1. Management of Neck Nodes in Head
and Neck Malignancies: A Radiation
Oncologist’s Perspective
Dr Suman Mallik
Radiation Oncologist
Westbank Cancer Centre
Westbank Health and Wellness Institute

2. Issues
• Where ?
• When ?
• How much ? (Risk stratification)

3. Aims
• Radical
• Prophylactic

4. • Radical
• Adjuvant

5. Situations
• Known Primary
• Unknown Primary

6. Imaging
• USG
• CECT
• MRI
• PET-CT

7. Sources of information
• Anatomy
• Clinical and surgical data
• Pattern of failure data

8. Modified Robbin’s nodal levels
Gregoire V, Radiotherapy Oncol
2013

11. Oral Cavity
3.5%
91%
3.9%
4.8%
Pantvaidya G 2013
698 Neck Dissection
566 oral cancer patient
434 unilateral, 132 bilateral
Tongue(255),
Buccal Mucosa(233)
698 Neck Dissection
566 oral cancer patient
434 unilateral, 132 bilateral
Tongue(255),
Buccal Mucosa(233)
Level I to III 91%
Skip metastasis to level III 13.8%
Skip Metastasis for tongue
primary 19%
Level I to III 91%
Skip metastasis to level III 13.8%
Skip Metastasis for tongue
primary 19%

12. Oral Cavity: determinants for nodal
irradiation
• Primary site
• T stage
• Depth (4 mm Vs 9mm)
• N stage
• Perinodal extension
• LVE, PNI

13. CTV node (oral cavity)
Gregoire V et al R&O 2000, 2006

14. Nasopharynx
Ipsilateral
3%
70%
45%
1%
11%
0% 27%
3%
Skip Metastasis 0.5 to 7.9%

15. CTV node (nasopharynx)
Gregoire V et al R&O 2000, 2006

16. Oropharyngeal Tumor (clinical examn)
Ipsilateral Contralateral
13%
82%
23%
2%
9%
0% 13%
1%
2%
24%
5%
3%
2%
0%
Bataini and Lindberg

17. Oropharyngeal (Pathological)
Clinical N0
Ipsilateral
Clinical N+
Ipsilateral
2%
25%
19%
8%
0% 2%
15%
71%
42%
27%
0% 9%
Candela 1990

18. T1-T2 Tonsil, clinical N0 or N+ (N=228)
• Contralateral Neck failure 8/228 (3.5%)
• For a well lateralized tumor it is safe to
treat neck unilaterally
O’Sullivan B IJROBP 2001

19. CTV node (oropharynx)
Gregoire V et al R&O 2000, 2006

20. Hypopharynx (Pharyngeal wall)
0% 9%
0%
18%
0%
0%
11% 84%
0%
72%
40%
20%
Clinical N0
Ipsilateral
Clinical N+
Ipsilateral
Chao KS IJROBP 2002

21. Hypopharynx (Pyriform sinus)
0% 15%
0%
8%
0%
0%
2% 77%
4%
57%
23%
22%
Clinical N0
Ipsilateral
Clinical N+
Ipsilateral
Chao KS IJROBP 2002

22. CTV node (Hypopharynx)
Gregoire V et al R&O 2000, 2006

23. Larynx (Supraglottic)
6% 18%
18%
9%
2%
2% 70%
48%
17%
16%
Chao KS IJROBP 2002
Clinical N0
Ipsilateral
Clinical N+
Ipsilateral

24. Larynx (Glottic)
0% 21%
29%
7%
7%
9% 42%
71%
24%
2%
Chao KS IJROBP 2002
Clinical N0
Ipsilateral
Clinical N+
Ipsilateral

25. CTV node (larynx)
Gregoire V et al R&O 2000, 2006

26. Contralateral Neck Node
cN+ Bilat cN+ Contralat cN-, pN+ bilat
Oral Tongue 12 33
FOM 27 21
BOT 37 55
Tonsil 16 2
Pharyngeal
wall
50 37
Pyriform Sinus 49 6 59
Supraglottic 39 2 26
Glottic 15
Chao KS IJROBP 2002

27. Unilateral Neck treatment
• Cheek
• Alveolus
• Retromolar trigone
• Early lateralised Tonsil

28. Retropharyngeal Node
Nasopharynx
40%
Oropharynx
4%
Hypopharynx
16%
Larynx
0%
Nasopharynx
86%
Oropharynx
12%
Hypopharynx
21%
Larynx
4%
N0N0 N+N+
Pharyngeal wall
N0= 16%, N+=21%
Soft Palate
N0= 5%, N+=19%
Tonsillar Fossa
N0= 4%, N+=12%
Base of Tongue
N0= 0%, N+=6%
Chao KS, McLaughlin, Chua, Chong

