This document provides a flowchart outlining the management of head and neck cancers. It discusses investigations, pathology testing, staging, pre-treatment assessments, general treatment considerations including multi-modality treatment for stage III/IV cancers, choice of treatment modalities including surgery, radiotherapy and chemotherapy. It provides details on the management of primary tumors and neck nodes, indications for adjuvant treatment, radiotherapy techniques and doses.

1. Flowchart of management in head and
neck cancer
Dr Pallavi Kalbande

2. Major sites
• Nasopharynx
• Oropharynx
• Oral cavity
• Larynx
• Hypopharynx

3. Investigations
US neck CT head, neck & chest
MRI head Good soft tissue
definition & useful if
artefact from dental
amalgam
PET-CT
T4 of hypopharynx or
nasopharynx
N3 cancer SCC Neck nodes
OPG Dental assessment

4. Pathology
• Biopsy– need core biopsy (not FNAC)
• IHC - HPV testing p16, p53 mutation

5. WHO prognostic groups
• HPV -ve, p16 inactivation, p53 mutation
I - High risk
• HPV +ve in smokers
• p16 inactivation
• p53 mutation
II - Intermediate risk
• HPV +ve in non-smokers
• p16 not inactivated
• p53 wildtype
III - Low risk

6. Pre-Treatment
• Smoking cessation Reduces SEs, improve outcomes, reduce chance of 2nd
cancer
• Dental assessment >2 weeks before RT
• Nutritional assessment If >10% weight loss anticipated, consider PEG
• SALT (speech and language test) assessment
• CBC, LFT, KFT Before chemo

7. General treatment considerations
• Stage I & II
Generally single modality treatment: surgery or RT
• Stage III & IV
Multi-modality treatment & aim to preserve organ function

8. Choice of Treatment Modality
• Treat primary and nodes
• elective nodes when risk of occult nodal metastases > 20%
• Risk > 20% in most sites except lip, early glottis and lower alveolar
ridge

9. Management of the neck nodes
Node Negative
• Prophylactic selective neck dissection
• Prophylactic neck RT
• Surveillance – should have regular US
• Depends upon risk of nodal involvement: treat if risk >15-20%
3 treatment options:

10. Node Positive
• N1: single ipsilateral node ≤ 3cm
• use same treatment as for primary
• N2a and above - require combined modality treatment
1. Modified radical neck dissection + resection of primary
adjuvant RT/CTRT depending on histology
2. CRT to primary and nodes
surveillance PET CT scan > 12 weeks after CRT

11. PET surveillance
surveillance PET CT scan > 12 weeks after CRT
ND in patients with uptake in neck nodes
PET -ve post CRT – surveillance

12. Surgery
• WLE +/- neck dissection +/- flaps
• Trans-oral laser micro-surgery (TLM), trans-oral robotic surgery (TORS)
• Limited role
• High chances of margin positive
• 66% require adjuvant RT/CRT

13. Adjuvant radiotherapy
• To improve loco-regional control and survival after resection in
‘intermediate’ and ‘high’ risk cases
• Start RT within 5 weeks of surgery: Aim for overall treatment time
from date of surgery to completion of RT 11 weeks
• Concurrent cisplatin: Fit and <70 yrs

14. Risk Factors
• High RF
• Positive margin (tumour 1mm )
• ECE
• Intermediate RF
• T3/T4 disease (RT alone)
• Close margin
• (tumour >1mm but 3cm or ≥2 LN)
• Multiple LN level involvement
• Multifocal disease
• Extensive CIS

15. Indications for adjuvant radiotherapy to primary
• Close margins <5mm
• Relative indications:
• T3,
• poorly differentiated
• Perineural invasion
• Lymphovascular invasion
• Depth of invasion
• T4

16. Indications for adjuvant radiotherapy to LN
• LN>3cm ie. N2a and above
• 3 or more +ve LN
• More than 3 nodal levels involved
• ECS
• Prophylactic dose RT to contralateral neck if non lateralised.

