Guidelines for the Management of Head and Neck Cancer

Transcription

1 Guidelines for the Management of Head and Neck Cancer Version: 2 Ref: AngCN-SSG-NH5

2 Contents 1. Introduction General Principles Site Specific Guidelines Oral Cavity Oropharynx Hypopharynx Nasopharynx Larynx Salivary Gland Maxilla, Ethmoid And Sinonasal Lateral Skull Base And Orbit Thyroid Unknown Primary And Neck Nodes Other Tumour Types Lymphoma Sarcoma Melanoma Clinical Trials Portfolio Appendices Appendix 1 - Document Control Appendix 2 - Referral Guidelines For Suspected Head And Neck Cancer Appendix 3 - Referral Guidelines For Suspected Thyroid Cancer Approved and Published April 2010 Reviewed and reissued no changes September 2012 Page 2 of 28

3 1. INTRODUCTION The purpose of these guidelines is to provide a summary guide for the management of patients with head and neck cancer. They should be regarded as a template for best practice but may be individualised according to specific patient requirements. The guidelines for primary care and in hospital referral are in a separate document and can be accessed from the website: 2. GENERAL PRINCIPLES 2.1 Imaging The Imaging guidelines are in a separate document and can be accessed from the Anglia Cancer Network website: Pathology The Pathology guidelines are in a separate document and can be accessed from the Anglia Cancer Network website: Referrals Primary Care Referral Guidelines and Internal Referral Guidelines for non designated clinicians are in separate documents and can be accessed from the website: Approved and Published April 2010 Page 3 of 28

4 3. SITE SPECIFIC GUIDELINES 3.1 Oral Cavity Lip, buccal mucosa, alveolus, hard palate, anterior tongue, floor of mouth Assessment Patients should be referred to the smdt as soon as cancer is strongly suspected on clinical and/or imaging grounds or if it is proven on biopsy. Initial assessment in the smdt includes: Clinical examination by bimanual palpation or EUA as appropriate to assess and document local extent and examination/documentation of lymphadenopathy. Biopsy FNA/core biopsy of primary or lymph nodes Imaging MRI (occasionally CT), CXR (or CT chest) FBC, U&E, LFTs, Ca Dietetic assessment. Consider prophylactic gastrostomy tube insertion Speech and language therapy assessment Dental assessment and OPG Smoking cessation advice Symptom control (e.g. analgesia) Consider baseline audiogram if having chemotherapy TNM Staging T1 T2 T3 T4a T4b N1 N2a N2b N2c N3 M1 Tumour 2cm Tumour > 2 but 4cm Tumour > 4 cm Tumour invades through cortical bone, into the deep/extrinsic muscles of the tongue (genioglossus, hyoglossus, palatoglossus and styloglossus), maxillary sinus or skin of the face Tumour invades masticator space, pterygoid plates, skull base or encases internal carotid artery Single ipsilateral node 3cm Single ipsilateral node > 3 but 6cm Multiple ipsilateral nodes 6cm Bilateral or contralateral nodes 6cm Any node >6cm Distant metastases present Treatment T1 T2 (<3cm) N0/1 Surgery alone, consider brachytherapy if available Surgery alone is usually the preferred treatment but if local expertise in brachytherapy exists this can be used instead, with or without external beam RT. Approved and Published April 2010 Page 4 of 28

5 Where a local excision is performed without a flap, a clinically node negative neck should be treated prophylactically if the risk of occult nodal metastases if >20%. In practice this is best correlated with depth of invasion. If the depth of the primary is 4mm, or the tumour is T2, the neck should be treated with either a selective neck dissection or prophylactic RT. When a free flap is used to reconstruct the deficit a selective neck dissection is performed. Lip tumours involving the commissure are best treated with radiotherapy. Other lip tumours can be treated with surgery or radiotherapy depending on likely cosmesis and function and on patient preference T2 (>3cm) T3 T4 or N2/3 Surgery and adjuvant (chemo)radiation Surgery followed by adjuvant (chemo)radiation provides best local control and long term cure If the tumour is inoperable (or patient declines surgery e.g. total glossectomy) consider primary (chemo)radiation Management of relapse. Any patient with suspected or proven recurrence should be reassessed by the smdt clinic. Palliation with symptomatic and supportive care, chemotherapy and/or palliative RT is usually paramount. Surgical salvage is sometimes possible and should be considered in fit patients with no distant metastases. Re-irradiation can be considered in selective patients (e.g. long disease free interval, small volume) Follow up Initial post-operative review in smdt clinic 1-2 weeks after discharge to discuss pathology and need for further treatment Weekly assessment during and immediately after chemoradiation until acute effects settling Then review at smdt clinic in 2-6 weeks after completion of all treatment Consider baseline MRI at 3 months if it is difficult to assess recurrence clinically. Follow up visits should assess symptom control and management of long term side effects (e.g. oral pain, xerostomia) as well as looking for locoregional recurrence and second primary tumours. Relevant imaging only in the presence of symptoms. Routine imaging is not recommended TFTs annually if low neck irradiated On going follow up should be tailored to the individual situation. Patients have lifelong access to the smdt clinic through any member of the MDT Consider less frequent appointments in patients without a salvage option. Follow up in smdt clinic as below. If no tumour present and nutrition/swallow normal, follow up can be by a member of the MDT in a general OFMS clinic. 1 st year 1-2 monthly 2 nd year 2-3 monthly 3 rd year 3-6 monthly 4 th and 5 th year 6-12 monthly Approved and Published April 2010 Page 5 of 28

