Head and Neck. 2012

Version 1.2012, 04/26/12 National Comprehensive Cancer Network, Inc. 2012, All rights reserved. The NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.

NCCN Guidelines IndexHead and Neck Table of Contents

Discussion

NCCN.org

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NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines )

Head and NeckCancers

Version 1.2012



Discussion

NCCN Guidelines Version 1.2012 Panel MembersHead and Neck Cancers

David G. Pfister, MD /ChairMemorial Sloan-Kettering Cancer Center

Kie-Kian Ang, MD, PhDThe University of TexasMD Anderson Cancer Center

David M. Brizel, MDDuke Cancer Institute

Barbara A. Burtness, MDFox Chase Cancer Center

Anthony J. Cmelak, MDVanderbilt-Ingram Cancer Center

A. Dimitrios Colevas, MDStanford Cancer Institute

Frank Dunphy, MDDuke Cancer Institute

David W. Eisele, MDThe Sidney Kimmel ComprehensiveCancer Center at Johns Hopkins

Jill Gilbert, MD

Maura L. Gillison, MD, PhD

Paul M. Busse, MD, PhDMassachusetts General HospitalCancer Center

Vanderbilt-Ingram Cancer Center

The Ohio State University ComprehensiveCancer Center - James Cancer Hospitaland Solove Research Institute

Harlan A. Pinto, MDStanford Cancer Institute

John A. Ridge, MD, PhDFox Chase Cancer Center

Sandeep Samant, MDSt. Jude Children's Research Hospital/University of Tennessee Cancer Institute

David E. Schuller, MDThe Ohio State University ComprehensiveCancer Center - James Cancer Hospitaland Solove Research Institute

&

Jatin P. Shah, MD, PhDMemorial Sloan-Kettering Cancer Center

Sharon Spencer, MDUniversity of Alabama at BirminghamComprehensive Cancer Center

Andy Trotti, III, MDH. Lee Moffitt Cancer CenterResearch Institute

Randal S. Weber, MDThe University of TexasMD Anderson Cancer Center

Gregory T. Wolf, MDUniversity of MichiganComprehensive Cancer Center

Frank Worden, MDUniversity of MichiganComprehensive Cancer Center

Sue S. Yom, MD, PhDUCSF Helen Diller FamilyComprehensive Cancer Center

Robert I. Haddad, MD Dana-Farber/Brigham and Womens Cancer Center

Bruce H. Haughey, MBChB, MSSiteman Cancer Center at Barnes-Jewish Hospitaland Washington University School of Medicine

Wesley L. Hicks, Jr., MDRoswell Park Cancer Institute

&

Bharat B. Mittal, MDRobert H. Lurie Comprehensive CancerCenter of Northwestern University

Ying J. Hitchcock, MDHuntsman Cancer Instituteat the University of Utah

Merrill S. Kies, MDThe University of TexasMD Anderson Cancer Center

William M. Lydiatt, MDUNMC Eppley Cancer Center atThe Nebraska Medical Center

Ellie Maghami, MDCity of Hope Comprehensive Cancer Center

Renato Martins, MD, MPHFred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance

Thomas McCaffrey, MD, PhDH. Lee Moffitt Cancer CenterResearch Institute

*

Medical oncology

Surgery/surgical oncology

Radiation oncology

Otolaryngology

Internal medicine

* Writing Committee MemberNCCN Guidelines Panel Disclosures

*

*

*

*

*

Continue NCCNLauren Gallagher, RPh, PhDMiranda Hughes, PhDNicole McMillian, MS

*

Printed by suha aloosi on 11/15/2012 6:46:00 AM. For personal use only. Not approved for distribution. Copyright 2012 National Comprehensive Cancer Network, Inc., All Rights Reserved.



Discussion

NCCN Guidelines Version Sub-CommitteesHead and Neck Cancers

1.2012

Continue

Mucosal Melanoma

William M. Lydiatt, MD /Lead

UNMC Eppley Cancer Center atThe Nebraska Medical Center

Jatin P. Shah, MD, PhD

Memorial Sloan-Kettering Cancer Center

Andy Trotti, III, MDH. Lee Moffitt Cancer Center &Research Institute

Medical oncology

Surgery/Surgical oncology

Radiation oncology

Otolaryngology

Internal medicine

NCCN Guidelines Panel Disclosures

Principles of Radiation TherapySharon Spencer, MD

University of Alabama at Birmingham

Comprehensive Cancer Center

Andy Trotti, III, MD

H. Lee Moffitt Cancer Center &

Research Institute

Kie-Kian Ang, MD, PhD

The University of Texas

MD Anderson Cancer Center

David Brizel, MD

Duke Cancer Institute

Paul M. Busse, MD, PhD

Massachusetts General Hospital

Cancer Center

Anthony J. Cmelak, MD

Vanderbilt-Ingram Cancer Center


Bharat B. Mittal, MD

Robert H. Lurie Comprehensive Cancer

Center of Northwestern University

/Lead

/Lead

Principles of Surgery

Gregory T. Wolf, MD

University of Michigan

Comprehensive Cancer CenterDavid M. Brizel, MDDuke Cancer Institute

David W. Eisele, MD

William M. Lydiatt, MDUNMC Eppley Cancer Center atThe Nebraska Medical Center

John A. Ridge, MD, PhDFox Chase Cancer Center

Sandeep Samant, MDSt. Jude Children's Research Hospital/University of Tennessee Cancer Institute

David E. Schuller, MDThe Ohio State UniversityComprehensive Cancer Center -James Cancer Hospital andSolove Research Institute

Randal S. Weber, MDThe University of TexasMD Anderson Cancer Center

/Lead

The Sidney Kimmel ComprehensiveCancer Center at Johns Hopkins

Principles of Systemic TherapyA. Dimitrios Colevas, MD

Stanford Cancer InstituteFrank Dunphy, MDDuke Cancer Institute

Renato Martins, MD, MPHFred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance

Principles of NutritionA. Dimitrios Colevas, MD /LeadStanford Cancer Institute

Paul M. Busse, MD, PhDMassachusetts General HospitalCancer Center


Gregory T. Wolf, MDUniversity of MichiganComprehensive Cancer Center




Discussion

NCCN Head Neck Cancers Panel Members

NCCN Head and Cancers Sub-Committee Members

Summary of the Guidelines UpdatesMultidisciplinary Team Approach and Support Services (TEAM-1)

Cancer of the Lip (LIP-1)

Cancer of the Oral Cavity (OR-1)

Cancer of the Oropharynx (ORPH-1)

Cancer of the Hypopharynx (HYPO-1)

Cancer of the Nasopharynx (NASO-1)

Cancer of the Glottic Larynx (GLOT-1)

Cancer of the Supraglottic Larynx (SUPRA-1)

Ethmoid Sinus Tumors (ETHM-1)

Maxillary Sinus Tumors (MAXI-1)

Very Advanced Head and Neck Cancer (ADV-1)

Recurrent/Persistent Head and Neck Cancer (ADV-2)

Occult Primary (OCC-1)

Salivary Gland Tumors (SALI-1)

Mucosal Melanoma (MM-1)

Follow-up Recommendations (FOLL-A)

Principles of Surgery (SURG-A)

Radiation Techniques (RAD-A)

Principles of Systemic Therapy (CHEM-A)

Staging (ST-1)

Principles of Nutrition: Management and Supportive Care (NUTR-A)

Clinical Trials:

Categories of Evidence andConsensus:NCCN

believes thatthe best management for any cancerpatient is in a clinical trial.Participation in clinical trials isespecially encouraged.

