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

Issues

• Where ?• When ?• How much ? (Risk stratification)

Aims

• Radical

• Prophylactic

• Radical

• Adjuvant

Situations

• Known Primary

• Unknown Primary

Imaging

• USG• CECT• MRI• PET-CT

Sources of information

• Anatomy

• Clinical and surgical data

• Pattern of failure data

Modified Robbin’s nodal levels

Gregoire V, Radiotherapy Oncol 2013

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%

Oral Cavity: determinants for nodal irradiation

• Primary site• T stage• Depth (4 mm Vs 9mm)• N stage• Perinodal extension• LVE, PNI

CTV node (oral cavity)

Gregoire V et al R&O 2000, 2006

NasopharynxIpsilateral

3% 70%

45%

1%

11%

0% 27%

3%

Skip Metastasis 0.5 to 7.9%

CTV node (nasopharynx)

Gregoire V et al R&O 2000, 2006

Oropharyngeal Tumor (clinical examn)Ipsilateral Contralateral

13% 82%

23%

2%

9%

0% 13%

1%

2%24%

5%

3%

2%

0%

Bataini and Lindberg

Oropharyngeal (Pathological)Clinical N0 Ipsilateral

Clinical N+ Ipsilateral

2% 25%

19%

8%

0% 2%

15% 71%

42%

27%

0% 9%

Candela 1990

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

CTV node (oropharynx)

Gregoire V et al R&O 2000, 2006

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

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

CTV node (Hypopharynx)

Gregoire V et al R&O 2000, 2006

Larynx (Supraglottic)

6% 18%

18%

9%

2%

2% 70%

48%

17%

16%

Chao KS IJROBP 2002

Clinical N0 Ipsilateral

Clinical N+ Ipsilateral

Larynx (Glottic)

0% 21%

29%

7%

7%

9% 42%

71%

24%

2%

Chao KS IJROBP 2002

Clinical N0 Ipsilateral

Clinical N+ Ipsilateral

CTV node (larynx)

Gregoire V et al R&O 2000, 2006

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

Unilateral Neck treatment

• Cheek• Alveolus• Retromolar trigone• Early lateralised Tonsil

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

Gregoire V et al R&O 2000, 2006

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

Nodal treatment in N+

• Primary

• Nodal staging

• ECE

ECE and nodal size

PIRUS GHADJAR IJROBP 2010

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

CTV in presence of ECE

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

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

Metastatic neck node from unknown primary

• 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

Imaging

• Local imaging (CECT, MRI, USG)• Metastatic workup• CXR/ CT Thorax• Whole body PET-CT

Importance of histology

ImmunohistochemistryLCA

CD-45

DAHANCA (Grau et al 2000)N=277

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

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

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

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

Take home message

• Optimal clinical examn and imaging modality

• Evolution and evidences of nodal delineation

• Optimal treatment approach

• Multimodality approach