6 3.2 Oropharynx Tonsil, tongue base and soft palate Assessment Patients should be referred to the smdt as soon as cancer is strongly suspected on clinical and/or imaging grounds or if it is proven on biopsy. Initial assessment in the smdt includes: Clinical examination by palpation, nasendoscopy, TNO or EUA as appropriate to assess and document local extent. Examination/documentation of lymphadenopathy. Biopsy FNA/core biopsy of primary or lymph nodes Imaging MRI (occasionally CT), CXR (or CT chest) FBC, U&E, LFTs, Ca Dietetic assessment. Consider prophylactic gastrotomy tube insertion Speech and language therapy assessment Dental assessment and OPG if having radiotherapy Smoking cessation advice Symptom control (e.g. analgesia) Consider baseline audiogram TNM Staging T1 T2 T3 T4a T4b Tumour 2cm Tumour > 2 but 4cm Tumour > 4 cm Tumour involves the larynx, deep muscles of the tongue, medial pterygoid, hard palate or mandible Tumour invades lateral pterygoid muscles or plates, nasopharynx, skullbase or encases carotid artery. Regional lymph node (N) and distant metastasis (M) are as described earlier Treatment T1 T2 N0 Radiotherapy alone Treat bilateral neck for base of tongue or tonsil/soft palate close to midline, unilateral for most tonsil/soft palate tumours. Consider surgery in small soft palate tumours where function is unlikely to be compromised. T3 T4 N+ Chemoradiation (ideally IMRT) or surgery for neck nodes followed by (chemo)radiotherapy Consider induction chemotherapy if good performance status Consider neck dissection before chemoradiation or if neck disease may fungate or if there is residual nodal disease after CRT Approved and Published April 2010 Page 6 of 28

7 3.2.4 Management of relapse. Any patient with suspected or proven recurrence should be reassessed by the smdt clinic. Palliation with symptomatic and supportive care, chemotherapy and/or palliative RT is usually paramount. Surgical salvage is rarely possible but should be considered in fit patients with no distant metastases. Re-irradiation can be considered in selective patients (e.g. long disease free interval, small volume) Follow up Weekly assessment during and immediately after chemoradiation until acute effects settling Then review at smdt clinic in 2-6 weeks Consider PET-CT 3 months after primary chemoradiation to assess need for neck dissection. Follow up visits should assess symptom control and management of long term side effects (e.g. xerostomia) as well as looking for locoregional recurrence and second primary tumours. Relevant imaging only in the presence of symptoms. Routine imaging not recommended TFTs annually if low neck irradiated On going follow up should be tailored to the individual situation. Patients have lifelong access to the MDT clinic through any member of the MDT Consider less frequent appointments in patients without a salvage option. Follow up in smdt clinic as below. If no tumour present and nutrition/swallow normal, follow up can be by a member of the MDT in a general ENT clinic. 1 st year 1-2 monthly 2 nd year 2-3 monthly 3 rd year 3-6 monthly 4 th and 5 th year 6-12 monthly Approved and Published April 2010 Page 7 of 28

8 3.3 Hypopharynx Post cricoid, piriform fossa and posterior pharyngeal wall Assessment Patients should be referred to the smdt as soon as cancer is strongly suspected on clinical and/or imaging grounds or if it is proven on biopsy. Initial assessment in the smdt includes: Clinical examination by palpation, nasendoscopy, TNO or EUA as appropriate to assess and document local extent. Examination/documentation of lymphadenopathy. Biopsy FNA/core of primary or lymph nodes Imaging MRI (occasionally CT), CXR (or CT chest) FBC, U&E, LFTs, Ca Dietetic assessment. Consider prophylactic gastrotomy tube insertion Speech and language therapy assessment Dental assessment and OPG if having radiotherapy Smoking cessation advice Symptom control (e.g. analgesia) Consider baseline audiogram TNM Staging T1 T2 T3 T4a T4b Tumour 2cm and limited to one subsite Tumour > 2 but 4cm or invades more than one subsite of the hypopharynx or an adjacent site, without fixation of the hemilarynx Tumour > 4 cm or with fixation of the hemilarynx Tumour invades any of thyroid or cricoid cartilage, hyoid bone, thyroid gland, oesophagus or central compartment soft tissue Tumour invades prevertebral fascia, encases carotid artery or invades mediastinal structures Regional lymph node (N) and distant metastasis (M) are as described earlier Treatment T1 T2 N0 Radiotherapy alone Either surgery or radiotherapy can be used but as clear margins and good pharyngolaryngeal function are difficult to achieve with surgery, radiotherapy is preferred. T3 T4 N+ Usually surgery and adjuvant (chemo)radiation or chemoradiation alone Most hypopharyngeal cancers are locally advanced at presentation and many patients have had significant smoking and alcohol exposure and cardiac, respiratory and other comorbidities. The options for treatment range from a pharyngolaryngectomy with adjuvant (chemo)radiation or (chemo)radiation alone to palliative care. Approved and Published April 2010 Page 8 of 28

