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NCCN Clinical Practice Guidelines in Oncology™
Head and Neck
Cancers
V.1.2007
www.nccn.org
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Guidelines Index
Head and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007
NCCN Head and Neck Cancers Panel Members
Head and Neck Cancers
Arlene A. Forastiere, MD/Chair The Sidney Kimmel ComprehensiveCancer Center at Johns Hopkins
Kie-Kian Ang, MD, PhDThe University of Texas M. D. AndersonCancer Center
David Brizel, MD
Duke Comprehensive Cancer Center
Bruce E. Brockstein, MDRobert H. Lurie Comprehensive Cancer Center of Northwestern University
Frank Dunphy, MDDuke Comprehensive Cancer Center
David W. Eisele, MD
UCSF Comprehensive Cancer Center
Helmuth Goepfert, MDThe University of Texas M. D. AndersonCancer Center
Wesley L. Hicks, Jr., MDRoswell Park Cancer Institute
Merrill S. Kies, MD
The University of Texas M. D. AndersonCancer Center
†
§
§
† Þ
†
¶
¶
¶
†
z
David E. Schuller, MDArthur G. James Cancer Hospital &Richard J. Solove Research Institute atThe Ohio State University
¶
¶
§
§
¶
¶ †
¶
Jatin P. Shah, MDMemorial Sloan-Kettering Cancer Center
Sharon Spencer, MD
University of Alabama at BirminghamComprehensive Cancer Center
Andy Trotti, III, MDH. Lee Moffitt Cancer Center & ResearchInstitute at the University of SouthFlorida
Gregory T. Wolf, MD
University of Michigan ComprehensiveCancer Center
Frank Worden, MDUniversity of Michigan ComprehensiveCancer Center
Bevan Yueh, MD, MPHFred Hutchinson Cancer ResearchCenter/Seattle Cancer Care Alliance
z
William M. Lydiatt, MDUNMC Eppley Cancer Center at TheNebraska Medical Center
¶
¶
§
† Þ
† Þ
† Þ
¶
¶
z
z
z
Ellie Maghami, MDCity of Hope Cancer Center
Thomas McCaffrey, MD, PhDH. Lee Moffitt Cancer Center & ResearchInstitute at the University of South Florida
Bharat B. Mittal, MDRobert H. Lurie Comprehensive Cancer Center of Northwestern University
David G. Pfister, MDMemorial Sloan-Kettering Cancer Center
Harlan A. Pinto, MDStanford Comprehensive Cancer Center
Marshall R. Posner, MDDana-Farber/Brigham and Women’sCancer Center | Massachusetts GeneralHospital Cancer Center
John A. Ridge, MD, PhDFox Chase Cancer Center
Sandeep Samant, MDSt. Jude Children's ResearchHospital/University of Tennessee Cancer Institute
*
† Medical Oncology
¶ Surgery/Surgical oncology
§ Radiation oncology/
Otolaryngology
Þ Internal medicine
Radiotherapy
* Writing Committee Member
z
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Guidelines Index
Head and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007
This manuscript is being
updated to correspond
with the newly updated
algorithm.
These guidelines are a statement of consensus of the authors regarding their views of currently accepted approaches to treatment. Any clinicianseeking to apply or consult these guidelines is expected to use independent medical judgment in the context of individual clinical circumstances todetermine any patient’s care or treatment. The National Comprehensive Cancer Network 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. These guidelines are copyrightedby National Comprehensive Cancer Network. All rights reserved. These guidelines and the illustrations herein may not be reproduced in any formwithout the express written permission of NCCN. ©2007.
Table of Contents
NCCN Head and Neck Cancers Panel Members
Ethmoid Sinus Tumors (ETHM-1)
Maxillary Sinus Tumors (MAXI-1)
Salivary Gland Tumors (SALI-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)
Occult Primary (OCC-1)
Guidelines Index
Print the Head and Neck Cancers Guideline
·
·
·
Multidisciplinary Team Approach (TEAM-1)
Support Modalities (TEAM-1)
Cancer of the Glottic Larynx (GLOT-1)
Cancer of the Supraglottic Larynx (N0) (SUPRA-1)
Cancer of the Supraglottic Larynx (N+) (SUPRA-5)
Cancer of the Nasopharynx (NASO-1)
Unresectable Head and Neck Cancer (ADV-1)
Recurrent Head and Neck Cancer (ADV-2)
·
·
··
·
·
·
·
·
·
·
·
·
Head and Neck Cancers
For help using thesedocuments, please click here
Staging
Manuscript
References
Clinical Trials:
Categories of Consensus:NCCN
Thebelieves that the best managementfor any cancer patient is in a clinicaltrial. Participation in clinical trials isespecially encouraged.
To find clinical trials online at NCCNmember institutions,
All recommendations are Category2A unless otherwise specified.
See
NCCN
click here:nccn.org/clinical_trials/physician.html
NCCN Categories of Consensus
Summary of Guidelines Updates
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Version 1.2007, 04/10/07 © 2007 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
Guidelines Index
Head and Neck Cancers TOC
Staging, MS, ReferencesNCCN® Practice Guidelines
in Oncology – v.1.2007
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.
Back to Head and Neck
Table of Contents
Follow-up should be performed by a physician 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:
··
··
Pain and symptom managementNutritional support
Enteral feeding
Dental care for RT effects
?
? Oral supplements
Xerostomia management
Smoking cessation
Tracheotomy care
Social work and Case management
Supportive Care
·
·
·
· (See NCCN Palliative Care Guideline)
SUPPORT AND SERVICES
TEAM-1
···
····
·
···
··
Head and neck surgeryRadiation oncologyMedical oncology
Plastic and reconstructive surgerySpecialized nursing careDentistry/prosthodonticsPhysical medicine andrehabilitationSpeech and swallowing therapy
Clinical Social workNutrition supportPathology
Diagnostic radiologyAdjunctive servicesNeurosurgeryOphthalmologyPsychiatryAddiction Services
?
?
?
?
MULTIDISCIPLINARY TEAM
The management of patients with head and neck cancers is complex. All
patients need access to the full range of specialists and support services
for optimal
treatment and follow-up.
with
expertise in the management of patients with head and neck cancer
Team Approach
Head and Neck Cancers
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Guidelines Index
Head and Neck Cancers TOC
Staging, MS, ReferencesNCCN® Practice Guidelines
in Oncology – v.1.2007
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.
WORKUP
Ethmoid sinus:
·
·
·
··
·
Squamous cell carcinoma
Undifferentiated
carcinoma
Adenocarcinoma
Salivary gland tumor Esthesioneuroblastomas
Sarcoma (non-
rhabdomyosarcoma)
··
·
H&PCT and/or
MRIChest x-ray
Biopsy MalignantUntreated
See Primary Treatment
and Follow-up (ETHM-2)
··
·
·
H&PCT and/or MRIPathologyreview
Chest x-ray
Diagnosedwith incompleteexcision
See Primary Treatmentand Follow-up (ETHM-2)
ETHM-1
LymphomaSee NCCN Non-Hodgkin’s
Lymphoma Guidelines
Ethmoid Sinus Tumors
Head and Neck Cancers
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Guidelines Index
Head and Neck Cancers TOC
Staging, MS, ReferencesNCCN® Practice Guidelines
in Oncology – v.1.2007
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.
PRIMARY TREATMENT FOLLOW-UP
·
·
·
·
Physical exam:
Chest imaging asclinically indicated
>
>
>
>
Year 1,
every 1–3 mo Year 2,
every 2–4 mo Years 3–5,
every 4–6 mo> 5 years,
every 6–12 mo
TSH every 6-12 mo if
neck irradiated
CT scan/MRI- baseline
(category 2B)
a
b
.
Adverse characteristics include positive margins and perineural invasion.
See Principles of (CHEM-A)Systemic Therapy
Newly diagnosed,
unresectable
Chemo/RT
or
RT
or
Clinical trial (preferred)
a
Complete surgical
resection (preferred)
or
Definitive RT
RTor
Consider Chemo/RT (category 2B)
if adverse characteristics
a
bNewly diagnosed;
T1, T2
Complete
surgical resection
Newly diagnosed;
T3, T4a resectable
Surgery (preferred), if feasibleor RTor Chemo/RT a
Diagnosed after incompleteexcision (eg, polypectomy,endoscopic procedure) andgross residual disease
Diagnosed after incompleteexision
and nodisease on physical exam,imaging, and/or endoscopy
(eg, polypectomy,endoscopic procedure)
RT
or
Surgery, if feasible
ADJUVANT TREATMENT
Recurrence(see ADV-2)
CLINICAL
PRESENTATION
ETHM-2
Ethmoid Sinus Tumors
Head and Neck Cancers
RTor
Consider Chemo/RT (category 2B)
if adverse characteristics
a
b
RTor
Consider Chemo/RT (category 2B)
if adverse characteristics
a
b
RT
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Guidelines Index
Head and Neck Cancers TOC
Staging, MS, ReferencesNCCN® Practice Guidelines
in Oncology – v.1.2007
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.
WORKUP PATHOLOGY
aBiopsy:
Preferred route is transnasal.
Needle biopsy may be acceptable.
Avoid canine fossa puncture or Caldwell-Luc approach.
·
·
·
··
·
·
H&PComplete head andneck CT withcontrast and/or MRIDental/prostheticconsultation asindicatedChest x-ray
Biopsya
LymphomaSee NCCN Non-Hodgkin’s
Lymphoma Guidelines
Malignant······
Squamous cell carcinomaUndifferentiated carcinomaAdenocarcinomaSalivary gland tumor EsthesioneuroblastomaSarcoma (non-rhabdomyosarcoma)
MAXI-1
T1-2, N0
All histologies
T3-4, N0, Any T, N+
All histologies
See Primary
Treatment (MAXI-2)
See PrimaryTreatment (MAXI-3)
Maxillary Sinus Tumors
Head and Neck Cancers
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Guidelines Index
Head and Neck Cancers TOC
Staging, MS, ReferencesNCCN® Practice Guidelines
in Oncology – v.1.2007
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.
PRIMARY TREATMENT ADJUVANT TREATMENTSTAGING
T1-2, N0
Adenoid cystic
Complete
surgical
resection
RTb
T1-2, N0
All histologiesexcept
adenoid cystic
Complete
surgical
resection
Margin
negative
Perineuralinvasion
Consider RT
or Consider chemo/RT
b
(category 2B)
Margin
positive
Surgical reresection,
if possible
Chemo/RT
(category 2B)
FOLLOW-UP
·
·
·
·
Physical exam:
Chest imaging as
clinically indicated
>
>
>
>
Year 1,
every 1–3 mo
Year 2,every 2–4 mo Years 3–5,
every 4–6 mo> 5 years,
every 6–12 mo
TSH every 6-12 mo,if neck irradiated
CT/MRI- baseline
(category 2B)
MAXI-2
b
.See Principles of Radiation Therapy (MAXI-A)
Maxillary Sinus Tumors
Head and Neck Cancers
Margin
negative
Margin
positive
Consider RTb
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Guidelines Index
Head and Neck Cancers TOC
Staging, MS, ReferencesNCCN® Practice Guidelines
in Oncology – v.1.2007
PRIMARY TREATMENT ADJUVANT TREATMENTSTAGING FOLLOW-UP
·
·
·
·
Physical exam:
Chest imaging as
clinically indicated
>
>
>
>
Year 1,
every 1–3 mo Year 2,
every 2–4 mo Years 3–5,
every 4–6 mo> 5 years,
every 6–12 mo
TSH every 6-12 mo,
if neck irradiated
CT/MRI- baseline
(category 2B)
MAXI-3
T any, N+,
resectable
Surgical
excision
+ neck
dissection
RT to primary + neck
T4b, N any, all
histologies
Clinical trial
or
Definitive RT
or Chemo/RT
b
b
T3, N0
Operable T4a,all histologies
Complete
surgicalresection RT to primary and neck (category 2B for
neck) (for squamous cell carcinoma and
undifferentiated tumors)
Adverse
characteristicsc
No adverse
characteristicsc
Chemo/RT to
primary and neck
(category 2B)
Adverse
characteristicsc
No adverse
characteristicsc
b
c
.
Adverse characteristics include positive margins, perineural invasion, or extracapsular nodal spread.
See Principles of Radiation Therapy (MAXI-A)
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.
