head-and-neck cancer gudelines 2007

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NCCN Clinical Practice Guidelines in Oncology™

Head and Neck

Cancers

V.1.2007

www.nccn.org



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, 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

Continue

http://contents.pdf/





Guidelines Index





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)

·

·

··

·

·

·

·

·

·

·

·

·


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



http://print/

http://help.pdf/

http://help.pdf/

http://www.nccn.org/clinical_trials/physician.html





http://help.pdf/


http://print/




Guidelines Index


Staging, MS, ReferencesNCCN® Practice Guidelines


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



http://palliative.pdf/

http://palliative.pdf/





Guidelines Index






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



http://nhl.pdf/

http://nhl.pdf/

http://nhl.pdf/





Guidelines Index






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


RTor



a

b

RTor



a

b

RT






Guidelines Index






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



http://nhl.pdf/

http://nhl.pdf/

http://nhl.pdf/





Guidelines Index






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 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)



Margin

negative

Margin

positive

Consider RTb







Guidelines Index




PRIMARY TREATMENT ADJUVANT TREATMENTSTAGING FOLLOW-UP

·

·

·

·

Physical exam:

Chest imaging as


>

>

>

>

Year 1,

every 1–3 mo Year 2,

every 2–4 mo Years 3–5,


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)





Chemo/RT to

primary and neck

(category 2B)

G id li I d








Guidelines Index




MAXI-A

PRINCIPLES OF RADIATION THERAPY



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?

?



Guidelines Index








Guidelines Index




See Follow-up (SALI-4)



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


Guidelines Index

H d d N k C








Guidelines Index






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



Guidelines Index



http://nhl.pdf/

http://nhl.pdf/

http://nhl.pdf/







Guidelines Index




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)



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)



Adjuvant RTb

or

Consider

Chemo/RT

(category 2B)

Guidelines Index









Guidelines Index




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




SALI-4



.bSee Principles of Radiation Therapy (SALI-A)

Guidelines Index












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




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



Guidelines Index

® Head and Neck Cancers













····

··

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


a

b

.

.

See Principles of Radiation Therapy (LIP-A)


Guidelines Index

NCCN® Head and Neck Cancers











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)


LIP-2

ADJUVANT TREATMENT

Cancer of the Lip


a

b

.

.



Guidelines Index

H d d N k C TOC

NCCN® P ti G id li












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.




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















Uninvolved

Definitive RT

Postoperative RT

·

·

··


External-beam RT 50 Gy +

brachytherapy or brachytherapy aloneNecknodal stations:

50 Gy (2.0 Gy/day)


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










Staging, MS, ReferencesNCCNPractice Guidelinesin Oncology – v.1.2007



···

·

·

··

H&PBiopsyChest x-rayor Chest CTAs indicated for evaluation

PanorexCT/MRI

Examination under anesthesia, if indicatedPreanesthesia studiesDental evaluation

a

?

?

Multidisciplinaryconsultation as indicated


T1–2, N0

T3, N0

T1–3, N1–3

T4a, any N

See Treatment of Primary and Neck (OR-2)




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













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).


FOLLOW-UP

·

·

·

·

Physical exam:

Chest imaging as


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



No adverse featuresb,c

No adverse featuresb,c RT (optional)d

ADJUVANT TREATMENT


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


features or 2 minor

risk features

³b,c

< 2 minor risk

featuresc

RTd< 2 minor riskfeaturesc

Guidelines Index









ead a d ec Ca ce s OC




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


·

·

·

·

Physical exam:

Chest imaging as


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



No adverse

featuresb,c

ADJUVANT

TREATMENT


Adverse

features

b

c

d

e


.

See Principles of Radiation Therapy (OR-A).


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












OR-4

T4a, Any N

Surgery (preferred

for bone invasion)

·

·

·

·

Physical exam:

Chest imaging as


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 4-6 mo> 5 yr,

every 6-12 mo

FOLLOW-UPCLINICAL

STAGING




Concurrent

systemic

therapy/RT

(category 3)

e

or

Residual

tumor


N1 (initial

stage)

N2-3 (initialstage)

Observe

Primary site:Completeresponse

Primary site:residualtumor

Salvage surgery + neckdissection as indicated

Observeor Neck dissection(category 3)


d .e .