9 3.3.4 Management of relapse. Any patient with suspected or proven recurrence should be reassessed by the smdt clinic. Palliation with symptomatic and supportive care, chemotherapy and/or palliative RT is usually paramount. Surgical salvage is rarely possible but should be considered in fit patients with no distant metastases. Re-irradiation can be considered in selective patients (e.g. long disease free interval, small volume) Follow up Initial post-operative review in smdt clinic 2 weeks after discharge to discuss pathology and need for further treatment Weekly assessment during and immediately after chemoradiation until acute effects settling Then review at smdt clinic in 2-6 weeks Consider PET-CT 3 months after primary chemoradiation to assess need for neck dissection. Follow up visits should assess symptom control and management of long term side effects (e.g. xerostomia) as well as looking for locoregional recurrence and second primary tumours. Relevant imaging only in the presence of symptoms. Routine imaging not recommended TFTs annually if low neck irradiated On going follow up should be tailored to the individual situation. Patients have lifelong access to the MDT clinic through any member of the MDT Consider less frequent appointments in patients without a salvage option. Follow up in smdt clinic as below. If no tumour present and nutrition/swallow normal, follow up can be by a member of the MDT in a general ENT clinic. 1 st year 1-2 monthly 2 nd year 2-3 monthly 3 rd year 3-6 monthly 4 th and 5 th year 6-12 monthly Approved and Published April 2010 Page 9 of 28

10 3.4 Nasopharynx Assessment Patients should be referred to the smdt as soon as cancer is strongly suspected on clinical and/or imaging grounds or if it is proven on biopsy. Initial assessment in the smdt includes: Clinical history and examination and nasendoscopy and/or examination under anaesthetic. Examination/documentation of lymphadenopathy Biopsy FNA/core biopsy of primary or lymph nodes Imaging - MRI scan of head and neck. Consider CT head and neck, CT thorax and upper abdomen. Consider bone scan in extensive disease or if alkaline phosphate raised FBC, U&E, LFTs, Ca Dietetic assessment. Consider prophylactic gastrotomy tube insertion Speech and language therapy assessment Dental assessment and OPG if having RT Sperm storage pre chemotherapy should be offered to male patients Symptom control (e.g. analgesia) Consider baseline audiogram TNM Staging T1 T2 T3 T4 N1 N2 N3 M0 M1 Tumour confined to the nasopharynx Extension to the oropharynx or nasal cavity A: Without parapharyngeal extension B: With parapharyngeal extension Bone invasion and or paransal sinuses Cranial nerve palsies, extension to the infratemporal fossa, intracranial extension. Unilateral lymph nodes 6 cm above supraclavicular fossa Bilateral lymph nodes 6cm above supraclavicular fossa. Unilateral or bilateral nodes(s) > 6 cm or nodes in the supraclavicular fossa No evidence of distant metastasis Distant metastasis Histopathology Majority of tumours are carcinoma. WHO classification: Type 1: keratinizing squamous cell carcinoma Type 2: Nonkeratinising carcinoma Type 3: Undifferentiated carcinoma. Approved and Published April 2010 Page 10 of 28

11 3.4.4 Treatment There is no established role for primary surgery even with bulky nodal metastases. T1/2 and N0/1 External beam radiotherapy T3/4 or N2/3 Combined chemo-radiotherapy Management of relapse Consider re-irradiation or brachytherapy for local recurrence Neck dissection may be considered for regional relapse. Early involvement of palliative care team for incurable disease Distant metastases may benefit from palliative chemotherapy Follow-up Weekly assessment during and immediately after chemoradiation until acute effects settling Then review at smdt clinic in 2-6 weeks Follow up visits should assess symptom control and management of long term side effects (e.g. xerostomia) as well as looking for locoregional recurrence and second primary tumours. Relevant imaging only in the presence of symptoms. Routine imaging not recommended TFTs annually Patients will need long term dental support. On going follow up should be tailored to the individual situation. Patients have lifelong access to the MDT clinic through any member of the MDT Consider less frequent appointments in patients without a salvage option. Follow up in smdt clinic as below. If no tumour present and nutrition/swallow normal, follow up can be by a member of the MDT in a general ENT clinic. 1 st year 1-2 monthly 2 nd year 2-3 monthly 3 rd year 3-6 monthly 4 th and 5 th year 6-12 monthly Approved and Published April 2010 Page 11 of 28