Maxillary Sinus Tumors
Head and Neck Cancers
Chemo/RT to
primary and neck
(category 2B)
G id li I d
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Guidelines Index
Head and Neck Cancers TOC
Staging, MS, ReferencesNCCN® Practice Guidelines
in Oncology – v.1.2007
MAXI-A
PRINCIPLES OF RADIATION THERAPY
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.
nodal stations:
50 Gy (2.0 Gy/day)
Definitive RT
Postoperative RT
·
·
··
³
Primary and gross adenopathy:66 Gy (2.0 Gy/day)
Neck
Uninvolved nodal stations:50 Gy (2.0 Gy/day)
Primary: 60 Gy (2.0 Gy/day)Neck
Involved nodal stations:60 Gy (2.0 Gy/day)
Uninvolved
³
³
³
³?
?
Maxillary Sinus Tumors
Head and Neck Cancers
Guidelines Index
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Guidelines Index
Head and Neck Cancers TOC
Staging, MS, ReferencesNCCN® Practice Guidelines
in Oncology – v.1.2007
See Follow-up (SALI-4)
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.
Untreated
resectable
Previously
treated
incompletely
resected
a
b
Site and stage determine therapeutic approaches.
.See Principles of Radiation Therapy (SALI-A)
Not resectable
Salivary gland
mass
ParotidSubmaxillaryMinor salivarygland
···
a
See Workup and PrimaryTreatment (SALI-2)
CLINICAL PRESENTATION
···
·
H&PCT/MRIPathologyreviewChest x-ray
Negativephysical
exam and
imaging
Adjuvant RTb
Definitive RT
or
Chemo/RT
(category 2B)
b
Gross residual
disease onphysical
exam or imaging
Surgical
resection,
if possible
No surgical
resection
possible
Definitive RT
or
Chemo/RT(category 2B)
b
Adjuvant RTb
Fine-needle
aspiration or
Open biopsy
TREATMENTWORKUP
SALI-1
Salivary Gland Tumors
Head and Neck Cancers
Guidelines Index
H d d N k C
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Guidelines Index
Head and Neck Cancers TOC
Staging, MS, ReferencesNCCN® Practice Guidelines
in Oncology – v.1.2007
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.
Complete
surgical
excisiond
Benign or
low gradeFollow-up
PRIMARY TREATMENT
Adenoid cystic;Indeterminate
or high grade
RT (category 2B
for T1)
Benign Follow-up
Surgicalresection
Cancer
Parotid
superficial
lobe
Parotid
deep lobe
Other
salivaryglandtumors
Consider
fine-needleaspiration
Lymphoma
See NCCN Non-Hodgkin’sLymphoma Guidelines
Untreated
resectable, clinically
suspicious for cancer,
> 4 cm or deep lobe
Characteristics of benign tumor include mobile superficial lobe, slow growth, painless, VII intact, and no neck nodes.
Surgical excision of clinically benign tumor: no enucleation of lateral lobe, intraoperative communication with pathologist if indicated.
c
d
WORKUP
See Treatment
(SALI-3)
Untreated resectable,
clinically benign,
< 4 cm (T1, T2)
c
CT/MRI:
base of skull to
clavicle
See Treatment(SALI-3)
See Treatment(SALI-3)
Back to Head and NeckTable of Contents
SALI-2
Salivary Gland Tumors
Head and Neck Cancers
Guidelines Index
Head and Neck Cancers
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Guidelines Index
Head and Neck Cancers TOC
Staging, MS, ReferencesNCCN® Practice Guidelines
in Oncology – v.1.2007
Total
parotidectomy
Total
parotidectomy +
comprehensive
neck dissection
Other salivarygland
tumors
Complete glandexcision
Complete
excision andlymph nodedissection
gland
Parotid
superficial
lobe
Parotid
deep lobe
Clinical N0
Clinical N+
Clinical N0
Clinical N+
Completely
excised
Incompletely
excised gross
residual disease
No further surgical
resection possible
No adverse characteristics
Adjuvant RTb
or
Consider
Chemo/RT
(category 2B)
Definitive RT
or Chemo/RT
(category 2B)
b
See Follow-up (SALI-4)
Follow-up andRecurrence(see SALI-4)
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.
TREATMENT
Clinical N0
Clinical N+
Parotidectomy
Parotidectomy +
comprehensive
neck dissection·
··
·
·
Intermediate or high grade or
adenoidcystic
Close or positive marginsNeural/perineural invasion
Lymph node metastases
Lymphatic/vascular invasion
SALI-3
No adverse characteristics See Follow-up (SALI-4)
·
·
·
·
·
Intermediate or high grade or
adenoidcystic
Close or positive margins
Neural/perineural invasion
Lymph node metastases
Lymphatic/vascular invasion
.bSee Principles of Radiation Therapy (SALI-A)
Salivary Gland Tumors
Head and Neck Cancers
Adjuvant RTb
or
Consider
Chemo/RT
(category 2B)
Guidelines Index
Head and Neck Cancers
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Guidelines Index
Head and Neck Cancers TOC
Staging, MS, ReferencesNCCN® Practice Guidelines
in Oncology – v.1.2007
FOLLOW-UP RECURRENCE
Locoregional or
distant disease;Resectable
Locoregional
disease;
Not resectable
Surgery or selected
metastasectomy (category 3)
RT
or
or
Chemotherapy
or
Best supportive care
b
Chemo/RT (category 2B)
·
·
·
Physical exam:>
>
>
>
Year 1, every 1–3 mo Year 2, every 2–4 mo Years 3–5, every 4–6 mo> 5 yr, every 6–12 mo
TSH every 6-12 mo, if neck
irradiated
Chest imaging as clinically
indicated
RT
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.
Back to Head and NeckTable of Contents
SALI-4
Salivary Gland Tumors
Head and Neck Cancers
.bSee Principles of Radiation Therapy (SALI-A)
Guidelines Index
Head and Neck Cancers
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Head and Neck Cancers TOC
Staging, MS, ReferencesNCCN® Practice Guidelines
in Oncology – v.1.2007
Definitive RTUnresectable disease or gross residual disease
··
·
·
Photon/electron therapy or neutron therapyDose
Primary and gross adenopathy:70 Gy (1.8-2.0 Gy/day) or
19.2 nGy (1.2 nGy/day)Uninvolved nodal stations:45-54 Gy (1.8-2.0 Gy/day) or 13.2 nGy (1.2 nGy/day)
Photon/electron therapy or neutron therapy
DosePrimary: 60 Gy (1.8-2.0 Gy/day)or 18 nGy (1.2 nGy/day)Neck: 45-54 Gy (1.8-2.0 Gy/day)or 13.2 nGy (1.2 nGy/day)
?
?
?
?
³
³
1
1
1
1
Postoperative RT
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.
PRINCIPLES OF RADIATION THERAPY
Back to Workup andPrimary Treatment(SALI-1)Range based on grade/natural history of disease (eg, 1.8 Gy fraction may be used for slower growing tumors).1
SALI-A
Salivary Gland Tumors
Head and Neck Cancers
Guidelines Index
® Head and Neck Cancers
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Head and Neck Cancers TOC
Staging, MS, ReferencesNCCN® Practice Guidelines
in Oncology – v.1.2007
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.
····
··
H&PBiopsyChest x-rayAs indicated for primary evaluation
PanorexCT/MRI
Preanesthesia studiesDental evaluation
?
?
Multidisciplinaryconsultation asindicated
WORKUP CLINICAL STAGING
T1-2, N0
Resectable
T3, T4a, N0
Any T, N1-3
See Treatment of Primary and Neck (LIP-2)
See Treatment of Primary and Neck (LIP-3)
Unresectable See Treatment of Head and Neck Cancer (ADV-1)
LIP-1
Surgical
candidate
Poor surgical
risk
Definitive RT toprimary and nodesor Chemo/RT
a
b
Follow-up
Cancer of the Lip
Head and Neck Cancers
a
b
.
.
See Principles of Radiation Therapy (LIP-A)
See Principles of (CHEM-A)Systemic Therapy
Guidelines Index
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Head and Neck Cancers TOC
Staging, MS, ReferencesNCCN® Practice Guidelines
in Oncology – v.1.2007
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.
TREATMENT OF PRIMARY AND NECKCLINICAL STAGING
T1–2, N0
Surgical excision
or
External-beam RT 50 Gy
+ brachytherapy
or
Brachytherapy alone
or
External-beam RT 66 Gy
³
³
FOLLOW-UP
Physical exam:·
·
·
·
Year 1,every 1–3 mo Year 2,every 2–4 mo Years 3–5,every 4–6 mo> 5 yr,every 6–12 mo
Perineural/vascular/
lymphatic invasion
Residual or
recurrent tumor
post-RT
Positive margins
No adverse
pathologic findings
Reexcision
or
RT
or
Chemo/RT
(category 3)
a
b
RT
or
Chemo/RT
(category 3)
a
b
Surgery/
reconstruction
Recurrence (see ADV-2)
Back to Head and NeckTable of Contents
LIP-2
ADJUVANT TREATMENT
Cancer of the Lip
Head and Neck Cancers
a
b
.
.
See Principles of Radiation Therapy (LIP-A)
See Principles of (CHEM-A)Systemic Therapy
Guidelines Index
H d d N k C TOC
NCCN® P ti G id li
Head and Neck Cancers
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Head and Neck Cancers TOC
Staging, MS, ReferencesNCCN® Practice Guidelines
in Oncology – v.1.2007
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.
Surgical
candidate
TREATMENT OF PRIMARY AND NECKCLINICAL STAGING:RESECTABLE T3, T4a, N0; Any T, N1-3
Excision of primary ±unilateral or bilateral
selective neck dissection
(reconstruction as indicated)
N0
External RT ±
brachytherapy
a
Excision of primary and
bilateral comprehensive neck
dissection (reconstruction as
indicated)
Excision of primary, ipsilateral
comprehensive neck
dissection ± contralateral
selective neck dissection(reconstruction as indicated)
N2c
(bilateral)
N1,
N2a–b,
N3
RT optionala
Chemo/RTb
One positive node
without adverse
featuresc,d
Physical exam:·
·
·
·
Year 1,every 1–3 mo Year 2,
every 2–4 mo Years 3–5,every 4–6 mo> 5 yr,every 6–12 mo
LIP-3
FOLLOW-UP
a
b
c
d
.
.
Extracapsular nodal spread and/or positive margins.
Minor risk features: multiple positive nodes (without extracapsular nodal spread) or perineural/lymphatic/vascular invasion.
See Principles of Radiation Therapy (LIP-A)
See Principles of (CHEM-A)Systemic Therapy
Recurrence (see ADV-2)
Surgery
Residual
tumor
Completeresponseof neck
N1(initialstage)
N2-3(initial
stage)
Observe
Primary site:Completeresponse
Primary site:< completeresponse
Salvage surgery + neckdissection as indicated
Observeor Neck dissection(category 3)
Neck dissection(category 3)
ADJUVANT
TREATMENT
Adversefeatures
Cancer of the Lip
Major risk
featuresc
Minor risk
featuresd
RTa
or
Chemo/RT
(multiple positive
nodes only)
(category 2B)
b
Guidelines Index
Head and Neck Cancers TOC
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Head and Neck Cancers
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Head and Neck Cancers TOC
Staging, MS, ReferencesNCCN® Practice Guidelines
in Oncology – v.1.2007
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.
PRINCIPLES OF RADIATION THERAPY
Uninvolved
Definitive RT
Postoperative RT
·
·
··
Primary and gross adenopathy:66 Gy (2.0 Gy/day)
External-beam RT 50 Gy +
brachytherapy or brachytherapy aloneNecknodal stations:
50 Gy (2.0 Gy/day)
Primary: 60 Gy (2.0 Gy/day)Neck
Involved nodal stations:
60 Gy (2.0 Gy/day)
³³
³
³
³
?
? Uninvolved nodal stations:50 Gy (2.0 Gy/day)³
Back to ClinicalStaging (LIP-1)
LIP-A
Cancer of the Lip
Guidelines Index
Head and Neck Cancers TOC
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Head and Neck Cancers
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Head and Neck Cancers TOC
Staging, MS, ReferencesNCCNPractice Guidelinesin Oncology – v.1.2007
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.
