
  58. 58. Cranial-> Caudal edge of the cricoid cartilage. Level IV
  59. 59. Anterior Posterior Lateral. Level IV Anterior edge , posterior edge and medial edge of the SCM muscle, respectively
  60. 60. Medial-> Medial edge of the internal carotid artery and the paraspinal muscles (scalenius) Level IV
  61. 61. Level IV Contouring 2 cm
  62. 62. Primary for level IV • Hypopharynx. • Larynx • Oropharynx. • Skip metastasis from ant tongue. • Cervical esophagus
  63. 63. Level V Clavicle SCM Trapezius
  64. 64. The uppermost part of level V contains superficial occipital lymph node(s), which are not involved in head and neck ca except skin cancer. So cranial limit is a horizontal plane crossing the cranial edge of the body of the hyoid bone Level V
  65. 65. Cranial -> Horizontal plane crossing the cranial edge of the body of the hyoid bone Level V
  66. 66. • For the caudal limit of level V, it appears from critical examination of neck dissection procedure, that surgeons never dissect up to clavicle but go only up to to the transverse cervical vessels. • Hence, caudal limit of level V is kept at CT slices encompassing the cervical transverse vessels Level V Caudal
  67. 67. Caudal -> CT slices at the level of transverse Cervical vessels Level V
  68. 68. Lateral-> Platysma muscle and the skin, Level V
  69. 69. Medial -> Paraspinal muscles (splenius capitis, levator scapulae and scaleni (posterior, medial and anterior) muscles) Level V
  70. 70. Anterior-> Posterior edge of the SCM muscle Level V
  71. 71. Posterior -> Antero-lateral border of the trapezius muscles .Practically, a virtual line joining the antero-lateral border of both trapezius muscles can be use to set the posterior limit of level V Level V
  72. 72. Level V Contouring
  73. 73. Primary for Level V • Nasopharynx. • Oropharynx. • Subglottic larynx. • Apex of the pyriform sinus. • Cervical esophagus. • Thyroid gland.
  74. 74. Va Vb Level V is divided into Va and Vb by omohyoid muscle where it crosses the internal jugular vein. But this crossing point can not be appreciated on CT film. Level V
  75. 75. Hyoid Thyroid Cricoid For practical purpose, use of the plane between levels III and IV extended posteriorly is recommended, which means lower border of cricoid can be taken as dividing line between Va and Vb Level V Level III Level IV Level Va Level Vb
  76. 76. Located in anterior neck compartment They are pre- and para tracheal nodes including the pre- cricoid (Delphian) node and lymph nodes along the recurrent laryngeal nerves. Level VI
  77. 77. Cranial -> Caudal edge of the body of the thyroid cartilage, Level VI
  78. 78. Caudal -> Cranial edge of the sternum manubrium Level VI
  79. 79. Anterior-> Platysma and the skin Level VI
  80. 80. Posterior -> Separation between the trachea and the esophagus. Level VI
  81. 81. . Lateral -> Medial edge of the thyroid gland and the antero-medial edge of the SCM muscle Level VI
  82. 82. Para-tracheal Pre-tracheal Contouring Level VI
  83. 83. Primary for Level VI • cancers of the thyroid gland, • the Trans glottic and subglottic larynx, • the apex of the piriform sinus and • the cervical esophagus.
  84. 84. Typically, retropharyngeal nodes are divided into Medial Group Lateral Group. The medial group is an inconsistent group which consist of one to two lymph nodes The lateral group lies medial to the carotid artery. The most superior lymph node of this group is also called the lymph node of Rouvie`re. lymph node of Rouvie`re. RP Nodes
  85. 85. Cranial-> Base of the skull Mastoid Process RP nodes
  86. 86. Caudal -> Cranial edge of the body of the hyoid bone RP nodes
  87. 87. Anterior-> Levator Veli palatini muscle. RP nodes
  88. 88. Posterior-> Pre-vertebral Muscles. . RP nodes
  89. 89. Lateral-> Medial edge of the carotid vessel. RP nodes
  90. 90. Medial-> Midline RP nodes
  91. 91. RP nodes Contouring
  92. 92. Node Positive Neck
  93. 93. Node positive Neck • With N+ve, one adjacent extra nodal level is also at high risk of occult metastasis, for eg. the level IV for oral cavity tumors and the level I and V for oropharyngeal, hypopharyngeal, and to a lesser extent laryngeal tumors.