12 3.5 Larynx Supraglottis - laryngeal ventricle, ventricular bands (false cords), arytenoid cartilages (except vocal process), laryngeal surface of aryepiglottic folds, infrahyoid epiglottis, suprahyoid epiglottis (laryngeal surface, lingual surface and tip) Glottis - vocal cords including vocal process of arytenoids, anterior commissure, posterior commissure Subglottis - under-surface of vocal cords to lower border of cricoid cartilage Assessment Patients should be referred to the smdt as soon as cancer is strongly suspected on clinical and/or imaging grounds or if it is proven on biopsy. Initial assessment in the smdt includes: Clinical examination by palpation, nasendoscopy, TNO or EUA as appropriate to assess and document local extent. Examination/documentation of lymphadenopathy. Biopsy FNA/core of primary or lymph nodes Imaging CT (occasionally MRI), CXR (or CT chest). Patients with small mid-cord T1 cancer do not need a CT. Patients having radiotherapy for any T1 cancer can have a radiotherapy planning CT reported instead of a diagnostic CT. FBC, U&E, LFTs, Ca Dietetic assessment. Consider prophylactic gastrotomy tube insertion Speech and language therapy assessment Smoking cessation advice Symptom control (e.g. analgesia) Staging Supraglottis T1 T2 T3 T4a T4b Tumour limited to one subsite of supraglottis with normal vocal cord mobility Tumour invades another subsite of the supraglottis, or invades glottis, or invades mucosa of region outside supraglottis Tumour limited to larynx with vocal cord fixation and/or invades postcricoid area or preepiglottic tissues Tumour invades through thyroid cartilage, and/or extends into soft tissues of neck beyond larynx Tumour invades prevertebral space, surrounds carotid artery or extends into anterior thoracic cavity Glottis T1 T2 T3 Tumour limited to vocal cord with normal mobility T1a Limited to one vocal cord T1b Involves both vocal cords or commissure Tumour extends to supraglottis and/or subglottis and/or reduced vocal cord mobility Tumour limited to larynx with vocal cord fixation and/or invades paraglottic space or minor thyroid cartilage invasion Approved and Published April 2010 Page 12 of 28

13 T4a T4b Tumour invades through thyroid cartilage and/or extends to other tissues beyond larynx Tumour invades prevertebral space, surrounds carotid artery or extends into anterior thoracic cavity Subglottis T1 T2 T3 T4a T4b Tumour limited to subglottis Tumour extends to vocal cord(s) with normal or impaired mobility Tumour limited to larynx with vocal cord fixation Tumour invades through cricoid or thyroid cartilage and/or extends to other tissues beyond the larynx Tumour invades prevertebral space, surrounds carotid artery or extends into anterior thoracic cavity Regional lymph node (N) and distant metastasis (M) are as described earlier Treatment T1, T2 Surgery or radiotherapy Cure and organ preservation is expected with either radiotherapy or laser resection. The choice is governed by patient desires, and acceptance of possible poorer voice outcome with laser resection if the anterior commissure is involved. Difficult access for laser surgery is a contra-indication for this modality. Treatment of the N0 neck should be considered in supraglottic tumours as the incidence of occult metastases is higher, particularly if the tumour involves the aryepiglottic folds. This will make it more likely that radiotherapy is treatment of choice T3, T4a Chemoradiation or surgery Most of these tumours should be treated with laryngeal preservation as the goal. Cure rates with chemoradiation and salvage surgery are as good as those with primary laryngectomy provided there is close follow up to detect and treat residual or recurrent disease. Treatment of the neck is indicated even in N0 necks as the incidence of occult metastases is higher, particularly in supraglottic tumours. T4b Surgery and adjuvant (chemo)radiation Total laryngectomy. Surgery will usually be followed by radiotherapy. All patients will be considered for surgical voice restoration with tracheooesophageal valve placement as a primary procedure (done at time of admission for laryngectomy) Management of relapse. Any patient with suspected or proven recurrence should be reassessed by the smdt clinic. Laser resection or open partial laryngectomy for localised low volume recurrence after radiotherapy is possible and should be considered For all other cases total laryngectomy is the treatment of choice for recurrent disease, with neck dissection on the side of the disease regardless of node status Palliation with symptomatic and supportive care, chemotherapy and/or palliative radiotherapy can be considered Approved and Published April 2010 Page 13 of 28

14 3.5.5 Follow up Initial post-operative review in smdt clinic 1-2 weeks after discharge to discuss pathology and need for further treatment Weekly assessment during and immediately after chemoradiation until acute effects settling Then review at smdt clinic in 2-6 weeks Follow up visits should assess symptom control and management of long term side effects as well as looking for locoregional recurrence and second primary tumours. Relevant imaging only in the presence of symptoms. Routine imaging not recommended TFTs annually if low neck irradiated On going follow up should be tailored to the individual situation. Patients have lifelong access to the MDT clinic through any member of the MDT Consider less frequent appointments in patients without a salvage option. Follow up in smdt clinic as below. If no tumour present and nutrition/swallow normal, follow up can be by a member of the MDT in a general ENT clinic. 1 st year 1-2 monthly 2 nd year 2-3 monthly 3 rd year 3-6 monthly 4 th and 5 th year 6-12 monthly Approved and Published April 2010 Page 14 of 28

