Head & Neck Cancer Clinical Guidelines

Transcription

1 Head & Neck Cancer Clinical Guidelines Head & Neck NSSG on behalf of NECN Document Information Title: NECN Head and Neck Cancer Clinical Guidelines Author: Head and Neck NSSG Members Circulation List: See page 2 Contact Details: Dr E Aynsley, Head and Neck NSSG Chair Telephone: Version History: Date: Version: V5.3 Review Date: May 2016 Document Control Version Date Summary Review Date V Patient pathway and 2ww referral added May 2016 V Oral surgery, sarcoma, salivary gland updated May 2016 V Document reviewed and updated Chairs detail input. May 2016 V Chemotherapy update May 2015 V Updated primary care referral guidelines May

2 Guidelines agreed by: Position: Head and Neck NSSG Chair Name: Dr E Aynsley, Organisation: South Tees NHS FT Date Agreed: Position: Head and Neck NSSG ViceChair Name: Dr S Endersby Organisation: City Hospital Sunderland NHS FT Date Agreed: Position: Medical Director Name: Dr M Prentice Organisation: NHS England in Cumbria and the North East Date Agreed: Position: CYPCG Chair for: 14-1C-111i Pathway Pathways UAT Cancer Name: Liz Rogerson, Assistant Director of Specialised Commissioning Organisation: NHS England in Cumbria and the North East Date Agreed NSSG members agreed the Guidelines on: Date Agreed: Review Date: May

3 CONTENTS The Network have adopted the National Guidelines which can be located via the link below;... 7 CONSULTATIONS... 7 CARCINOMA OF THE PHARYNX... 8 Anatomic Description of Site... 9 Generic MDT Workup In The Pharynx Clinical Staging Imaging NASOPHARYNX Anatomic Description of Site Tumour Type Pathology squamous and other Tumour Staging UICC Regional Lymph Nodes Nasopharynx Stage Grouping: Nasopharynx Additional Pre MDT Workup Specifics of Treatment: Radiotherapy Chemotherapy Follow-Up Schedule and Post Treatment Investigations Management of Recurrent Disease/Salvage OROPHARYNX Anatomic Description of Site Tumour type pathology squamous and other Tumour Staging Additional Pre MDT Workup Oropharynx Dental Assessment Treatment Modality Options In Early/Late Disease Early (Stage I and II) Patients with early oropharyngeal disease Late (Stage III and IV) Patients with advanced oropharyngeal disease Primary Surgery Organ Preservation Specifics of Treatment: Surgery Radiotherapy Chemotherapy Follow-up schedule and post treatment investigations Management of Recurrent Disease/Salvage

4 HYPOPHARYNX Anatomic Description of Site Tumour type pathology squamous and other Tumour Staging Primary Tumour (T) UICC Stage Grouping Additional Pre MDT Workup Management of Neck Specifics Of Treatment: Early Disease Surgery Advanced disease Resection and reconstruction Palliation Radiotherapy Chemotherapy Follow-Up Schedule and Post Treatment Investigations Management of Recurrent Disease/Salvage CARCINOMA OF THE LARYNX Site Subsites Glottis Supraglottis Subglottis Regional Lymph Nodes Glottis Anatomic Description of Site Tumour Type Pathology squamous and other Tumour Staging UICC Additional Pre MDT Workup Early Laryngeal Cancer Advanced Glottic Cancer Management of the Neck in Glottic Cancer Specifics of Treatment: Surgery Radiotherapy Chemotherapy Follow-Up Schedule and Post Treatment Investigations Management of Recurrent Disease/Salvage Supraglottis Anatomic Description of Site Stage Summary... 30

5 Additional Pre MDT workup Early Supraglottic Tumours T Advanced Supraglottic Tumours T Management of the Neck in Supraglottic Cancer Specifics of Treatment: Surgery Radiotherapy Chemotherapy Follow-up schedule and post treatment investigations Management of recurrent disease/salvage Subglottis Anatomic Description of Site Tumour type pathology Tumour Staging UICC Stage Summary Additional Pre MDT Workup Management of the Neck in Subglottic Cancer Specifics of Treatment: Surgery Radiotherapy Chemotherapy Follow-Up Schedule and Post Treatment Investigations Management of Recurrent Disease/Salvage CARCINOMA OF THE ORAL CAVITY and LIP TNM Classification: UICC VERSION Lip and Oral Cavity Anatomical Sites and Subsites Anatomy Rules for Classification Clinical Staging Definition of TNM Confirmation of Diagnosis Examination and biopsy Additional imaging Definitive Treatment Treatment of Primary Tumour Recurrence HEAD AND NECK SARCOMA MDT Management Summary

6 SALIVARY GLANDS Characterisation Confirmation of Diagnosis Submandibular Gland Surgery Radiotherapy Palliation Parotid Gland Surgery Radiotherapy Post-operative Recurrent Disease Minor Salivary Glands Confirmation of diagnosis Treatment Neck Radiotherapy Indications: CONTACTS The Policy and the Named Hospitals for Head and Neck Cancer The Distribution of Neck Lump Clinics Referral Guidelines for Primary Care Practitioners - UAT Patients Distribution Process for Referral Guidelines Network Agreed Referral Proformas Internal Referral Guidelines for Non-Designated Hospital Clinicians Network Agreed Named Hospital for Surgical Treatment Delivery Network MDT Configuration Trust MDT linkages Trust The Distribution of Local Support Teams in the Network Appendix 1 - Referral Guidelines for Primary Care Referral Guidelines for Primary Care Practitioners - UAT Patients Appendix 2 - NSSG Guidelines for Teenage and Young Adults Appendix 3 Teenage and Young Adult Pathway for initial Management Appendix 4 Contact Details Appendix 5 NHS Specialised Services Pathway Appendix 6 - Imaging Guidelines Appendix 7- Chemotherapy Protocols

7 The Network have adopted the National Guidelines which can be located via the link below; Head and Neck National Guidelines CONSULTATIONS All patients with a diagnosis of head and neck cancer must be seen in a multidisciplinary team meeting to allow adequate discussion of the case and appropriate decision-making. Team members should include: Oncologist specialising in head & neck cancer Appropriately trained head & neck surgeons with skills encompassing ablation and reconstruction including free tissue transfer Specialist head and neck nurse Additionally prosthetic support may be required both peri-operatively and in the post operative phase: for example obturation of surgical defects. An appropriately equipped and staffed oral & maxillofacial laboratory is required to support this aspect of care Speech and language therapists for pre-operative counselling regarding possible post-operative speech and swallowing rehabilitation. To assess in conjunction with dietician the nutritional status and need for percutaneous gastrostomy (PEG) or radiographically inserted gastrostomy, (RIG). Specialist anaesthetic assessment may be needed to evaluate co-morbidities that could preclude or increase the risk of general anaesthesia. Smoking and alcohol cessation advisors Data collation officer; Demographic and patient journey information, regarding the cancer care spell and follow up should be collected prospectively in an appropriate electronic database. Diagnosis and assessment services outside the MDT are required to produce sufficient information to merit referral to the MDT. Following which, the MDT will undertake further investigations as appropriate in order to produce a definitive treatment plan as per protocol. It is undesirable for investigations to proceed outside the MDT once a cancer diagnosis is reached. All nebulous neck lumps will be referred to the MDT for discussion. 7

8 Patient pathway 8

9 CARCINOMA OF THE PHARYNX MAIN AUTHOR: Richard Wight PHARYNX The division of the pharynx is summarized in the following table (including base of tongue, soft palate and uvula) (Non-epithelial tumours such as those of lymphoid tissue, soft tissue, bone, and cartilage are not included.) Oropharynx Nasopharynx Hypopharnx C01.9 Base of tongue, C11.0 Superior wall of C13.0 Postcricoid region NOS nasopharynx C02.4 Lingual tonsil C11.1 Posterior wall of nasopharynx C13.1 Hypopharyngeal aspect of aryepicglottic fold C05.1 Soft palate, NOS C11.2 Lateral wall of nasopharynx C13.2 Posterior wall of hypopharynx C05.2 Uvula C11.3 Anterior wall of C13.8 Overlapping lesion nasopharynx C09.0 Tonsillar fossa C11.8 Overlapping lesion C13.9 Hypopharynx, NOS C09.1 Tonsillar pillar C11.9 Nasopharynx, C14.0 Pharynx, NOS NOS C09.9 Tonsil, NOS C14.1 Laryngopharynx C09.8 Overlapping lesion C12.9 Pyriform sinus C14.2 Waldeyer s ring C14.8 Overlapping lesion of lip, oral cavity and pharynx C10.0 Vallecula C10.2 Lateral wall of oropharynx C10.4 Branchial cleft C10.8 Overlapping lesion C10.9 Oropharynx, NOS Anatomic Description of Site Primary Sites and Sub-sites. The pharynx (including base of tongue, soft palate, and uvula) is divided into three regions: nasopharynx, oropharynx and hypopharynx. Each region is further subdivided into specific sites as summarized above. Regional Lymph Nodes. The risk of regional nodal spread from cancers of the pharynx is high. Primary nasopharyngeal tumours commonly spread to retropharyngeal, upper jugular, and spinal accessory nodes, often bilaterally. Oropharyngeal cancers involve upper and mid-jugular lymph nodes, less likely submental / submandibular nodes. 9