All recommendationsare Category 2A unless otherwisespecified.

NCCN

To find clinical trials online at NCCNMember Institutions, click here:nccn.org/clinical_trials/physician.html.

See NCCN Categories of Evidenceand Consensus.

The NCCN Guidelines are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment.

Any clinician seeking to apply or consult the NCCN Guidelines is expected to use independent medical judgment in the context of individual clinical

circumstances to determine any patients care or treatment. The National Comprehensive Cancer Network (NCCN) makes no representations or

warranties of any kind regarding their content, use or application and disclaims any responsibility for their application or use in any way. The NCCN

Guidelines are copyrighted by National Comprehensive Cancer Network. All rights reserved. The NCCN Guidelines and the illustrations herein may

not be reproduced in any form without the express written permission of NCCN. 2012.

NCCN Guidelines Version 1.2012 Table of ContentsHead and Neck Cancers




Discussion

NCCN Guidelines Version 1.2012 UpdatesHead and Neck Cancers

UPDATES1 of 4

Global Changes

The term excision was changed to resection throughout the guidelines.

A Principles of Nutrition: Management and Supportive Care section was developed that includes recommendations for Assessment and

Management (nutrition, speech and swallowing) and Use of Alternative Routes for Nutrition (NG and PEG Tubes) for head and neck cancer

patients.

The Principles of Radiation page for each cancer site was revised extensively.

( )NUTR-A

Cancer of the Lip

Cancer of the Oral Cavity

LIP-2

OR-1

OR-3

T1-2, N0: Treatment of Primary and Neck: The recommendation

External beam RT to primary site brachytherapy changed to

Definitive RT to primary site. (Also for )

T3,T4a, N0; Any T, N1-3; Treatment of Primary and Neck: The

recommendation External beam RT brachytherapy or Chemo/RT

changed to Definitive RT or Chemo/RT.

A new section on brachytherapy (including low-dose rate and

high-dose rate) was added. (Also for )Footnotes 2 and 3 regarding brachytherapy are new to the

algorithm. (The same footnotes were added to )

Clinical Staging; Bottom pathway: Changed to T4b, Any N, or

Unresectable nodal disease or . (Also for ,

, , , )

T1-2, N0: Treatment of Primary and Neck: The recommendation

External beam RT to primary site brachytherapy changed to

Definitive RT.

T3, N0;T4a, Any N; T1-3, N1-3;Treatment of Primary and Neck: N0,

N1, N2a-b,N3 pathway: After the recommendation Resection of

primary ipsilateral or bilateral neck dissection, the following phrase

was removed, guided by tumor thickness, extent of disease.

OR-2

OR-A

OR-A

Unfit for surgery ORPH-1

HYPO-1 GLOT-1 SUPRA-1 ADV-1

LIP-3

LIP-A

OR-2

Cancer of the Oropharynx

ORPH-1

ORPH-2

Workup; Third bullet: Tumor HPV testing suggested changed to

Tumor HPV testing .

Footnote a was revised as follows,

. Although

not used to guide treatment, HPV testing is valuable prognostically...

Adjuvant Treatment for T1-2, N0-1 tumors: For patients with adverse

features and positive margins after resection, the following

recommendation was added as an option, Consider chemo/RT (for

T2 only).

The statement IMRT is a preferred technique for cancers of the

oropharynx in order to minimize dose to critical structures, changed

to IMRT o for cancers of

the oropharynx in order to minimize dose to critical structures,

. A comparable change was also made

to other cancer sites within the Guidelines (NASO-A, ETHM-A,

MAXI-A, OCC-A).

Footnote 3: The first sentence changed to, Based on published data,

concurrent chemoradiation most commonly uses conventional

fractionation at 2.0 Gy per fraction to 70 Gy in 7

weeks with single-agent cisplatin given every 3 weeks at 100 mg/m

). Also for , ,

, , )

recommended

Either immunohistochemistry

for analysis of p16 expression or HPV in situ hybridization for

detection of HPV DNA in tumor cell nuclei is recommended

Either r 3-D conformal RT is recommended

especially the parotid glands

a typical dose of

2-3 cycles of chemotherapy are used depending on the radiation

fractionation scheme (RTOG 0522 HYPO-A GLOT-A

SUPRA-A ADV-A OCC-A

2

ORPH-A

Updates in Version 1.2012 of the NCCN Guidelines for from Version 2.2011 include:Head and Neck Cancer

Continued




Discussion


UPDATES2 of 4

Cancer of the HypopharynxHYPO-1

HYPO-2

NASO-A

GLOT-1

GLOT-2

Cancer of the Nasopharynx

Either r 3-D conformal RT is recommended

Cancer of the Glottic Larynx

The statement IMRT is a preferred technique for cancers of the

nasopharynx to minimize dose to critical structures, changed to

IMRT o for cancers of

the nasopharynx in order to minimize dose to critical structures.

Under Clinical Staging: Advanced cancer requiring total

laryngectomy changed to Advanced cancer requiring

total laryngectomy.

Most T1, N0, selected T2, N0 (not requiring total laryngectomy);

Adjuvant treatment: For patients with adverse features and positive

margins after surgery, the following recommendation was added as

an option, Consider chemo/RT (for T2 only).

Clinical Staging; Second pathway: Total laryngectomy not

required changed to Total laryngectomy not required

.

Treatment of Primary and NeckCarcinoma in situ: The recommendation Clinical trial was

removed.Total laryngectomy not required (T1-T2 or select T3) pathway:

After Partial laryngectomy... three new pathways regarding

adverse features and adjuvant treatment were added.

T4a, Any N pathway:After Treatment of Primary and Neck: The recommendation

Laryngectomy with ipsilateral thyroidectomy... changed to

laryngectomy with thyroidectomy ...

pharyngectomy with

(T1-T2 or

Select T3)

Total

as indicated

GLOT-6

Cancer of the Glottic Larynx

Selected T3

appropriate

Very Advanced Head and Neck Cancer

T4a, Any N pathway:Adjuvant Treatment: The recommendation Chemo/RT (category 1)

changed to RT or Consider chemo/RT or Observation for highly

selected patients. A corresponding footnote l was also added

regarding good risk features for favorable T4a patients who could

be observed after surgery.

Under Clinical Staging: First pathway changed to Not requiring total

laryngectomy (Most T1-2, N0; ).