15 3.6 Salivary gland Approximately 20% of parotid tumours, 35%-40% of submandibular tumours and 50% of minor salivary gland tumours are malignant Assessment Patients with suspected salivary gland tumours should be referred to a member of the H&N smdt for investigation and surgery When salivary gland cancer is discovered unexpectedly after initial surgery for what was believed to be a benign condition, the patient should be referred immediately to a head and neck cancer smdt which specialises in salivary gland cancers. Initial assessment in the smdt includes: Clinical examination by palpation, nasendoscopy, and examination/documentation of lymphadenopathy Biopsy FNA/core biopsy of primary or lymph nodes Imaging MRI (occasionally CT), CXR (or CT chest) FBC, U&E, LFTs, Ca Dietetic advice Speech and Language therapy assessment Dental assessment and OPG if having RT Smoking cessation advice Symptom control (e.g. analgesia) Consider baseline audiogram TNM Staging T1 T2 T3 T4a T4b Tumour 2cm without extrapareynchymal spread Tumour > 2 but 4cm without extraparenchymal spread Tumour > 4cm and/or tumour with extraparenchymal extension Tumour invades skin, mandible, ear canal, or facial nerve Tumour invades base of skull, pterygoid plates or encases carotid artery Regional lymph node (N) and distant metastasis (M) are as described earlier Treatment Surgery +/- adjuvant radiotherapy. Low-grade malignancies of the superficial portion of the parotid gland are excised with a cuff of normal parotid tissue. For all other lesions, a total conservative parotidectomy is usually indicated. The facial nerve or its branches should be resected only if involved by tumour. This is generally evidenced by clinical facial nerve weakness. Adjuvant radiotherapy unless low grade and completely excised The incidence of lymph node metastases is generally low. Neck dissection is recommended for patients presenting with positive nodes but otherwise the neck is managed expectantly. Approved and Published April 2010 Page 15 of 28

16 3.6.4 Management of relapse. Any patient with suspected or proven recurrence should be reassessed by the smdt clinic. Palliation with symptomatic and supportive care, chemotherapy and/or palliative radiotherapy. Surgical salvage is sometimes possible but should be considered in fit patients with no distant metastases. Re-irradiation can be considered in selective patients (e.g. long disease free interval, small volume) Follow up Initial post-operative review in smdt clinic1-2 weeks after discharge to discuss pathology and need for further treatment Weekly assessment during and immediately after radiotherapy until acute effects settling Then review at smdt clinic in 2-6 weeks Follow up visits should assess symptom control and management of long term side effects (e.g. xerostomia) as well as looking for locoregional recurrence and second primary tumours. Relevant imaging only in the presence of symptoms. Routine imaging not recommended On going follow up should be tailored to the individual situation. Patients have lifelong access to the MDT clinic through any member of the MDT Consider less frequent appointments in patients without a salvage option. Follow up in smdt clinic as below. If no tumour present and nutrition/swallow normal, follow up can be by a member of the MDT in a general OFMS or ENT clinic. 1 st year 3 monthly 2 nd year 3-4 monthly 3 rd year 6 monthly 4 th and 5 th year 6-12 monthly Approved and Published April 2010 Page 16 of 28

17 3.7 Maxilla, ethmoid and sinonasal Assessment Patients should be referred to the smdt as soon as cancer is strongly suspected on clinical and/or imaging grounds or if it is proven on biopsy. Clinical examination by palpation and nasendoscopy to assess and document local extent. Examination/documentation of lymphadenopathy. Biopsy to obtain representative tissue. An endoscopic nasal approach should be used to avoid transgression of tissue planes Imaging MRI scans are often more useful than CT scans in delineating the extent of the primary tumour and differentiation from inflammatory mucosal disease or retained secretions. CT for definition of bone erosion. CXR (or CT chest) FBC, U&E, LFTs, Ca Dietetic assessment. Consider prophylactic gastrotomy tube insertion Speech and language therapy assessment Dental assessment and OPG if having radiotherapy Smoking cessation advice Symptom control (e.g. analgesia) Hearing loss is common following maxillectomy - baseline audiogram Refer to anterior skull base and oculoplastic teams as appropriate TNM staging Maxilla T1 Tumour limited to maxillary sinus mucosa, no bone erosion or destruction T2 Tumour causing bone erosion or deconstruction including extension into the hard plate and/or middle nasal meatus, except extension to posterior wall of maxillary sinus and pterygoid plates T3 Tumour invades any of the following: bone of the posterior wall of maxillary sinus, subcutaneous tissues, floor or medial wall of orbit, pterygoid fossa, ethmoid sinuses T4a Tumour invades anterior orbital contents, skin of cheek, pterygoid plates, infratemporal fossa, cribriform plate, sphenoid or frontal sinus T4b Tumour invades any of the following: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than maxillary division of trigeminal nerve (V2), nasopharynx, or clivus Nasal cavity and Ethmoid T1 Tumour restricted to any one subsite (septum, floor, lateral nasal wall and vestibule) with or without bony invasion T2 Tumour invading two subsites in a single region or extending to involve an adjacent region within the nasoethmoidal complex, with or without bony invasion T3 Tumour extends to invade the medial wall or floor of the orbit, maxillary sinus, palate, or cribriform plate T4a Tumour invades and of the following: anterior orbital contents, skin of the nose or cheek, minimal extension to anterior cranial fossa, pterygoid plates, sphenoid or frontal sinuses T4b Tumour invades any of the following: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than nasopharynx or clivus Regional lymph node (N) and distant metastasis (M) are as described earlier Approved and Published April 2010 Page 17 of 28