···
·
·
··
H&PBiopsyChest x-rayor Chest CTAs indicated for evaluation
PanorexCT/MRI
Examination under anesthesia, if indicatedPreanesthesia studiesDental evaluation
a
?
?
Multidisciplinaryconsultation as indicated
WORKUP CLINICAL STAGING
T1–2, N0
T3, N0
T1–3, N1–3
T4a, any N
See Treatment of Primary and Neck (OR-2)
See Treatment of Primary and Neck (OR-2)
See Treatment of Primary and Neck (OR-3)
See Treatment of Primary and Neck (OR-4)
Unresectable See Treatment of Head and Neck Cancer (ADV-1)
Buccal mucosa, floor of mouth, anterior tongue, alveolar ridge, retromolar trigone, hard palate
OR-1
aChest CT should be considered for patients at high risk for thoracic metastases.
Cancer of the Oral Cavity
Guidelines Index
Head and Neck Cancers TOC
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Head and Neck Cancers
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Head and Neck Cancers TOC
Staging, MS, ReferencesNCCNPractice Guidelinesin Oncology – v.1.2007
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.
CLINICAL
STAGING
TREATMENT OF PRIMARY AND NECK
T1–2, N0
Excision of primary
and reconstruction
as indicated and
unilateral or bilateral
selective neck
dissection
T3, N0
Excision of primary
(preferred) ± unilateral
or bilateral selective
neck dissection
or
External-beam RT ±
brachytherapy
70 Gy to primary
50 Gy to neck at risk
³
³
One positive node without
adverse featuresb,c RT optionald
b
c
d
e
Major risk features: positive margins and/or extracapsular nodal spread.Minor risk features: pT3 or pT4 primary; N2 or N3 nodal disease, nodal disease in levels IV or V, perineural invasion, vascular embolism.
.
See Principles of Radiation Therapy (OR-A).
See Principles of (CHEM-A)Systemic Therapy
FOLLOW-UP
·
·
·
·
Physical exam:
Chest imaging as
clinically indicated
TSH every 6-12 mo,
if neck irradiatedSpeech and
swallowing
evaluation and
rehabilitation as
indicated
>
>
>
>
Year 1,
every 1-3 mo Year 2,
every 2-4 mo Years 3-5,
every 4-6 mo> 5 yr,
every 6-12 mo
OR-2
Buccal mucosa, floor of mouth, anterior tongue, alveolar ridge, retromolar trigone, hard palate
Recurrence (see ADV-2)
No adverse featuresb,c
No adverse featuresb,c RT (optional)d
ADJUVANT TREATMENT
Cancer of the Oral Cavity
Chemo/RTd,e
(category 1)
Adverse
features
One or both major risk
features or 2 minor
risk features
³b,c
RTd
Chemo/RTd,e
(category 1)Adverse
features
Residual diseaseSalvage
surgery
No residual disease
One or both major risk
features or 2 minor
risk features
³b,c
< 2 minor risk
featuresc
RTd< 2 minor riskfeaturesc
Guidelines Index
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Head and Neck Cancers
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ead a d ec Ca ce s OC
Staging, MS, ReferencesNCCNPractice Guidelinesin Oncology – v.1.2007
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.
T1-3, N1-3
RT
optional
d
Excision of primary and
bilateral comprehensive
neck dissection(reconstruction as
indicated)
N2c
(bilateral)
Excision of primary,
ipsilateral
comprehensive neck
dissection ± contralateralselective neck dissection
(reconstruction as
indicated)
N1,
N2a-b,N3
CLINICAL
STAGING
TREATMENT OF PRIMARY AND NECK
·
·
·
·
Physical exam:
Chest imaging as
clinically indicated
TSH every 6-12 mo,
if neck irradiated
Speech and
swallowing
evaluation and
rehabilitation as
indicated
>
>
>
>
Year 1,
every 1-3 mo
Year 2,every 2-4 mo Years 3-5,
every 4-6 mo> 5 yr,
every 6-12 mo
OR-3
FOLLOW-UP
Surgery
Buccal mucosa, floor of mouth, anterior tongue, alveolar ridge, retromolar trigone, hard palate
Recurrence (see ADV-2)
No adverse
featuresb,c
ADJUVANT
TREATMENT
Cancer of the Oral Cavity
Adverse
features
b
c
d
e
Major risk features: positive margins and/or extracapsular nodal spread.Minor risk features: pT3 or pT4 primary; N2 or N3 nodal disease, nodal disease in levels IV or V, perineural invasion, vascular embolism.
.
See Principles of Radiation Therapy (OR-A).
See Principles of (CHEM-A)Systemic Therapy
Chemo/RTd,e
(category 1)
One or both
major risk
features or 2
minor risk
features
³
b,c
RTd< 2 minor risk
featuresc
Guidelines Index
Head and Neck Cancers TOC
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Head and Neck Cancers
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Staging, MS, ReferencesNCCNPractice Guidelinesin Oncology – v.1.2007
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.
OR-4
T4a, Any N
Surgery (preferred
for bone invasion)
·
·
·
·
Physical exam:
Chest imaging as
clinically indicated
TSH every 6-12 mo,
if neck irradiated
Speech and
swallowing
evaluation and
rehabilitation as
indicated
>
>
>
>
Year 1,every 1-3 mo Year 2,
every 2-4 mo Years 3-5,
every 4-6 mo> 5 yr,
every 6-12 mo
FOLLOW-UPCLINICAL
STAGING
TREATMENT OF PRIMARY AND NECK
Buccal mucosa, floor of mouth, anterior tongue, alveolar ridge, retromolar trigone, hard palate
Recurrence (see ADV-2)
Concurrent
systemic
therapy/RT
(category 3)
e
or
Residual
tumor
Completeresponseof neck
N1 (initial
stage)
N2-3 (initialstage)
Observe
Primary site:Completeresponse
Primary site:residualtumor
Salvage surgery + neckdissection as indicated
Observeor Neck dissection(category 3)
Neck dissection(category 3)
d .e .
See Principles of Radiation Therapy (OR-A)
See Principles of (CHEM-A)Systemic Therapy
Chemotherapy/RT
(category 1)
d,e
Cancer of the Oral Cavity
Guidelines Index
Head and Neck Cancers TOC
NCCN® Practice Guidelines
C f th O l C it
Head and Neck Cancers
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Version 1.2007, 04/10/07 © 2007 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
Staging, MS, ReferencesNCCN in Oncology – v.1.2007
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.
PRINCIPLES OF RADIATION THERAPY
OR-A
Cancer of the Oral Cavity
Definitive RT
Postoperative RT
·
·
··
Primary and gross adenopathy:70 Gy (2.0 Gy/day)
External-beam RT 50 Gy ± brachytherapyNeckUninvolved nodal stations:
50 Gy (2.0 Gy/day)
Primary: 60 Gy (2.0 Gy/day)Neck
Involved nodal stations:60 Gy (2.0 Gy/day)
Uninvolved nodal stations:50 Gy (2.0 Gy/day)
pT3 or pT4 primary; N2 or N3 nodal disease, nodal
disease in levels IV or V, perineural invasion, vascular embolism.
³³
³
³
³
³
?
?
Any one minor risk feature:
Postoperative chemoradiation for high pathologic risk features1,2,3
2·
·
One or both major risk features or two or more minor risk features.
Concurrent single agent cisplatin at 100 mg/m every 3 wks is recommended.
1
2
3
Bernier J, Domenge C, Ozsahin M et al. Postoperative irradiation with or without concomitant 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 and chemotherapy for high-risk squamous-cell carcinoma of the head and neck. N EnglJ Med 2004;350(19):1937-1944.
Bernier J, Cooper JS, Pajuk TF, et al. Defining risk levels in locally advanced head and neck cancers: A comparative analysis of concurrent postoperative radiation pluschemotherapy trials of the EORTC (#22931) and RTOG (#9501). Head Neck 2005;27:843-850.
Guidelines Index
Head and Neck Cancers TOC
NCCN® Practice Guidelines
C f th O h
Head and Neck Cancers
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Staging, MS, ReferencesNCCN in Oncology – v.1.2007
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.
Base of tongue/tonsil/posterior pharyngeal wall/soft palate
CLINICAL STAGING
T1-2, N0-1
Any T, N2-3T3-4a, N+
T3-4a, N0
WORKUP
·
·
·
·
·
·
·
·
H&P
Biopsy
Chest x-ray
or Chest CTCT with contrast or MRI
recommended for primary and
neck
Panorex as indicated
Dental evaluation as indicated
Speech & swallowing
evaluation as indicated
Examination under anesthesia
with laryngoscopy
Preanesthesia studies
a
·
Multidisciplinary consultation as
indicated
See Treatment of Primary and Neck (ORPH-2)
See Treatment of Primary and Neck (ORPH-3)
See Treatment of Primary and Neck (ORPH-4)
ORPH-1
aChest CT should be considered for patients at high risk for thoracic metastases.
Unresectable See Treatment of Headand Neck Cancer (ADV-1)
Cancer of the Oropharynx
Guidelines Index
Head and Neck Cancers TOC
St i MS R f
NCCN® Practice Guidelines
i O l 1 2007 Cancer of the Oropharynx
Head and Neck Cancers
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Staging, MS, ReferencesNCCN in Oncology – v.1.2007
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.
CLINICAL
STAGING
T1-2,
N0-1
TREATMENT OF PRIMARY AND NECK
No adverse featuresc,d
One positive node without
adverse featuresc,d Consider RTb
Primary controlled
Residual disease Salvagesurgery
Definitive RT preferred
(category 2B)
b
b
c
d
e
Major risk features: positive margins and/or extracapsular nodal spread.Minor risk features: pT3 or pT4 primary; N2 or N3 nodal disease, nodal disease in levels IV or V, perineural invasion, vascular embolism.
.
See Principles of Radiation Therapy (ORPH-A).
See Principles of Systemic Therapy (CHEM-A)
Excision of primary ±
unilateral or bilateral
neck dissection
or
FOLLOW-UP
ORPH-2
Base of tongue/tonsil/posterior pharyngeal wall/soft palate
or
RT
+ systemic therapy
(category 3)
For T1-T2, N1 onlye
Primary controlled
Residual disease Salvagesurgery
Recurrence (see ADV-2)
ADJUVANT
TREATMENT
Cancer of the Oropharynx
·
·
·
·
Physical exam:
Chest imaging as
clinically indicated
TSH every 6-12 mo, if neck irradiated
Speech and swallowing
evaluation and
rehabilitation as
indicated
>
>
>
>
Year 1,
every 1-3 mo
Year 2,every 2-4 mo Years 3-5,
every 4-6 mo> 5 yr,
every 6-12 mo
Adverse
features
Chemo/RTb,e
(category 1)
One or both major risk
features or 2 minor risk features
³c,d
RTb< 2 minor risk
featuresd
Guidelines Index
Head and Neck Cancers TOC
Staging MS References
NCCN® Practice Guidelines
i O l 1 2007 Cancer of the Oropharynx
Head and Neck Cancers
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Version 1.2007, 04/10/07 © 2007 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
Staging, MS, ReferencesNCCN in Oncology – v.1.2007
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.
T3-4a, N0
Salvage
surgeryResidual disease
Primary controlled
Surgery
CLINICAL
STAGING
TREATMENT OF PRIMARY AND NECK FOLLOW-UP
·
·
·
·
Physical exam:
Chest imaging as
clinically indicated
TSH every 6-12 mo, if
neck irradiated
Speech and
swallowing evaluation
and rehabilitation as
indicated
>
>
>
>
Year 1,
every 1-3 mo Year 2,
every 2-4 mo Years 3-5,
every 4-6 mo> 5 yr,
every 6-12 mo
ORPH-3
Base of tongue/tonsil/posterior pharyngeal wall/soft palate
Recurrence (see ADV-2)
No adverse featuresc,d
Concurrent systemic therapy/RT
cisplatin (category 1) preferred
b,e
or
or
ADJUVANT
TREATMENT
Cancer of the Oropharynx
Induction chemotherapy
followed by chemo/RT
off protocol (category 3)
Multimodality clinical trials that
include function evaluation
or
Salvage
surgeryResidual disease
Primary controlled
Adverse
features
RTb
b
c
d
e
Major risk features: positive margins and/or extracapsular nodal spread.Minor risk features: pT3 or pT4 primary; N2 or N3 nodal disease, nodal disease in levels IV or V, perineural invasion, vascular embolism.