T4a, N0-N3 Top pathway; Treatment of Primary Neck: Laryngectomy,

ipsilateral thyroidectomy... changed to Laryngectomy,

thryoidectomy...

radiation therapy dosing

Cancer of the Supraglottic Larynx

Ethmoid Sinus Tumors

GLOT-6

SUPRA-8

--continued

SUPRA-1

ETHM-A

ADV-2

Footnote 4 regarding the avoidance of critical neural structures in

the paranasal sinus area is new to the page. (Also for )

Recurrent or Persistent disease; Distant metastases; Standard

therapy; PS 0-1: Platinum + 5-FU + cetuximab (category 1) was

added as a treatment option.

Chemoradiation: First sentence changed to, Based on published

data, concurrent chemoradiation most commonly uses conventional

fractionation at 2.0 Gy per fraction to of 70 Gy in 7

weeks with single-agent cisplatin given every 3 weeks at 100 mg/m ;

.

A section on postoperative was added to the

page.

Footnote 2 regarding re-irradiation is new to the algorithm.

MAXI-A

a typical dose

2-3 cycles of chemotherapy are used depending on the radiation

fractionation scheme

2

ADV-A

Continued




Discussion


UPDATES3 of 4

Occult Primary

Neck mass; Second column: Recommendation changed to read,

H&P complete head and neck exam with attention to skin;

; mirror and

fiberoptic examination...

Third column: Fine-needle aspiration (preferred) or Open biopsy

changed to Fine-needle aspiration.

Squamous cell carcinoma, adenocarcinoma, and anaplastic

epithelial tumors;Workup: The third bullet changed to PET/CT scan

(before ).Footnote d that states, Strongly consider referral to high-

volume multidisciplinary cancer center, is new to the algorithm.

and

palpation of the base of tongue and oropharynx

as indicated

exam under anesthesia

OCC-1

OCC-3

Poorly differentiated or nonkeratinizing squamous cell or NOS or

anaplastic (not thyroid) or Squamous cell carcinoma; Definitive

treatment:The option of Surgery changed to Surgery

.The option of RT (category 3) changed to RT

.The option of Chemotherapy/RT (category 2B) changed to

Chemotherapy (category 2B).

Post neck dissection; N1 without extracapsular spread:Level I only; Treatment; RT recommendation: Waldeyers ring

was removed.Level II, III, upper level V; Treatment; RT recommendation:

Nasopharynx and Hypopharynx were added.Level IV only; Treatment; RT recommendation: Waldeyers ring

was removed. Oropharynx was added.Footnote c was revised as follows: HPV or EBV positive

status may help to define the radiation fields

.

(preferred for < N2

disease)for < N2

(category 2B)

for N2

Whether

is being

investigated

OCC-4

Occult Primary

Salivary Gland Tumors

---continued

Post neck dissection; N2, N3 without extracapsular spread:Level I only; Treatment; RT recommendation: Waldeyers ring was

removed.Level IV only; Treatment; RT recommendation: Waldeyers ring

was removed. Oropharynx was added.

Post neck dissection; Extracapsular spread:Level I only; Treatment; RT recommendation: Waldeyers ring was

removed.Level IV only; Treatment; RT recommendation: Waldeyers ring

was removed. Oropharynx was added.

A section on postoperative radiation therapy dosing was added to the

page.

OCC-5

OCC-6

SALI-1

SALI-2

SALI-3

SALI-4

OCC-A

Workup; Last bullet: The recommendation Open biopsy or consider

fine-needle aspiration (may not be necessary in incompletely resected

patients) changed to Fine-needle aspiration biopsy.

Clinically benign or carcinoma, T1, T2 pathway; Pathology result; Low

grade: The recommendation If tumor spillage, consider RT changed

to If tumor spillage , consider RT.

Cancer site: Parotid gland changed to Parotid

gland.

Locoregional recurrence without prior RT pathway; After Completely

resected: The pathway for Adenoid cystic disease was removed.

or perineural invasion

and sub-mandibular

Continued




Discussion

UPDATES4 of 4

FOLL-A

SURG-A

CHEM-A

Follow-up Recommendations

The page title changed to, Follow-up Recommendations .

History and physical exam:Year 2, every 2-4 mo changed to ...every 2-6 moYears 3-5, every 4-6 changed to ...every 4-8 mo> 5 years, every 6-12 mo changed to ...every 12 mo

Third bullet; Chest imaging...: A link to the was added.

Principles of Surgery

This section was revised extensively.

Principles of Systemic Therapy

(based on risk of relapse, second primaries, treatment sequalae and toxicities)

NCCN Guidelines for Lung Cancer Screening

A new section of bulleted statements was added regarding therapy for locally advanced disease.

Squamous Cell Cancers; Primary systemic therapy + concurrent RT: For non-nasopharyngeal cancers, Carboplatin/infusional 5-FU was

changed from category 2A to category 1.

For non-nasopharyngeal cancers: Paclitaxel/cisplatin/infusional 5-FU was added as an Induction/Sequential chemotherapy regimen.

A new section denoting Induction/Sequent

Docetaxel/cisplatin/5-FUCisplatin/5-FUCisplatin/epirubicin/paclitaxelFollowing induction, agents to be used with concurrent chemoradiation typically include weekly cisplatin or carboplatin.

ial chemotherapy for nasopharynx cancers was added as follows: Induction/Sequential chemotherapy





Discussion

Note: All recommendations are category 2A unless otherwise indicated.

Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.

NCCN Guidelines Version 1.2012Team Approach

Follow-up should be performed by a physician and other health care professionals with expertise in

the management and prevention of treatment sequelae. It should include a comprehensive head and

neck exam. The management of head and neck cancer patients may involve the following:

SUPPORT AND SERVICES

TEAM-1

Head and neck surgeryRadiation oncologyMedical oncologyPlastic and reconstructive surgerySpecialized nursing careDentistry/prosthodonticsPhysical medicine and rehabilitationSpeech and swallowing therapyClinical social workNutrition support

Pathology (including cytopathology)Diagnostic radiologyAdjunctive services

NeurosurgeryOphthalmologyPsychiatryAddiction servicesAudiologyPalliative care

MULTIDISCIPLINARY TEAM

The management of patients with head and neck cancers is complex. All patients need

access to the full range of support services and specialists

for optimal treatment and follow-up.

with expertise in the

management of patients with head and neck cancer

General medical carePain and symptom managementNutritional support

Dental care for radiation therapy effectsXerostomia management

Smoking and alcohol cessation

Speech and swallowing therapy

Audiology

Tracheotomy care

Wound management

Depression assessment and management

Social work and case management

Supportive care

Enteral feedingOral supplements

(See NCCN Guidelines for Palliative Care)




Discussion



NCCN Guidelines Version 1.2012Cancer of the Lip

History and physical (H&P)

BiopsyChest imagingAs indicated for primaryevaluation

Preanesthesia studiesDental evaluation

including a complete head andneck exam; mirror andfiberoptic examination asclinically indicated

Panorex

Multidisciplinary consultationas indicated

Computed tomography

(CT)/magnetic resonance

imaging (MRI) of primary

and neck as indicated

WORKUP CLINICAL STAGING

T1-2, N0

T3, T4a, N0

Any T, N1-3

See Treatment of Primary and Neck (LIP-2)

See Treatment of Primary and Neck (LIP-3)

T4b, any N, or

unresectable nodal

disease

See Treatment of Very Advanced Head and NeckCancer (ADV-1)

LIP-1

Surgical

candidate

Poor

surgical

risk

Definitive RT toprimary and nodesorChemo/RT

a

b

Follow-up(See FOLL-A)

a

b

.