18 3.7.3 Treatment Surgery and adjuvant radiotherapy Radiotherapy can be omitted if T1, completely excised and favourable and may be omitted in sinonasal melanoma The incidence of lymph node metastases is generally low (approximately 20% of all cases). Neck dissection is only recommended for patients presenting with positive nodes Management of relapse. Any patient with suspected or proven recurrence should be reassessed by the smdt clinic. Palliation with symptomatic and supportive care, chemotherapy and/or palliative RT is usually paramount. Surgical salvage is rarely possible but should be considered in fit patients with no distant metastases. Re-irradiation can be considered in selective patients (e.g. long disease free interval, small volume) Follow up Initial post-operative review in smdt clinic 1-2 weeks after discharge to discuss pathology and need for further treatment Weekly assessment during and immediately after chemoradiation until acute effects settling Then review at smdt clinic in 2-6 weeks Consider baseline MRI at 3-6 months. Subsequent imaging only in the presence of symptoms. Routine imaging not recommended Follow up visits should be tailored to symptom control and management of long term side effects and the need for supportive therapy (speech, swallowing, physiotherapy, social and psychological support) as well as looking for locoregional recurrence On going follow up should be tailored to the individual situation. Patients have lifelong access to the MDT clinic though any member of the MDT Consider less frequent appointments in patients without a salvage option. Follow up in smdt clinic as below. If no tumour present and nutrition/swallow normal, follow up can be by a member of the MDT in a general ENT clinic. 1 st year 1-2 monthly 2 nd year 2-3 monthly 3 rd year 3-6 monthly 4 th and 5 th year 6-12 monthly Approved and Published April 2010 Page 18 of 28

19 3.8 Lateral skull base and orbit Tumours invading the base of skull/orbit should be investigated within the smdt but referred promptly to a team specializing in skull base tumours. Anterior skull base tumours usually arise from the ethmoid sinuses and are managed by a team with expertise in craniofacial surgery (e.g. ethmoids see 3.7). Lateral skull base tumours (e.g. involving the petrous temporal bone) should be referred to a team with appropriate surgical expertise. Tumours originating in or involving the orbit should be managed in conjunction with the oculoplastic team Adjuvant radiotherapy and rehabilitation after surgery should be carried out as near to the patient s home as possible. Excellent communication between the referring team and specialist surgical team is essential Assessment Patients should be referred to the smdt as soon as cancer is strongly suspected on clinical and/or imaging grounds or if it is proven on biopsy. Clinical examination by palpation and nasendoscopy. Assess and document local extent, involvement of cranial nerves. Examination/documentation of lymphadenopathy. Biopsy to obtain representative tissue. Consider an endoscopic nasal approach Imaging MRI scans are often more useful than CT scans in delineating the extent of the primary tumour, intracranial extension and differentiation from inflammatory mucosal disease or retained secretions. CT for definition of bone erosion. CXR (or CT chest) FBC, U&E, LFTs, Ca Dietetic assessment. Consider prophylactic gastrotomy tube insertion Speech and language therapy assessment Dental assessment and OPG if having RT Smoking cessation advice Symptom control (e.g. analgesia) Hearing loss is common following petrosectomy - baseline audiogram These patients may require oral and orbital prosthetic rehabilitation Refer to anterior skull base, lateral skull base or oculoplastic multidisciplinary teams as appropriate TNM staging See relevant section e.g , Treatment Surgery and adjuvant radiotherapy Resection when possible (and not precluded by morbidity) with planned postoperative radiotherapy. Approved and Published April 2010 Page 19 of 28

20 The incidence of lymph node metastases is generally low (less than 20% of all cases). Neck dissection is recommended for patients presenting with positive nodes or where the neck is opened for free flap reconstruction Management of relapse. Any patient with suspected or proven recurrence should be reassessed by the smdt clinic. Palliation with symptomatic and supportive care, chemotherapy and/or palliative RT if possible. Surgical salvage is rarely possible but should be considered in fit patients with no distant metastases. Re-irradiation can be considered in selective patients (e.g. long disease free interval, small volume) Follow up Initial post-operative review in smdt clinic 1-2 weeks after discharge to discuss pathology and need for further treatment Weekly assessment during and immediately after chemoradiation until acute effects settling Then review at smdt clinic in 2-6 weeks Consider baseline MRI at 3-6 months. Subsequent imaging only in the presence of symptoms. Routine imaging not recommended Pituitary function should be monitored Follow up visits should be tailored to symptom control and management of long term side effects and the need for supportive therapy (speech, swallowing, physiotherapy, social and psychological support) as well as looking for locoregional recurrence Patients have lifelong access to the MDT clinic though any member of the MDT Consider less frequent appointments in patients without a salvage option. Follow up in smdt clinic as below. If no tumour present and nutrition/swallow normal, follow up can be by a member of the MDT in a general ENT clinic. 1 st year 1-2 monthly 2 nd year 2-3 monthly 3 rd year 3-6 monthly 4 th and 5 th year 6-12 monthly Approved and Published April 2010 Page 20 of 28