29. Gregoire V et al R&O 2000, 2006

30. Risk Stratification
Target Definitive RT PORT High
risk
PORT
intermediate
risk
CTV1 Gross Tumor, node
and adjacent nodal
region
70 Gy equivalent
Surgical bed with
soft tissue
involvement or
nodal region with
extracapsular
spread
56-60 Gy eqv
Surgical bed
without soft tissue
involvement or
nodal region
without
extracapsular
extension
56-60 Gy eqv
CTV2 Elective nodal
region.
50-60 Gy eqv
Elective nodal
region
50-54 Gy eqv
Elective nodal
region
50-54 Gy eqv
CTV3 Elective nodal
region
50-54 Gy eqv
Elective nodal
region
50 Gy eqv
Elective nodal
region
50 Gy eqv

31. Nodal treatment in N+
• Primary
• Nodal staging
• ECE

32. ECE and nodal size
PIRUS GHADJAR IJROBP 2010

33. Extent of ECE
• The mean and median extent
values of ECE were 1.8 and 1
mm
• ECE 5 mm in 97% and 3 mm in
91% of the 231 LN analyzed.
• The largest percentage of LN
had an ECE of 1 mm (58%)
• In 17 (17%) patients,
infiltration of the adjacent
• muscular fascia was observed,
with mean and median
extension values of 2.8 and
2.0 mm, respectively (range,
1–9 mm).
PIRUS GHADJAR IJROBP 2010

34. CTV in presence of ECE

36. ECE
• For metastatic lymph node the risk of ECE is
associated with lymph node size.
• The extention of EC spread is not related to
lymph node size.
• In 96 % of all ECE, extension is less than 5 mm.
• 1 cm margin over node will cover >99% ECE
but also significantly increase the high dose
volume

37. Delineation of nodal stations
Harari et al 2004
Grégoire V et al Radiother
Oncol 2000;56:135–50.
Grégoire V et al, Radiother
Oncol 2003;69:227–36.
Grégoire V et al, Radiother
Oncol 2013.
RTOG contouring guideline
www.dahanca.dk

38. Metastatic neck node from
unknown primary

39. • Hist and Physical Examination
• Triple scopy
• FNAC/ Biopsy
Biopsy to search primary (Blind biopsy from
nasopharynx, base of the tongue, pyriform
sinus + ipsilateral tonsillectomy)
• HPV, P-16, EBV

40. Imaging
• Local imaging (CECT, MRI, USG)
• Metastatic workup
• CXR/ CT Thorax
• Whole body PET-CT

41. Importance of histology

42. Immunohistochemistry
LCA
CD-45

44. DAHANCA (Grau et al 2000)N=277

45. CUP
• The five-year estimates of neck control, disease-
specific survival and overall survival for radically
treated patients were 51%, 48% and 36%, respectively.
• Oropharynx, hypopharynx and oral cavity being the
most common sites.
• Emerging primaries outside the head and neck region
are primarily located in the lung and oesophagus .
• The most important factor for neck control is nodal
stage (5-year estimates 69% [N1], 58% [N2] and 30%
[N3]).
• Conflicting results on surgery and radiotherapy.
Grau 2000 Head and Neck

46. Post Neck Dissection
N1 disease ECE(-)
Level involved Target area
Level 1 only RT to oral cavity, Waldeyer’s
ring, oropharynx, bilateral neck
Level 2,3 RT to oropharynx and bilateral
neck
Level 4 only RT to Waldeyer’s ring, larynx,
hypopharynx, bilateral neck
Level 5 RT to npx, larynx,
hypopharynx, bilateral neck
OR
OBSERVATION

47. Post Neck Dissection
N2-3 disease ECE(-)
Level involved Target area
Level 1 only RT to oral cavity, Waldeyer’s
ring, oropharynx, bilateral neck
Level 2,3, upper 5 RT to nasopharynx,
oropharynx, hypopharynx,
larynx and bilateral neck
Level 4 only RT to Waldeyer’s ring, larynx,
hypopharynx, bilateral neck
Level 5 RT to npx, larynx,
hypopharynx, bilateral neck
+ Chemotherapy

48. Post Neck Dissection ECE(+)
Level involved Target area
Level 1 only RT to oral cavity, Waldeyer’s
ring, oropharynx, bilateral neck
Level 2,3, upper 5 RT to nasopharynx,
oropharynx, hypopharynx,
larynx and bilateral neck
Level 4 only RT to Waldeyer’s ring, larynx,
hypopharynx, bilateral neck
Level 5 RT to npx, larynx,
hypopharynx, bilateral neck
+ Chemotherapy

50. Take home message
• Optimal clinical examn and imaging modality
• Evolution and evidences of nodal delineation
• Optimal treatment approach
• Multimodality approach