.

See Principles of Radiation Therapy (LIP-A)

See Principles of (CHEM-A)Systemic Therapy




Discussion



NCCN Guidelines VersioCancer of the Lip

n 1.2012

LIP-2

TREATMENT OF PRIMARY AND NECKCLINICAL STAGING

T1-2, N0

Surgical resection

(preferred)

(elective neck

dissection not

recommended)

or

Definitive RT to

primary site

d

a,c

FOLLOW-UP


Residual or

recurrent tumor

post-RT

Positive margins,

perineural/vascular/

lymphatic invasion

No adverse

pathologic findings

Re-resection

or

RT

e

a

Surgery /

reconstruction

d

ADJUVANT TREATMENT

a

c

d

e

.

No elective treatment to neck is preferred for the T1-2, N0.

Consider o achieve negative margins, if feasible.


See Principles of Surgery (SURG-A).

re-resection t

RecurrentorPersistentDisease(See ADV-2)




Discussion




n 1.2012

Treatment of Primary and Neck (LIP-4)

CLINICAL STAGING:

T3,T4a, N0; Any T, N1-3

Resection of primary

ipsilateral or bilateral neck

dissectiondN0

Definitive RT

or

a

Chemo/RTb

Resection of primary and

bilateral neck dissectiond

Resection of primary,

ipsilateral neck dissection

contralateral neck dissectiond

N2c

(bilateral)

N2a-b,

N3

RT (optional)aOne positive node without

adverse featuresf


FOLLOW-UP

a

b

d

f

.

.

eConsider achieve negative margins, if feasible.

Adverse features: extracapsular nodal spread, positive margins, multiple positive nodes, or perineural/lymphatic/vascular invasion.


See Principles of (CHEM-A)

See Principles of Surgery (SURG-A)

Systemic Therapy

.

re-resection to

Surgery

(preferred)

d

ADJUVANT

TREATMENT

Adverse

featuresf

Other risk

features

RTa

or

Consider

chemo/RTb

N1

or


ipsilateral neck dissection

contralateral neck dissectiond

N0

Chemo/RTb

preferred

(category 1)

RT

or

Re-resection

or

e

a

Extracapsular

spread and/or

positive

margin

TREATMENT OF PRIMARY AND NECK


LIP-3




Discussion




n 1.2012

TREATMENT OF PRIMARY AND NECKCLINICAL STAGING:

T3, T4a, N0; Any T, N1-3

Definitive RT

Chemo/RT

a

bor


FOLLOW-UP

a

b

d

g

.

.




See Post Chemoradiation or RT Neck Evaluation (SURG-A 7 of 7)

Systemic Therapy

.

.

Residual tumor

in neck

Complete clinicalresponse of neck

Primary site:Completeclinicalresponse (N+ atinitial staging)

Primary site:< completeclinicalresponse

Salvage surgery + neckdissection as indicatedd

Neckdissectiond

ADJUVANT

TREATMENT

Post-treatment

evaluationg

Negative

Positive

Observe

Neck

dissectiond

Primary site:Complete clinicalresponse(N0 at initial staging)


LIP-4




Discussion




n 1.2012

PRINCIPLES OF RADIATION THERAPY1

:RT

Uninvolved nodal stations:

44-64 Gy (1.6-2.0 Gy/fraction)

:RT

Involved nodal stations:

60-66 Gy (2.0 Gy/fraction)


DEFINITIVE

POSTOPERATIVE

Primary and gross adenopathy:

Neck

Primary: 60-66 Gy (2.0 Gy/fraction)Neck

Uninvolved nodal stations:

Conventional fractionation: 66-74 Gy

(2.0 Gy/fraction; daily Monday-Friday) in 7 weeks

External-beam RT (EBRT) brachytherapyBrachytherapy

Interstitial brachytherapy is considered for selected cases.-Low-dose rate (LDR) brachytherapy:

Consider LDR boost 20-35 Gy if combined with 50 Gy EBRT

or 60-70 Gy over several days if using LDR as sole therapy-High-dose rate (HDR) brachytherapy:

Consider HDR boost 21 Gy at 3 Gy/fraction if combined with 40-50 Gy EBRT

or 45-60 Gy at 3-6 Gy/fraction if using HDR as sole therapy.

2,3

2,3

1 .See Radiation Techniques (RAD-A) and Discussion2

3

Nag S, Cano ER, Demances DJ, et al. The American Brachytherapy Societyrecommendations for high-dose-rate brachytherapy for head-neck carcinomas. Int J Radiat Oncol Biol Phys 2001;50:1190-1198; and Mazeron JJ, Ardiet JM, Hale-Meder C, et al. GEC-ESTRO recommendations for brachytherapy for head and neck squamous cell carcinoma. Radiother Oncol 91:150-156.)

The interval between EBRT and brachytherapy should be as short as possible (1-2 weeks) depending on recovery from acute toxicity. The interval between HDRfractions should be at least 6 hours.

Brachytherapy should be performed at centers where there is expertise in this modality. (

2009;

LIP-A




Discussion



NCCN Guidelines VersioCancer of the Oral Cavity

n 1.2012

H&P

BiopsyChest imaging

Examination under anesthesia (EUA) withendoscopy, if indicatedPreanesthesia studiesDental/prosthodontic evaluation,including jaw imaging as indicated

including a complete head and neckexam; mirror and fiberoptic examinationas clinically indicated

CT with contrast and/or MRI with contrast

of primary and neck as indicated

Consider positron emission tomography

(PET)-CT for stage III-IV disease

Nutrition, speech and swallowingevaluation/therapy as indicated

Multidisciplinary consultation as indicated

a

b


T1-2, N0

T3, N0

T1-3, N1-3

T4a, any N

See Treatment of Primary and Neck (OR-2)




See Treatment of Very Advanced Head and NeckCancer (ADV-1)

Buccal mucosa, floor of mouth, anterior tongue, alveolar ridge, retromolar trigone, hard palate

T4b, any N,

or

Unresectable nodal disease

or

Unfit for surgery

aSee Discussion.bSee Principles of Nutrition: Management and Supportive Care (NUTR-A).

OR-1




Discussion




n 1.2012


CLINICAL

STAGING


T12, N0

Resection of primary (preferred)


dissection (guided by tumor

thickness)c

or

Definitive RTd

One positive node without

adverse featureseRT optional (category 2B)d

c

d

e

f

Adverse risk features: extracapsular nodal spread, positive margins, pT3 or pT4 primary, N2 or N3 nodal disease, nodal disease in levels IV or V, perineural invasion,vascular embolism .

r re-resection tog


See Principles of Radiation Therapy (OR-A)


.

( )See Discussion

Systemic Therapy

.

.

Conside achieve negative margins, if feasible.