21 3.9 Thyroid The management of thyroid cancer has already been the subject of extensive review and the head & neck and thyroid smdts endorse and follow the guidelines from the national bodies (British Thyroid Association). Approved and Published April 2010 Page 21 of 28

22 3.10 Unknown primary and neck nodes Assessment Patients presenting with cervical lymphadenopathy should be referred to a neck lump clinic where facilities for nasendoscopy and biopsy are available. Patients should be referred to the appropriate smdt as soon as cancer is strongly suspected on clinical and/or imaging grounds or if it is proven on biopsy. If the pathology suggests squamous cell carcinoma the patient should then be referred to the head and neck smdt and managed as below For lymphoma refer to haematology. For non head and neck cancers refer to appropriate MDT or oncologist. Initial assessment in the smdt includes: Clinical examination including nasendoscopy or TNO. Examination/documentation of lymphadenopathy. Biopsy FNA/core biopsy of primary or lymph nodes Imaging MRI (occasionally CT), CXR (or CT chest). Consider PET-CT before EUA and biopsies if MRI shows no primary site. Nasendoscopy and examination under anaesthetic with bilateral tonsillectomies and deep biopsies of base of tongue, nasopharynx and piriform fossae (or directed biopsies if indicated by imaging) FBC, U&E, LFTs, Ca Dietetic assessment. Consider prophylactic gastrotomy tube insertion Speech and language therapy assessment Dental assessment and OPG if having radiotherapy Smoking cessation advice Symptom control (e.g. analgesia) Consider baseline audiogram TNM Staging Regional lymph node (N) and distant metastasis (M) are as described earlier Treatment If primary found see protocol for specific tumour site Manage as for oropharynx if high clinical suspicion for tongue base/tonsil primary N1 (Chemo)-radiation or surgery +/- adjuvant chemo(radiation) Either surgery and adjuvant (chemo)radiation if extracapsular spread Or primary (chemo)radiation either to ipsilateral neck alone or to bilateral neck and possible mucosal primary sites N2/3 Chemoradiation or surgery + (chemo)radiaton Approved and Published April 2010 Page 22 of 28

23 Either surgery followed by (chemo)radiation to the ipsilateral neck Or primary (chemo)radiation either to ipsilateral neck alone or to bilateral neck and possible mucosal primary sites. Neck nodes thought to be from a previous skin primary are usually managed with surgery. Adjuvant radiotherapy unless N1 with no extracapsular spread Management of relapse. Any patient with suspected or proven recurrence should be reassessed by the smdt clinic. Palliation with symptomatic and supportive care, chemotherapy and/or palliative RT is usually paramount. Surgical salvage is sometimes possible but should be considered in fit patients with no distant metastases. Re-irradiation can be considered in selective patients (e.g. long disease free interval, small volume) Follow up Initial post-operative review in smdt clinic 1-2 weeks after discharge to discuss pathology and need for further treatment Weekly assessment during and immediately after chemoradiation until acute effects settling Then review at smdt clinic in 2-6 weeks Consider PET-CT 3 months after primary chemoradiation to assess need for neck dissection. Follow up visits should assess symptom control and management of long term side effects (e.g. xerostomia) as well as looking for locoregional recurrence and second primary tumours. Relevant imaging only in the presence of symptoms. Routine imaging not recommended TFTs annually if low neck irradiated On going follow up should be tailored to the individual situation. Patients have lifelong access to the MDT clinic through any member of the MDT Consider less frequent appointments in patients without a salvage option. Follow up in smdt clinic as below. If no tumour present and nutrition/swallow normal, follow up can be by a member of the MDT in a general ENT clinic. 1 st year 1-2 monthly 2 nd year 2-3 monthly 3 rd year 3-6 monthly 4 th and 5 th year 6-12 monthly Approved and Published April 2010 Page 23 of 28