10 Hypopharyngeal cancers spread to adjacent parapharyngeal, paratracheal and midand lower jugular nodes. Bilateral lymphatic drainage is common. Metastatic Sites. The lungs are the commonest sites of distant metastases; skeletal or hepatic metastases occur less often. Mediastinal lymph node metastases are considered distant metastases. Generic MDT Workup In The Pharynx All patients should have a chest imaging at presentation. Clinical Staging Clinical staging is employed for squamous cell carcinomas of the pharynx. Assessment is based primarily on inspection, and by indirect and direct endoscopy. Palpation of sites (when feasible) and of neck nodes is essential. Neurologic evaluation of all cranial nerves is required. Imaging studies are essential in clinical staging of pharynx tumours. Imaging Cross-sectional imaging in nasopharyngeal cancer is mandatory to complete the staging process. Computed tomography (CT) staging with axial and coronal thin section technique with contrast is the study of choice. Magnetic resonance imaging (MRI) can provide supplementary information because of its multiplanar capability, superior soft tissue contrast and its sensitivity to skull base and intracranial tumour spread. Radiologic nodal staging should be done to assess adequately the retropharyngeal and cervical nodal status. Cross-sectional imaging in oropharyngeal carcinoma is recommended when the deep tissue extent of the primary tumour is in question. CT (or MRI) may be employed. Radiologic nodal staging should also be done simultaneously. Cross-sectional imaging of hypopharyngeal carcinoma is recommended when the extent of the primary tumour is in doubt, particularly its deep extent in relationship to adjacent structures (i.e., larynx, thyroid, cervical vertebrae, and carotid sheath). CT is preferred currently because of less motion artifact than MRI. Radiologic nodal staging should be done simultaneously. PET is an emerging technology that may have a role in uncertain disease extent. The Network is gaining increased access to the modality and will continue to define its appropriate usage. Pathologic Staging Pathologic staging requires the use of all information obtained in clinical staging in addition to histological study of the surgically resected specimen. The surgeon s evaluation of gross unresected residual tumour must also be included. The pathologic description of any lymphadenectomy specimen should describe the size, number and level of any involved nodes. 10

11 The general pathology services are required to provide a diagnosis sufficient to merit referral to the MDT. The MDT pathology service will produce further reports as referred to in the pathology protocol. NASOPHARYNX Anatomic Description of Site The nasopharynx begins anteriorly at the posterior choana and extends along the plane of the airway to the level of the free border of the soft palate. It includes the vault, the lateral walls including the fossae of Rosenmuller and the mucosa covering the torus tubaris forming the eustachian tube orifice, and the posterior wall. The floor is the superior surface of the soft palate. The posterior margins of the choanal orifices and of the nasal septum are included in the nasal fossa. Parapharyngeal involvement denotes postero-lateral infiltration of tumour beyond the pharyngobasilar fascia. Involvement of the masticator space denotes extension of tumour beyond the anterior surface of the lateral pterygoid muscle, or lateral extension beyond the postero-lateral wall of the maxillary antrum, pterygo-maxillary fissure. Tumour Type Pathology squamous and other (excludes salivary and thyroid) The predominant cancer type is squamous cell carcinoma for all pharyngeal sites. Nonepithelial tumours such as those of lymphoid tissue, soft tissue, bone and cartilage are not included in this system. For nasopharyngeal carcinomas it is recommended that the World Health Organization (WHO) Classification is used (Table 1). Histologic diagnosis is required to use this classification. Table 1. Classification of Nasopharyngeal Carcinoma WHO Classification Former Terminology Type 1. Squamous cell carcinoma Squamous cell carcinoma Type 2. Non-keratinizing carcinoma Transitional cell carcinoma without lymphoid stroma Intermediate cell carcinoma with lymphoid Lymphoepithelial cell carcinoma (Regaud) Type 3. Undifferentiated carcinoma Anaplastic carcinoma, clear cell carcinoma -without lymphoid stroma -with lymphoid stroma Lymphoepithelial carcinoma (Schminke) Tumour Staging UICC 6 Primary Tumour (T) 11

12 TX Primary tumour cannot be assessed T0 No evidence of primary tumour Tis Carcinoma in situ Nasopharynx T1 Tumour confined to the nasopharynx T2 Tumour extends to soft tissues T2a Tumour extends to oropharynx +/- nasal cavity without parapharyngeal extension* T2b Any tumour with parapharyngeal extension* T3 Tumour involves bony structures and/or paranasal sinuses T4 Tumour with intracranial extension and/or involvement of cranial nerves, infratemporal fossa, hypopharynx, orbit, or masticator space *Note: Parapharyngeal extension denotes posterolateral infiltration of tumour beyond the pharyngobasilar fascia. Regional Lymph Nodes Nasopharynx The distribution and the prognostic impact of regional lymph node spread from nasopharynx cancer, particularly of the undifferentiated type, is different than that of other head and neck mucosal cancers and justifies use of a different N classification scheme. NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Unilateral metastasis in lymph node(s). 6 cm or less in greatest dimension, above the supraclavicular fossa* N2 Bilateral metastasis in lymph node(s), 6 cm or less in greatest dimension, above the supraclavicular fossa* N3 Metastasis in a lymph node(s) N3a greater than 6 cm in dimension N3b extension to the supraclavicular fossa* * Midline nodes are considered ipsilateral nodes. Supraclavicular zone or fossa is relevant to the staging of nasopharyngeal carcinoma and is the triangular region originally described by Ho. It is defined by three points: (1) the superior margin of the sternal end of the clavicle; (2) the superior margin of the lateral end of the clavicle; (3) the point where the neck meets the shoulder. Note that this would include caudal portions of Levels IV and V. All cases with lymph nodes (whole or part) in the fossa are considered N3b. 12

13 Stage Grouping: Nasopharynx Stage 0 Tis N0 M0 Stage I T1 N0 M0 Stage IIA T2a N0 M0 Stage IIB T1 N1 M0 T2a N1 M0 T2b N0, N1 M0 Stage III T1 N2 M0 T2a, T2b N2 M0 T3 N0, N1, N2 M0 Stage IVA T4 N0, N1, N2 M0 Stage IVB Any T N3 M0 Stage IVC Any T Any N M1 Additional Pre MDT Workup (outside of generic or specific aspects) EBV specific serologic tests:- IgA anti-viral capsule antigen (VCA) titres. Positive results are principally associated with WHO type 2 and type 3 NPC and more commonly associated with patients of Asian descent. Healthy teeth and surrounding soft tissue are required prior to radiotherapy. Early dental assessment is required with OPG x ray. Treatment to be delivered in hospital or primary dental care setting as appropriate. Treatment modality options in early/late disease in Network and reasons for preference (include EBM references) including multimodality if applicable. Any treatments for referral outside of Network. For management purposes patients are divided into those with type 1 squamous carcinomas (usually well differentiated in the older patient with localised disease at presentation) and those with type 2/3 carcinomas (usually poorly differentiated/ anaplastic in the younger patient presenting with bilateral neck disease). Concurrent chemoradiotherapy is the standard of care using IMRT. 13

14 Specifics of Treatment: Radiotherapy See local department radiotherapy and oncology protocols. Chemotherapy See local department radiotherapy and oncology protocols. Follow-Up Schedule and Post Treatment Investigations EBV specific serologic tests:- IgA anti-viral capsule antigen(vca) titres. In those with a positive result at presentation (WHO type 2 and type 3 NPC) repeat titres for monitoring recurrence may be considered. Follow up schedule: YEAR 1 YEAR 2 YEAR 3 YEAR 4/5 YEAR 5 to 10 4 to 6 weekly 2 monthly 3 to 4 monthly 6 monthly yearly Management of Recurrent Disease/Salvage There is limited scope for salvaging patients in this situation, but local surgery may be applicable to nodal disease and chemotherapy may be an option for systemic disease. 14

15 OROPHARYNX Anatomic Description of Site Oropharynx The oropharynx is the portion of the continuity of the pharynx extending from the plane of the superior surface of the soft palate to the superior surface of the hyoid bone (or floor of the vallecula) and includes the base of tongue, the inferior surface of the soft palate and the uvula, the anterior and posterior tonsillar pillars, the glossotonsillar sulci, the pharyngeal tonsils; the lateral and posteriors walls. Tumour type pathology squamous and other (excludes salivary and thyroid) HISTOPATHOLOGIC GRADE (G): Oropharynx, Hypopharynx GX Grade cannot be assessed G1 Well differentiated G2 Moderately differentiated G3 Poorly differentiated Tumour Staging Primary Tumour (T) TX Primary tumour cannot be assessed T0 No evidence of primary tumour Tis Carcinoma in situ Oropharynx T1 Tumour 2cm or less in greatest dimension T2 Tumour more than 2cm but not more than 4cm in greatest dimension T3 Tumour more than 4cm in greatest dimension T4a Tumour invades the larynx, deep/extrinsic muscle of tongue, medial pterygoid, hard palate, or mandible T4b Tumour invades lateral pterygoid muscle, pterygoid plates, lateral nasopharynx, skull base, or carotid artery. STAGE GROUPING: Oropharynx, Hypopharynx: Identical to Larynx Stage 0 Tis N0 M0 Stage I T1 N0 M0 Stage II T2 N0 M0 Stage III T1, T2 N1 M0 T3 N0, N1 M0 T1, T2 N1 M0 Stage IVA T1, T2, T3 N1, N2 M0 T4a, N0, N1, N2 M0 Stage IVB T4b Any N M0 Any T N3 M0 Stage IVC Any T Any N M1 15

16 Additional Pre MDT Workup Oropharynx (outside of generic or specific aspects) Dental Assessment Healthy teeth and surrounding soft tissue are required prior to radiotherapy. Early dental assessment is required with OPG X-ray. Treatment to be delivered in hospital or primary dental care setting as appropriate. EUA Pan- endoscopy, under general anaesthesia, is performed after completion of other staging studies, to accurately assess the surface extent of the tumour and to assess deep involvement by palpation for muscle resistance and to facilitate biopsy. A careful search for other primary tumours of the upper aero-digestive tract is indicated because of the incidence of multiple independent primary tumours occurring simultaneously. Photographs Photographs of accessible tumours. Treatment Modality Options In Early/Late Disease In the Network and reasons for preference (include EBM references) including multimodality if applicable. Any treatments for referral outside of Network Early (Stage I and II) Management of early oropharyngeal cancer should be individualised for each patient. Decisions regarding primary treatment modality should be made in consultation with the patient and should take into account the anatomical location of the tumour and availability of local expertise. Patients with early oropharyngeal disease may be treated by either primary resection with reconstruction as appropriate +/- neck dissection (selective neck dissection encompassing levels II-IV) or external beam radiotherapy encompassing the primary tumour and first echelon nodes. In well lateralised tumours prophylactic treatment of the ipsilateral neck is considered (contralateral neck left alone). Bilateral treatment of the neck is recommended when the incidence of occult disease in the contralateral neck is high (i.e. base of tongue). Postoperative radiotherapy should be considered for patients with clinical and pathological features that indicate a high risk of recurrence. Late (Stage III and IV) Management of late oropharyngeal cancer should be individualised for each patient. Decisions regarding primary treatment modality should be made in consultation with the patient and should take into account the anatomical location of the tumour and availability of local expertise. In patients where surgical resection is possible, the likelihood of obtaining adequate surgical margins with acceptable morbidity, functional outcome and quality of life must be taken into account. Patients with advanced oropharyngeal disease 16