FOLLOW-UP



No adverse featurese

ADJUVANT TREATMENT

Adverse

featurese

Residual disease Salvage surgery

No residual disease

Chemo/RT

Re-resection

d,f

g

(preferred) (category 1)

or

RT

or

d

Extracapsular

spread and/or

positive margin

Other risk

features

RTd

or

Consider chemo/RTd,f

OR-2




Discussion




n 1.2012


T3,N0;

T4a, Any N;

T1-3, N1-3


and bilateral neck

dissectionc

N2c

(bilateral)


ipsilateral or bilateral

neck dissectionc

N0, N1,

N2a-b,

N3

CLINICAL

STAGING

TREATMENT OF PRIMARY AND NECK FOLLOW-UP

Surgeryc

ADJUVANT

TREATMENT

No adverse

featureseRT (optional)d

Adverse

featurese

Other risk

features

RTd

d,f

or

Consider

chemo/RT

Chemo/RT

(preferred)

Re-resection

d,f

g

d

(category 1)

or

RT

or

c

d

e

f

Adverse risk features: extracapsular nodal spread, positive margins, pT3 or pT4 primary, N2 or N3 nodal disease, nodal disease in levels IV or V, perineural invasion,vascular embolism .

re-resection tog


See Principles of Radiation Therapy (OR-A)


.

.

.Systemic Therapy( )See Discussion

Consider achieve negative margins, if feasible.

Extracapsular

spread and/or

positive

margin Follow-up(See FOLL-A)


OR-3




Discussion




n 1.2012


DEFINITIVE:RT

For unresectable disease

NeckUninvolved nodal stations:44-64 Gy (1.6-2.0 Gy/fraction)

Primary and gross adenopathy:Conventional fractionation:

66-74 Gy (2.0 Gy/fraction; daily Monday-Friday) in 7 weeksAltered fractionation:

2.0 Gy/fraction; 6 fractions/week accelerated;

66-74 Gy to gross disease; 44-64 Gy to subclinical disease.Concomitant boost accelerated RT: 72 Gy/6 weeks

(1.8 Gy/fraction, large field; 1.5 Gy boost as second daily

fraction during last 12 treatment days)Hyperfractionation: 81.6 Gy/7 weeks (1.2 Gy/fraction, twice daily)

BrachytherapyInterstitial brachytherapy is considered for selected cases.

-LDR brachytherapy:

Consider LDR boost 20-35 Gy if combined with 50 Gy EBRT

or 60-70 Gy over several days if using LDR as sole therapy.-HDR brachytherapy:

Consider HDR boost 21 Gy at 3 Gy/fraction if combined with

40-50 Gy EBRT or 45-60 Gy at 3-6 Gy/fraction if using HDR as

sole therapy.

2,3

( )See ADV-1

1See Radiation Techniques (RAD-A) and Discussion.2

3

Brachytherapy should be performed at centers where there is expertise in this modality. (Nag S,Cano ER, Demances DJ, et al. The American Brachytherapy Society recommendations for high-dose-rate brachytherapy for head-neck carcinomas. Int. J. Radiat Oncol Biol Phys.2001;50:1190-1198; and Mazeron JJ, Ardiet JM, Hale-Meder C, et al.,GEC-ESTROrecommendations for brachytherapy for head and neck squamous cell carcinoma. RadiotherOncol 2009;91:150-156.)

The interval between EBRT and brachytherapy should be as short as possible(1-2 weeks) depending on recovery from acute toxicity. The interval between HDR fractionsshould be at least 6 hours.

POSTOPERATIVE:RT

Preferred interval between resection and postoperative RT

is 6 weeks.

Involved nodal stations:

60-66 Gy (2.0 Gy/fraction)Uninvolved nodal stations:


Postoper


ative chemoradiation

Concurrent single-agent cisplatin at 100 mg/m every 3 weeks

is recommended.

2

4-6

OR-A

4

5

6

Bernier J, Domenge C, Ozsahin M, et al. Postoperative irradiation with or without concomitantchemotherapy for locally advanced head and neck cancer. N Engl J Med 2004;350:1945-1952.

Cooper JS, Pajak TF, Forastiere AA, et al. Postoperative concurrent radiotherapy andchemotherapy for high-risk squamous-cell carcinoma of the head and neck. N Engl J Med2004;350(19):1937-1944.

Bernier J, Cooper JS, Pajak TF, et al. Defining risk levels in locally advanced head and neckcancers: A comparative analysis of concurrent postoperative radiation plus chemotherapy trials ofthe EORTC (#22931) and RTOG (#9501). Head Neck 2005;27:843-850.




Discussion



NCCN Guidelines VersioCancer of the Oropharynx

n 1.2012

Base of tongue/tonsil/posterior pharyngeal wall/soft palate

CLINICAL STAGING

T1-2, N0-1

Any T, N2-3

T3-4a, N0-1

WORKUP

H&P including a complete head and neck

exam; mirror and fiberoptic examination

as clinically indicated

Biopsy

Tumor human papilloma virus (HPV)

testing

Chest imaging

CT with contrast and/or MRI with

contrast of primary and neck

Consider PET-CT for

stage III-IV disease

Dental evaluation, including panorex as

indicated

Nutrition, speech and swallowing

evaluat

Examination under anesthesia with

endoscopy as indicated

Preanesthesia studies

a

b


recommended

ion/therapy and audiogram as

indicatedc

See Treatment of Primary and Neck (ORPH-2)



T4b, any N,

or


or

Unfit for surgery

See Treatment of Very AdvancedHead and Neck Cancer (ADV-1)

a

b

Although not

used to guide treatment, HPV testing is valuable prognostically. The results of HPV testing should not change management decisions except in the context of a clinical

trial.Anatomical imaging is also recommended.

Either immunohistochemistry for analysis of p16 expression or HPV in situ hybridization for detection of HPV DNA in tumor cell nuclei is recommended.

cSee Principles of Nutrition: Management and Supportive Care (NUTR-A).

ORPH-1




Discussion




n 1.2012

CLINICAL

STAGING

T1-2, N0-1


No adverse featuresg


adverse featuresgConsider RTd

Complete clinical response

Residual disease Salvagesurgery

Definitive RTd

d

e

f

g

h

Adverse features: extracapsular nodal spread, positive margins, pT3 or pT4 primary, N2 or N3 nodal disease, nodal disease in levels IV or V, perineural invasion,vascular embolism .

C re-resection to

See Principles of Radiation Therapy (ORPH-A).


See Principles of Systemic Therapy (CHEM-A).

onsider achieve negative margins, if feasible.

