ORAL BOARDS (H&N)

ORAL CAVITY

FLOOR OF MOUTHT2N1

ORAL TONGUERECURRENTPOST-OP

6300

ORAL TONGUET2N1POST-OP

RMTpT4N2b (Mandible invasion)s/p glossectmy, pharyngectmy, palatctmy, hemimandibulctmys/p R-MRND

BUCCAL MUCOSAT2N1PRIMARY CHEMO-RT

GINGIVA(ALVEOLAR RIDGE)

USE WP & APFields include entire hemi-mandible

GINGIVA(ALVEOLAR RIDGE)

USE WP & AP

BUCCAL MUCOSA[AP & WEDGED PAIR]-also boost w/ e-

Ant & Sup: 2cm ant to tumorInf: Thyroid Notch

BUCCAL MUCOSA[AP FIELD]

T3N0 BUCCAL MUCOSA(GINGIVO-BUCCAL)

HARD PALATEpT4N0 (max sinus invasion)s/p intra-oral palatectomy & maxillectomy

OROPHARYNX

TONSILT3N2

TONSILR-TF: T3N2L-ATP: T1N0

BOTT2N2a

SOFT PALATET2N0

LARYNX

SUPRAGLOTTICLARYNX

GLOTTICLARYNX

T2: If supragltc xtnsn take higherT2: if subglottic xtnsn drop lower

SUP: Top thyroid cartilageINF: Bottom cricoidANT: 1cm flashPOST: Ant edge VB

LARYNXGLOTTICT1N0

LARYNXT2N0 GLOTTIC

LARYNXGLOTTICT3N0

LARYNXGLOTTICT4N0

HYPOPHARYNX

Sup: BOS ant & 2 cm sup to mastoid tip

Post: include jx & RP LN

Inferior: 1–2 cm below cricoid or lower, depending upon inf dz extent

AnteriorPharyngeal wall tumors: exclude ant third of glottis (broken line)Pyriform sinus tumors: 1 cm post to ant skin edge (solid line)

Posterior: post aspect of C2 spinous process to include posterior cervical nodes

Off-cord upper neck: opposed lateral fieldsPharyngeal wall tumors: posterior aspect of VB (broken line)Pyriform sinus tumors: split VB (solid line)

70

PYRIFORM SINUST1N2a

POSTERIORPHARYNGEALWALLT1N1

NASOPHARYNX

ethmoids

pterygoids

Op down to level of mid-tonsil

Sup AntT1–2 & early T3: split pituitary fossa & include sphenoid sinus and BOS w/2 cm mrgnAdv T3 & T4 involving BOS & CNs: include entire pit fossa, base of brain in suprasellar region, adjacent middle cranial fossa, and post ant cranial fossa

Sup Post: 2 cm sup to mastoid tip

Inf: thyroid notch

Ant: try to spare some oral cavity

Ant Sup: include posterior 2 cm of NC & Max sinus & post ¼ orbit

Ant Inf: 2 cm post to mentus to include the submandibular nodes

Post: 2 cm post to post aspect of the SCM mm to include jx & posterior cervical LN

NASOPHARYNXT1N2

Sphenoid floorCavern sinus

Ethmoid

NP

Post 1/3-Max Sinus-OrbitPost ½- NC

Pterygoid Fossa

OP walls to level of mid-tonsillar fossa

RPLN

CERVICAL LN

SPINAL ACCSSRY LN

BOS

(7cm wideCover foramina)

ADENOID CYSTICNASOPHARYNX

UNKNOWN PRIMARY

UNKNOWNPRIMARYTXN2

SINUS

2-3 : 1ORBITAL INVSN MIN ORBIT INVSN NO ORBIT

3-FIELD TECHNIQUE (AP & OPP LATS)- 1 anterior portal and 2 posteriorly tilted lat portals (w/wedges) used- Beams are weighted 2 – 3:1 in favor of the anterior portal- Lateral portals often do not encompass all dz b/c ant tumor extnsn cannot be treated w/lateral portals w/out also exposing both eyes - Lateral portals tilted posteriorly ~ 5o to avoid exit dose thru c/l eye