17 May be treated by either primary resection (if a clear surgical margin can be obtained) or an organ preservation approach. Primary Surgery Resection should be followed by reconstruction as appropriate. Transoral resection using either the surgical robot or laser microsurgery is now a recognised option for patients. Patients having surgery who are N+ should have a neck dissection. In well lateralised tumours prophylactic treatment of the ipsilateral neck is considered (contralateral neck left alone). Prophylactic treatment of the contralateral neck should be considered especially when tumours encroach on the midline. PET-CT is an emerging technology that may have a role in uncertain disease extent. The Network is gaining increased access to the modality and will continue to define its appropriate usage. Post-operative radiotherapy to the primary site should be considered for patients with adverse pathological features that indicate a high risk of recurrence (see below). Post-operative chemoradiotherapy is generally offered for positive margins and extracapsular spread. Patients treated with primary laser resection and neck dissection should have post-operative (chemo)radiotherapy to primary site and neck with involved nodes. Organ Preservation Radiotherapy should be administered with chemotherapy in those with high performance status Patients treated with primary chemoradiotherapy with nodal disease should undergo and PET-CT scan at 12 weeks following completion of therapy, to assess nodal response. Nonnormal scans should be discussed at the MDT and the need for neck dissection discussed. We await to results of the PET-Neck study. Specifics of Treatment: Surgery (procedure specifics) The extensive nature of the surgery requires two surgical teams. Tonsil/Posterior pharyngeal wall For early disease trans oral laser surgery is an appropriate treatment option. For late disease, to ensure adequate exposure of the tumour ipsilateral paramedian mandibulotomy is generally the most effective and when carried out in the most appropriate site results in little morbidity. Flap reconstruction Soft palate Tumours in this area tend to appear on the free edge of the soft palate or uvula, are predominantly T1 or T2 at presentation, and can be treated effectively by either endoscopic 17

18 resection, with or without the CO2 laser, or by radical radiotherapy. If they are larger and radical resection is employed effective, functional reconstruction is a challenge and frequently results in significant morbidity. Base of tongue Transoral techniques are possible and the surgical robot has advanced conservative resection for this site. Due to its high morbidity total glossectomy combined with total laryngectomy is usually only applicable if other treatment avenues have been exhausted e.g. if there is recurrence in an otherwise fit and highly motivated patient. Adverse pathological features indicating post operative therapy should be considered:- - advanced T stage -close or positive surgical margins -perineural invasion -lymphovascular invasion -any positive lymph nodes, but especially if > 1 -positive nodes at level Iv or V -any node > 3 cm -extracapsular lymph node spread Radiotherapy See local department radiotherapy and oncology protocols Chemotherapy See local department radiotherapy and oncology protocols Follow-up schedule and post treatment investigations YEAR 1 YEAR 2 YEAR 3 YEAR 4/5 YEAR 5 to 10 4 to 6 weekly 2 monthly 3 to 4 monthly 6 monthly yearly Management of Recurrent Disease/Salvage In general, surgery is used for recurrent disease if it is resectable. Post-operative radiotherapy is used if it has not been given before. Chemotherapy may have a palliative role. 18

19 HYPOPHARYNX Anatomic Description of Site The hypopharynx is that portion of the pharynx extending from the plane of the superior border of hyoid bone (or floor of vallecula) to a plane corresponding to the lower border of cricoid cartilage and includes pyriform fossae (right and left), lateral and posterior hypopharyngeal walls, and postcricoid region. Post cricoid area extends from the level of the arytenoid cartilages and connecting folds to the inferior border of cricoid cartilage and connects the two pyriform sinuses thus forming the anterior wall of the hypopharynx. The pyriform sinus extends from the pharyngoepiglottic fold to the upper end of the oesophagus at the lower border of cricoid cartilage and is bounded laterally by the lateral pharyngeal wall and medially by the lateral surface of the aryepicglottic fold, arytenoid and cricoid cartilages. The posterior pharyngeal wall extends from the level of the superior surface of the hyoid bone (or floor of the vallecula) to the inferior border of cricoid cartilage and from the apex of one pyriform sinus to the other. Tumour type pathology squamous and other (excludes salivary and thyroid) Most are squamous carcinomas, and may include high-grade basaloid variants which have a poorer prognosis. Rarely sarcomas can arise. Tumour Staging Primary Tumour (T) UICC 6 TX Primary tumour cannot be assessed T0 No evidence of primary tumour Tis Carcinoma in situ T1 Tumour limited to one subsite of hypopharynx and 2 cm or less in greatest dimension T2 Tumour invades more than one subsite of hypopharynx or an adjacent site, or measures >2 cm but < 4 cm in greatest diameter without fixation of hemilarynx T3 Tumour measures > than 4 cm in greatest dimension or with fixation of hemilarynx T4a Tumour invades thyroid/cricoid cartilage, hyoid bone, thyroid gland, oesophagus or central compartment soft tissue* T4b Tumour invades prevertebral fascia, encases carotid artery, or invades mediastinal structures. *Note: Central compartment soft tissue includes prelaryngeal strap muscles and subcutaneous fat. Stage Grouping - see oropharynx above Additional Pre MDT Workup (outside of generic aspects) 19

20 Nutritional status - is frequently impaired in hypopharyngeal lesions and early nutritional assessment and dietetic advice is essential at the earliest opportunity Alcohol counselling - High levels of alcohol consumption are frequently found in association with hypopharyngeal carcinoma, and appropriate support should be instigated early in the care pathway. Pan-endoscopy - under general anaesthesia, is performed after completion of other staging studies, to accurately assess the surface extent of the tumour and to assess deep involvement into prevertebral muscles and to facilitate biopsy. Synchronous primaries may be found within the oesophagus and UADT, as well as submucosal spread a significant distance from the primary. Pan-endoscopy should include tracheoscopy for post cricoid/upper oesophageal lesions to exclude direct tracheal invasion. Apart from CT (see imaging) of the primary, neck and mediastinum, additional information may be provided by barium swallow, to assess distal extent. Pulmonary function tests are required for all patients considered for surgery Treatment modality options in early/late disease in Network and reasons for preference (include EBM references) including multimodality if applicable. Any treatments for referral outside of Network Management of Neck Approximately 2/3 of patients are N+ at presentation. Occult metastases are found in about 40% of neck dissections for N0 staged disease. Pathological studies show spread in the N0 neck occurs to levels II-IV and rarely to levels I or V (25-27). Spread is bilateral in midline or bilateral tumours. Level VI involvement may occur in apical pyriform fossa or post-cricoid tumours. N0 Neck There is very little good randomised control trial or even retrospective evidence on how to manage the node negative neck most effectively. If a patient is having primary radiotherapy then first echelon nodes can be covered with the radiotherapy field. If surgical treatment is used then selective neck dissection of levels II, III, IV as a minimum is recommended, with the inclusion of level VI in those tumours that extend to the postcricoid region or apex of the pyriform fossa. If there is oropharyngeal extension then level I should be included. Bilateral dissection is required for central tumours. N1-3 Neck Comprehensive neck dissection has been the accepted standard for the N+ staged neck. The pattern of invasion of the nodes will dictate whether radical or modified radical dissection is required. This would usually mean a modified radical (functional) dissection for N1-2 disease. Pathological studies suggest that selective neck dissection of levels II - IV may be adequate for N1 disease. Although its use is controversial, there is some comparative 20

21 evidence of its clinical effectiveness. The available evidence on functional and quality of life outcomes suggests that selective neck dissection is superior to comprehensive dissection. Specifics Of Treatment: Treatment planning takes the patient s physical and mental state and wishes into consideration and recommendations may be modified according to individual circumstances. Early Disease T1 and T2 tumours are very infrequent. Single modality treatment of the primary tumour by partial pharyngolaryngectomy, radiotherapy or endoscopic resection has been reported but there is insufficient evidence to distinguish between them on the basis of local control or survival. There is a consensus that optimal treatment for all except the earliest stage tumours is combined surgery and radiotherapy, although there is little in the way of evidence. The validity of survival as a parameter to compare the effectiveness of primary treatment is hindered by the high incidence of regional and distant metastases. Local control appears to be improved by combined surgery and radiotherapy according to the little comparative data that are available. This may improve quality of survival but more data on functional outcomes of treatment is needed. Surgery T1 and T2 Conservation surgical techniques are preferable in early stage disease if feasible. Precise treatment depends on the site of the tumour. Some tumours (limited tumours upper piriform fossa and posterior pharyngeal wall) may be suitable for endoscopic resection and may offer the best functional results and lowest morbidity. The use of different modalities to treat the primary tumour and cervical nodes is appropriate in some circumstances. Resection should be wide enough to provide clear margins because positive margins are a poor prognostic factor. Submucosal tumour spread is more extensive in piriform sinus carcinoma (c.10mm) than postcricoid carcinoma (c.5mm). There appears to be a worse survival if the piriform sinus apex is involved and if disease is bulky. Radiotherapy appears to be less effective in such circumstances. Advanced disease T3-4 tumours are likely to be optimally controlled by combining radical surgery with postoperative radiotherapy. The nature of the surgery depends on the site and extent of the tumour. Some advanced tumours may be suitable for more extensive conservation or endoscopic surgery but most require total laryngectomy with partial pharyngectomy or total pharyngolaryngectomy. Studies concerning conservation surgery (near total laryngectomy and supracricoid hemilaryngopharngectomy) have reported highly selected cases but good functional results in terms of voice function have been described. Concurrent chemoradiotherapy is a very reasonable treatment for patients with a functioning larynx and serviceable swallow. There is little evidence to show a survival advantage with radical surgery over CRT as survival is so poor generally. If a patient does not have a functioning organ, then CRT would be unwise as function would not be restored after therapy, even with a good disease response. 21

