Head & Neck cancer treatment Protocols

Specialty	RADIATION ONCOLOGY
Category:	Head&Neck
ICD10 topography:	Site
Intent:	Primary
Definition:	Radical IMRT and chemotherapy for H&N cancer
Patient population	AJCC/UICC Stage cancer Squamous cell carcinoma ECOG 0-2 No prior H&N RT
Pre-treatment arrangements	PET scan if surgical salvage is an option PEG if circumferential dose is inevitable Medical Oncology referral Dietitian referral Dental review
Simulation	CT simulator with software beam manipulation supine, head in neutral position thermoplastic shell Bolus over all nodal areas and wherever disease encroaches within 1.0cm of skin surface No bite blocks except if absolutely necessary Simulator RTs set isocentre according to H&N protocol (anterior, inferior C4)
Volume definition	undertaken on the planning CT scan, but with fusion of MRI and PET scans as available. Contrast is only required where diagnostic scans with contrast show adequate enhancement and delineation of invasive tumour GTVp, GTVn are "anti-anatomic" outlines of the boundaries between normal tissue and tumour affected tissues (fat streaking included), and all visible nodes are contoured CTVp, CTVn are strict anatomic outlines beginning as 3mm expansions of the respective GTVs with cropping at soft tissue boundaries, air and bony interfaces CTV0 is an anatomic definition of normal nodal regions, and described by selecting nodal stations to be included. Nodal stations only included if risk exceeds 15% CTVn0 is calculated from previous volumes according to the formula : CTV0 - (CTVp + CTVn) PTV60 is calculated from previous volumes according to the formula : CTVp +CTVn +CTVn0 + IGRT margin for movement (3mm in our unit) PTV70 is calculated from previous volumes according to the formula : CTVp +CTVn + IGRT margin for movement (3mm in our unit)
Contour (OAR) definition	spinal cord, parotid glands, submandibular glands, mucosa, mandible, inner ear, brainstem, optic apparatus, eye, lens.
PRV definition	expand PTV60 by 7mm to PTV_PRV expand each OAR by 3mm and exclude volume inside the PTV_PRV except spinal cord and optic structures where expansion occurs with no exclusion
Dose prescription	95% of 70Gy (66.5Gy) to cover at least 98% of PTV70 delivered in 35 fractions, and 95% of 60Gy (57.0Gy) to cover at least 98% of PTV60 delivered in 35 fractions using 6MVX beam usually with 5, 7 or 9 gantry angles delivering 1 Fx per day and 5 Fx per week with a total duration of 49 calendar days. If needed BD fractions can be given with a minimum 6 hour break dose is prescribed to a 100% isodose/point which is NOT the isocentre. The isocentre is situated on anterior, inferior lip of C4 for rapid and easy IGRT positioning
Dose constraints	spinal cord & optic structures <45Gy parotid_PRV & submandibular_PRV minimised, aim for maximum dose of 12Gy and slowly relax until plan coverage looks good (note that the aim is NOT for "median dose of 26Gy", we can do much better than this.
Chemotherapy	concurrent weekly cisplatin according to CISCaT protocol chemotherapy delivered before radiotherapy on either Monday or Tuesday
Treatment verification	daily IGRT orthogonal EPIs to verify that isocentre is within 3mm of designated position reposition if excessive
Clinical Instructions	Weekly dietitian review during treatment weekly FBC - consider delaying/ceasing chemotherapy if platelets <100 X109/L or neutrophils <1 X109/L weekly weight weekly review and grading of acute toxicities
Toxicities	grade skin, oral mucosa, dysphagia, fatigue and xerostomia

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Larynx Cancer

Treatment Guidelines

Site	Stage	Chemotherapy/ Immunotherapy	LN treatment	Nodal Volume	Dose/Fractionation
Supraglottic larynx	T1	no	yes	ipsilateral for lateralised primary	* high dose area: [GTVp/n + 3mm] = CTVp/n + IM/SM (3mm IGRT)]= PTV70, this means gross disease will be covered by 95% of 70 Gy (i.e., 66.5 Gy) * moderate dose area: [GTVp/n + 3mm] = CTVp/n + CTVn0 + IM/SM (3mm IGRT)]= PTV60, this means gross disease will be covered by 95% of 60 Gy (i.e., 57.0 Gy) * there is no third dose level differentiated
	T2	yes	yes	bilateral	multi-volume target as above
	T3	yes	yes	bilateral	multi-volume target as above
	T4	yes	yes	bilateral	multi-volume target as above
Glottic larynx	T1	no	no		CTVn and CTVn0 are not marked
	T2	no	no		CTVn and CTVn0 are not marked
	T3	yes	yes	bilateral	multi-volume target as above
	T4	yes	yes	bilateral	multi-volume target as above
Subglottic larynx	T1	no	yes	leave nodes above digastric alone	multi-volume target as above
	T2	yes	yes	bilateral	multi-volume target as above
	T3	yes	yes	bilateral	multi-volume target as above
	T4	yes	yes	bilateral	multi-volume target as above
Hypopharynx	T1	no	yes	leave nodes above digastric alone	multi-volume target as above
	T2	yes	yes	bilateral	multi-volume target as above
	T3	yes	yes	bilateral	multi-volume target as above
	T4	yes	yes	bilateral	multi-volume target as above