.
See Principles of Radiation Therapy (ORPH-A).
See Principles of Systemic Therapy (CHEM-A)
Chemo/RTb,e
(category 1)
One or both major risk
features or 2 minor
risk features
³c,d
RTb< 2 minor risk
featuresd
Guidelines Index
Head and Neck Cancers TOC
Staging MS References
NCCN® Practice Guidelines
in Oncology v 1 2007 Cancer of the Oropharynx
Head and Neck Cancers
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Version 1.2007, 04/10/07 © 2007 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
Staging, MS, ReferencesNCCN in Oncology – v.1.2007
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.
Any T3-4a,
N+ or Any T, N2-3
Residual
tumor
Completeresponseof neck
N1(initialstage)
N2-3(initialstage)
Observe
Primary site:
complete
response
Primary site:
residual tumor Salvage surgery + neckdissection as indicated
Concurrent systemic
therapy/RT
cisplatin (category 1)
preferred
b,e
Observe
or
Neck dissection
(category 3)
Neck dissection
(category 3)
CLINICAL
STAGING
TREATMENT OF PRIMARY AND NECK
or
ORPH-4
FOLLOW-UP
Base of tongue/tonsil/posterior pharyngeal wall/soft palate
N2c
RTb
or
Chemo/RT
(category 1)
b,e
Excision of primary, ipsilateral
comprehensive neck dissection
(reconstruction as indicated)
Excision of primary and bilateral
comprehensive neck dissection
(bilateral is category 3 if neck
nodes contralateral only)
(reconstruction as indicated)
N1
N2a–b
N3Surgery:
primary and
neck
b .e .
See Principles of Radiation Therapy
See Principles of Systemic Therapy (CHEM-A)
(ORPH-A)Recurrence (see ADV-2)
or
ADJUVANT
TREATMENT
Cancer of the Oropharynx
·
·
·
·
Physical exam:
Chest imaging as
clinically indicated
TSH every 6-12 mo, if
neck irradiated
Speech andswallowing evaluation
and rehabilitation as
indicated
>
>
>
>
Year 1,
every 1-3 mo Year 2,
every 2-4 mo
Years 3-5,every 4-6 mo> 5 yr,
every 6-12 mo
Induction chemotherapy
followed by chemo/RT
off protocol (category 3)
or
Multimodality clinical trials that
include function evaluation
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Guidelines Index
Head and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v 1 2007 Cancer of the Hypopharynx
Head and Neck Cancers
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g g, ,NCCN in Oncology – v.1.2007
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.
T1, N2-3;
T2-3, Any N
T4a, Any N
WORKUP CLINICAL STAGING
Early T stage not requiring
total laryngectomy
· Most T1, N0-1; small T2, N0
Resectable advanced cancer
requiring total laryngectomy
· T1, N2-3; T2-4a, Any N
(Participation in clinical
trials preferred)
·
·
·
·
·
·
·
H&P
Biopsy
Chest x-ray
or Chest CTCT with contrast or MRI of
primary and neck
recommended
Examination under
anesthesia with laryngoscopy
and esophagoscopy
Preanesthesia studies
Dental evaluation
a
Multidisciplinary consultation
as indicated
See Treatment of Primary andNeck (HYPO-2)
See Treatment of Primary andNeck (HYPO-3)
See Treatment of Primary andNeck (HYPO-5)
HYPO-1
Unresectable See Treatment of Head andNeck Cancer (ADV-1)
aChest CT should be considered for patients at high risk for thoracic metastases.
Cancer of the Hypopharynx
Guidelines Index
Head and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v 1 2007 Cancer of the Hypopharynx
Head and Neck Cancers
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g gNCCN in Oncology v.1.2007
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.
Residual
tumor
Completeresponse
of neck
Observe
Primary site:completeresponse
Primary site:residualtumor
Salvage surgery+ neck dissectionas indicated
Neck dissection(category 3)
Early T stage
(not requiring
total
laryngectomy)
Most T1, N0-1,
small T2, N0
·
Definitive RTb
CLINICAL
STAGING
TREATMENT OF PRIMARY AND NECK
Surgery: Partial
laryngopharyngectomy
(open or endoscopic)
+ ipsilateral or bilateral
selective neck dissection
(N0); Comprehensive neck
dissection levels 1-5 (N1)
or
FOLLOW-UP
·
·
·
Physical exam:
Chest imaging as
clinically indicated
TSH every 6-12 mo,
if neck irradiated
>
>
>
>
Year 1,every 1-3 mo Year 2,
every 2-4 mo Years 3-5,
every 4-6 mo> 5 yr,
every 6-12 mo
HYPO-2
No adverse featuresc,d
b .c
d
e
Major risk features: positive margins and/or extracapsular nodal spread.Minor risk features: pT3 or pT4 primary; N2 or N3 nodal disease, perineural invasion, vascular embolism.
.
See Principles of Radiation Therapy
See Principles of Systemic Therapy (CHEM-A)
(HYPO-A)
ADJUVANT TREATMENT
Cancer of the Hypopharynx
Adverse
features
Chemo/RT b,e
(category 1)
One or both major risk
features or 2 minor
risk features
³c,d
RTb< 2 minor riskfeaturesd
Guidelines Index
Head and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007 Cancer of the Hypopharynx
Head and Neck Cancers
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NCCN in Oncology v.1.2007
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.
Induction chemotherapy x 2
cycles (category 1)See Response After InductionChemotherapy (HYPO-4)
T1, N2-3;
T2-3, any N
(if total
laryngectomy
required)
FOLLOW-UP
HYPO-3
·
·
·
Physical exam:
Chest imaging as
clinically indicated
TSH every 6-12 mo,if neck irradiated
>
>
>
>
Year 1,
every 1-3 mo
Year 2,every 2-4 mo Years 3-5,
every 4-6 mo> 5 yr,
every 6-12 mo
CLINICAL
STAGING
TREATMENT OF PRIMARY AND NECK
RTbNo adverse
featuresc,d
ADJUVANT TREATMENT
Residual
tumor
Completeresponseof neck
N1
(initial stage)
N2-3(initial stage)
Observe
Primary site:
complete
response
Primary site:
residual tumor Salvage surgery + neckdissection as indicated
Observe
or
Neck dissection
(category 3)
Neck dissection
(category 3)
Multimodality clinicaltrials that include
function evaluation
Cancer of the Hypopharynx
Laryngopharyngectomy
+ selective (N0) or
comprehensive (N+)
neck dissection
Concurrent systemic
therapy/RT
cisplatin preferred
(category 2B)
b,e
or
or
or
Adverse
features
b .c
d
e
Major risk features: positive margins and/or extracapsular nodal spread.Minor risk features: pT3 or pT4 primary; N2 or N3 nodal disease, perineural invasion, vascular embolism.
.
See Principles of Radiation Therapy
See Principles of Systemic Therapy (CHEM-A)
(HYPO-A)
Chemo/RTb,e
(category 1)
One or both major risk
features or 2 minor
risk features
³c,d
RTb< 2 minor risk
featuresd
Guidelines Index
Head and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007 Cancer of the Hypopharynx
Head and Neck Cancers
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gy
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.
Primary site:
Partial response
(evaluation may
require
endoscopy)
Primary site:
< Partial
response
Surgery
RTb
Primary site:
Complete
response
Primary site:
residualtumor
Chemotherapy
x 1 cycle
Salvage
surgery
Definitive RTb N1
(initial
stage)Observe
Observe
or
Neck dissection
(category 3)
N2-3
(initial
stage)
Residual
tumor
Complete
responseof neck
Neck dissection
(category 3)
Primary site:
Complete
response
RESPONSE AFTER INDUCTION CHEMOTHERAPY
FOR T1, N2-3; T2-3, ANY N TUMORS
FOLLOW-UP
HYPO-4
·
·
·
Physical exam:
Chest imaging as
clinically indicated
TSH every 6-12 mo,
if neck irradiated
>
>
>
>
Year 1,
every 1-3 mo Year 2,
every 2-4 mo Years 3-5,
every 4-6 mo> 5 yr,
every 6-12 moNo adversefeaturesc,d
ADJUVANT
TREATMENT
yp p y
Adverse
features
b .c
d
e
Major risk features: positive margins and/or extracapsular nodal spread.Minor risk features: pT3 or pT4 primary; N2 or N3 nodal disease, perineural invasion, vascular embolism.
.
See Principles of Radiation Therapy
See Principles of Systemic Therapy (CHEM-A)
(HYPO-A)
Chemo/RTb,e
(category 1)
One or both major
risk features or 2
minor risk
features
³
c,d
RTb< 2 minor risk
featuresd
Guidelines Index
Head and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007 Cancer of the Hypopharynx
Head and Neck Cancers
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gy
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.
HYPO-5
Surgery + comprehensive
neck dissection (preferred)
FOLLOW-UP
·
·
·
Physical exam:
Chest imaging as
clinically indicated
TSH every 6-12 mo,
if neck irradiated
>
>
>
>
Year 1,every 1-3 mo Year 2,
every 2-4 mo Years 3-5,
every 4-6 mo> 5 yr,
every 6-12 mo
CLINICAL
STAGING
TREATMENT OF PRIMARY AND NECK
Chemo/RT
(category 1)
b,e
ADJUVANT TREATMENT
T4a, any N
b .e .
See Principles of Radiation Therapy
See Principles of Systemic Therapy (CHEM-A)
(HYPO-A)
yp p y
Residual
tumor
Completeresponseof neck
N1(initialstage)
N2-3(initial
stage)
Observe
Primary site:
complete
response
Primary site:
residual tumor Salvage surgery + neckdissection as indicated
Observe
or
Neck dissection(category 3)
Neck dissection
(category 3)
Multimodality clinical
trials that include
function evaluation
or
or
Concurrent systemic
therapy/RT
(category 3)
b,e
Guidelines Index
Head and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007 Cancer of the Hypopharynx
Head and Neck Cancers
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Version 1.2007, 04/10/07 © 2007 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
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.
Back to ClinicalStaging (HYPO-1)
One or both major risk features or two or more minor risk features.
Concurrent single agent cisplatin at 100 mg/m every 3 wks is recommended.
Definitive RT
Postoperative RT
Postoperative chemoradiation for high pathologic risk features
·
·
·
·
·
Primary and gross adenopathy:70 Gy (2.0 Gy/day)
Uninvolved odal stations:50 Gy (2.0 Gy/day)
Primary: 60 Gy (2.0 Gy/day)
NeckInvolved nodal stations:
60 Gy (2.0 Gy/day)Uninvolved nodal stations:
50 Gy (2.0 Gy/day)Any one minor risk feature: pT3 or pT4 primary; N2 or N3 nodal disease,
perineural invasion, vascular embolism.
³
³
³
³
³
Neckn
?
?
1,2,3
2·
HYPO-A
PRINCIPLES OF RADIATION THERAPY
1
2
Bernier J, Domenge C, Ozsahin M, et al. Postoperative irradiation with or without concomitant chemotherapy for locally advanced headand neck cancer. N Engl J Med 2004;350:1945-1952.
Cooper JS, Pajak TF, Forastiere AA, et al. Postoperative concurrent radiotherapy and chemotherapy for high-risk squamous-cellcarcinoma of the head and neck. N Engl J Med 2004;350:1937-1944.
3Bernier J, Cooper JS, Pajuk TF, et al. Defining risk levels in locally advanced head and neck cancers: A comparative analysis of concurrent postoperative radiation plus chemotherapy trials of the EORTC (#22931) and RTOG (#9501). Head Neck 2005;27:843-850.
Guidelines Index
Head and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007 Occult Primary
Head and Neck Cancers
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Version 1.2007, 04/10/07 © 2007 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
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.
WORKUPPRESENTATION
Neck massFine-needle
aspirationa
Lymphoma
Melanoma
See NCCN Non-Hodgkin’sLymphoma Guidelines
Squamous cell
carcinoma,
adenocarcinoma,
and anaplastic
epithelial tumorsb
·
·
·
·
Complete head and neck examwith attention to skin, including
nasopharyngoscopy
Chest x-ray
CT with contrast or MRI with
gadolinium (skull base through
thoracic inlet)
PET scan only if other tests do
not identify a primary
Systemic work-up per
NCCN Melanoma Guidelines
· skin exam, note regressinglesions
See Workup and PrimaryTreatment (OCC-2)
See Primary Therapy for
Melanoma (OCC-5)
aRepeat FNA, core or open biopsy may be necessary for uncertain histologies. Patient should beprepared for neck dissection at time of biopsy, if necessary.
bDetermined with appropriate immunohistochemical stains.