22 Resection and reconstruction It is difficult to be dogmatic about individual techniques in the absence of good quality data on functional outcomes. Partial pharyngectomy with or without partial laryngectomy may be used for more advanced tumours. Reconstructive options range from none (small posterior wall defects) through primary closure to flaps. Radial forearm, myofascial, myocutaneous and jejunal patch flaps have all been successfully used to reconstruct partial pharyngectomy defects. Reconstruction of total pharyngolaryngectomy by single stage techniques is the accepted standard. Free jejunal transfer is the technique that is best supported by the literature but tubed free radial forearm free flaps are an appropriate alternative with less donor site morbidity. Anterolateral thigh flaps are becoming more common. More extensive defects involving the oesophagus may require gastric transposition. Palliation Approximately one third of patients are incurable at presentation. The specialist palliative care team should be involved as early as possible in the disease process. Pain can be controlled and local protocols should be followed. Percutaneous endoscopic gastrostomies (PEGs) placed early can help maintain nutrition in an acceptable manner, though some will require open gastrostomies. Radiotherapy Primary radiotherapy with salvage surgery, although only effective in a small number of patients, is a recognised treatment in the UK. Primary radiotherapy is an appropriate treatment for small hypopharyngeal tumours. It is also indicated in those patients who are medically unfit for surgery and can obviate the need for pharyngo-laryngectomy in some circumstances. Whilst primary radiotherapy for advanced tumours does not produce as good survival figures as radical surgery, the quality of studies is impaired by selection bias in favour of surgery for fitter patients. See local department radiotherapy and oncology protocols Chemotherapy See local department radiotherapy and oncology protocols Adverse pathological features indicating post operative therapy should be considered:- - advanced T stage -close or positive surgical margins -perineural invasion -lymphovascular invasion -any positive lymph nodes, but especially if 2 or greater -any node > 3 cm -extracpasular lymph node spread 22

23 Follow-Up Schedule and Post Treatment Investigations Therapeutic intervention frequently involves the thyroid and thyroid function tests should be considered for monitoring for both early and late thyroid failure. If all parathyroids have been removed calcium replacement therapy is required. YEAR 1 YEAR 2 YEAR 3 YEAR 4/5 YEAR 5 to 10 4 to 6 weekly 2 monthly 3 to 4 monthly 6 monthly yearly In lesions involving the postcricoid region, oesophagoscopy to be performed within 3 months of completion of radiotherapy. Neck imaging based on clinical findings. Management of Recurrent Disease/Salvage In general, surgery is used for recurrent disease if it is resectable. Post-operative radiotherapy is used if it has not been given before. Chemotherapy may have a palliative role. 23

24 CARCINOMA OF THE LARYNX The division of the larynx is summarized in the following table: Site Glottis Supraglottis Subglottis Subsites True vocal cords including anterior and posterior commissures Suprahyoid epiglottis Infrahyoid epiglottis Aryepicglottic folds (laryngeal aspect) Arytenoids Ventricular bands (false cords) Subglottis Regional Lymph Nodes. Incidence and distribution of cervical nodal metastases from larynx cancer varies with site of origin and the T category of the primary. The true cords are nearly devoid of lymphatics and rarely spread to regional nodes. The supraglottis has a rich and bilaterally interconnected lymphatic network and primary supraglottic cancers are commonly accompanied by regional lymph node spread. Glottic tumours may spread directly to adjacent soft tissue and prelaryngeal, pretracheal, paralaryngeal and paratracheal nodes as well as upper, mid and lower jugular nodes. Supraglottic tumours spread to upper/midjugular nodes, considerably less commonly to submental/submandibular nodes, but occasionally to retropharyngeal nodes. Glottis Anatomic Description of Site The glottis is composed of the true vocal cords, including the anterior and posterior commissures, superior and inferior surfaces of cords. It occupies a horizontal plane 1cm in thickness, extending inferiorly from the lateral margin of the ventricle. Tumour Type Pathology squamous and other The predominant cancer is squamous cell carcinoma. The staging guidelines are applicable to all forms of carcinoma. A number of variants of squamous carcinoma are found including verrucous, basaloid sqaumous, sarcomatoid (spindle cell), as well as neuroendocrine carcinoma. Cartilage tumours and plasmacytomas can also rarely arise. Tumour Staging UICC 6 Glottis Tis Carcinoma in situ T1 Tumour limited to the vocal cord(s) (may involve anterior or posterior commissure with normal mobility. T1a Tumour limited to one vocal cord T1b Tumour involves both vocal cords T2 Tumour extends to supraglottis and/or subglottis, and/or with impaired vocal cord mobility. T3 Tumour limited to the larynx with vocal cord fixation, and/or invades paraglottic space, and or minor thyroid cartilage erosion (e.g. inner cortex). 24

25 T4a Tumour invades through the thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck including deep extrinsic muscle of the tongue, strap muscles, thyroid or esophagus) T4b Tumour invades prevertebral space or encases carotid artery or invades mediastinal structures Stage 0 Tis N0 M0 Stage I T1 N0 M0 Stage II T2 N0 M0 Stage III T1, T2 N1 M0 T3 N0, N1 M0 T1, T2 N1 M0 Stage IVA T1, T2, T3 N2 M0 T4a, N0, N1, N2 M0 Stage IVB T4b Any N M0 Any T N3 M0 Stage IVC Any T Any N M1 Additional Pre MDT Workup (outside of generic or specific aspects) All patients should undergo a panendoscopy and biopsy, CXR, CT scan of larynx, neck and thorax (for T2 and above) as well as comorbidity scoring. Patients being considered for laryngeal surgery should have pulmonary function tests. Where possible, imaging of the larynx should occur. Treatment modality options in early/late disease in Network and reasons for preference (include EBM references) including multimodality if applicable. Any treatments for referral outside of Network. Early Laryngeal Cancer The Network is currently contributing to the Easter Feasibility Trial. Tis: Evidence suggests carcinoma-in-situ can be reversible with cessation of smoking, and smoking cessation advice supports treatment Excision biopsy is the treatment of choice although excellent control rates can be achieved with both endolaryngeal microsurgery and radiotherapy. Excision with preservation of the vocal ligament if possible is probably the best option; if not then an initial biopsy followed by definitive treatment is indicated. Close follow-up where possible by the same treatment team is important. T1a T1a: A large amount of literature, almost exclusively case series, reports that radiotherapy or endoscopic laser resection offer comparable local control rates for accessible lesions. Patient choice should be the main determinant. There is an unproven but widespread opinion that radiotherapy may offer better voice outcomes for all but mid-cord lesions.. 25

26 Where access for endolaryngeal laser surgery is restricted radiotherapy is the treatment of choice. T1b: Treatment options here are the same as T1a (Radiotherapy, Laser surgery and Partial laryngectomy). In the UK radiotherapy remains the overall treatment of choice. Involvement of the anterior commissure in some series correlates with poorer outcome for both radiotherapy and laser therapy. This may however relate to under-staging of the disease at diagnosis. For partial laryngectomy, excellent oncological results can be obtained, but voice is likely to worse than radiotherapy. The literature supports the belief that continued smoking and alcohol consumption during and after radiotherapy worsens the outcome in terms of local control. T2: Superficial tumours without restricted cord mobility (T2a) can be treated by radiotherapy or surgery. Radiotherapy is preferable for extensive superficial tumours because of better functional results. Tumours impairing cord movement (T2b) are treated with radiotherapy (possibly considering the addition of chemotherapy) or partial laryngectomy. One recent paper reports high local control rates ( %) in patients undergoing induction chemotherapy and partial laryngectomy for T2 glottic carcinoma. In the absence of randomised controlled trial evidence however the impact of combined versus single modality therapy in early glottic cancer remains unclear. Advanced Glottic Cancer T3: Large variations in tumour volume affect treatment outcome in similarly staged tumours. Treatment needs to be individualised, and volume determined based on clinical and CT findings. Bulky disease is treated surgically, while low volume disease is treated primarily with chemoradiotherapy It may be that some T3 tumours are under-staged and are really T4 due to unsuspected cartilage invasion. Treatment options are surgery or radiotherapy or combined therapy. Partial laryngectomy may be suitable for small volume tumours while radiotherapy may be the preferred option for medically unfit patients and can give better voice outcomes. Combined chemoradiotherapy gives superior survival outcomes to radiotherapy alone. In patients unfit for CRT, serious consideration should be given to surgery. A review of prognostic factors in T3 laryngeal cancers concluded that glottic lesions, female patients and N0 disease did better with primary radiotherapy and salvage surgery while patients with pre-operative tracheostomy or N+ disease did better with primary surgery. As the role of chemotherapy is changing, in otherwise fit patients with advanced disease (T3 or T4/N2+) undergoing radical radiotherapy concurrent chemotherapy is offered. T4: Primary surgery with post-operative radiotherapy is the treatment of choice since authors report higher disease-free survival compared with primary radiotherapy. Patients who are not fit for or refuse surgery may be candidates for radiotherapy. In those who are fit see above re concurrent chemotherapy. 26