( )See Discussion


ipsilateral or bilateral

neck dissectione

or

RT + systemic

therapy (category 2B

for systemic therapy)

For T2, N1 only,d

f

Residual disease Salvagesurgery

ADJUVANT TREATMENT

Adverse

featuresg

Other risk

features

RTd

or


Complete clinical

response


Chemo/RTd,f

(category 1)

Positive margin

Re-resection or RTd

or

hemo/RT

(for T2 only)

h

Consider c

Extracapsular

spread

positive margin

or



ORPH-2




Discussion




n 1.2012

T3-4a,

N0-1

Salvage

surgeryResidual disease


Surgery for

primary and

necke

CLINICAL

STAGING


No adverse featuresg

Concurrent systemic

therapy/RT,cisplatin (category 1)

preferred

d,f

or

or

ADJUVANT TREATMENT

Induction chemotherapy

(category 3)followed by RT or

chemo/RT

f,i

d

d

Multimodality clinical trials

or

Salvage

surgeryResidual disease


RTg

Adverse

featuresg

Other risk

features

RTd

or


Extracapsular

spread and/or

positive margin

Chemo/RTd,f

(category 1)

d

e

f

g

i




See Principles of Systemic Therapy (CHEM-A)

See Discussion

.

on induction chemotherapy.

( )See Discussion




ORPH-3




Discussion




n 1.2012

Any T, N2-3

Concurrent systemic

therapy/RT,d,f

cisplatin (category 1)

preferred

CLINICAL

STAGING


or

N2c



dissectione

Resection of primary and

bilateral neck dissectione

N1

N2a-b

N3Surgery:

Primary and

neck

e

or

ADJUVANT TREATMENT

Induction

chemotherapy

(category 2B) followed

by RT or chemo/RT

f,i

or


Residual tumor

in neck

Complete clinicalresponse of neck

Primary site:

Complete

clinical

response

Primary site:Residual tumor

Salvage surgery + neckdissection as indicatede

Neck

dissectione

Negative

Positive

Observe

Neck

dissectione

No adverse

featuresg

Adverse

featuresg

Extracapsular

spread and/or

positive margin

Other risk

features

RTd

or

Consider

chemo/RTd,fd

e

f

g

i

j





.

.


See Discussion

.


( )See Discussion

Chemo/RTd,f

(category 1)


Post-treatmentevaluationj



ORPH-4




Discussion




n 1.2012


1

ased on published

no consensus on theoptimal approach. In general, the use of concurrent chemoradiation carries a high toxicityburden; altered fractionation or multiagent chemotherapy will likely further increase thetoxicity burden. For any chemoradiation approach, close attention should be paid topublished reports for the specific chemotherapy agent, dose, and schedule ofadministration. Chemoradiation should be performed by an experienced team and shouldinclude substantial supportive care.

ernier J, Cooper JS, Pajak TF, et al. Defining risk levels in locally advanced head and neckcancers: A comparative analysis of concurrent postoperative radiation plus chemotherapytrials of the EORTC (#22931) and RTOG (#9501). Head Neck 2005;27:843-850.

See Radiation Techniques (RAD-A) and Discussion.2

3

2

6

B data, concurrent chemoradiation most commonly uses conventionalfractionation at 2.0 Gy per fraction to a typical dose of 70 Gy in 7 weeks with single-agentcisplatin given every 3 weeks at 100 mg/m 2-3 cycles of chemotherapy are useddepending on the radiation fractionation scheme (RTOG 0522). Other fraction sizes (eg,1.8 Gy, conventional), multiagent chemotherapy, other dosing schedules of cisplatin oraltered fractionation with chemotherapy are efficacious, and there is

B

4

5

Bernier J, Domenge C, Ozsahin M, et al. Postoperative irradiation with or withoutconcomitant chemotherapy for locally advanced head and neck cancer. N Engl J Med2004;350:1945-1952.

Cooper JS, Pajak TF, Forastiere AA, et al. Postoperative concurrent radiotherapy andchemotherapy for high-risk squamous-cell carcinoma of the head and neck.N Engl J Med 2004;350:1937-1944.


Either intensity-modulated RT (IMRT) or 3-D conformal RT is recommended for cancers of the oropharynx in order to minimize dose to

critical structures, especially the parotid glands.

ORPH-A

D

)

EFINITIVE:RT

Conventional fractionation: 66-74 Gy

(2.0 Gy/fraction; daily Monday-Friday) in 7 weeks

Altered fractionation:2.0 Gy/fraction; 6 fractions/week accelerated;

66-74 Gy to gross disease;

44-64 Gy to subclinical disease.Concomitant boost accelerated RT: 72 Gy/6 weeks

(1.8 Gy/fraction, large field; 1.5 Gy boost as second daily fraction

during last 12 treatment days)Hyperfractionation: 81.6 Gy/7 weeks

(1.2 Gy/fraction, twice daily)

Uninvolved nodal stations: 44-64 Gy (1.6-2.0 Gy/fraction)Concurrent chemoradiation

Conventional fractionation:Primary and gross adenopathy: typically 70 Gy (2.0 Gy/fraction)Neck

Uninvolved nodal stations: 44-64 Gy (1.6-2.0 Gy/fraction

Neck

2

3

POSTOPERATIVE:RT


is 6 weeks.

Primary: 60-66 Gy (2.0 Gy/fraction)

NeckInvolved nodal stations: 60-66 Gy (2.0 Gy/fraction)Uninvolved nodal stations: 44-64 Gy (1.6-2.0 Gy/fraction)

Postoperative chemoradiation

Concurrent single-age

nt cisplatin at 100 mg/m every 3 weeks is

recommended.

2

4-6




Discussion



NCCN Guidelines VersioCancer of the Hypopharynx

n 1.2012

T1, N+;

T2-3, Any N

T4a, Any N


Advanced cancer requiring

pharyngectomy with total

laryngectomy

H&P including a complete

head and neck exam; mirror

and fiberoptic examination as

clinically indicated

Biopsy

Chest imaging

CT with contrast and/or MRI

with contrast of primary and

neck

Consider PET-CT for stage

III-IV disease

Examination under

anesthesia with endoscopy


Nutrition, speech and

swallowing

evaluation/therapy and

audiogram as indicated

Dental evaluation

Consider videostrobe for

select patients

a

b

Multidisciplinary consultation

as indicated

See Treatment of Primary andNeck (HYPO-2)



See Treatment of VeryAdvanced Head and NeckCancer (ADV-1)

aAnatomical imaging is also recommended.bSee Principles of Nutrition: Management and Supportive Care (NUTR-A).

T4b, any N

or


or

Unfit for surgery

HYPO-1

Most T1, N0, selected T2, N0(not requiring total laryngectomy)




Discussion




n 1.2012

Primary site:Completeclinicalresponse

Primary site:Residualtumor

Salvage surgery+ neck dissectionas indicatedd

Most T1, N0,

selected T2, N0(not requiring

total

laryngectomy)

Definitive RTc

CLINICAL

STAGING


Surgery: Partial

laryngopharyngectomy

(open or endoscopic)

+ ipsilateral or bilateral

neck dissectiond

or

No adverse

featurese

c

d

f

g

eAdverse features: extracapsular nodal spread, positive margins, pT3 or pT4 primary, N2 or N3 nodal disease, perineural invasion, vascular embolism .

r re-resection to

See Principles of Radiation Therapy


(HYPO-A)


.

.

Conside achieve negative margins, if feasible.