OCC-1
Thyroid See NCCN ThyroidCarcinoma Guidelines
Guidelines Index
Head and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007 Occult Primary
Head and Neck Cancers
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Version 1.2007, 04/10/07 © 2007 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
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.
PATHOLOGIC
FINDINGS
Primary
found
Node level
I, II, III,
upper V
Node level
IV, lower V
Treat as appropriate(See Guidelines Index)
·
·
Direct laryngoscopy,
bronchoscopy,
esophagoscopy
Chest/abdominal/pelvic CT
·
·
·
·
Examination under
anesthesiaPalpation and inspection
Biopsy of areas of clinical
concern, including
tonsillectomy
Direct laryngoscopy and
nasopharynx survey
Squamous cell
carcinoma
Adenocarcinoma
(levels I–III)
Poorly
differentiatedor
Nonkeratinizing
squamous cell
or NOS or
Anaplastic
(Not thyroid)
Comprehensive
neck dissection
(levels I–V)
Residual
tumor
No residual
tumor
Observe
or
Consider neck dissectionfor initial stage N3
Comprehensive
neck dissection
Comprehensiveneck dissection
+ parotidectomy,
if indicated N1 with FNA
or
or
See N1 with openbiopsy (OCC-3)
Extracapsular spreador N2, N3 (OCC-4)
WORKUP PRIMARY TREATMENT
c
d.See Principles of Radiation Therapy (OCC-A)
See Principles of Systemic Therapy (CHEM-A).
OCC-2
RT to neck ±
parotid bed
Primary
foundTreat as appropriate(See Guidelines Index)
Consider RT
as per OCC-3
Surgery
RT (category 3)c
Chemotherapy/RT
(category 3)
d
or
or
Guidelines Index
Head and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007 Occult Primary
Head and Neck Cancers
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Version 1.2007, 04/10/07 © 2007 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
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.
RT to neck only (category 3)
or
RT to oral cavity, Waldeyer’s ring, oropharynx,
both sides of the neck (block RT to the larynx)
c
c
RT to neck only (category 3)
or
RT to nasopharynx, both sides of the neck,
hypopharynx, larynx, oropharynx
c
c
RT to neck only (category 3)
or
RT to Waldeyer’s ring, larynx,hypopharynx, both sides of the neck
c
c
RT to neck only (category 3)
or
RT to larynx, hypopharynx,
both sides of the neck
c
c
Level I only
Level II, III, upper level V
Level IV only
Lower level V
N1 with open
biopsy
POSTSURGICAL TREATMENT FOR SQUAMOUS CELL CARCINOMA;
NOS OR ANAPLASTIC
OCC-3
c .See Principles of Radiation Therapy (OCC-A)
Guidelines Index
Head and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007 Occult Primary
Head and Neck Cancers
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Version 1.2007, 04/10/07 © 2007 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
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.
POSTSURGICAL TREATMENT FOR SQUAMOUS CELL CARCINOMA;
NOS OR ANAPLASTIC
OCC-4
Extracapsular
spread
or
N2, N3
RT to neck only (category 3)or
RT to oral cavity, Waldeyer’s ring, oropharynx,
both sides of the neck (block RT to the larynx)or Chemotherapy/RT (category 2B)
c
c
d
RT to neck only (category 3)
or
RT to nasopharynx, both sides of the neck,hypopharynx, larynx, oropharynx
c
c
or Chemotherapy/RT (category 2B)d
RT to neck only (category 3)
or
RT to Waldeyer’s ring, larynx,
hypopharynx, both sides of the neck
c
c
or Chemotherapy/RT (category 2B)d
RT to neck only (category 3)
or
RT to larynx, hypopharynx, both
sides of the neck
c
c
or Chemotherapy/RT (category 2B)d
Level I only
Level II, III, upper level V
Level IV only
Lower level V
c
d.See Principles of Radiation Therapy
Systemic Therapy
(OCC-A)
See Principles of (CHEM-A).
Guidelines Index
Head and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007 Occult Primary
Head and Neck Cancers
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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.
Level V,
occipital node
All other
nodal sites
Posterior lateral
node dissection
Comprehensive
neck dissection
± RT to nodal bedd ± Adjuvant systemic therapy, per
NCCN Melanoma Guidelines
Adjuvant radiotherapy: 30 Gy/5 fx over 2.5 weeks (6.0 Gy/fx). Careful attention to dosimetry is necessary.(Ang KK, Peters LJ, Weber RS, et al. Postoperative radiotherapy for cutaneous melanoma of the head and neck region.International Journal of Radiation Oncology, Biology, Physics 30:795-798, 1994).
d
PRIMARY THERAPY FOR OCCULT PRIMARY- MELANOMA
OCC-5
Guidelines Index
Head and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007 Occult Primary
Head and Neck Cancers
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Version 1.2007, 04/10/07 © 2007 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
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.
OCC-A
PRINCIPLES OF RADIATION THERAPY
Mucosal sites:
Neck
·
·
·
50-60 Gy (2.0 Gy/day) to mucosa, depending on
field size and use of chemotherapy. Consider
boost to 60-64 Gy to particularly suspicious areas
Uninvolved nodal stations:
50 Gy (2.0 Gy/day)Involved nodal station(s):
60-66 Gy* (2.0 Gy/day)
* Up to 70 Gy in case of excision only for N1 neck.
³
Guidelines Index
Head and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007 Cancer of the Glottic Larynx
Head and Neck Cancers
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Version 1.2007, 04/10/07 © 2007 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
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.
WORKUP a
·
·
Total laryngectomy
not required
Most T1-2, any N
·
·
·
Resectable
Requiring total
laryngectomy
Most T3, any N
Severe dysplasia/carcinoma in situ
T4a disease
·
·
·
·
·
·
·
·
H&P
Biopsy
Chest x-ray
or Chest CTCT with contrast and thin cuts
through larynx, or MRI of
primary and neck recommended
Examination under anesthesia
with laryngoscopy
Preanesthesia studies
Dental evaluation as indicated
Speech & swallowing evaluationas indicated
Multidisciplinary consultation as
indicated
b
CLINICAL STAGING TREATMENT OF PRIMARY AND NECK
See Treatment and Follow-up (GLOT-2)
See Treatment and Follow-up (GLOT-2)
See Treatment and Follow-up (GLOT-4)
aComplete workup not indicated for Tis, T1.bChest CT should be considered for patients at high risk for thoracic metastases.
See Treatment and Follow-up (GLOT-3)
GLOT-1
Unresectable See Treatment of Head andNeck Cancer (ADV-1)
Guidelines Index
Head and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007 Cancer of the Glottic Larynx
Head and Neck Cancers
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Version 1.2007, 04/10/07 © 2007 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
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.
CLINICAL STAGING TREATMENT OF PRIMARY AND NECK
N0 Observe
Neck dissection
and/or RTcN+ (rare)
·
·
Total laryngectomy
not required
Most T1-2, any N
Severe dysplasia/carcinoma in situ
Clinical trialor Endoscopic removal(stripping/laser)or
RTc
RTor Partial laryngectomy/endoscopic resection
(selected superficial lesions)or Open partial laryngectomy
c
FOLLOW-UP
·
·
·
·
Physical exam: Year 1, every 1-3 mo Year 2, every 2-4 mo Years 3-5, every 4-6 mo> 5 years, every 6-12 mo
Chest imaging as
clinically indicated
TSH every 6-12 mo, if
neck irradiated
Speech and swallowingevaluation and
rehabilitation as indicated
>
>
>
>
c .See Principles of Radiation Therapy (GLOT-A)
GLOT-2
Recurrence (see ADV-2)
Guidelines Index
Head and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007 Cancer of the Glottic Larynx
Head and Neck Cancers
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Version 1.2007, 04/10/07 © 2007 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
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.
Residual
tumor
Completeresponse
of neck
N1(initialstage)
N2-3(initialstage)
Observe
Primary site:
Complete
response
Primary site:residualtumor
Salvage surgery+ neck dissectionas indicated
Observe
or
Neck dissection(category 3 for
selective vs
comprehensive)
Neck dissection
(category 3)·
·
·
·
Physical exam: Year 1,
every 1-3 mo Year 2,
every 2-4 mo Years 3-5, every 4-6
mo> 5 years, every 6-
12 mo
Chest imaging as
clinically indicated
TSH every 6-12 mo, if
neck irradiated
>
>
>
>
Speech and
swallowing evaluation
and rehabilitation asindicated
·
·
·
Resectable
Requiring
total
laryngectomy
Most T3,
any N
CLINICAL
STAGING
TREATMENT OF PRIMARY AND NECK
Surgery
Laryngectomy with ipsilateral
thyroidectomy unilateral or
bilateral selective neck dissection(reconstruction as indicated)
±
N2-3
N1
N0
Laryngectomy with ipsilateralthyroidectomy, ipsilateral or bilateral
comprehensive neck dissection
(reconstruction as indicated)
Laryngectomy with ipsilateral
thyroidectomy, ipsilateral
comprehensive neck dissection ±
contralateral selective neck dissection
(reconstruction as indicated)
No adversefeaturese,f
Recurrence(see ADV-2)
GLOT-3
c .d
e
f
.
Major risk features: positive margins and/or extracapsular nodal spread.Minor risk features: pT4 primary; N2 or N3 nodal disease, perineural invasion, vascular embolism.
See Principles of Radiation Therapy
See Principles of Systemic Therapy (CHEM-A)
(GLOT-A)
ADJUVANT
TREATMENT
FOLLOW-UP
or
Adversefeatures
Concurrent systemic
therapy/RT
cisplatin (category 1)preferred
c,d
Chemo/RTc,d
(category 1)
One or both
major risk
features or
2 minor risk
features
³e,f
RTc< 2 minor risk
featuresf
Guidelines Index
Head and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007 Cancer of the Glottic Larynx
Head and Neck Cancers
8/3/2019 Head-And-neck Cancer Gudelines 2007
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Version 1.2007, 04/10/07 © 2007 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
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.
CLINICAL
STAGING
TREATMENT OF PRIMARY AND NECK
T4a
disease
SelectedT4a
Consider concurrent
chemoradiationor Clinical trial for function preservingsurgical or nonsurgicalmanagement
d
T4a, Any N
·
·
·
·
Physical exam: Year 1,
every 1-3 mo Year 2,
every 2-4 mo
Years 3-5, every 4-6 mo> 5 years, every 6-12
mo
Chest imaging as
clinically indicated
TSH every 6-12 mo, if
neck irradiated
>
>
>
>
Speech and swallowing
evaluation andrehabilitation as
indicated
GLOT-4
Recurrence (see ADV-2)
Residual
tumor
Completeresponseof neck
N1(initialstage)
N2-3(initialstage)
Observe
Primary site:
Complete
response
Primary site:residualtumor
Salvage surgery+ neck dissectionas indicated
Observe
or
Neck dissection(category 3 for
selective vs
comprehensive)
Neck dissection
(category 3)
c .d .
See Principles of Radiation Therapy
See Principles of Systemic Therapy (CHEM-A)
(GLOT-A)
ADJUVANT
TREATMENT
Chemo/RT(category 1)
c,d
Laryngectomy with ipsilateral
thyroidectomy unilateral or bilateralselective neck dissection (reconstruction
as indicated)
±
N2-3
N1
N0
Laryngectomy with ipsilateral thyroidectomy,
ipsilateral or bilateral comprehensive neck
dissection (reconstruction as indicated)
Laryngectomy with ipsilateral thyroidectomy,
ipsilateral comprehensive neck dissection ±
contralateral selective neck dissection
(reconstruction as indicated)
Guidelines Index
Head and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007 Cancer of the Glottic Larynx
Head and Neck Cancers
8/3/2019 Head-And-neck Cancer Gudelines 2007
http://slidepdf.com/reader/full/head-and-neck-cancer-gudelines-2007 47/105
Version 1.2007, 04/10/07 © 2007 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
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.