27 A randomised controlled trial of alternating chemo-radiotherapy compared with radiotherapy alone in patients with advanced inoperable head and neck cancer (including laryngeal) reported higher disease free and overall survival in the combined treatment group. Management of the Neck in Glottic Cancer N0 In early glottic cancer (T1-T2), there should be no need for elective neck treatment as the risk for occult neck metastases is low. There is no Level I or II evidence that elective treatment of the N0 neck in laryngeal cancer improves survival. Elective treatment of the neck inevitably carries some morbidity. Elective neck irradiation is as effective as elective neck dissection. With advanced glottic cancer (T3-T4) and transglottic, cancer there is at the present time a consensus that the neck needs to be treated electively. Treatment of the primary site will determine how the neck is treated. If the primary site is treated with radiotherapy then elective neck radiation via a wider treatment field should be performed. If the primary site is treated with surgery then an appropriate elective neck dissection should be performed. Unilateral glottic cancer would be treated with an ipsilateral selective neck dissection, and a bilateral selective neck dissection for lesions crossing the midline. Levels II, III, IV are at greatest risk. Subglottic extension of glottic cancers cancer tend to spread to the paratracheal nodes (level VI) and these should be included in the bilateral neck dissection. If the paratracheal nodes are positive then the mediastinum should be included in the post-operative radiotherapy fields. In salvage surgery treatment of the N0 neck should always be considered. N+ If radiotherapy (with or without chemotherapy) is used to treat the primary tumour both sides of the neck should be included in the irradiation fields. If post radiotherapy assessment at 6 weeks demonstrates, on clinical examination or CT scan, residual neck disease, then this should be treated with a modified or radical neck dissection. If the primary tumour is treated with surgery then a neck dissection(s) is performed with postoperative radiotherapy for multiple positive nodes (>2), or nodes demonstrating extra capsular spread or node >3cm (N2), vascular invasion or perineural spread. Histological positive paratracheal nodes indicate post-operative radiotherapy to the upper mediastinum. Specifics of Treatment: Surgery (procedure specifics) All patients undergoing laryngeal surgery should be assessed preoperatively by a SALT and considered for surgical voice restoration in laryngectomy. 27

28 Radiotherapy See local department radiotherapy and oncology protocols Chemotherapy See local department radiotherapy and oncology protocols The role of chemotherapy and biologic therapy in laryngeal cancer continues to evolve. Carefully controlled trials of chemotherapy with other treatment modalities should be supported. Patients treated with chemotherapy in conjunction with other modalities outside of trials should be managed in strictly controlled situations. Chemotherapy with radiotherapy may improve larynx preservation rates but remains under investigation. -radiotherapy may be to increase toxicity but the impact on survival remains unclear. The optimal combinations of chemotherapy with differing schedules of radiotherapy have yet to be determined. Further studies and trials for chemotherapy and biological therapy are required and should be supported by the Network for recruitment when available. Studies of chemotherapy on laryngeal preservation have shown that the larynx could be preserved in a quarter to a third of cases without detriment to overall survival. The American VA trial, which has the longest follow-up (median follow-up over 8 years), confirms the larynx can be preserved in up to 2/3 of patients achieving complete or partial response to induction chemotherapy without jeopardising survival. The EORTC trial (of larynx preservation in patients with hypopharyngeal cancers) showed a similar effect. An interim report on a French randomised trial (GETTEC) concerning just 68 patients of a planned 300 accrual showed a worse survival outcome for those receiving induction chemotherapy. Meta-analysis of all three trials demonstrated there were no differences in overall or disease free survival, but a functional larynx was preserved in two thirds of surviving patients. A more recent authoritative meta-analysis (Meta-Analysis of Chemotherapy on Head and Neck Cancer Collaborative Group, MACHNC) confirms a significance benefit from cisplatin and fluorouracil given concurrently with radiotherapy absolute 2 year survival benefit=7%. Such benefits however must be balanced against the side effects of the chemotherapy. Combining chemotherapy concurrently with radiotherapy may be superior to induction or neoadjuvant chemotherapy in advanced head and neck cancers, and may improve overall survival. Two randomised trials have shown improved local control and survival in over 5 years of follow-up in patients receiving an alternating chemo-radiotherapy regime. Follow-Up Schedule and Post Treatment Investigations YEAR 1 YEAR to 6 weekly 2 monthly

29 YEAR 3 YEAR 4/5 YEAR 5 to 10 YEAR 10 3 to 4 monthly 6 monthly Yearly continue under ENT follow if continue to smoke In lesions involving the ventricle direct laryngoscopy to be performed within 3 months of completion of radiotherapy. Neck or chest imaging based on clinical findings Management of Recurrent Disease/Salvage Recurrent or Residual Disease The treatment will depend on whether the patient has been treated with initial irradiation or surgery. Recurrence after previous irradiation is managed with salvage surgery which generally implies total laryngectomy however some authors now report good results with salvage partial laryngectomy The surgical approach for recurrent disease is planned according to the site and extent of the original lesion. Unresectable post-surgical recurrences are treated with radiation. Stomal recurrence, particularly if arising superiorly may be resectable, requiring mediastinal resection with the cardiothoracic team and possible pharyngeal replacement. Palliative radiotherapy may be applicable for stomal recurrence if it is below the previous treatment field. Supraglottis Anatomic Description of Site The supraglottis is composed of the epiglottis (both its lingual and laryngeal aspects), aryepicglottic folds (laryngeal aspect), arytenoids, and ventricular bands (false cords). The epiglottis is divided for staging purposes into suprahyoid and infrahyoid portions by a plane at the level of the hyoid bone. The inferior boundary of the supraglottis is a horizontal plane passing through the lateral margin of the ventricle at its junction with the superior surface of the vocal cord. 29 Tumour type pathology squamous and other (excludes salivary and thyroid) See glottis Tumour staging UICC 6 Supraglottis T1 Tumour limited to one subsite of supraglottis with normal vocal cord mobility T2 Tumour invades mucosa of more than one adjacent subsite of supraglottis or glottis or region outside the supraglottis (e.g. mucosa of base of tongue, vallecula, medial wall of pyriform sinus) without fixation of the larynx.

30 30 T3 Tumour limited to larynx with vocal cord fixation and./or invades any of the following Postcricoid area, pre-epiglottic tissues, paraglottic space, and/or minor thyroid cartilage erosion (e.g. inner cortex) T4A Tumour invades through the thyroid cartilage and or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus). T4B Tumour invades prevertebral space or encases carotid artery or invades mediastinal structures Stage Summary see glottis Additional Pre MDT workup (outside of generic or specific aspects) All patients should undergo a panendoscopy and biopsy, CXR, CT scan of larynx, neck and upper thorax as well as comorbidity scoring. Patients being considered for laryngeal surgery should have pulmonary function tests. Treatment modality options in early/late disease in Network and reasons for preference (include EBM references) including multimodality if applicable. Any treatments for referral outside of Network Early Supraglottic Tumours T1-2 Conservation surgery (including laser endolaryngeal resection) or radiotherapy are alternatives. The choice depends on the tumour distribution and co morbidity/performance status. Consideration should be given to bilateral elective neck treatment by a wider radiotherapy field. Advanced Supraglottic Tumours T3-4 Studies have suggested there is no survival advantage for T3 laryngeal cancers in performing laryngectomy with or without post operative radiotherapy, compared to radical radiotherapy with salvage surgery, but that primary laryngectomy with post operative radiotherapy does confer a significant survival advantage in T4 laryngeal disease compared to radical radiotherapy, with if necessary, salvage surgery. The only prospective randomised trial for advanced laryngeal cancer suggests that total laryngectomy with post operative radiotherapy confers no survival advantage when compared to induction chemotherapy followed by radiotherapy, and if necessary salvage laryngectomy. This may suggest chemoradiation to be the treatment of choice in low volume T3 laryngeal disease, but that primary surgery with follow up radiotherapy should be considered for high volume T3 supraglottic disease. Primary surgery does have the advantage of allowing access to the neck nodes. Midline cancers must have both sides of the neck treated. Patients with supraglottic tumours involving the pre-epiglottic space or upper piriform fossae may be suitable for an extended supraglottic or subtotal laryngectomy rather than total laryngectomy.

31 To perform conservation laryngeal surgery the patient must have good health and pulmonary function otherwise total laryngectomy is the surgical option of choice. As the role of chemotherapy is changing, in otherwise fit patients with advanced disease (T3 or T4/N2+) undergoing radical radiotherapy concurrent chemotherapy is offered. Management of the Neck in Supraglottic Cancer N0 In T2 and above stages of supraglottic cancer there is at the present time a consensus that the neck needs to be treated electively. Treatment of the primary site will determine how the neck is treated. If the primary site is treated with radiotherapy then elective neck radiation should be performed, usually with extended fields. If the primary site is treated with surgery then an appropriate bilateral selective neck dissection is performed. N+ If radiotherapy (with or without chemotherapy) is used to treat the primary tumour both sides of the neck should be included in the irradiation fields. If post radiotherapy assessment at 6 weeks demonstrates, on clinical examination, ultrasound +/- FNA or CT scan, residual neck disease, then this should be treated with a modified or radical neck dissection. If the primary tumour is treated with surgery then a modified radical neck dissection(s) is performed with post-operative radiotherapy for multiple positive nodes (>2), or nodes demonstrating extra capsular spread or node >3cm (N2), vascular invasion or perineural spread. Histological positive paratracheal nodes would indicate post-operative radiotherapy to the mediastinum. Bilateral dissection is arguably required for all supraglottic disease, but is essential when the disease crosses the midline. Irresectable nodal disease may be palliated by radiotherapy Specifics of Treatment: Surgery (procedure specifics) - see glottis section and neck Radiotherapy - see glottis section and neck Chemotherapy - see glottic section Follow-up schedule and post treatment investigations - see glottic section 31

32 Management of recurrent disease/salvage - see glottic section Subglottis Anatomic Description of Site The subglottis is the region extending from the lower boundary of the glottis to the lower margin of the cricoid cartilage. Tumour type pathology squamous and other (excludes salivary and thyroid) See glottic section Tumour Staging UICC6 Subglottis T1 Tumour limited to the subglottis 32 T2 Tumour extends to vocal cord(s) with normal or impaired mobility T3 Tumour limited to larynx with vocal cord fixation T4a Tumour invades cricoid or thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck including deep extrinsic muscles of the tongue, strap muscles, thyroid or esophagus) T4b Tumour invades prevertebral space or encases carotid artery or invades mediastinal structures Stage Summary see glottis Additional Pre MDT Workup (outside of generic or specific aspects) See glottic section Treatment modality options in early/late disease in Network and reasons for preference (include EBM references) including multimodality if applicable. Any treatments for referral outside of Network. Most tumours are indistinguishable from glottic tumours with subglottic extension. Radiotherapy may be suitable for early tumours, but most present at a late stage often with stridor, and treatment with total laryngectomy and post-operative radiotherapy is indicated. As the role of chemotherapy is changing, in otherwise fit patients with advanced disease (T3 or T4/N2+) undergoing radical radiotherapy concurrent chemotherapy is offered. Management of the Neck in Subglottic Cancer N0