See Principles of Radiation Therapy (OR-A)


Chemotherapy/RT

(category 1)

d,e


Guidelines Index



C f th O l C it







Staging, MS, ReferencesNCCN in Oncology – v.1.2007




OR-A


Definitive RT

Postoperative RT

·

·

··


External-beam RT 50 Gy ± brachytherapyNeckUninvolved 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



C f th O h










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)



ORPH-1


Unresectable See Treatment of Headand Neck Cancer (ADV-1)

Cancer of the Oropharynx

Guidelines Index


St i MS R f


i O l 1 2007 Cancer of the Oropharynx










CLINICAL

STAGING

T1-2,

N0-1


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


.

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


or

RT

+ systemic therapy

(category 3)

For T1-T2, N1 onlye

Primary controlled

Residual disease Salvagesurgery


ADJUVANT

TREATMENT


·

·

·

·

Physical exam:

Chest imaging as


TSH every 6-12 mo, if neck irradiated

Speech and swallowing

evaluation and

rehabilitation as

indicated

>

>

>

>

Year 1,

every 1-3 mo


every 4-6 mo> 5 yr,

every 6-12 mo

Adverse

features

Chemo/RTb,e

(category 1)


features or 2 minor risk features

³c,d

RTb< 2 minor risk

featuresd

Guidelines Index


Staging MS References


i O l 1 2007 Cancer of the Oropharynx










T3-4a, N0

Salvage

surgeryResidual disease

Primary controlled

Surgery

CLINICAL

STAGING

TREATMENT OF PRIMARY AND NECK FOLLOW-UP

·

·

·

·

Physical exam:

Chest imaging as


TSH every 6-12 mo, if

neck irradiated

Speech and

swallowing evaluation

and rehabilitation as

indicated

>

>

>

>

Year 1,



every 4-6 mo> 5 yr,

every 6-12 mo

ORPH-3




Concurrent systemic therapy/RT

cisplatin (category 1) preferred

b,e

or

or

ADJUVANT

TREATMENT


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


.

See Principles of Radiation Therapy (ORPH-A).


Chemo/RTb,e

(category 1)


features or 2 minor

risk features

³c,d

RTb< 2 minor risk

featuresd

Guidelines Index


Staging MS References


in Oncology v 1 2007 Cancer of the Oropharynx










Any T3-4a,

N+ or Any T, N2-3

Residual

tumor


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


or

ORPH-4

FOLLOW-UP


N2c

RTb

or

Chemo/RT

(category 1)

b,e

Excision of primary, ipsilateral

comprehensive neck dissection


Excision of primary and bilateral


(bilateral is category 3 if neck

nodes contralateral only)


N1

N2a–b

N3Surgery:

primary and

neck

b .e .

See Principles of Radiation Therapy


(ORPH-A)Recurrence (see ADV-2)

or

ADJUVANT

TREATMENT


·

·

·

·

Physical exam:

Chest imaging as



neck irradiated

Speech andswallowing evaluation


indicated

>

>

>

>

Year 1,


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




Guidelines Index




in Oncology – v 1 2007 Cancer of the Hypopharynx







g g, ,NCCN in Oncology – v.1.2007



T1, N2-3;

T2-3, Any N

T4a, Any N


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


Dental evaluation

a

Multidisciplinary consultation

as indicated

See Treatment of Primary andNeck (HYPO-2)



HYPO-1

Unresectable See Treatment of Head andNeck Cancer (ADV-1)


Cancer of the Hypopharynx

Guidelines Index




in Oncology – v 1 2007 Cancer of the Hypopharynx







g gNCCN in Oncology v.1.2007



Residual

tumor

Completeresponse

of neck

Observe

Primary site:completeresponse


Salvage surgery+ neck dissectionas indicated


Early T stage

(not requiring

total

laryngectomy)

Most T1, N0-1,

small T2, N0

·

Definitive RTb

CLINICAL

STAGING


Surgery: Partial

laryngopharyngectomy

(open or endoscopic)

+ ipsilateral or bilateral


(N0); Comprehensive neck

dissection levels 1-5 (N1)

or

FOLLOW-UP

·

·

·

Physical exam:

Chest imaging as


TSH every 6-12 mo,

if neck irradiated

>

>

>

>



every 4-6 mo> 5 yr,

every 6-12 mo

HYPO-2


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.

