management of neck: a radiation oncologist's perspective
TRANSCRIPT
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Management of Neck Nodes in Head and Neck Malignancies: A Radiation
Oncologist’s Perspective
Dr Suman MallikRadiation Oncologist
Westbank Cancer CentreWestbank Health and Wellness Institute
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Issues
• Where ?• When ?• How much ? (Risk stratification)
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Aims
• Radical
• Prophylactic
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• Radical
• Adjuvant
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Situations
• Known Primary
• Unknown Primary
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Imaging
• USG• CECT• MRI• PET-CT
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Sources of information
• Anatomy
• Clinical and surgical data
• Pattern of failure data
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Modified Robbin’s nodal levels
Gregoire V, Radiotherapy Oncol 2013
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Oral Cavity
3.5%
91%
3.9%
4.8%
Pantvaidya G 2013
698 Neck Dissection566 oral cancer patient434 unilateral, 132 bilateralTongue(255), Buccal Mucosa(233)
698 Neck Dissection566 oral cancer patient434 unilateral, 132 bilateralTongue(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%
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Oral Cavity: determinants for nodal irradiation
• Primary site• T stage• Depth (4 mm Vs 9mm)• N stage• Perinodal extension• LVE, PNI
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CTV node (oral cavity)
Gregoire V et al R&O 2000, 2006
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NasopharynxIpsilateral
3% 70%
45%
1%
11%
0% 27%
3%
Skip Metastasis 0.5 to 7.9%
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CTV node (nasopharynx)
Gregoire V et al R&O 2000, 2006
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Oropharyngeal Tumor (clinical examn)Ipsilateral Contralateral
13% 82%
23%
2%
9%
0% 13%
1%
2%24%
5%
3%
2%
0%
Bataini and Lindberg
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Oropharyngeal (Pathological)Clinical N0 Ipsilateral
Clinical N+ Ipsilateral
2% 25%
19%
8%
0% 2%
15% 71%
42%
27%
0% 9%
Candela 1990
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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
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CTV node (oropharynx)
Gregoire V et al R&O 2000, 2006
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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
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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
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CTV node (Hypopharynx)
Gregoire V et al R&O 2000, 2006
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Larynx (Supraglottic)
6% 18%
18%
9%
2%
2% 70%
48%
17%
16%
Chao KS IJROBP 2002
Clinical N0 Ipsilateral
Clinical N+ Ipsilateral
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Larynx (Glottic)
0% 21%
29%
7%
7%
9% 42%
71%
24%
2%
Chao KS IJROBP 2002
Clinical N0 Ipsilateral
Clinical N+ Ipsilateral
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CTV node (larynx)
Gregoire V et al R&O 2000, 2006
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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
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Unilateral Neck treatment
• Cheek• Alveolus• Retromolar trigone• Early lateralised Tonsil
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Retropharyngeal Node
Nasopharynx40%
Oropharynx4%
Hypopharynx16%
Larynx0%
Nasopharynx86%
Oropharynx12%
Hypopharynx21%
Larynx4%
N0N0 N+N+
Pharyngeal wallN0= 16%, N+=21%
Soft PalateN0= 5%, N+=19%
Tonsillar FossaN0= 4%, N+=12%
Base of TongueN0= 0%, N+=6%
Chao KS, McLaughlin, Chua, Chong
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Gregoire V et al R&O 2000, 2006
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Risk StratificationTarget Definitive RT PORT High
riskPORT intermediate risk
CTV1 Gross Tumor, node and adjacent nodal region
70 Gy equivalent
Surgical bed with soft tissue involvement or nodal region with extracapsular spread56-60 Gy eqv
Surgical bed without soft tissue involvement or nodal region without extracapsular extension56-60 Gy eqv
CTV2 Elective nodal region. 50-60 Gy eqv
Elective nodal region50-54 Gy eqv
Elective nodal region50-54 Gy eqv
CTV3 Elective nodal region50-54 Gy eqv
Elective nodal region50 Gy eqv
Elective nodal region50 Gy eqv
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Nodal treatment in N+
• Primary
• Nodal staging
• ECE
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ECE and nodal size
PIRUS GHADJAR IJROBP 2010
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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
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CTV in presence of ECE
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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
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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
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Metastatic neck node from unknown primary
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• 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
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Imaging
• Local imaging (CECT, MRI, USG)• Metastatic workup• CXR/ CT Thorax• Whole body PET-CT
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Importance of histology
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ImmunohistochemistryLCA
CD-45
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DAHANCA (Grau et al 2000)N=277
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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
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Post Neck Dissection N1 disease ECE(-)
Level involved Target areaLevel 1 only RT to oral cavity, Waldeyer’s
ring, oropharynx, bilateral neckLevel 2,3 RT to oropharynx and bilateral
neckLevel 4 only RT to Waldeyer’s ring, larynx,
hypopharynx, bilateral neckLevel 5 RT to npx, larynx,
hypopharynx, bilateral neck
OROBSERVATION
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Post Neck Dissection N2-3 disease ECE(-)
Level involved Target areaLevel 1 only RT to oral cavity, Waldeyer’s
ring, oropharynx, bilateral neckLevel 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
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Post Neck Dissection ECE(+)
Level involved Target areaLevel 1 only RT to oral cavity, Waldeyer’s
ring, oropharynx, bilateral neckLevel 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
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Take home message
• Optimal clinical examn and imaging modality
• Evolution and evidences of nodal delineation
• Optimal treatment approach
• Multimodality approach