33 In all T stages of subglottic cancer there is at the present time a consensus that the neck needs to be treated electively. Treatment of the primary site will determine how the neck is treated. If the primary site is treated with radiotherapy then elective neck radiation with extended fields should be performed. If the primary site is treated with surgery then an appropriate bilateral selective neck dissection to include level V1 nodes should be performed. N+ If radiotherapy (with or without chemotherapy) is used to treat the primary tumour both sides of the lower neck and mediastinum should be included in the irradiation fields. If post radiotherapy assessment at 6 weeks demonstrates, on clinical examination, ultrasound +/-FNA or CT scan, residual neck disease, then this should be treated with a modified or radical neck dissection. If the primary tumour is treated with surgery then a modified radical neck dissection(s) is performed with post-operative radiotherapy for multiple positive nodes (>2), or nodes demonstrating extra capsular spread or node >3cm (N2), vascular invasion or perineural spread. Histological positive paratracheal nodes would indicate post-operative radiotherapy to the mediastinum. Bilateral dissection is essential for all subglottic disease. Specifics of Treatment: Surgery (procedure specifics) see glottic section Radiotherapy - see glottic section Chemotherapy - see glottic section Follow-Up Schedule and Post Treatment Investigations - see glottic section Management of Recurrent Disease/Salvage - see glottic section CARCINOMA OF THE ORAL CAVITY and LIP MAIN AUTHOR: Update 2015: DG Bryant S Endersby TNM Classification: UICC VERSION 7 Lip and Oral Cavity (Non-epithelial tumours such as those of lymphoid tissue, soft tissue, bone, and cartilage are not included.) 33

34 Anatomical Sites and Subsites Lip External upper lip (vermilion border ) (C00.0) External lower lip (vermilion border) (C00.1) Commissures (C00.6) Oral cavity Buccal mucosa - mucosa of the upper and lower lips (C00.3, 4) - cheek mucosa (C06.0) - retromolar areas (C06.2) - bucco-alveolar sulci, upper and lower (vestibule of mouth) (C06.1) Upper alveolus and gingiva (upper gum) (C03.0) Lower alveolus and gingiva (lower gum) (C03.1) Hard palate (C05.0) Tongue dorsal surface and lateral borders anterior to vallate papillae (anterior two-thirds) (C02.0/1). inferior (ventral) surface (C02.2) Floor of mouth (C04) Anatomy Primary Site. The oral cavity extends from the skin-vermilion junction of the lips to the junction of the hard and soft palate above and to the line of circumvallate papillae below and is divided into the following specific areas: Mucosal Lip. The lip begins at the junction of the vermilion border with the skin and includes only the vermilion surface or that portion of the lip that comes into contact with the opposing lip. It is well defined into an upper and lower lip joined at the commissures of the mouth. Buccal Mucosa. This includes all the membrane lining of the inner surface of the cheeks and lips from the line of contact of the opposing lips to the line of attachment of mucosa of the alveolar ridge (upper and lower) and pterygomandibular raphe. Lower Alveolar Ridge. This refers to the mucosa overlying the alveolar process of the mandible which extends from the line of attachment of mucosa in the buccal gutter to the line of free mucosa of the floor of the mouth. Posteriorly it extends to the ascending ramus of the mandible. Upper Alveolar Ridge. This refers to the mucosa overlying the alveolar process of the maxilla which extends from the line of attachment of mucosa in the upper gingival buccal gutter to the junction of the hard palate. Its posterior margin is the upper end of the pterygopalatine arch. 34

35 Retromolar Gingiva (Retromolar Trigone). This is the attached mucosa overlying the ascending ramus of the mandible from the level of the posterior surface of the last molar tooth to the apex superiorly, adjacent to the tuberosity of the maxilla. Floor of the Mouth. This is a semilunar space over the mylohyoid and hyoglossus muscles, extending from the inner surface of the lower alveolar ridge to the under surface of the tongue. Its posterior boundary is the base of the anterior pillar of the tonsil. It is divided into two sides by the frenulum of the tongue and contains the ostia of the submandibular and sublingual salivary glands. Hard Palate. This is the semilunar area between the upper alveolar ridge and the mucous membrane covering the palatine process of the maxillary palatine bones. It extends from the inner surface of the superior alveolar ridge to the posterior edge of the palatine bone. Anterior Two-Thirds of the Tongue (Oral Tongue). This is a freely mobile portion of the tongue that extends anteriorly from the line of circumvallate papillae to the undersurface of the tongue at the junction of the floor of the mouth. It is composed of four areas: the tip, the lateral borders, the dorsum, and the under-surface (non-villous ventral surface of the tongue). The under-surface of the tongue is considered as a separate category by the World Health Organisation (WHO). Regional Lymph Nodes. Mucosal cancer of the oral cavity may spread to regional lymph node(s). Tumours of each anatomic site have their own predictable patterns of regional spread. The risk of regional metastasis generally relates to the T category and probably more importantly to the depth of infiltration of the primary tumours. Cancer of the lip carries a low metastatic risk and initially involves adjacent submental and submandibular nodes, then jugular nodes. Cancers of the hard palate and alveolar ridge likewise have a low metastatic potential and involve buccinator, submandibular, jugular and occasionally retropharyngeal nodes. Other oral cancers will primarily spread to submandibular and jugular nodes, uncommonly posterior triangle/supraclavicular nodes. Cancer of the anterior oral tongue may spread directly to lower jugular nodes. The closer to the midline of the primary, the greater the risk of bilateral cervical nodal spread. Any previous treatment to the neck, surgical and/or radiation, may alter normal lymphatic drainage patterns resulting in unusual distribution of regional spread of disease to the cervical lymph nodes. In general, cervical lymph node involvement from oral cavity primary sites is predictable and orderly, spreading from the primary to upper, then middle, and subsequently lower cervical nodes. However, disease in the anterior oral cavity may also spread directly to the mid cervical lymph nodes. The risk of distant metastasis is more dependent upon the "N" than the "T" status of the head and neck cancer. Metastatic Sites The lungs are the commonest site of distant metastases; skeletal or hepatic metastases occur less often. Mediastinal lymph node metastases are considered distant metastases. 35

36 Rules for Classification Clinical Staging The assessment of the primary tumour is based upon clinical inspection and palpation of the oral cavity and neck. The assessment of the regional lymph nodes is by palpation; ultrasound is also useful in experienced practitioner s hands. Imaging of the primary site with MRI gives good soft tissue views and will show extent of soft tissue invasion, perivascular and perineural spread, skull base involvement and intracranial tumour extension On the other hand, high resolution CT with contrast will often provide similar information if carefully done and will provide better images of bone and larynx detail and is minimally affected by motion due to much shorter acquisition times. The presence of nodal metastases should be done by CT or MRI. Ultrasonography with or without FNAC sampling may also be useful in equivocal nodes. Distant metastasis should be assessed by CT of the thorax and upper abdomen to include the lung, liver and adrenal glands. All clinical, imaging, and pathologic data should be used for accurate staging and should be available prior to first definitive treatment. Early lip tumors are often staged clinically alone. Definition of TNM Primary Tumour (T) TX Primary tumour cannot be assessed T0 No evidence of primary tumour Tis Carcinoma in situ T1 Tumour 2 cm or less in greatest dimension T2 Tumour more than 2 cm but not more than 4 cm. in greatest dimension T3 Tumour more than 4 cm in greatest dimension T4 (lip) Tumour invades adjacent structures (e.g., through cortical bone, inferior alveolar nerve, floor of mouth, skin of face, i.e. chin or nose) T4a (oral cavity) Tumour invades adjacent structures (e.g., through cortical bone, into deep [extrinsic] muscle of tongue (genioglossus, hyoglossus, palatoglossus, and styloglossus), maxillary sinus, skin of face. Superficial erosion alone of bone/tooth socket by gingival primary is not sufficient to classify as T4) T4b Tumour invades masticator space, pterygoid plates, skull base and internal carotid artery NOTE: Superficial erosion alone of bone/tooth socket by gingival primary is not sufficient to classify a tumour as T4. Stage Grouping Identical to Larynx Confirmation of Diagnosis 36

37 Examination and biopsy Careful physical examination is mandatory and has not been superseded by imaging. Examination should include either fibre-optic or direct examination of pharynx, larynx and postnasal space. Tumour site and areas of field cancerisation should be carefully documented; use of standardised tumour maps and photographs may be useful. If physical examination and biopsy is not achievable then examination under anaesthesia (EUA) is recommended. Consideration of dental extractions of poor quality teeth, re-biopsy and tonsillectomy may be indicated whilst undergoing EUA. Formal biopsy is a cornerstone of the management pathway. UK guidelines by the Royal College of Pathologists should be followed when reporting results to include degree of differentiation, tumour thickness, vascular and perineural invasion. The increased importance of high risk HPV means that testing is often desirable for certain sub-sites and should include HPV16 in situ hybridisation in addition to p16 immunohistochemistry. Additional imaging All patients need a full dental assessment and dentate patients and those with planned bone resections or osteotomies for access in open surgery should have an orthopantomagram (OPG) PET-CT is used in recurrent tumours to detect disease at primary site as well as neck and distant metastasis. It also has a role n assessing response to chemoradiotherapy. Photographs of accessible tumours is very useful. Definitive Treatment Treatment of Primary Tumour LIP Lip tumours may be treated by surgery or by radical radiotherapy. Surgical excision however is generally the preferred. Most early lesions may be excised under local anaesthesia +/- intravenous sedation. Adjacent pre-malignant tissue should also be excised. FLOOR OF MOUTH Small volume T1 and T2 tumours may be treated by surgery including trans-oral laser treatment or radiotherapy (both external beam megavoltage and interstitial techniques). In contrast, larger T2 lesions (>3 cm) usually require combination therapy with surgery and adjuvant radiotherapy. Smaller lesions may be allowed to heal following excision by a primary repair or by secondary intention. Flap reconstruction may be required for larger volume tumours For anterior tongue, buccal mucosa and floor of mouth surgery is preferred if tumour involves periosteum. 37

