B E T H M . B E A D L E , M D / P H D

A S S O C I AT E P R O F E S S O R O F R A D I AT I O N O N C O L O G Y

N ATA L I YA K O VA L C H U K , P H D

C L I N I C A L A S S I S TA N T P R O F E S S O R O F R A D I AT I O N P H Y S I C S

S TA N F O R D U N I V E R S I T Y

Meet Me in Treatment Planning:Head & Neck

May 29, 2018

W E H AV E N O D I S C L O S U R E S

Case 1: HNARRO 2

• 73 year old male presented with a painless left neck mass.

• No dysphagia, odynophagia, weight loss, bleeding

• PMH: BPH

• No prior radiation, no pacemaker, no collagen

vascular disease

• PSH: Tonsillectomy as a child

• SH: Never smoker, retired executive.

• PE:

• Left palpable level II lymph node

• Oral examination: Firmness in the low left base of

tongue

• Endoscopy:

Case 1: HNARRO 2

• FNA Left Neck: Squamous cell carcinoma – p16/HPV+

• MRI:

• PET:

• AJCC 8: T1 N1 M0 (Stage I)

Case 1: HNARRO 2

• Contouring targets & normal tissues

• Dose allocations

• Use of templates

• Instructions to treatment planning team

• Be practical

Case 1: HNARRO 2

Case 1: HNARRO 2 Plan Review

Case 2: HNARRO 3

• 67 year old female presented with painful right retromolar

trigone mass.

• No teeth loose, no bleeding, no weight loss

• PMH: Chronic kidney disease, hypothyroidism

• No prior radiation, no pacemaker, no collagen

vascular disease

• PSH: Cholecystectomy

• SH: 36 pack-year smoker; quit 20 years ago.

• PE:

• No palpable adenopathy

• Oral examination: Heaped lesion in the right RMT

with central ulceration

Case 2: HNARRO 3

• Right RMT biopsy: Squamous cell carcinoma

• MRI:

• PET:

• AJCC 8: clinical T2 N0 M0 (Stage II)

Case 2: HNARRO 3

• Surgical resection of the primary and right neck dissection:

• 2.8 cm moderately differentiated squamous carcinoma

• 8 mm depth of invasion

• Final margins negative

• LVSI present

• No PNI

• 32 lymph nodes removed

• 0 positive

• AJCC 8: pathologic T2 N0 M0 (Stage II)

Case 2: HNARRO 3 Plan Review

Case 3: HNARRO 1

• 24 year old female presented with left neck masses

• No dysphagia, odynophagia, pain, weight loss

• PMH: None

• No prior radiation, no pacemaker, no collagen

vascular disease

• PSH: None

• SH: No smoking history. Nursing student.

• PE:

• Confluent left level II-IV adenopathy

• No oral lesions

• Endoscopy: Mass arising from the left nasopharyngeal

wall and involving left torus and Eustachian tube. Lesion

extends to the roof of the nasopharynx.

Case 3: HNARRO 1

• FNA Left Neck: Nasopharyngeal carcinoma, EBV-positive.

• MRI:

• PET:

• AJCC 8: clinical T1 N1 M0 (Stage II)

Case 3: HNARRO 1 Plan Review

Case 4: HNARRO 4

• 78 year old female presented with tongue pain

• Dysphagia, odynophagia, tongue mass.

• PMH: Hypertension, osteoporosis

• No prior radiation, no pacemaker, no collagen

vascular disease

• PSH: None

• SH: No smoking history.

• PE:

• Ulcerated right oral tongue mass

• No palpable adenopathy

Case 4: HNARRO 4

• Biopsy: Squamous cell carcinoma

• MRI:

• PET:

• AJCC 8: clinical T3 N2b vs. N2c M0 (Stage IVa)

Case 4: HNARRO 4

• Surgical resection of the primary and bilateral neck

dissection:

• 4.3 cm moderately differentiated squamous carcinoma

• 1.7 cm tumor thickness

• Final margins negative

• Perineural invasion present

• No LVSI

• 105 lymph nodes removed

• 0 positive

• AJCC 8: pathologic T3 N0 M0 (Stage III)

Case 4: HNARRO 4 Plan Review

Questions?

• Head and neck physicists

• Head and neck dosimetrists

• Radiation therapy team

• ASTRO

• ARRO

Acknowledgements