.



(HYPO-A)

ADJUVANT TREATMENT


Adverse

features

Chemo/RT b,e

(category 1)


features or 2 minor

risk features

³c,d

RTb< 2 minor riskfeaturesd

Guidelines Index




in Oncology – v.1.2007 Cancer of the Hypopharynx







NCCN in Oncology v.1.2007



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


TSH every 6-12 mo,if neck irradiated

>

>

>

>

Year 1,

every 1-3 mo


every 4-6 mo> 5 yr,

every 6-12 mo

CLINICAL

STAGING


RTbNo adverse

featuresc,d

ADJUVANT TREATMENT

Residual

tumor


N1

(initial stage)

N2-3(initial stage)

Observe

Primary site:

complete

response

Primary site:


Observe

or

Neck dissection

(category 3)

Neck dissection

(category 3)

Multimodality clinicaltrials that include

function evaluation


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


.



(HYPO-A)

Chemo/RTb,e

(category 1)


features or 2 minor

risk features

³c,d

RTb< 2 minor risk

featuresd

Guidelines Index











gy



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


TSH every 6-12 mo,

if neck irradiated

>

>

>

>

Year 1,



every 4-6 mo> 5 yr,

every 6-12 moNo adversefeaturesc,d

ADJUVANT

TREATMENT

yp p y

Adverse

features

b .c

d

e


.



(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











gy



HYPO-5

Surgery + comprehensive

neck dissection (preferred)

FOLLOW-UP

·

·

·

Physical exam:

Chest imaging as


TSH every 6-12 mo,

if neck irradiated

>

>

>

>



every 4-6 mo> 5 yr,

every 6-12 mo

CLINICAL

STAGING


Chemo/RT

(category 1)

b,e

ADJUVANT TREATMENT

T4a, any N

b .e .



(HYPO-A)

yp p y

Residual

tumor


N1(initialstage)

N2-3(initial

stage)

Observe

Primary site:

complete

response

Primary site:


Observe

or


Neck dissection

(category 3)

Multimodality clinical

trials that include

function evaluation

or

or

Concurrent systemic

therapy/RT

(category 3)

b,e

Guidelines Index













Back to ClinicalStaging (HYPO-1)



Definitive RT

Postoperative RT

Postoperative chemoradiation for high pathologic risk features

·

·

·

·

·


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


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




in Oncology – v.1.2007 Occult Primary









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






http://nhl.pdf/

http://nhl.pdf/

http://melanoma.pdf/


http://thyroid.pdf/

http://thyroid.pdf/


http://nhl.pdf/

http://thyroid.pdf/








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



















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


or

RT to nasopharynx, both sides of the neck,

hypopharynx, larynx, oropharynx

c

c


or

RT to Waldeyer’s ring, larynx,hypopharynx, both sides of the neck

c

c


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













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


or

RT to nasopharynx, both sides of the neck,hypopharynx, larynx, oropharynx

c

c

or Chemotherapy/RT (category 2B)d


or

RT to Waldeyer’s ring, larynx,

hypopharynx, both sides of the neck

c

c



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

c

d.See Principles of Radiation Therapy

Systemic Therapy

(OCC-A)

See Principles of (CHEM-A).

Guidelines Index













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
















OCC-A


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




in Oncology – v.1.2007 Cancer of the Glottic Larynx









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



Speech & swallowing evaluationas indicated

Multidisciplinary consultation as

indicated

b

CLINICAL STAGING TREATMENT OF PRIMARY AND NECK

See Treatment and Follow-up (GLOT-2)



aComplete workup not indicated for Tis, T1.bChest CT should be considered for patients at high risk for thoracic metastases.