38 Large volume T2 T3 and T4 tumours require surgery with surgical excision combined with neck dissection. There will be a high probability that adjuvant radiotherapy will also be required. Tumours involving the mandible will require a rim resection or segmental mandibulotomy. Access may be facilitated by open surgery with a lip split mandibulotomy. The morbidity and potential functional impairment should be carefully discussed with patients who have massive disease. ORAL TONGUE Oral tongue tumours appear to have a different biological behaviour than other oral cavity sub-sites, metastasising more frequently to levels II and III than level I and a higher incidence of skip lesions to level IV. Therefore, excision with an elective neck dissection is usually warranted in the N0 neck. This should include levels II to IV and possibly level I. Level IIb is omitted in the N0 neck. However, in low volume T1 oral tongue tumours, without evidence of metastatic disease, laser excision of the primary tumour and a careful follow up of the neck may be considered. The N +ve neck requires an appropriate neck dissection dependent on clinical and radiographic imaging. In most of these cases, post-operative adjuvant radiotherapy should be considered. BASE OF TONGUE T1 lesions can be treated by surgery. Transoral approaches with transoral laser (TOL) surgery utilising a Steiner excision technique and more recently en-bloc resection with transoral robotic surgery (TORS) have grown in use and popularity. Advantages are rapid recovery with equivalent control rates to open surgery. Open approaches via lip and tongue split or transcervical pharyngotomy are rarely considered. They can however be treated equally well by radical radiotherapy. T2,T3 and T4 lesions require radical radiotherapy in conjunction with chemotherapy in line with an attempt at organ preservation. Surgery for residual neck disease may also be required, the diagnosis of which is aided by PET-CT follow up. If there is recurrence, or if the extent of the original tumour is deemed incurable by the above techniques, total glossectomy with laryngectomy may be considered. This has extremely high morbidity, but with careful counselling and extensive rehabilitation it can be performed in an appropriate group of patients. HARD PALATE T1 lesions may be managed by surgery with surgical excision and periosteal strip or radical radiotherapy. T2m T3 and T4 lesions require excision with a bone margin possibly amounting to a partial maxillectomy. This may require obturation or flap reconstruction. Neck involvement is unusual and a watchful waiting policy may be adopted where there is no evidence of nodal involvement. NECK 38

39 As base of tongue, posterior pharyngeal wall, and palatal lesions predominantly affect the midline then spread to lymph nodes bilaterally, both sides of the neck must be considered when planning treatment. In the N0 neck consideration should be given to elective treatment, either by prophylactic radiotherapy or by selective neck dissection if open resection is being employed. The N1 neck is treated by surgery either by selective or modified radical neck dissection, depending on the treatment of the primary. In early lesions radical radiotherapy may be used. In N2/N3 necks a neck dissection is indicated but may not be possible depending on the site of the disease in N2 and the extent in N3. Post operative radical radiotherapy is indicated if more than one node is involved or if extracapsular spread is present. Radiotherapy Adjuvant radiotherapy is considered in all patients with close margins, ECS and more than one positive node. Tumour size, thickness and adverse features such as differentiation, noncohesive front and perineural or lymphovascular invasion are also considered. Chemotherapy Chemotherapy should additionally be considered in patients without contraindication who have close margins or ECS. Recurrence Best managed with aggressive surgical resection with frozen section control. Elective neck dissection advocated as 25% have occult metastases. High success rate in management of local recurrence, 75-85%. HEAD AND NECK SARCOMA MDT Management Diagnosis of sarcoma is often made late, when the tumour is already large and often unexpectedly. Optimal management and survival requires specialized care, particularly in relation to extirpative and reconstructive surgery, pathology and oncology. MDTs are the accepted form of management for conditions requiring complex care, but have to see sufficient patients annually to maintain expertise and justify resource allocation. The draft sarcoma IOG (published March 2005) recommends that All patients with a bone or soft tissue sarcoma should be managed by a sarcoma MDT. These would thus likely service a population of 2-3 million for soft tissue sarcoma (STS) and 7-8 million for bone sarcoma (BS)`, managing at least 100 STS and or 50 BS a year. It further recommends that all cancer centres must either: 39 Host a sarcoma MDT Use the facilities of a nearby sarcoma MDT Have a medical oncologist acting as an approved extended team member of another sarcoma MDT It is accepted, however, that more than one MDT may need to be involved in the care of sarcoma patients dependent upon the site of the tumour. This is particularly so for tumours in

40 the head and neck, where all patients must have their case discussed at an MDT appropriately qualified for that site. There is recognition that the skills required for management of head and neck sarcomas are very similar to those for other tumour groups at this site. These groups, it is felt, should work in conjunction with the sarcoma MDT. Summary For patients with head and neck sarcomas to be adequately managed in the Network: All patients with a provisional histological or radiological diagnosis of bone or soft tissue sarcoma should have their diagnosis reviewed by a specialist sarcoma pathologist or radiologist. Patients should undergo definitive resection of their sarcoma by a surgeon who is a member of a sarcoma MDT or by a surgeon with site specific skills in consultation with the sarcoma MDT. 40

41 SALIVARY GLANDS MAIN AUTHORS: - DG Bryant This section has been produced with reference to the Evidence Based Conference of the Management of Salivary Gland Neoplasms held at the Freeman Hospital, Newcastle upon Tyne on the 19th November A full reference list from the meeting is available on the NOTO website Characterisation Salivary gland malignancies are rare and present a diverse range of histology and clinical behaviour. The original 1972 WHO histological classification of salivary gland tumours insisted of four subgroups: Epithelial tumours, non-epithelial tumours, unclassified tumours and allied conditions of which the epithelial group was the larger in number. Under the new system there are seven categories: Adenomas 2. Carcinomas 3. Non Epithelial tumours 4. Malignant Lymphomas 5. Secondary tumours 6. Unclassified tumours 7. Tumour-like disorders Carcinomas are often further classified as high grade, low grade or mixed, the latter inferring a variable behaviour depending on the histological picture. Except in the case of mucoepidermoid tumours however, clinicopathological correlation has proved to be unreliable and often the clinical behaviour rather than the histology of a tumour provides a better guide for treatment. Although, overall, tumours are more common in the parotid, the incidence of malignancy is higher in the submandibular, sublingual and minor salivary glands. The more common adenomas and carcinomas are shown below: Adenomas Carcinomas ex Pleomorphic adenoma Myoepithelial (myoepithelian adenoma) Basal cell adenoma Warthin s tumour (adenolymphoma) Ductal Papilloma Cystadenoma Acinic cell carcinoma Mucoepidermoid carcinoma Adenoid cystic carcinoma Polymorphous low-grade (terminal duct) Papillary cystadenocarcinoma Mucinous adenocarcinoma

42 42 Adenocarcinoma Carcinoma in pleomorphic adenoma (malignant mixed tumour) Squamous cell carcinoma Undifferentiated carcinoma Confirmation of Diagnosis Malignant tumours may be clinically indistinguishable from benign lesions and definitive histology is usually unavailable until after surgical resection. Diagnosis is therefore based on: Clinical presentation - pain, rapid growth, fixation, nerve involvement or neck metastasis all suggestive of malignancy. Fine Needle Aspirate Cytology is useful for major salivary gland lesions and must be examined by a cytopathologist experienced in the diagnosis of salivary gland disease. This should distinguish malignant from benign disease in 90% of cases. MRI scanning may demonstrate non-homogeneity, muscle infiltration or suspicious regional lymph node appearance suggestive of malignancy. Open biopsy should be avoided in major salivary gland lesions due to the risk of tumour spillage. It may be indicated for minor salivary gland lesions where the overlying epithelium will be excised at the time of surgery. Frozen section should be avoided, accurate diagnosis is often difficult and false negative rates are significant and therefore should not be relied upon. Submandibular Gland Surgery Primary Tumour A total excision is appropriate for most tumours confined to the gland. Some argue in favour of wider resection for adenoid cystic tumours including the lingual, hypoglossal and marginal mandibular nerve if there is any suspicion of involvement by tumour, but evidence is not strong, and the advice is counter to recommendations for the uninvolved facial nerve in parotid disease. Clinically high-grade tumours in young individuals should be treated more aggressively with excision of the gland plus a 2cm margin of apparently healthy tissue Large Tumours with bone involvement should be treated with composite resection of tumour, adjacent soft tissue cuff and segmental mandibulectomy. Neck Disease All Patients should undergo clearance of nodes in suprahyoid region. Clinically high-grade tumours or with suspicious MRI appearance should have an elective supra-omohyoid dissection.

