This document provides information on head and neck cancer including: 1. It describes the anatomy of the head and neck region including lymph nodes and locations of salivary glands. 2. It discusses imaging techniques like CT and PET scans which are used to detect and stage head and neck cancers. 3. It outlines the AJCC TNM staging system for various head and neck cancers and describes how the cancer can spread from different primary sites.

4. Larynx or Vocal Cord Anatomy

8. There are multiple lymph nodes in the head and neck area

11. Neck Node Levels

12. Location of the Salivary Glands – is important in order to limit radiation side effects such as a dry mouth

13. Cross section anatomy of the neck

14. Cross section anatomy of the neck

15. Cross section anatomy of the neck

16. CT Scan and Anatomy

17. CT-Pet Anatomy

18. The value of PET scans

19. PET Scans are valuable in finding hidden cancers, such as this patient with cancer in the left base of tongue, which was not visible when looking in the mouth

20. CT and PET Scans

21. Small base of tongue cancer with spread to a lymph node CT Scan PET Scan

22. Tongue cancer, hard to see on the CT scan but obvious on the PET scan CT Scan PET Scan

24. Patterns of spread. The primary cancer (oral cavity) invades in various directions, which are color-coded vectors (arrows) representing stage of progression: Tis, yellow; T1, green; T2, blue; T3, purple; T4A, red; and T4B, black.

25. The three-planar views are crucial to understanding the malignant gradient. A. Coronal. B. Sagittal. C. Transverse. (1) Maxillary sinus. (2) Inferior concha. (3) Tongue. (4) Mandible. (5) Mylohyoid. (6) Sublingual gland. (7) Pharyngeal tonsil. (8) Retromolar trigone. (9) Axis (C2). (10) Epiglottis. (11) Retropharyngeal space. (12) Palatine tonsil. (13) Parotid gland. (14) Carotid sheath. (15) Cavity of pharynx.

26. Oral Cavity Lymph Node Spread The red node highlights the sentinel node, which is the submaxillary and jugulodigastric node. A. Coronal. B. Sagittal.

27. The primary cancer (oropharynx) invades in various directions, which are color-coded vectors (arrows) representing stage of progression: Tis, yellow; T1, green; T2, blue; T3, purple; T4a; red; and T4b, black.

28. Lymph Node Spread from oropharyngeal cancer . The red node highlights the sentinel node, which is the jugulodigastric node. A. Coronal. B. Sagittal.

29. The primary cancer (hypopharynx) invades in various directions, which are color-coded vectors (arrows) representing stage of progression: Tis, yellow; T1, green; T2, blue; T3, purple; T4a, red; and T4b, black.

30. The three planar views are crucial to understanding the malignant gradient. A. Coronal. B. Sagittal. C. Transverse. (1) Root of tongue. (2) Epiglottis. (3) Thyroid gland. (4) Esophagus. (5) Superior pharyngeal constrictor. (6) Glossopharyngeal nerve. (7) Middle pharyngeal constrictor. (8) Vagus nerve. (9) Inferior pharyngeal constrictor. (10) Thyroid lamina. (11) Trachea. (12) Larynx. (13) Vestibular fold. (14) Pharynx. (15) Retropharyngeal space. (16) Common carotid artery. (17) Internal jugular vein.

31. Lymph Node Spread form Hypopharynx Cancer The red node highlights the sentinel node, which is the jugulo-omohyoid node. A. Coronal. B. Sagittal.

32. The primary cancer (supraglottic larynx) invades in various directions, which are color-coded vectors (arrows) representing stage of progression: Tis, yellow; T1, green; T2, blue; T3, purple; T4a, red; and T4b, black.

33. The three planar views are crucial to understanding the malignant gradient. A. Coronal. B. Sagittal. C. Transverse. (1) Epiglottis. (2) Thyroid cartilage. (3) Vestibular fold. (4) Vocal fold. (5) Ventricle of larynx. (6) Vestibule of larynx. (7) Pharynx. (8) Retropharyngeal space. (9) Inferior pharyngeal constrictor. (10) Pre-epiglottic space. (11) Para-epiglottic space.

34. Supraglottic Larynx lymph node spread The red node highlights the sentinel node, which is the jugulodigastric node. A. Coronal. B. Sagittal.

35. The primary cancer (glottic larynx) invades in various directions which are color-coded vectors (arrows) representing stage of progression: Tis, yellow; T1, green; T2, blue; T3, purple; T4a, red; and T4b, black .

36. Glottic Cancer The three planar views are crucial to understanding the malignant gradient. A. Coronal. B. Sagittal. C. Transverse. (1) Vestibule. (2) Vestibular fold. (3) Ventricle. (4) Vocal fold. (5) Trachea. (6) Epiglottic cartilage. (7) Vocal ligament. (8) Corniculate cartilage. (9) Arytenoid cartilage. (10) Thyroid cartilage.