GLOT-1

Unresectable See Treatment of Head andNeck Cancer (ADV-1)

Guidelines Index













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



neck irradiated

Speech and swallowingevaluation and

rehabilitation as indicated

>

>

>

>

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

GLOT-2


Guidelines Index













Residual

tumor

Completeresponse

of neck

N1(initialstage)

N2-3(initialstage)

Observe

Primary site:

Complete

response



Observe

or

Neck dissection(category 3 for

selective vs

comprehensive)

Neck dissection

(category 3)·

·

·

·

Physical exam: Year 1,


every 2-4 mo Years 3-5, every 4-6

mo> 5 years, every 6-

12 mo

Chest imaging as



neck irradiated

>

>

>

>

Speech and


and rehabilitation asindicated

·

·

·

Resectable

Requiring

total

laryngectomy

Most T3,

any N

CLINICAL

STAGING


Surgery

Laryngectomy with ipsilateral

thyroidectomy unilateral or

bilateral selective neck dissection(reconstruction as indicated)

±

N2-3

N1

N0

Laryngectomy with ipsilateralthyroidectomy, ipsilateral or bilateral




thyroidectomy, ipsilateral

comprehensive neck dissection ±

contralateral selective neck dissection


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.



(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













CLINICAL

STAGING


T4a

disease

SelectedT4a

Consider concurrent

chemoradiationor Clinical trial for function preservingsurgical or nonsurgicalmanagement

d

T4a, Any N

·

·

·

·



every 2-4 mo

Years 3-5, every 4-6 mo> 5 years, every 6-12

mo

Chest imaging as



neck irradiated

>

>

>

>


evaluation andrehabilitation as

indicated

GLOT-4


Residual

tumor


N1(initialstage)

N2-3(initialstage)

Observe

Primary site:

Complete

response



Observe

or

Neck dissection(category 3 for

selective vs

comprehensive)

Neck dissection

(category 3)

c .d .



(GLOT-A)

ADJUVANT

TREATMENT

Chemo/RT(category 1)

c,d


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


Guidelines Index













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:



Definitive RT

Postoperative RT


··

··

·

·

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)




pT4 primary; N2 or N3 nodal disease,


³

³

³

³

>

>

>

>

·

?

?

1,2,3

2

GLOT-A


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




in Oncology – v.1.2007 Cancer of the Supraglottic Larynx










··

·

·

·

··

·

H&PBiopsy

Chest x-rayor Chest CTCT with contrast and thin cutsthrough larynx or MRI of primaryand neck recommendedExamination under anesthesiawith laryngoscopyPreanesthesia studies

a


Speech & swallowing evaluationas 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


Guidelines Index




in Oncology – v.1.2007 Cancer of the Supraglottic Larynx










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 ±


or

Open partial supraglottic

laryngectomy ± selective

neck dissection

or

Definitive RTbAdverse features:extracapsular nodal

spread

b .c .



(SUPRA-A)

SUPRA-2

·

·

·

·




every 4-6 mo> 5 years,

every 6-12 mo

Chest imaging as



neck irradiated

>

>

>

>

Speech and swallowingrehabilitation and

therapy as indicated

FOLLOW-UPADJUVANT

TREATMENT


Adverse features:positive margins

Further surgery

or

RTb

Guidelines Index





TREATMENT OF PRIMARY AND NECKCLINICAL FOLLOW UPADJUVANT

Cancer of the Supraglottic Larynx









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


Salvage surgery +neck dissectionas indicated

Concurrent systemictherapy/RTcisplatin (category 1)preferred

b,c

or

·

·

·

·


every 1-3 mo



every 6-12 mo

Chest imaging as


TSH every 6-12 mo, if neck irradiated

>

>

>

>

Speech and



indicated

FOLLOW-UP

SUPRA-3

b .c

d

e

.




(SUPRA-A)


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




TREATMENT OF PRIMARY AND NECKCLINICAL STAGING FOLLOW UPADJUVANT










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


or

Clinical trial


b .c .