  94. 94. Retrostyloid Region S/C fossa Till Sternum Point No 1 In level II node positive include retro styloid region and in level IV and Vb nodes enlargement include s/c fossa up to sternum on the side of the positive node.
  95. 95. Retro Styloid Region
  96. 96. S/C Fossa
  97. 97. Point No 2 In fact, this recommendation will only apply to patients with a single involved lymph node (pN1) for whom post-operative radiotherapy is considered (e.g. because of a capsular rupture) and for whom selective treatment may be advocated.
  98. 98. When an involved lymph node abuts a muscle (e.g. sterno-cleido- mastoid or para-spinal) it is recommended to include this muscle at the vicinity of the node in the CTV for the entire invaded level and at least with a 1 cm margins in cranio-caudal direction. Point No 3 1 cm 1 cm
  99. 99. Extra Capsular Extension(ECE) Incidence of ECE is 20 to 40% in metastatic node <1cm size while goes up to 75% if size is >3 cm. The incidence of local recurrence increases, and the survival rate decreases by greater than 50% when metastatic nodal disease expands beyond the capsule i. e. if ECE present.
  100. 100. Magnitude of ECE The majority of the ECE extend <5mm from the capsule of node. None extend >10mm
  101. 101. Margins of 1 cm from the nodal GTV to the CTV would be sufficient to fully cover any subclinical nodal extension for lymph nodes smaller than 3 cm in head-and-neck cancer patients receiving IMRT. For larger nodes or matted nodes more generous margins should be given. Point No 4
  102. 102. Post Operative Neck
  103. 103. Point No 1
  104. 104. Retrostyloid Region S/C fossa Till Sternum Point No 2
  105. 105. Point No 3
  106. 106. Point No 4
  107. 107. Pattern of Spread •Prophylactic neck node irradiation is required if the incidence of occult metastasis is >5%.
  108. 108. • Typically, nasopharyngeal and hypopharyngeal tumors have the highest propensity of nodal involvement which occurs in 80 and 70%, respectively. • Interestingly, the node distribution follows the same pattern in the contralateral neck as in the ipsilateral neck. • Contra lateral level V is usually not involeved
  109. 109. Incidence and distribution of regional metastasis for Levels I–V for clinically N0 neck • Tumor site Levels involved (%) I II III IV V • Oral cavity 20 17 9 3 0.5 • Oropharynx 2 25 19 8 2 • Hypopharynx 0 13 13 0 0 • Larynx 5 19 20 9 2.5 • In non-nasopharyngeal cancers of head and neck, level V is not included in N0 neck as incidence of involvement is <5%. • Similarly, in oro-pharynx, hypo-pharynx and larynx, level I is not included as again incidence of occult metastasis is <5%.
  110. 110. Non Nasopharyngeal N0 Neck • Oral Cavity Ca • Oro pharynx • Hypo pharynx • larynx Level I, II, III and in ca tongue level IV Level II, II, IV
  111. 111. Incidence and distribution of regional metastasis for Levels I–V for clinically N+ve neck • Tumor site Levels involved (%) • I II III IV V • Oral cavity 48 39 31 15 4 • Oropharynx 15 71 42 27 9 • Hypopharynx 10 75 72 45 11 • Larynx 6 61 54 30 6 • Nasopharynx* 13 95 60 21 44 • In non-nasopharyngeal cancers of head and neck, level V is included in N+ve neck except in ca oral cavity where incidence is <5%. • Similarly level I should be included in neck positive disease except in larynx.
  112. 112. Primary site for RP Nodes inclusion N0 Neck  Nasopharynx and Pharyngeal Wall N+ Neck  All sites except larynx In non nasopharyngeal cancers usually lateral RP nodes are involved
  113. 113. Thanks Questions???

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