37. Lymph Node Spread from Glottic Cancer The red node highlights the sentinel node, which is the pretracheal node. A. Coronal. B. Sagittal.

38. Stage 0: Tis N0 M0 Stage I: T1 N0 M0 Stage II: T2 N0 M0 Stage III: T3 N0 M0, T1 N1 M0, T2 N1 M0, T3 N1 M0 Stage IVA: T4a N0 M0, T4a N1 M0, T1 N2 M0, T2 N2 M0, T3 N2 M0, T4a N2 M0 Stage IVB: Any T N3 M0, T4b Any N M0 Stage IVC: Any T Any N M1 NX: Regional nodes cannot be assessed N0: No regional lymph node metastasis N1: Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension N2: Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension; or in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension; or in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension N2a: Metastasis in single ipsilateral lymph node more than 3 cm but not more than 6 cm in greatest dimension N2b: Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension N2c: Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension N3: Metastasis in a lymph node more than 6 cm in greatest dimension 2002 American Joint Committee on Cancer (AJCC) TNM Staging System for the Lip and Oral Cavity Tx; Primary tumor cannot be assessed T0: No evidence of primary tumor Tis: Carcinoma in Situ T1: Tumor 2 cm or less in greatest dimension T2: Tumor more than 2 cm but not more than 4 cm in greatest dimension T3: Tumor more than 4 cm in greatest dimension T4 (lip): Tumor invades through cortical bone, inferior alveolar nerve, floor of mouth, or skin of face (ie, chin or nose) T4a: (oral cavity) Tumor invades adjacent structures (eg, through cortical bone, into deep [extrinsic] muscle of tongue [genioglossus, hyoglossus, palatoglossus, and styloglossus], maxillary sinus, skin of face) T4b: Tumor invades masticator space, pterygoid plates, or skull base and/or encases internal carotid artery

39. Stage 0: Tis N0 M0 Stage I: T1 N0 M0 Stage II: T2 N0 M0 Stage III: T3 N0 M0, T1 N1 M0, T2 N1 M0, T3 N1 M0 Stage IVa: T4a N0 M0, T4a N1 M0, T1 N2 M0, T2 N2 M0, T3 N2 M0, T4a N2 M0 Stage IVb: T4b Any N M0, Any T N3 M0 Stage IVc: Any T Any N M1 Nx: Regional lymph nodes cannot be assessed N0: No regional lymph node metastasis N1: Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension N2: Metastasis in a single ipsilateral lymph node, more than 3cm but not more than 6 cm in greatest dimension, or in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension, or in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension N2a: Metastasis in a single ipsilateral lymph node more than 3cm but not more than 6 cm in greatest dimension N2b: Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension N2c: Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension N3: Metastasis in a lymph node more than 6 cm in greatest dimension 2002 American Joint Committee on Cancer (AJCC) TNM Staging System for the Pharynx (Including Base of Tongue, Soft Palate, and Uvula) T1: Tumor 2 cm or less in greatest dimension T2: Tumor more than 2 cm but not more than 4 cm in greatest dimension T3:Tumor more than 4 cm in greatest dimension T4a: Tumor invades the larynx, deep/extrinsic muscle of tongue, medial pterygoid, hard palate, or mandible T4b: Tumor invades lateral pterygoid muscle, pterygoid plates, lateral nasopharynx, or skull base or encases carotid artery

40. Stage 0: Tis N0 M0 Stage I: T1 N0 M0 Stage IIa: T2a N0 M0 Stage IIb: T1 N1 M0, T2 N1 M0, T2a N1 M0, T2b N0 M0. T2b N1 M0 Stage III: T1 N2 M0, T2a N2 M0, T2b N2 M0, T3 N0 M0, T3 N1 M0, T3 N2 M0 Stage IVa: T4 N0 M0, T4 N1 M0, T4 N2 M0 Stage IVb: Any T N3 M0 Stage IVc: Any T Any N M1 NX: Regional lymph nodes cannot be assessed N0: No regional lymph node metastasis N1: Unilateral metastasis in lymph node(s), 6 cm or less in greatest dimension, above the supraclavicular fossa* N2: Bilateral metastasis in lymph node(s), 6 cm or less in greatest dimension, above the supraclavicular fossa* N3: Metastasis in a lymph node(s)* more than 6 cm and/or to supraclavicular fossa N3a: More than 6 cm in dimension N3b: Extension to the supraclavicular fossa** 2002 American Joint Committee on Cancer (AJCC) TNM Staging System for Nasopharynx Cancer T1: Tumor confined to the nasopharynx T2: Tumor extends to soft tissues T2a: Tumor extends to the oropharynx and/or nasal cavity without parapharyngeal extension* T2b: Any tumor with parapharyngeal extension* T3: Tumor invades bony structures and/or paranasal sinuses T4: Tumor with intracranial extension and/or involvement of cranial nerves, infratemporal fossa, hypopharynx, orbit, or masticator space *Note: Parapharyngeal extension denotes posterolateral infiltration of tumor beyond the pharyngobasilar fascia.