70 Gy (2.0 Gy/day) in 7 weeks72 Gy in 6 weeks
Elective nodal RT> 50 Gy (2.0 Gy/day)
Any one minor risk feature:
One or both major risk features or two or more minor risk features.
Concurrent single agent cisplatin at 100 mg/m every 3 wks is recommended.
Definitive RT
Postoperative RT
Postoperative chemoradiation for high pathologic risk features
··
··
·
·
T1, N0: 63-66 Gy in 2.25-2.0 Gy/dayT2 and gross adenopathy:
(1.8 Gy/fraction, large field; 1.5 Gy boost as second daily
fraction during last 12 treatment days)79.2 - 81.6 Gy in 7 weeks (1.2 Gy/fraction, twice daily)
Primary: 60 Gy (2.0 Gy/day)Neck
Involved nodal stations:60 Gy (2.0 Gy/day)
Uninvolved nodal stations:50 Gy (2.0 Gy/day)
pT4 primary; N2 or N3 nodal disease,
perineural invasion, vascular embolism.
³
³
³
³
>
>
>
>
·
?
?
1,2,3
2
GLOT-A
PRINCIPLES OF RADIATION THERAPY
1
2
Bernier J, Domenge C, Ozsahin M, et al. Postoperative irradiation with or without concomitant 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 and chemotherapy for high-risk squamous-cell carcinoma of the head and neck. NEngl J Med 2004;350:1937-1944.
3Bernier J, Cooper JS, Pajuk TF, et al. Defining risk levels in locally advanced head and neck cancers: A comparative analysis of concurrent postoperative radiation pluschemotherapy trials of the EORTC (#22931) and RTOG (#9501). Head Neck 2005;27:843-850.
Guidelines Index
Head and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007 Cancer of the Supraglottic Larynx
Head and Neck Cancers
8/3/2019 Head-And-neck Cancer Gudelines 2007
http://slidepdf.com/reader/full/head-and-neck-cancer-gudelines-2007 48/105
Version 1.2007, 04/10/07 © 2007 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
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.
WORKUP CLINICAL STAGING
··
·
·
·
··
·
H&PBiopsy
Chest x-rayor Chest CTCT with contrast and thin cutsthrough larynx or MRI of primaryand neck recommendedExamination under anesthesiawith laryngoscopyPreanesthesia studies
a
Dental evaluation as indicated
Speech & swallowing evaluationas indicated
Multidisciplinaryconsultation as indicated
· Not requiring total
laryngectomy
· Most T1–2, N0
See Treatment of Primaryand Neck (SUPRA-2)
···
Requiring laryngectomyT3, N0T4a, N0
Low-volume base-of-
tongue involvement
>
>No cartilage destruction
See Treatment of Primary
and Neck (SUPRA-3)
· T4a, N0
Skin involvement
High-volume invasionof base of tongue
>
>
>
Cartilage destructionSee Treatment of Primaryand Neck (SUPRA-4)
Node positive disease See Workup and ClinicalStaging (SUPRA-5)
Unresectable See Treatment of Headand Neck Cancer (ADV-1)
SUPRA-1
aChest CT should be considered for patients at high risk for thoracic metastases.
Guidelines Index
Head and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007 Cancer of the Supraglottic Larynx
Head and Neck Cancers
8/3/2019 Head-And-neck Cancer Gudelines 2007
http://slidepdf.com/reader/full/head-and-neck-cancer-gudelines-2007 49/105
Version 1.2007, 04/10/07 © 2007 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
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.
TREATMENT OF PRIMARY AND NECK
One positive node
without other
adverse features
Consider RTb
Chemo/RT
(category 2B)
or
RT (category 2B)
b,c
b
CLINICAL STAGING
·
·
Not requiring totallaryngectomyMost T1–2, N0
Endoscopic resection ±
selective neck dissection
or
Open partial supraglottic
laryngectomy ± selective
neck dissection
or
Definitive RTbAdverse features:extracapsular nodal
spread
b .c .
See Principles of Radiation Therapy
See Principles of Systemic Therapy (CHEM-A)
(SUPRA-A)
SUPRA-2
·
·
·
·
Physical exam: Year 1,
every 1-3 mo Year 2,
every 2-4 mo Years 3-5,
every 4-6 mo> 5 years,
every 6-12 mo
Chest imaging as
clinically indicated
TSH every 6-12 mo, if
neck irradiated
>
>
>
>
Speech and swallowingrehabilitation and
therapy as indicated
FOLLOW-UPADJUVANT
TREATMENT
Recurrence (see ADV-2)
Adverse features:positive margins
Further surgery
or
RTb
Guidelines Index
Head and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007
TREATMENT OF PRIMARY AND NECKCLINICAL FOLLOW UPADJUVANT
Cancer of the Supraglottic Larynx
Head and Neck Cancers
8/3/2019 Head-And-neck Cancer Gudelines 2007
http://slidepdf.com/reader/full/head-and-neck-cancer-gudelines-2007 50/105
Version 1.2007, 04/10/07 © 2007 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
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.
TREATMENT OF PRIMARY AND NECKCLINICAL
STAGING
N0 or one positive node
without adverse featuresd,e RT optionalb
Laryngectomy,ipsilateralthyroidectomywith ipsilateral or bilateral selectiveneck dissection
·
··
RequiringlaryngectomyT3, N0T4a, N0
Low-volume base-of-
tongue involvement
>
>
No cartilage
destruction
Primary site:
Completeresponse
Primary site:residualtumor
Salvage surgery +neck dissectionas indicated
Concurrent systemictherapy/RTcisplatin (category 1)preferred
b,c
or
·
·
·
·
Physical exam: Year 1,
every 1-3 mo
Year 2,every 2-4 mo Years 3-5,
every 4-6 mo> 5 years,
every 6-12 mo
Chest imaging as
clinically indicated
TSH every 6-12 mo, if neck irradiated
>
>
>
>
Speech and
swallowing evaluation
and rehabilitation as
indicated
FOLLOW-UP
SUPRA-3
b .c
d
e
.
Major risk features: positive margins and/or extracapsular nodal spread.Minor risk features: pT4 primary; N2 or N3 nodal disease, perineural invasion, vascular embolism.
See Principles of Radiation Therapy
See Principles of Systemic Therapy (CHEM-A)
(SUPRA-A)
Recurrence (see ADV-2)
ADJUVANT
TREATMENT
Adverse
features
Chemo/RTb,c
(category 1)
One or both
major risk
features or
2 minor risk
features
³d,e
RTb< 2 minor risk
featurese
Guidelines IndexHead and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007
TREATMENT OF PRIMARY AND NECKCLINICAL STAGING FOLLOW UPADJUVANT
Cancer of the Supraglottic Larynx
Head and Neck Cancers
8/3/2019 Head-And-neck Cancer Gudelines 2007
http://slidepdf.com/reader/full/head-and-neck-cancer-gudelines-2007 51/105
Version 1.2007, 04/10/07 © 2007 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
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.
RTb
b,cor Chemo/RT(category 1)
· T4a, N0
Skin involvementHigh-volume invasion
of base of tongue
>
>
>
Cartilage destruction
Laryngectomy, ipsilateral
thyroidectomy with
ipsilateral or bilateral
selective neck dissection
or
Clinical trial
TREATMENT OF PRIMARY AND NECKCLINICAL STAGING
b .c .
See Principles of Radiation Therapy
See Principles of Systemic Therapy (CHEM-A)
(SUPRA-A)
·
·
·
·
Physical exam: Year 1,
every 1-3 mo
Year 2,every 2-4 mo Years 3-5,
every 4-6 mo> 5 years,
every 6-12 mo
Chest imaging as clinically
indicated
TSH every 6-12 mo, if neck
irradiated
>
>
>
>
Speech and swallowing evaluation
and rehabilitation as indicated
FOLLOW-UP
SUPRA-4
Recurrence (see ADV-2)
ADJUVANT
TREATMENT
Guidelines IndexHead and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007
WORKUP CLINICAL STAGING
Cancer of the Supraglottic Larynx
Head and Neck Cancers
8/3/2019 Head-And-neck Cancer Gudelines 2007
http://slidepdf.com/reader/full/head-and-neck-cancer-gudelines-2007 52/105
Version 1.2007, 04/10/07 © 2007 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
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.
WORKUP
···
·
·
·
··
·
H&PBiopsyChest x-rayor Chest CTCT with contrast and thincuts through larynxMRI of primary and neckrecommendedExamination under anesthesiawith laryngoscopyPreanesthesia studies
a
Dental evaluation as indicated
Speech & swallowing
evaluation as indicated
Multidisciplinaryconsultation as indicated
CLINICAL STAGING
·
·
Not requiring totallaryngectomyT1–2, N+ andselected T3–4a
See Treatment of Primaryand Neck (SUPRA-6)
·
·
Requiring total
laryngectomyMost T3–4a, N+
Low-volume base-of-
tongue involvement
>
>
No cartilage destructionSee Treatment of Primaryand Neck (SUPRA-7)
· T4a, N+Cartilage destructionSkin involvementHigh-volume invasion
of base of tongue
>
>
>
See Treatment of Primaryand Neck (SUPRA-8)
Unresectable (T4b) See Treatment of Head andNeck Cancer (ADV-1)
SUPRA-5
Node positive
disease
aChest CT should be considered for patients at high risk for thoracic metastases.
Guidelines IndexHead and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007
TREATMENT OF PRIMARY AND NECKCLINICAL FOLLOW-UPADJUVANT
Cancer of the Supraglottic Larynx
Head and Neck Cancers
8/3/2019 Head-And-neck Cancer Gudelines 2007
http://slidepdf.com/reader/full/head-and-neck-cancer-gudelines-2007 53/105
Version 1.2007, 04/10/07 © 2007 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
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.
·
·
Not requiringtotallaryngectomyT1–2, N+ andselectedT3–4a
TREATMENT OF PRIMARY AND NECKCLINICAL
STAGING
Observe
Partial supraglotticlaryngectomy andcomprehensiveneck dissection(s)
or
Definitive RTb ·
·
·
·
Physical exam: Year 1,
every 1-3 mo Year 2,
every 2-4 mo Years 3-5,
every 4-6 mo> 5 years,
every 6-12 mo
Chest imaging as
clinically indicated
TSH every 6-12 mo,
if neck irradiated
>
>
>
>
Speech and
swallowing
evaluation and
rehabilitation as
indicated
FOLLOW-UP
SUPRA-6
Residual
tumor
Completeresponse
of neck
N1(initialstage)
N2-3(initialstage)
Observe
Primary site:
Complete
response
Primary site:residualtumor
Salvage surgery+ neck dissectionas indicated
Observeor neck
dissection
(category 3)
Neck dissection
(category 3)
Concurrentsystemic therapy/RTcisplatin(category 1)preferredc
or
Recurrence (see ADV-2)
ADJUVANT
TREATMENT
No adverse
featuresd,e
Adverse
features
b .c
d
e
.
Major risk features: positive margins and/or extracapsular nodal spread.Minor risk features: pT4 primary; N2 or N3 nodal disease, perineural invasion, vascular embolism.
See Principles of Radiation Therapy
See Principles of Systemic Therapy (CHEM-A)
(SUPRA-A)
Chemo/RTb,c
(category 1)
One or both major risk
features or 2 minor
risk features
³d,e
RTb< 2 minor risk
featurese
Guidelines IndexHead and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007
TREATMENT OF PRIMARY AND NECKCLINICAL STAGING FOLLOW-UPADJUVANT
Cancer of the Supraglottic Larynx
Head and Neck Cancers
8/3/2019 Head-And-neck Cancer Gudelines 2007
http://slidepdf.com/reader/full/head-and-neck-cancer-gudelines-2007 54/105
Version 1.2007, 04/10/07 © 2007 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
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.