( )See Discussion

ADJUVANT

TREATMENT

Adverse

featurese

Other risk

features

RTc

or

Consider

chemo/RTc,f


Extracapsular

spread

positive margin

Chemo/RTc,f

(category 1)

Positive margins

Re-resection or RTor

Consider chemo/RT

(for T2 only)

g c


HYPO-2




Discussion




n 1.2012

Induction chemotherapyf,h See Response After InductionChemotherapy (HYPO-4)

Selected T2, N0

(requiring

laryngectomy)T1, N+;

T2-3, any N

(if

otal

laryngectomy

required)

pharyngectomy

with t

CLINICAL

STAGING

TREATMENT OF PRIMARY AND NECK ADJUVANT TREATMENT

Residual tumor

in neck

Completeclinicalresponseof neck

Primary site:

complete

clinical

response

Primary site:

residual

tumor


Neck dissectiond


Laryngopharyngectomy

+ neck dissection,

including level VI

d

Concurrent systemic

therapy/RT (cisplatin

preferred)c,f

or

or

or

c

d

e

f

i

Adverse features: extracapsular nodal spread, positive margins, pT3 or pT4 primary, N2 or N3 nodal disease, perineural invasion, vascular embolism .

h



(HYPO-A)



.

.

.

.In randomized clinical trials, assessment of response has been done after 2 or 3 cycles.

(See Discussion)

No adverse

featurese

Adverse

featuresf

Other risk

features

RTc

or

Consider chemo/RTc,f

Extracapsular

spread and/or

positive margin

Chemo/RTc,f (category 1)

Negative

Positive

Observe

Neck

dissectiond



Post-treatmentevaluationi

HYPO-3




Discussion




n 1.2012

c

d

e

f

h

i

Adverse features: extracapsular nodal spread, positive margins, pT3 or pT4 primary, N2 or N3 nodal disease, perineural invasion, vascular embolism .

In randomized clinical trials, assessment of response has been done after 2 or 3 cycles.

See Principles of Radiation Therapy (HYPO-A).See Principles of Surgery (SURG-A)


.

.


(See Discussion)

Response

after

induction

chemo-

therapyf,h

Primary site:

Partial

response

(PR)

Primary site:

< PRSurgeryd

Definitive RTc

c,f

(category 1)

or

Consider

chemo/RT

(category 2B)

Residual

tumor in neck

Complete

clinical

response

of neck

Neck dissectiond

Primary site:

Complete

response

(CR)

Chemo/RTc,f

(category 2B)

CR Observe

Salvage

surgery

Residual

disease

Negative

Positive

Observe

Neck

dissectiond

No adverse

featurese

Adverse

featurese RTc

c,for

Consider chemo/RT

Extracapsular

spread and/or

positive margin

Chemo/RTc,f (category 1)

RTc

Post-treatmentevaluationi

RESPONSE

ASSESSMENT

Other risk

features



HYPO-4




Discussion




n 1.2012

Surgery + neck dissection

(preferred)

d

CLINICAL

STAGING


RTorChemo/RT

c

c,f

ADJUVANT TREATMENT

T4a,any N

Residual

tumor in neckPrimary site:

Complete

clinical

response

Primary site:

Residual tumorSalvage surgery + neckdissection as indicatedd

Neck dissectiond


or

or

Concurrent systemic

therapy/RT

(category 3)

c,f

Induction

chemo-

therapy

(category 3)

f,h

j

or

c

d

f



(HYPO-A)


.

.

Complete

clinical

response

of neck

Negative

Positive

Observe

Neck

dissectiond

Primary site:

CR or PR

and stable

disease in

neck

Primary site:

< PR or

progression

in neck


For CR:

For PR:

RT orconsiderchemo/RT;

Chemo/RT

c,f

c,f

Residual

tumor in

neck

Primary site:

Complete

response

clinical

Primary site:

residual tumorSalvage surgery + neckdissection as indicatedd

Neck dissectiond

Complete

clinical

response

of neck

Negative

Positive

Observe

Neck

dissectiond

RTorChemo/RT

c

c,f


Post-treatmentevaluationh


Post-treatment

evaluationi

h

i

j

In randomized clinical trials, assessment of response has been done after2 or 3 cycles.

See Post Chemoradiation or RT Neck Evaluation (SURG-A 7 of 7).

See Discussion on induction chemotherapy.

HYPO-5




Discussion




n 1.2012

:RT

2.0 Gy/fraction; 6 fractions/week accelerated;

66-74 Gy to gross disease; 44-64 Gy to subclinical disease.Concomitant boost accelerated RT:

72 Gy/6 weeks (1.8 Gy/fraction, large field; 1.5 Gy boost as

second daily fraction during last 12 treatment days)Hyperfractionation: 81.6 Gy/7 weeks (1.2 Gy/fraction, twice daily)

Uninvolved odal stations: 44-64 Gy (1.6-2.0 Gy/fraction)

Concurrent chemoradiation

Primary and gross adenopathy: typically 70 Gy (2.0 Gy/fraction)Neck

Uninvolved nodal stations: 44-64 Gy (1.6-2.0 Gy/fraction)

DEFINITIVE

Primary and gross adenopathy:Conventional fractionation: 66-74 Gy (2.0 Gy/fraction; dailyMonday-Friday) in 7 weeksAltered fractionation:

Neckn

Conventional fractionation

3

4

PRINCIPLES OF RADIATION THERAPY1,2

1 .

B

ther dosing schedules of cisplatin; altered fractionation withchemotherapy are efficacious, and there is no consensus on the optimalapproach. In general, the use of concurrent chemoradiation carries a high toxicityburden; altered fractionation or multiagent chemotherapy will likely furtherincrease the toxicity burden. For any chemoradiation approach, close attentionshould be paid to published reports for the specific chemotherapy agent, dose,and schedule of administration. Chemoradiation should be performed by anexperienced team and should include substantial supportive care.

ernier J, Cooper JS, Pajak TF, et al. Defining risk levels in locally advanced headand neck cancers: A comparative analysis of concurrent postoperative radiationplus chemotherapy trials of the EORTC (#22931) and RTOG (#9501). Head Neck2005;27:843-850.

See Radiation Techniques (RAD-A) and Discussion2

3Particular attention to speech and swallowing is needed during therapy.

ased on published data, concurrent chemoradiation most commonly usesconventional fractionation at 2.0 Gy per fraction to a typical dose of 70 Gy in 7weeks with singleiagent cisplatin given every 3 weeks at 100 mg/m ; 2-3 cyclesof chemotherapy are used depending on the radiation fractionation scheme

. Other fraction sizes (eg, 1.8 Gy, conventional), multiagentchemotherapy, o

Bernier J, Domenge C, Ozsahin M, et al. Postoperative irradiation with or withoutconcomitant chemotherapy for locally advanced head and neck cancer. N Engl JMed 2004;350:1945-1952.

Cooper JS, Pajak TF, Forastiere AA, et al. Postoperative concurrent radiotherapyand chemotherapy for high-risk squamous-cell carcinoma of the head and neck.N Engl J Med 2004;350:1937-1944.

B

4

2

5

6

7

(RTOG 0522)


POSTOPERATIVE:RT


is 6 weeks.