17. Indications for adjuvant chemoradiotherapy
• ECS
• Close margin eg. <1mm
• Dose 66Gy in 33 fractions
• 60Gy in 30 or
• 65Gy in 30 fractions

18. Radical Concurrent CRT
Indications
<70yrs & fit – locally advanced disease (stage III & IV)
Cisplatin 100mg/m2 (D1, D22, and D43)
or weekly cisplatin 40mg/m2 – minimum of 5 weeks

19. Concurrent Chemotherapy
• Cetuximab
• if cisplatin contra-indicated (renal function)
• but still good PS
• Start 1 week before RT (loading dose 400mg/m2 ), then give weekly
(250mg/m2 )
• Only for oropharynx, larynx, hypopharynx - Don’t give in nasopharynx,
paranasal sinus
• Carboplatin if cisplatin is contra-indicated

20. RT Doses
• Radical
• 65Gy/30# or 55Gy/20# (small volume e.g. larynx)
• 65Gy/30# GTV + 1cm and involved nodal levels
• 60Gy/30# High risk sites adjacent to gross disease
• 54Gy/30# Prophylactic dose: uninvolved nodal levels at risk of involvement
Adjuvant
• 60Gy/30#
• Boost to 65 - 66Gy à positive margins or ECS (high risk features)
Palliative
• 20Gy/5#
• 30Gy/10#
• 27Gy/6# over 2 weeks (4.5Gy per #)

21. Radiotherapy planning
• Set up
• Supine, head rest, knee support
• 5-point thermoplastic H&N shell
• Mouth bite Oral cavity and Maxillary sinus
tumours
• Scan from vertex to carina in 2mm slices with
IV contrast
• Consider bolus: if needing to treat skin or
superficial tissue
• Wire scars if required

22. Radical CTRT
• CTV65
GTV + 1cm edit off muscle, bone, air Extend to
include adjacent high-risk regions (e.g.
parapharyngeal spaces, remaining
oropharynx/larynx)
• CTV54
At risk nodal levels: Levels Ib – Vb are irradiated in
most node +ve necks
If level II involved, include Ib and VIIb (retrostyloid
nodes)
Node –ve neck: RT when risk is >15-20%, (Include
II-IV for most sub-sites)

23. When are LN GTV?
• >10mm in short axis (5mm for retropharyngeal LN, 1.5cm for
jugulodigastric)
• Inhomogenous node – any size
• Necrotic core
• Evidence of ECS
• Rounded

24. Nodal CTV
• Include ipsilateral retrostyloid if bulky level II or
ipsilateral VIIa involvement
• Include bilateral retropharyngeal LN for
posterior pharyngeal well involvement
• Usually include ipsilateral VIIa for
oropharyngeal cancer
• Gregoire Radiother Oncol. 2006 Apr;79(1):15-20.

25. Adjuvant RT
• GTVp & GTVn Recreate pre-operative GTVs
• CTV65 or CTV_60
GTVp + 1-1.5cm GTVn + 1cm
If ECS - include whole muscle at involved nodal level
include all pathologically involved nodal levels
Include seromas/other post operative changes
• CTV54
All uninvolved nodal levels in dissected neck and other at-risk nodal
levels

26. Management of neck
• Neck needs to be electively treated for all but v. early lesions
of oral cavity (eg. early with <3mm depth)
• Unilateral or bilateral guided by laterality of lesion
• Usually selective neck dissection eg. levels I-III, I-IVa

27. Indication of adjuvant RT/CRT
• Primary
• T3/T4
• • +ve margin (<1mm)
• Close margin
• LVI
• PNI
• G3
• High Risk:
• Nodes
• ≥ N2a
• ECS
CRT if PS0-1, <70year old, SCC, adequate renal function
Dose: 66Gy/33#

28. Define laterality of tonsil tumour

30. Unilateral RT for lateralised tonsil
squamous cell carcinoma
• GTV confined to tonsillar fossa or lateral pharyngeal wall
• <1cm extension onto soft palate or BOT
• >1cm from midline

31. Organ preservation
• Eligiblity of larynx preservation:
• Laryngeal or hypopharyngeal ca T2/3 (or T4) without
massive cartilage destruction or extension to soft tissues
• Functioning larynx (no NG, no aspiration, pre-Tx tracheostomy)
• Age <70 fit for chemo, adequate PS
• >70yrs can offer but higher chance of needing salvage
laryngectomy

32. Neo-adjuvant chemotherapy
• T4 disease or Nasopharynx
• Bulky nodes: N2C – in order to reduce bulk in neck prior to RT
• TPF if fit and <65yrs
Docetaxel 75mg/m2
Cisplatin 100mg/m2
5FU 1000mg/m2 D1-4
re-stage after C2 and plan during C3 , often may just give 2 cycles

33. Palliative chemotherapy
• 1st line
Cisplatin/5FU
Cisplatin/5FU + Cetuximab
only use in oral cavity - recurrent or metastatic
• 2nd line
Docetaxel 10% RR
Nivolumab