·
·
Requiring totallaryngectomy
Most T3–4a, N+> No cartilage
destruction
TREATMENT OF PRIMARY AND NECKCLINICAL STAGING
Residual
tumor
Completeresponseof neck
N1(initialstage)
N2-3(initial
stage)
Observe
Primary site:
Complete
response
Primary site:residualtumor
Observe
or
Neck dissection(category 3)
Neck dissection
(category 3)
Concurrent systemictherapy/RTcisplatin (category 1)
preferred
b,c
Salvage surgery +neck dissection asindicated
FOLLOW UP
SUPRA-7
·
·
·
·
Physical exam: Year 1,
every 1-3 mo Year 2,
every 2-4 mo Years 3-5,
every 4-6 mo> 5 years,
every 6-12 mo
Chest imaging as
clinically indicated
TSH every 6-12 mo,
if neck irradiated
>
>
>
>
Speech and
swallowing
evaluation and
rehabilitation as
indicated
Recurrence (see ADV-2)
ADJUVANT
TREATMENT
Induction chemotherapyfollowed by chemo/RT(category 3) in selectedN2, N3 patients
or
Laryngectomy,ipsilateral
thyroidectomy withcomprehensiveneck dissection
or
RTNo adverse
featuresd,e
Adverse
features
b .c
d
e
.
Major risk features: positive margins and/or extracapsular nodal spread.Minor risk features: pT4 primary; N2 or N3 nodal disease, perineural invasion, vascular embolism.
See Principles of Radiation Therapy
See Principles of Systemic Therapy (CHEM-A)
(SUPRA-A)
Chemo/RTb,c
(category 1)
One or both major
risk features or
2 minor risk
features
³d,e
RTb< 2 minor risk
featurese
Guidelines IndexHead and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007
TREATMENT OFCLINICAL STAGING FOLLOW-UPADJUVANT
Cancer of the Supraglottic Larynx
Head and Neck Cancers
8/3/2019 Head-And-neck Cancer Gudelines 2007
http://slidepdf.com/reader/full/head-and-neck-cancer-gudelines-2007 55/105
Version 1.2007, 04/10/07 © 2007 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
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.
Chemo/RT(category 1)
b,cLaryngectomy,ipsilateral thyroidectomywith ipsilateral or bilateralneck dissectionor
Clinical trial
T4a, N+>
>
Cartilage destructionSkin involvement
PRIMARY AND NECK
FOLLOW UP
SUPRA-8
·
·
·
·
Physical exam: Year 1,
every 1-3 mo
Year 2,every 2-4 mo Years 3-5,
every 4-6 mo> 5 years,
every 6-12 mo
Chest imaging as clinically
indicated
TSH every 6-12 mo, if neckirradiated
>
>
>
>
Speech and swallowing
evaluation and rehabilitation as
indicated
b .c .
See Principles of Radiation Therapy
See Principles of Systemic Therapy (CHEM-A)
(SUPRA-A)
Recurrence (see ADV-2)
ADJUVANT
TREATMENT
Guidelines IndexHead and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007
PRINCIPLES OF RADIATION THERAPY
Cancer of the Supraglottic Larynx
Head and Neck Cancers
8/3/2019 Head-And-neck Cancer Gudelines 2007
http://slidepdf.com/reader/full/head-and-neck-cancer-gudelines-2007 56/105
Version 1.2007, 04/10/07 © 2007 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
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.
Back to Clinical StagingNode negative (SUPRA-1)Node positive (SUPRA-5)
One or both major risk features or two or more minor risk features.Concurrent single agent cisplatin at 100 mg/m every 3 wks is recommended.
Definitive RT
Postoperative RT
Postoperative chemoradiation for high pathologic risk features
·
·
·
·
··
Primary and gross adenopathy:70 Gy (2.0 Gy/day)
Uninvolved nodal stations:50 Gy (2.0 Gy/day)
Primary: 60 Gy (2.0 Gy/day)
NeckInvolved nodal stations:
60 Gy (2.0 Gy/day)Uninvolved nodal stations:
50 Gy (2.0 Gy/day)Any one minor risk feature: pT4 primary; N2 or N3 nodal disease,
perineural invasion, vascular embolism.
³
³
³
³
³
Neck?
?
?
1,2,3
2
SUPRA-A
1
2
Bernier J, Domenge C, Ozsahin M, et al. Postoperative irradiation with or without concomitant chemotherapy for locally advanced headand neck cancer. N Engl J Med 2004;350:1945-1952.
Cooper JS, Pajak TF, Forastiere AA, et al. Postoperative concurrent radiotherapy and chemotherapy for high-risk squamous-cellcarcinoma of the head and neck. N Engl J Med 2004;350:1937-1944.
3Bernier J, Cooper JS, Pajuk TF, et al. Defining risk levels in locally advanced head and neck cancers: A comparative analysis of concurrent postoperative radiation plus chemotherapy trials of the EORTC (#22931) and RTOG (#9501). Head Neck 2005;27:843-850.
Guidelines IndexHead and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007
WORKUP CLINICAL STAGING
Cancer of the Nasopharynx
Head and Neck Cancers
8/3/2019 Head-And-neck Cancer Gudelines 2007
http://slidepdf.com/reader/full/head-and-neck-cancer-gudelines-2007 57/105
Version 1.2007, 04/10/07 © 2007 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
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.
T1, N0, M0 andT2a, N0, M0
T1-T2a, N1-3;T2b-T4a, Any N
Any T, Any N, M1
··
·
H&PNasopharyngeal exam and biopsy
·
·
·
·
Chest x-ray
or Chest CT
Dental evaluation as indicated
Speech & swallowing evaluation
as indicated
WHO class
2-3/N2-3 disease (may include
PET scan and/or CT)
a
MRI with gadolinium of
nasopharynx and base of skull toclavicles and/or CT with contrast
Imaging for distant metastases
(chest, liver, bone) for
Multidisciplinary consultation
See Treatment of Primaryand Neck (NASO-2)
See Treatment of Primaryand Neck (NASO-2)
See Treatment of Primaryand Neck (NASO-2)
NASO-1
aChest CT should be considered for patients at high risk for thoracic metastases.
Guidelines IndexHead and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007
CLINICAL STAGING TREATMENT OF PRIMARY AND NECK FOLLOW-UP
Cancer of the Nasopharynx
Head and Neck Cancers
8/3/2019 Head-And-neck Cancer Gudelines 2007
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Version 1.2007, 04/10/07 © 2007 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
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.
T1, N0, M0 andT2a, N0, M0
Definitive RT tonasopharynx andelective RT to neck
b
·
·
·
Physical exam: Year 1, every 1–3 mo Year 2, every 2–4 mo Year 3–5, every 4–6
mo> 5 years, 6–12 mo
TSH every 6-12 mo, if
neck irradiated
Speech and swallowing
evaluation and
rehabilitation asindicated
>
>
>
>
bSee Principles of Radiation Therapy (NASO-A).
Cisplatin, 100 mg/mon days 1, 22, 43, +RT ( 70 Gy) toprimary and grossnodal disease(category 1) andbilateral neck:
50 Gy
2
³
³
Neck:residualtumor
Neck:completeresponse
NeckdissectionCisplatin, 80 mg/m
day 1+ 5-FU, 1,000mg/m ,CI x 4 days; repeatevery 4 wk x 3courses
2
2
Platinum-basedcombinationchemotherapy
Definitive RT
to primary
and neck
b
If completeresponse
Any T, any N, M1
NASO-2
Observe
T1-T2a, N1-3;T2b-T4a, any N
Recurrence (see ADV-2)
Guidelines IndexHead and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007
PRINCIPLES OF RADIATION THERAPY
Cancer of the Nasopharynx
Head and Neck Cancers
8/3/2019 Head-And-neck Cancer Gudelines 2007
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Version 1.2007, 04/10/07 © 2007 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
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.
Definitive RT
Radiation Techniques
·
·
Primary and gross adenopathy:70 Gy (2.0 Gy/day)
NeckUninvolved nodal stations:
50 Gy (2.0 Gy/day)
³
³?
Radiation technique may play a critical role in reducing toxicity
and enhancing tumor control in nasopharyngeal cancers. 3Dconformal techniques and IMRT techniques should be strongly
considered, though consensus on optimal technique has not yet
emerged. IMRT techniques are an area of active development
among the NCCN institutions and others. Target delineation and
optimal dose distribution require special training in head and neck
imaging, a thorough understanding of patterns of disease spread,
and special training in IMRT techniques. Standards for target
definition, dose specification, fractionation (with and withoutconcurrent chemotherapy), and normal tissue constraints should
emerge within the next few years.
NASO-A
Guidelines IndexHead and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007
TREATMENT OF HEAD AND NECK CANCERDIAGNOSIS
Unresectable Head and Neck Cancer
Head and Neck Cancers
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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.
Newly diagnosed
Unresectable(M0);T4b, N any, or unresectable N+
Clinical trial preferred
Standardtherapy
Concurrent cisplatin or carboplatin-based chemotherapy + RT(category 1)
a
c
b
or Induction chemotherapy followedby chemoradiation (category 3)
Induction chemotherapy followed
by RT (category 3)
c
or Definitive RT ± concurrent
systemic therapy
b
PS 0-1
PS 2
a
b
The single-agent cisplatin or carboplatin-based chemoradiotherapy regimens have not been compared in randomized trials. Therefore, no optimal standard regimenis defined. Combination chemotherapy regimens are more toxic and have not been directly compared to single-agent regimens.
c 2 2Cisplatin 100 mg/m day 1 + 5-FU 1000mg/m /24 hrs continuous IV infusion for 120 hours for 3 cycles.
See Principles of Radiation Therapy (ADV-A).
Definitive RT
or
Best supportive care
b
PS 3
ADV-1
Residual neck disease:
Neck dissection, if
feasible + primary site
controlled
Guidelines IndexHead and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007
TREATMENT OF HEAD AND NECK CANCERDIAGNOSIS
Recurrent Head and Neck Cancer
Head and Neck Cancers
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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.
Recurrence
Standard
therapyd
Clinical trial preferred
PS 0–1
PS 2
PS 3 Best supportive care
Chemotherapy on
clinical trial
or
Best supportive care
Best supportive care
Distantmetastases
Locoregionalrecurrence or second primarywith prior RT
Locoregionalrecurrencewithoutprior RT
Resectable
Unresectable
Surgery ± reirradiation, clinical trial preferred
Resectable
Unresectable
Surgery RT± b
Reirradiation, clinical trial preferredor Chemotherapy (see distant metastases pathway)
Combination chemotherapy
or
Single-agent chemotherapy
Single- agent chemotherapy
or
Best supportive care
b
d
.
.
See Principles of Radiation Therapy
Systemic Therapy
(ADV-A)
See Principles of (CHEM-A)
ADV-2
See Treatment of Head andNeck Cancer (ADV-1)
Guidelines IndexHead and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007
PRINCIPLES OF RADIATION THERAPY
Advanced Head and Neck Cancer
Head and Neck Cancers
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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.
ADV-A
1
2The majority of the published experience with concurrent chemoradiation has utilized conventional fractionation at 2.0 g per fraction to 70 Gy in 7 wks with singleagent cisplatin given every 3 wks at 100 mg/m . Use of other fraction sizes (eg, 1.8 Gy, conventional), multiagent chemotherapy or altered fractionation withchemotherapy has been evaluated with no consensus on the optimal approach. In general, the use of concurrent chemoradiation carries a high toxicity burden--altered fractionation or multiagent chemotherapy will likely further increase toxicity burden. For any chemoradiation approach, close attention should be paid topublished reports for the specific chemotherapy agent, dose and schedule of administration. Chemoradiation should be performed by an experienced team andinclude substantial supportive care.
³
Concurrent chemoradiation (preferred)
Definitive RT + cetuximab (for patients not able to tolerate
cytotoxic therapy)
Radiation Techniques
Conventional fractionation:Primary and gross adenopathy
70 Gy (2.0 Gy/day)
Neck
Uninvolved nodal stations:
44-50 Gy (2.0 Gy/day)
3D conformal techniques may be used depending on thestage, tumor location, physician training/experience and
available physics support. IMRT techniques are an area
of active development among the NCCN institutions and
others. Target delineation and optimal dose distribution
require special training in head and neck imaging, a
thorough understanding of patterns of disease spread,
and special training in IMRT techniques. Standards for
target definition, dose specification, fractionation (withand without concurrent chemotherapy), and normal
tissue constraints should emerge within the next few
years.
1
·
³
·
·
·
·
Definitive RT without chemotherapy (for medically unfit
or those who refuse chemotherapy)Altered fractionation (hyperfractionation or concomitantboost) regimens preferred for RT alone.