(SUPRA-A)

·

·

·

·


every 1-3 mo



every 6-12 mo


indicated

TSH every 6-12 mo, if neck

irradiated

>

>

>

>

Speech and swallowing evaluation

and rehabilitation as indicated

FOLLOW-UP

SUPRA-4


ADJUVANT

TREATMENT















WORKUP

···

·

·

·

··

·

H&PBiopsyChest x-rayor Chest CTCT with contrast and thincuts through larynxMRI of primary and neckrecommendedExamination under anesthesiawith laryngoscopyPreanesthesia studies

a


Speech & swallowing

evaluation as indicated


CLINICAL STAGING

·

·

Not requiring totallaryngectomyT1–2, N+ andselected T3–4a


·

·

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

>

>

>


Unresectable (T4b) See Treatment of Head andNeck Cancer (ADV-1)

SUPRA-5

Node positive

disease






TREATMENT OF PRIMARY AND NECKCLINICAL FOLLOW-UPADJUVANT










·

·

Not requiringtotallaryngectomyT1–2, N+ andselectedT3–4a

TREATMENT OF PRIMARY AND NECKCLINICAL

STAGING

Observe

Partial supraglotticlaryngectomy andcomprehensiveneck dissection(s)

or

Definitive RTb ·

·

·

·





every 6-12 mo

Chest imaging as


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



Observeor neck

dissection

(category 3)

Neck dissection

(category 3)

Concurrentsystemic therapy/RTcisplatin(category 1)preferredc

or


ADJUVANT

TREATMENT

No adverse

featuresd,e

Adverse

features

b .c

d

e

.




(SUPRA-A)

Chemo/RTb,c

(category 1)


features or 2 minor

risk features

³d,e

RTb< 2 minor risk

featurese





TREATMENT OF PRIMARY AND NECKCLINICAL STAGING FOLLOW-UPADJUVANT










·

·

Requiring totallaryngectomy

Most T3–4a, N+> No cartilage

destruction


Residual

tumor


N1(initialstage)

N2-3(initial

stage)

Observe

Primary site:

Complete

response


Observe

or


Neck dissection

(category 3)

Concurrent systemictherapy/RTcisplatin (category 1)

preferred

b,c

Salvage surgery +neck dissection asindicated

FOLLOW UP

SUPRA-7

·

·

·

·





every 6-12 mo

Chest imaging as


TSH every 6-12 mo,

if neck irradiated

>

>

>

>

Speech and

swallowing

evaluation and

rehabilitation as

indicated


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

.




(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





TREATMENT OFCLINICAL STAGING FOLLOW-UPADJUVANT










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

·

·

·

·


every 1-3 mo



every 6-12 mo


indicated

TSH every 6-12 mo, if neckirradiated

>

>

>

>


evaluation and rehabilitation as

indicated

b .c .



(SUPRA-A)


ADJUVANT

TREATMENT















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


·

·

·

·

··



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,


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.






Cancer of the Nasopharynx









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


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)



NASO-1






CLINICAL STAGING TREATMENT OF PRIMARY AND NECK FOLLOW-UP










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


neck irradiated


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
















Definitive RT

Radiation Techniques

·

·


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





TREATMENT OF HEAD AND NECK CANCERDIAGNOSIS

Unresectable Head and Neck Cancer









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


b

PS 3

ADV-1

Residual neck disease:

Neck dissection, if

feasible + primary site

controlled





TREATMENT OF HEAD AND NECK CANCERDIAGNOSIS

Recurrent Head and Neck Cancer









Recurrence

Standard

therapyd

Clinical trial preferred

PS 0–1

PS 2

PS 3 Best supportive care

Chemotherapy on

clinical trial

or



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


b

d

.

.


Systemic Therapy

(ADV-A)

See Principles of (CHEM-A)

ADV-2

See Treatment of Head andNeck Cancer (ADV-1)






Advanced Head and Neck Cancer









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


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


50 Gy (2.0 Gy/day)³





PRINCIPLES OF SYSTEMIC THERAPY (Page 1 of 2)







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




http://www.cancerstaging.net/








Table 2 - Continued T3 N0 M0

T3 N1 M0






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. ST-3

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











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)






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. ST-5

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.



GX

G1G2

G3

Grade cannot beassessedWell differentiatedModeratelydifferentiatedPoorly differentiated





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










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



ST-6











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







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



ST-8


GX

G1G2

G3

Grade cannot beassessedWell differentiatedModeratelydifferentiatedPoorly differentiated






Guidelines Index





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,







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





Figure 1

Anatomic sites and subsites of the head and neck

Figure 2

Level designation for cervical lymphatics in the right neck







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.


head-and-neck cancer gudelines 2007

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