24 4. OTHER TUMOUR TYPES 4.1 Lymphoma Once a diagnosis of lymphoma is made through the H&N smdt referral is made directly to the haematologists who will organise future management. The Haematology MDT is made aware of the diagnosis directly from pathology. 4.2 Sarcoma Patients should be discussed at both the H&N smdt and the sarcoma MDT The Sarcoma MDT offer: Specialist histopathological review and classification. An opinion on the role of chemotherapy, surgery and radiotherapy both at initial presentation and following each treatment modality e.g. the need for post operative radiotherapy. Surgery should be within the appropriate head and neck MDT setting. Specialist surgical referral may be indicated The head and neck clinical oncologists will undertake the radiotherapy element after liaising with a sarcoma team oncologist. The head and neck team have all of the relevant support as regards specialist nurses, dieticians, speech therapist and dental support. Follow up should be conducted by the head and neck team but letters should be copied to the sarcoma team especially in patients who have had chemotherapy as part of their management. 4.3 Melanoma Primary treatment for both cutaneous and mucosal melanoma is surgery. Cutaneous melanoma is normally managed in the skin MDT unless disease is advanced or a neck dissection is being considered. Mucosal melanoma will come through the H&N smdt. See section Paediatric Head and Neck oncology Cervical lymph node biopsies will be carried out by paediatric-trained surgeons. Other head and neck surgery may involve one or more of the surgical specialities (ENT, neurosurgery, maxillofacial, plastics). Neurosurgical cases are referred to Miss Fernandes or Mr Garnett (Addenbrookes). All other cases are to be referred to the Head and Neck MDT via the chair or co-chair (Richard Benson, Sarah Jefferies in Cambridge, Tom Roques in Norwich). Approved and Published April 2010 Page 24 of 28

25 5. CLINICAL TRIALS PORTFOLIO The Manual for Cancer Services 2004 states that one of the responsibilities of the MDT Lead Clinician is To ensure mechanisms are in place to support entry of eligible patients into clinical trials. The infrastructure to support clinical trials activity is the responsibility of the West Anglia, Norfolk & Waveney and Ipswich locality of the Mid-Anglia Cancer Research Networks (WACRN, NWCRN and MACRN) which provide facilities enabling patient entry into clinical trials in all of its units. The Head & Neck NSSG is committed to participation in high quality research studies and clinical trials. Whenever possible, patients should be considered for inclusion in local and national research studies and clinical trials. There is an NSSG agreed single list of clinical trials and research studies supported by the individual MDTs. This is updated at least annually. Further details and protocols are available as follows: Trust Contact Telephone Addenbrooke s Bedford Hinchingbrooke Ipswich James Paget King s Lynn Norfolk & Norwich Papworth Peterborough West Suffolk West Anglia Cancer Research Network West Anglia Cancer Research Network West Anglia Cancer Research Network Mid-Anglia Cancer Research Network Norfolk & Waveney Cancer Research Network West Anglia Cancer Research Network Norfolk & Waveney Cancer Research Network West Anglia Cancer Research Network West Anglia Cancer Research Network West Anglia Cancer Research Network roy.harris@addenbrookes.nhs.uk roy.harris@addenbrookes.nhs.uk roy.harris@addenbrookes.nhs.uk To be confirmed To be confirmed jane.beety@nnuh.nhs.uk roy.harris@addenbrookes.nhs.uk jane.beety@nnuh.nhs.uk roy.harris@addenbrookes.nhs.uk roy.harris@addenbrookes.nhs.uk roy.harris@addenbrookes.nhs.uk Approved and Published April 2010 Page 25 of 28

26 6. APPENDICES Appendix 1 - Document Control Document ratification and history Approved by: NSSG Chairs by in December 2009, Head and Neck NSSG on 17 th March 2010 and Network Board on 21 st April 2010 Review period: 2 years Date placed on electronic library: December 2009 Reviewed and reissued no changes: September 2012 Authors: Tom Roques and Richard Benson Document Owner: Tel: Version number as approved and published: 2 Unique identifier no.: AngCN-SSG-HN5 For clinical comments / amendments to the guidelines, please contact: Clinical Panel Name Hospital Tel. No Tom Roques NNUHFT Tom.roques@nnuh.nhs.uk Richard Benson Addenbrookes Richard.benson@addenbrookes.nhs.uk For copies of guidelines, please refer to the website: Monitoring the effectiveness of the Process a) Process for Monitoring compliance and Effectiveness - Review of compliance as determined by audit. Any non compliance to be presented by the QA Manager to the Business Meeting on an annual basis the minutes of this meeting are retained for a minimum of five years. b) Standards/Key Performance Indicators This process forms part of a quality system working to, but not accredited to, International Standard BS EN ISO 9001:2008. The effectiveness of the process will be monitored in accordance with the methods given in the quality manual, AngCN-QM. Equality and Diversity Statement This document complies with the Suffolk PCT Equality and Diversity statement an EqIA assessment is available on request to QA Manager, Gibson Centre, Exning Road, Newmarket, CB8 7JG. Disclaimer It is your responsibility to check against the electronic library that this printed out copy is the most recent issue of this document. Approved and Published April 2010 Page 26 of 28

27 Appendix 2 - Referral guidelines for suspected head and neck cancer National Institute for Health and Clinical Excellence Approved and Published April 2010 Page 27 of 28

28 Appendix 3 - Referral guidelines for suspected thyroid cancer National Institute for Health and Clinical Excellence Approved and Published April 2010 Page 28 of 28