Single Anterior Portal

Superior: include cribriform plate and all/part of frontal sinus

Inferior: lip commissure to include the maxillary antrum-for maxillary tumors extending into OC, inf border may be lowered to encompass gross dz

Medial: 2 cm across midline to include entire NC, ethmoid-sphenoid complex, and medial c/l orbit

Lateral: entire ipsi orbit should never be completely blocked b/c doing so would also block posteroinferior ethmoid cells and a portion of the maxillary antrum- for no radiographic orbital invsn and min ethmoid dz (C): portal transects ipsi eye just medial to the limbus to preserve lacrimal and retinal function- for no radiographic orbital invsn but extnsv ethmoid dz (not diagramed below): 50% of the orbit included in initial tx field to 4500 cGy - portal is then reduced to transect the ipsi eye just medial to limbus to preserve lacrimal and retinal fcn- for min radiographic orbital invsn (B): orbit included in initial tx field except major lacrimal gland and lateral upper eyelid may be blocked- for clinical orbital invasion (A): entire orbit is included in the initial treatment field

Opposed Lateral Portals (D)

Superior1 cm superior to the roof of the ethmoid sinusesborder is extended 2 – 3 cm superior to the roof of the ethmoid sinuses for intracranial invasion

Inferiorlip commissurefor maxillary tumors extending into the oral cavity, inferior border may be lowered to encompass gross disease

Anterior: lateral bony canthus

Posterior: split VB to avoid dose to brain stem and spinal cord

RECURRENT R-NASAL CAVITY& MAXILLARY SINUS

RIGHT ETHMOIDSINUS

NASAL VESTIBULETx volume if >1.5cm or poorly diff-B/l facial lymphatics (moustache)-Submandib & subdigastric

NASAL VESTIBULE

Opposed lateral techniqueportals angled post to ensure adequate post coverage; wedges added to compensate for angulationAdvantage: Avoid exposure of underlying structures (i.e., brain)Disadvantage: Full skin reaction occurs b/c wax bolus over entire nose is required to ensure homogenous dose distribution

NASAL VESTIBULEAnterior portalconsists of electrons alone or photon-electron mixed beambolus is not applied to the tip of the nose unless it is involved by tumorAdvantage: ease of setupDisadvantage: exposure of underlying structures

WEDGED PAIR PHOTON FIELDUse technique only w/ CT-based planning to define tumor bed, LN groups, and perineural pathways- rec if tx perineural pathways and BOS- max neck xtnsn important to min exit dose thru c/l orbit- if neck xtnsn not eliminatng dose thru c/l orbit, then couch rotated to angulate beams inf

HOMOLATERAL MIXED BEAM FIELDOF PRIMARY & UPPER NECK

PHOTON FIELDSuperior: 2 cm sup to zygomatic archInferior: thyroid notchAnterior: ant border masseter mm (level of 2nd upper molar where Stensen’s duct drains) Posterior: 2 cm post to mastoid

ELECTRON FIELD1 cm larger than photon portal to accommodate constriction of electron isodose lines at depth

• Not rec for pts tX to perineural pathways and BOS• Sim film taken at 100 SSD, which is std for e-• 12–16 MeV e- combined w/ 60Co or 4–6 MV phtns with 80% of the dose given w/ e-• Dose prescibed to depth of deep lobe; ~ 4–5 cm• To reduce dose to cord, place either a wedge in photon field with the heel toward the cord or an electron compensator in e-field to reduce beam depth

THYROID

THYROIDMEDULLARY

THYROIDMEDULLARY

THYROIDMEDULLARY

THYROIDMEDULLARY

SKIN CANCER

L-MEDIAL CANTHUST2N0

(L-ant oblique w/ 9Mev electrons)

MELANOMA