Hyperfractionation:
81.6 Gy/7 wks (1.2 Gy/fraction BID)
Concomitant boost accelerated RT:
72 Gy/6 wks (1.8 Gy/fraction, large field; 1.5 Gy boost as
second daily fraction during last 12 treatment days)
Conventional fractionation:Primary and gross adenopathy:
70 Gy (2.0 Gy/day)
>
>
³Neck
Uninvolved nodal stations:
50 Gy (2.0 Gy/day)³
Guidelines IndexHead and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007
PRINCIPLES OF SYSTEMIC THERAPY (Page 1 of 2)
Head and Neck Cancers
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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.
CHEM-A(1 of 2)
The choice of chemotherapy should be individualized based on patient characteristics (performance status, goals of therapy).
Single agentCisplatinCarboplatinPaclitaxelDocetaxel5-FUMethotrexate
IfosfamideBleomycinGemcitabine
(nasopharyngeal)Cetuximab
Combination therapyCisplatin or
carboplatin + 5-FUCisplatin or
carboplatin + taxaneCisplatin/cetuximab
>
>
>
>
>
>
>
>
>
>
>
>
>
4,13
4
14 15
Unresectable Recurrent Head and Neck Cancers
Maxillary Sinus, Ethmoid Sinus, Lip, Oral Cavity, Oropharynx,
Hypopharynx, Glottic larynx, Supraglottic larynx, Occult Primary
Nasopharynx
Chemoradiation followed by adjuvant chemotherapy
Cisplatin + RT followed by Cisplatin/5-FU· 12
Induction chemotherapy (followed by chemoradiation)
Docetaxel/cisplatin/5-FU· 10,11
Primary Systemic Therapy + concurrent RT
Cisplatin alone (preferred)·
·
·
·
·
·
1,2
5-FU/hydroxyurea
Cisplatin/paclitaxel
Cisplatin/infusional 5-FU
Carboplatin/infusional 5-FU
Cetuximab
3
3
3,4
5
6
See References on page CHEM-A 2 of 2
Squamous Cell Cancers
Postoperative Chemoradiation
Cisplatin alone· 7-9
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Guidelines IndexHead and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007
Table 2 - Continued T3 N0 M0
T3 N1 M0
Head and Neck Cancers
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Oropharynx and Hypopharynx
NXN0
N1
N2
N2a
N2b
N2c
N3
Distant Metastasis (M)MX
M0
M1
Stage Grouping: Nasopharynx
Stage 0
Stage I
Stage IIAStage IIB
Stage III
Stage IVA
Stage IVB
Stage IVC
Stage Grouping: Oropharynx, Hypopharynx
Stage 0
Stage IStage II
Stage III
Stage IVA
Stage IVB
Stage IVC
Regional lymph nodes cannot be assessedNo regional lymph node metastasis
Metastasis in a single ipsilateral lymph node, 3 cm or lessin greatest dimension
Metastasis in a single ipsilateral lymph node, more than 3cm but not more than 6 cm in greatest dimension, or inmultiple ipsilateral lymph nodes, none more than 6 cm ingreatest dimension, or in bilateral or contralateral lymphnodes, none more than 6 cm in greatest dimension
Metastasis in a single ipsilateral lymph node more than 3cm but not more than 6 cm in greatest dimension
Metastasis in multiple ipsilateral lymph nodes, none morethan 6 cm in greatest dimension
Metastasis in bilateral or contralateral lymph nodes, nonemore than 6 cm in greatest dimension
Metastasis in a lymph node more than 6 cm in greatestdimension
Distant metastasis cannot be assessed
No distant metastasis
Distant metastasis
Tis N0 M0
T1 N0 M0
T2a N0 M0T1 N1 M0
T2 N1 M0
T2a N1 M0
T2b N0 M0
T2b N1 M0
T1 N2 M0
T2a N2 M0
T2b N2 M0
T3 N2 M0
T4 N0 M0
T4 N1 M0
T4 N2 M0
Any T N3 M0
Any T Any N M1
Tis N0 M0
T1 N0 M0T2 N0 M0
T3 N0 M0
T1 N1 M0
T2 N1 M0
T3 N1 M0
T4a N0 M0
T4a N1 M0
T1 N2 M0T2 N2 M0
T3 N2 M0
T4a N2 M0
T4b Any N M0
Any T N3 M0
Any T Any N M1
Used with the permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original and primary source for thisinformation is the AJCC Cancer Staging Manual, Sixth Edition (2002)published by Springer-Verlag New York. (For more information, visit
.) Any citation or quotation of this material must becredited to the AJCC as its primary source. The inclusion of this informationherein does not authorize any reuse or further distribution without theexpressed, written permission of Springer-Verlag New York, Inc., on behalf of the AJCC.
www.cancerstaging.net
Histologic Grade (G)
GX
G1G2
G3
· Oropharynx
Hypopharynx·Grade cannot beassessedWell differentiatedModeratelydifferentiatedPoorly differentiated
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Guidelines IndexHead and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007
Table 3 - Continued
Stage Grouping
Used with the permission of the American Joint Committee on Cancer
(AJCC), Chicago, Illinois. The original and primary source for this
i f i i h AJCC C S i M l Si h Edi i (2002)
Head and Neck Cancers
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Stage 0
Stage IStage II
Stage III
Stage IVA
Stage IVB
Stage IVC
Tis N0 M0
T1 N0 M0T2 N0 M0
T3 N0 M0
T1 N1 M0
T2 N1 M0
T3 N1 M0
T4a N0 M0
T4a N1 M0
T1 N2 M0T2 N2 M0
T3 N2 M0
T4a N2 M0
T4b Any N M0
Any T N3 M0
Any T Any N M1
information is the AJCC Cancer Staging Manual, Sixth Edition (2002)
published by Springer-Verlag New York. (For more information, visit.) Any citation or quotation of this material must be
credited to the AJCC as its primary source. The inclusion of this information
herein does not authorize any reuse or further distribution without the
expressed, written permission of Springer-Verlag New York, Inc., on behalf
of the AJCC.
www.cancerstaging.net
Histologic Grade (G)
GX
G1G2
G3
Grade cannot beassessedWell differentiatedModeratelydifferentiatedPoorly differentiated
Guidelines IndexHead and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007
Table 4
2002 American Joint Committee on Cancer (AJCC)TNM St i S t f th M j S li Gl d (P tid
N2c
N3
Metastasis in bilateral or contralateral lymph nodes, nonemore than 6 cm in greatest dimension
Metastasis in a lymph node more than 6 cm in greatest
Head and Neck Cancers
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TNM Staging System for the Major Salivary Glands (Parotid,
Submandibular, and Sublingual)Distant Metastasis (M)
Stage Grouping
Primary Tumor (T)TX
T0
T1
T2
T3
T4a
T4b
Regional Lymph Nodes (N)
NX
N0
N1
N2
N2a
N2b
N3
MxM0M1
Stage IStage IIStage III
Stage IVA
Stage IVB
Stage IVC
Primary tumor cannot be assessed
No evidence of primary tumor
Tumor 2 cm or less in greatest dimension withoutextraparenchymal extension*
Tumor more than 2 cm but not more than 4 cm in greatest
dimension without extraparenchymal extension*Tumor more than 4 cm and/or tumor havingextraparenchymal extension*
Tumor invades skin, mandible, ear canal, and/or facialnerve
Tumor invades skull base and/or pterygoid plates and/or encases carotid artery
Regional lymph nodes cannot be assessed
No regional lymph node metastasis
Metastasis in a single ipsilateral lymph node, 3 cm or lessin greatest dimension
Metastasis in a single ipsilateral lymph node, more than 3cm but not more than 6 cm in greatest dimension, or inmultiple ipsilateral lymph nodes, none more than 6 cm ingreatest dimension, or in bilateral or contralateral lymphnodes, none more than 6 cm in greatest dimension
Metastasis in a single ipsilateral lymph node, more than 3cm but not more than 6 cm in greatest dimension
Metastasis in multiple ipsilateral lymph nodes, none morethan 6 cm in greatest dimension
Metastasis in a lymph node, more than 6 cm in greatestdimension
Distant metastasis cannot be assessedNo distant metastasisDistant metastasis
T1 N0 M0T2 N0 M0T3 N0 M0T1 N1 M0T2 N1 M0T3 N1 M0
T4a N0 M0T4a N1 M0T1 N2 M0
T2 N2 M0T3 N2 M0
T4a N2 M0T4b Any N M0
Any T N3 M0 Any T Any N M1
*Note: Extraparenchymal extension is clinical or macroscopic evidence of
invasion of soft tissues. Microscopic evidence alone does not constituteextraparenchymal extension for classification purposes.
Used with the permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original and primary source for this
information is the AJCC Cancer Staging Manual, Sixth Edition (2002)published by Springer-Verlag New York. (For more information, visit
.) Any citation or quotation of this material must becredited to the AJCC as its primary source. The inclusion of this informationherein does not authorize any reuse or further distribution without theexpressed, written permission of Springer-Verlag New York, Inc., on behalf of the AJCC.
www.cancerstaging.net
ST-6
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Guidelines IndexHead and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007
Table 5 - Continued
Stage Grouping
Used with the permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original and primary source for thisinformation is the AJCC Cancer Staging Manual, Sixth Edition (2002)
bli h d b S i V l N Y k (F i f ti i it
Head and Neck Cancers
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Stage 0
Stage IStage IIStage III
Stage IVA
Stage IVB
Stage IVC
Tis N0 M0
T1 N0 M0T2 N0 M0T3 N0 M0T1 N1 M0T2 N1 M0T3 N1 M0
T4a N0 M0T4a N1 M0T1 N2 M0T2 N2 M0T3 N2 M0
T4a N2 M0T4b Any N M0
Any T N3 M0 Any T Any N M1
published by Springer-Verlag New York. (For more information, visit
.) Any citation or quotation of this material must becredited to the AJCC as its primary source. The inclusion of this informationherein does not authorize any reuse or further distribution without theexpressed, written permission of Springer-Verlag New York, Inc., on behalf of the AJCC.
www.cancerstaging.net
ST-8
Histologic Grade (G)
GX
G1G2
G3
Grade cannot beassessedWell differentiatedModeratelydifferentiatedPoorly differentiated
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Guidelines Index
Head and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007
Disclosures for the NCCN Head and Neck Cancers Guidelines
Panel
At the beginning of each panel meeting to develop NCCN
guidelines, panel members disclosed the names of companies,
Head and Neck Cancers
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Manuscriptupdate inprogress
foundations, and/or funding agencies from which they received
research support; for which they participate in speakers' bureau,
advisory boards; and/or in which they have equity interest or
patents. Members of the panel indicated that they have received
support from the following: Amgen Inc; AstraZeneca; Bristol Myers-
Squibb; CEL-SCI; Eastern Collaborative Oncology Group; Eli Lilly;
GEM Pharmaceuticals; Genentech Inc; GlaxoSmithKline; ImClone
Systems Inc; MedImmune Inc; NCI; NeoPharm Inc; NIAID; NPS
Pharmaceuticals; OSI Pharmaceuticals; Pfizer Inc; Roche
Pharmaceuticals; and Sanofi-Aventis. Some panel members do not
accept any support from industry. The panel did not regard any
potential conflicts of interest as sufficient reason to disallow
participation in panel deliberations by any member.
MS-23
Guidelines Index
Head and Neck Cancers TOC
Staging, MS, References
NCCN® Practice Guidelines
in Oncology – v.1.2007
Figure 1
Anatomic sites and subsites of the head and neck
Figure 2
Level designation for cervical lymphatics in the right neck
Head and Neck Cancers
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Larynx
SupraglottisFalse cords ArytenoidsEpiglottis Arytenoepiglottic fold
GlottisSubglottis
Nasopharynx
Nasal antrum
Oral cavity
LipBuccalmucosa Alveolar ridgeandretromolar trigoneFloor of mouthHard palateOral tongue(anterior two thirds)
Pharynx
OropharynxBaseof tongueSoft palateTonsillar pillar and fossa
Hypopharynx
Esophagus
MS-24
Reprinted with permission, from CMP Healthcare Media. Source: Cancer Management: A Multidisciplinary Approach, 9th ed. Pazdur R, Coia L,Hoskins W, et al (eds), Chapter 4. Copyright 2005, All rights reserved.
Reprinted with permission, from CMP Healthcare Media. Source: Cancer Management: A Multidisciplinary Approach, 9th ed. Pazdur R, Coia L,Hoskins W, et al (eds), Chapter 4. Copyright 2005, All rights reserved.
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