Involved nodal stations: 60-66 Gy (2.0 Gy/fraction)Uninvolved nodal stations: 44-64 Gy (1.6-2.0 Gy/fraction)

Concurrent single-agent cisplatin at 100 mg/m every 3 weeks is

recommended.


Postoperative chemoradiation2

5-7

HYPO-A




Discussion



NCCN Guidelines VersioCancer of the Nasopharynx

n 1.2012

T1, N0, M0

T1, N1-3; T2-T4,Any N

Any T, Any N, M1

H&P

Nasopharyngeal exam and biopsy

including a complete head and neckexam; mirror and fiberoptic examinationas clinically indicated

Chest imaging

Consider PET-CT for stage III-IV disease

Dental evaluation as indicated


evaluation/therapy, and audiogram as

indicated

WHO) class 2-3/N2-3

disease (may include PET scan and/or CT)

MRI with gadolinium of nasopharynx and

base of skull to clavicles and CT (as

indicated) with contrast

Imaging for distant metastases

(ie, chest, liver, bone) for World Health

Organization (


a


See Treatment of Primaryand Neck (NASO-2)



NASO-1

aSee Principles of Nutrition: Management and Supportive Care (NUTR-A).




Discussion




n 1.2012

T1, N0, M0Definitive RT tonasopharynx andelective RT to neckb

CLINICAL

STAGING



FOLLOW-UP

b

e

f

c

d

Can be used for select patients with distant metastasis in limited site or with small tumor burden, or for patients with symptoms in the primary or any nodal site.



See Discussion

(NASO-A)


.

.

.


Concurrent chemo/RT(category 1)

or

Induction chemotherapy (category 3)followed by chemo/RT

b,c

d

Neck:Residualtumor

Neck:Completeclinicalresponse

Neckdissectionf

Adjuvant chemotherapyc

Platinum-basedcombinationchemotherapyc

RT to primary

and neck

or

Chemo/RT as


b

c

Any T,any N, M1

Observe

T1, N1-3;T2-T4, any N

Recurrent orPersistentDisease(See ADV-2)

Concurrent

chemo/RTb,c,e

NASO-2




Discussion




n 1.2012

Definitive RT:

Uninvolved nodal stations: 44-64 Gy (1.6-2.0 Gy/fraction)

Conventional fractionation:

Primary and gross adenopathy:66-70 Gy (2.0 Gy/fraction; daily Monday-Friday) in 7 weeksNeck

Concurrent Chemoradiation:

Primary and gross adenopathy: 70 Gy (2.0 Gy/fraction)

NeckUninvolved nodal stations: 44-64 Gy (1.6-2.0 Gy/fraction)


1See Radiation Techniques (RAD-A) and Discussion.

Either IMRT or 3-D conformal RT is recommended in cancer

of the nasopharynx to minimize dose to critical structures.

NASO-A




Discussion



NCCN Guidelines VersioCancer of the Glottic Larynx

n 1.2012

WORKUPa

Total laryngectomy

not required

(T1-T2 or Select T3)

T3 requiring total

laryngectomy

(N0-1)

Carcinoma in situ

T4a disease

H&P

Biopsy

Chest imaging

CT with contrast and thin cuts through

larynx and/or MRI of primary and neck

Consider PET-CT for stage III-IV disease

Examination under anesthesia with

endoscopy


Dental/evaluation as indicated


including a complete head and neck

exam; mirror and fiberoptic examination as



evaluation/therapy, and audiogram as

indicated

Consider videostrobe for select patients

b

CLINICAL STAGING TREATMENT OF PRIMARY AND NECK

See Treatment (GLOT-2)

See Treatment (GLOT-2)

See Treatment of Primary and Neck(GLOT-6)

aComplete workup is not indicated for Tis, T1.bSee Principles of Nutrition: Management and Supportive Care (NUTR-A).


See Treatment of Very AdvancedHead and Neck Cancer (ADV-1)

T3 requiring total

laryngectomy

(N2-3)


T4b, any N

or

Unresectable nodal

disease

or

Unfit for surgery

GLOT-1




Discussion




n 1.2012

CLINICAL STAGING TREATMENT OF PRIMARY AND NECK

N0 or no adverse featurese ObserveTotal laryngectomy

not required

(T1-T2 or select T3)

Carcinoma in situEndoscopic resectionorRTc

RT

or

Partial laryngectomy/

endoscopic or open

resection as indicated

c

d

FOLLOW-UP


c .See Principles of Radiation Therapy (GLOT-A)

See Principles of Surgery (SURG-A).d

e

f

g

Adverse features: extracapsular nodal spread, positive margins, pT3 or pT4 primary, N2 or N3 nodal disease, perineural invasion, vascular embolism ).

Consider re-resection to achieve negative margins, if feasible.

(

.

See Discussion



GLOT-2

Adverse

featurese

Other risk

features

RTc

or

Consider

chemo/RTc,f

Extracapsular

spread

positive margin

Chemo/RTc,f

(category 1)

Positive

margins

Re-resection

orRTorConsider chemo/RT

(for T2 patients)

g

c

c,f

ADJUVANT

TREATMENT


adverse featureseConsider RTc




Discussion




n 1.2012

Residual

tumor in

neck




Neck

dissectiond

T3 requiring

total

laryngectomy

(N0-1)

CLINICAL

STAGING


Surgeryd

Laryngectomy with ipsilateral

thyroidectomyd

N1

N0

Laryngectomy with ipsilateral

thyroidectomy, ipsilateral neck

dissection bilateral neck

dissection

ord

c

d

f

h

iA




See Discussion

(GLOT-A)

.

( )

See Post Chemoradiation or RT Neck Evaluation (SURG-A 7 of 7).

.

.

dverse features: extracapsular nodal spread, positive margins, pT4 primary, N2 or N3 nodal disease, perineural invasion, vascular embolism .

ADJUVANT TREATMENT

or

Concurrent

systemic

therapy/RT,

cisplatin

(

c,f

category 1)

preferred

orRT if patient

not candidate

for systemic

therapy/RT

c

Follow-up(See

FOLL-A)

Negative

Positive

Observe

Neck

dissectiond

No adverse

featuresi

Adverse

featuresi

Other risk

features

RTc

or

Consider

chemo/RTc,f

Extracapsular

spread and/or

positive margin

Chemo/RTc,f

(category 1)

Primary site:Completeclinicalresponse (N+ atinitial staging)

Primary site:Completeclinicalresponse (N0 atinitial staging)

RecurrentorPersistentDisease(SeeADV-2)

Post-treatment

evaluationh

GLOT-3




Discussion




n 1.2012

Residual

tumor in neck


Primary site:

Completeclinical

response



Neck

dissectiond

T3 requiring

total

laryngectomy

(N2-3) SurgerydLaryngectomy with ipsilateral

thyroidectomy, ipsilateral or bilateral

neck dissectiond

or

Concurrent systemic

therapy/RT, cisplatin

(category 1) preferred

c,f

Negative

Positive

Observe

Neck

dissectiond

CLINICAL

STAGING

TREATMENT OF PRIMARY AND NECK ADJUVANT TREATMENT

or

No adverse

featuresi

Head and Neck. 2012

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Transcript of Head and Neck. 2012