41. 2002 American Joint Committee on Cancer (AJCC) TNM Staging System for the Larynx Supraglottis T1: Tumor limited to one subsite of supraglottis with normal vocal cord mobility T2: Tumor invades mucosa of more than one adjacent subsite of supraglottis or glottis or region outside the supraglottis eg, mucosa of base of tongue, vallecula, medial wall of pyriform sinus) without fixation of the larynx T3: Tumor limited to larynx with vocal cord fixation and/or invades any of the following: postcricoid area, preepiglottic tissues, paraglottic space, and/or minor thyroid cartilage erosion (eg, inner cortex) T4a: Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx (eg, trachea, soft tissues of neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus) T4b: Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures Glottis T1: Tumor limited to the vocal cord(s) (may involve anterior or posterior commissure) with normal mobility T1a: Tumor limited to one vocal cord T1b: Tumor involves both vocal cords T2: Tumor extends to supraglottis and/or subglottis, and/or with impaired vocal cord mobility T3: Tumor limited to the larynx with vocal cord fixation and/or invades paraglottic space, and/or minor thyroid cartilage erosion (eg, inner cortex) T4a: Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx (eg, trachea, soft tissues of neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus) T4b: Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures

42. 2002 American Joint Committee on Cancer (AJCC) TNM Staging System for the Larynx Supraglottis Nx:: Regional lymph nodes cannot be assessed N): No regional lymph node metastasis N1: Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension N2: Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension; or in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension, or in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension N2a: Metastasis in single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension N2b: Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension N2c: Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension N3: Metastasis in a lymph node, more than 6 cm in greatest dimensionStage 0: Tis N0 M0 Stage I: T1 N0 M0 Stage II: T2 N0 M0 Stage III: T3 N0 M0, T1 N1 M0, T2 N1 M0, T3 N1 M0 Stage IVa: T4a N0 M0, T4a N1 M0, T1 N2 M0, T2 N2 M0, T3 N2 M0, T4a N2 M0 Stage IVb: T4b Any N M0, Any T N3 M0 Stage IVc: Any T Any N M1

46. Simulation A face mask is usually made to hold the head still and allow the targeting markings to be painted on the mask.

47. CT scan is obtained at this time CT images are then imported into the treatment planning computer

48. In the simulation process the CT and PET scan images are used to create a computer plan

49. Computer plans are then generated from the CT scan images

50. CT scan and computer generated targets and avoidance structures so that the ideal plan (hit the cancer and avoid the normal structures) can be created

51. Computer generated images of small vocal cord cancer

52. Radiation field surrounds the target in the larynx (avoiding critical structures like the jaw, skull or spinal cord

53. Radiation dose cloud completely surrounds the target

54. For small cancers in the vocal cords it is possible to keep the radiation far away from other normal structures

55. Image Fusion (merging a PET scan with a CT scan) Step 1 Cancer on PET Scan Cancer on CT Simulation Red - cancer Purple – radiation zone

56. Image Fusion step 2 cancer cancer radiation

57. Normal structures are identified on the computer generated images

58. Radiation zone is designed to cover the cancer and nodes and avoid normal structures as much as possible

59. PET Scan transformed into radiation target PET Scan lights up cancer in left neck nodes Cancer nodes (green) surrounded by radiation zone (orange) with lower dose radiation to other targets

60. PET Scan used to create radiation target PET Scan , showing cancer in right tongue Computer generated reconstruction, the target area is in red

61. Cancer (blue) surrounded by large field low dose radiation and then high dose boost field

62. Shrinking field technique, the first phase covers a large area and the final boost phase is more targeted

64. In the treatment the lasers are used to line up the beam and the patient receives the radiation treatment

67. Combine a CT scan and linear accelerator to ultimate in targeting (IGRT) and ultimate in delivery (dynamic, helical IMRT) ability to daily adjust the beam (ART or adaptive radiotherapy)

68. Low risk parotid gland tumor (in red) may be possible to keep the radiation zone (blue) as small as possible

69. Low risk parotid gland tumor, then using Tomotherapy to ensure coverage of the tumor on the left, but avoiding going too deep and hitting normal parotid on other side

71. Radiation combined with Chemotherapy

72. Combining chemotherapy with radiation, complete remission

73. Stage III larynx cancer, PET scan showing complete response after radiation

75. Radiation targeting and results on PET scan

78. Radiation prescription for # Diagnosis: squamous cell carcinoma of the # Stage: Stage # Chemotherapy: # Number of radiation treatments: #