43 Patients with clinically confirmed neck metastasis should have a neck dissection. Radiotherapy Palliation Is useful for inoperable tumours where palliation can be achieved. Post-operative radiotherapy is indicated for: Parotid Gland Surgery Primary Tumour High grade or advanced stage tumours with a high risk of local recurrence Residual disease or microscopic extra-capsular spread from lymph nodes Surgery for recurrent disease Apart from lymphomas, surgery is the treatment of choice. A conservative parotidectomy should be performed with preservation of the facial nerve providing there is no tumour invasion. For deep lobe tumours this will involve a total parotidectomy plus resection of adjacent structures if necessary to achieve an en-bloc resection. Any part of the facial nerve not infiltrated by tumour should be preserved. Primary nerve grafting should be considered if microscopic clearance of the main trunk and peripheral branches can be achieved. Adenoid cystic carcinoma requires a parotidectomy with sacrifice of any part of the nerve involved by tumour. Resection of an intact nerve has been shown to improve local disease control but will not improve survival. It is unlikely that nerve grafting will compromise outcome and therefore could be considered particularly if combined with post-operative radiotherapy. Neck Neck dissection should be performed in patients with evidence of nodal disease either clinically or on MRI scanning. A prophylactic neck dissection should be considered for patients with clinically high grade tumours, i.e. adenocarcinoma, squamous and undifferentiated. Radiotherapy Post-operative As for the submandibular gland plus any patient in whom the facial nerve has been preserved despite close approximation of the tumour. 43

44 Recurrent Disease Requires careful evaluation of the patient with repeat imaging and a review of the histology from the initial excision. This will usually require more radical surgery with sacrifice of the nerve and overlying skin if any suspicion of involvement by tumour. Super-radical resections of skull base have not to date shown convincing evidence of improved survival. Consider chemotherapy and/or radiotherapy for palliation. Minor Salivary Glands Confirmation of diagnosis Clinical history and examination with particular reference to palate and nasal cavity. Open biopsy is permissible to confirm diagnosis. The prognosis for these patients is more closely related to stage of disease rather than histology. Treatment En-bloc resection with depth of excision equal to width to ensure adequate resection margins. Neck Therapeutic neck dissection is indicated for lymph node involvement. Elective neck dissection is indicated for adenocarcinoma, carcinoma in pleomorphic adenoma and undifferentiated carcinoma. Radiotherapy Indications: Post-operative Microscopic residual disease Adenoid cystic tumours Aggressive undifferentiated tumours CONTACTS The Policy and the Named Hospitals for Head and Neck Cancer The named designated Hospitals for Head and Neck Cancer in the North of England Cancer Network are described below: Each hospital has a clinic for referral of patients with head and neck cancer in line with their locally primary care referral guidelines. In line with the manual, each designated hospital has a minimum of two designated clinicians. 44

45 CCG populations Designated Hospital Head and Neck Designated Hospital - Thyroid Area Population* Newcastle West 144 Freeman Hospital Freeman Hospital Newcastle North & East 143 Royal Victoria Infirmary North Tyneside 202 Northumberland 316 South Tyneside Freeman Hospital 149 South Tyneside District Hospital Palmer Community Hospital North Tyneside General Hospital Palmer Community Hospital Sunderland 276 Sunderland Royal Hospital Sunderland Royal Hospital Gateshead 200 Queen Elizabeth Hospital Queen Elizabeth Hospital Durham Dales, Easington & Sedgefield Darlington Darlington Memorial Hospital Darlington Memorial Hospital North Durham 243 Sunderland Royal Hospital University Hospital of North Durham Shotley Bridge Hospital South Tees 274 James Cook University Hospital James Cook University Hospital Hambleton, Richmondshire & Whitby 154 Stockton 193 James Cook University Hospital University Hospital of North Tees Hartlepool 93 University Hospital of Hartlepool Cumbria 328 Cumberland Infirmary West Cumberland Hospital Cumberland Infirmary * Mid Year Population Estimates Please note: Across NECN, Endocrine Surgeons also operate on Thyroid Cancer in addition to Head and Neck Surgeons The Distribution of Neck Lump Clinics The distribution of neck lump clinics for suspected Head and Neck Cancer in the North of England Cancer Network are described below in the table below, Referral Guidelines for Primary Care Practitioners UAT patients. Each hospital has a clinic for referral of patients with head and neck cancer in line with the locally agreed primary care referral guidelines. Designated clinics are distributed such that the PCT s agreed populations have sufficient access. 45

46 Referral Guidelines for Primary Care Practitioners - UAT Patients The NICE Referral guidelines for suspected cancer have been agreed and adopted as the Network Referral Guidelines. These guidelines in conjunction with the Referral Forms for Patients with Suspected Cancer, Coding sheet and Cancer Services Directories provide Primary Care Practitioners with all necessary information regarding named local services and contact points. Also see Appendix 1, Primary Care Referral Guidelines. 46

47 Referral Guidelines for Primary Care Practitioners - UAT Patients Area Population* Newcastle West 144 Freeman Hospital (FH) Freeman Hospital GDP - FH Mr A Welch Newcastle North & East week wait central office Mr V Paleri Northumberland 316 Fax: Mr D Meikle North Tyneside 202 Choose & Book Mr Adams Tel: Cumbria CCG populations 328 Designated Hospital Cumberland Infirmary Cumberland Infirmary 2 week central office Mr J Elliott Fax: Mr A Robson West Cumberland Hospital Neck Lump Clinic Location West Cumberland Hospital Contact Points Designated Lead Clinicians Mr G Putnam Mr P Counter Sunderland 276 Sunderland Royal Hospital (SRH) Sunderland Royal Appointments Office Mr R Banks Hospital (SRH) Fax: Mr C Hartley North Durham 243 Ms H Cocks Mr I C Martin Mr A Burns Mr J O Hara Haematooncologists Location MDT with direct care sessions timetabled for the clinic Dr A Lennard Dr G Jackson Dr G Jones Dr T Menne (do not attend cliniccontactable by phone /bleep only) H Ob'rien R Oakes Locum (do not attend cliniccontactable by phone/bleep only) V Hervey (does not attend clinic- but contactable as liaison haematologist) Freeman Hospital Thursday AM South Tyneside 149 South Tyneside DH South Tyneside DH Fax: Ms H Cocks Miss J Heaton Palmer Community Hospital Palmer Community Hospital Mr T Leontsinis Mr Pardeshi Mr A Burns V Hervey (does not attend clinic- but contactable as liaison haematologist) SRH Friday AM Gateshead 200 Queen Elizabeth Hospital Queen Elizabeth Hospital Ms K Stone Miss N Jones Choose & Book Mr J Moor Tel: Ms H Cocks S Marshall (does not attend clinicbut contactable by Bleep only) Cancer Booking Team Mr P Arul (within call centre) QE Durham Dales, Easington & Sedgefield 273 Darlington Memorial Hospital Darlington Memorial Hospital Choose & Book Mr S Lester Mr R Wight Darlington 105 Tel: Mr C Edge Col D Bryant South Tees 274 James Cook University Hospital James Cook Tel: Mr C Pace (JCUH) University Hospital Fax: Hartlepool & Stockton 286 (JCUH) Dr D Plews (unable to attend clinic however they are able to see the patient hrs) JCUH Tuesday AM Hambleton, Richmondshire & Whitby 154 * Mid Year Population Estimates 47

48 Distribution Process for Referral Guidelines Primary Care Medical Practices Primary Care referral guidelines for Head & Neck cancer, including Thyroid are sent to the Primary Care Commissioners for onward distribution to general practice and general dental practices, and also through Cancer Unit Managers for onward distribution to the relevant clinical specialities. Copies of the guidelines are available on the North of England Cancer Network s website: Network Agreed Referral Proformas All Network wide referral proformas are in line with NICE guidance for urgent referral for suspicion of cancer 2005 and comply with the following: it is used for patients with UAT symptoms which are outside the 'urgent suspicion of cancer' definition and who have no neck lumps it allows for the referrer to categorise a patient by presenting features, so that the hospital can direct the referral to the relevant specialty (e.g. ENT, OMFS) the network-wide format is made locally specific by identifying a single referral point for each designated hospital to which proformas can be sent for direction to individual specialists. Internal Referral Guidelines for Non-Designated Hospital Clinicians The Schema below is adopted from The Manual for Cancer Services (Head & Neck 2008) 48

49 Network Agreed Named Hospital for Surgical Treatment Delivery Area CCG populations Population* Hospitals for Surgical Delivery Designated Ward Designated Hospital Newcastle West 144 Newcastle upon Tyne Hospitals Ward 10 Freeman Hospital Newcastle North & East 143 NHS FT Northumberland 316 Lead Clinician North Tyneside 202 Mr D Meikle Gateshead 200 City Hospitals Sunderland NHS Wards Sunderland Royal Sunderland 276 FT C33 Hospital South Tyneside 149 North Durham 243 Darlington 105 South Tees Hospitals NHS FT Ward 6 and Ward 35 South Tees 274 Hartlepool & Stockton 286 Hambleton, Richmondshire & Whitby Durham Dales, Easington & Sedgefield Lead Clinician Mr R Banks James Cook University Hospital Lead Clinician Mr S Lester Cumbria 328 North Cumbria University Hospitals NHS Trust Ward for H&N Cumberland Infirmary surgery is Beech C/D Lead Clinician Mr G Putnam Source - Mid-2013 Population Estimates for Clinical Commissioning Groups (CCGs) in England - ONS.gov.uk Network MDT Configuration Trust Designated MDT Case Mix South Tees Hospitals NHS FT North Tees & Hartlepool NHS FT Co Durham & Darlington FT (South) Newcastle Upon Tyne Hospitals NHS FT Northumbria Healthcare NHS FT North Cumbria University Hospitals NHS FT City Hospitals Sunderland NHS FT Co Durham & Darlington NHS FT (North) Gateshead Health NHS FT South Tyneside NHS FT James Cook University Hospital Freeman Hospital Sunderland Royal Hospital Upper Aero-digestive Tract dealing with one or more of salivary gland tumours Upper Aero-digestive Tract dealing with one or more of salivary gland tumours; UAT cancer involving skull base Upper Aero-digestive Tract dealing with Salivary gland tumours 49

50 MDT linkages Trust Designated MDT Case Mix South Tees Hospitals NHS FT North Tees & Hartlepool NHS FT Co Durham & Darlington NHS FT Newcastle Upon Tyne Hospitals NHS FT Northumbria Healthcare NHS FT North Cumbria University Hospitals NHS FT City Hospitals Sunderland NHS FT South Tyneside NHS FT Gateshead Health NHS FT James Cook University Hospital Royal Victoria Infirmary Thyroid cancer Thyroid Cancer The Distribution of Local Support Teams in the Network Designated Hospital Freeman Hospital Sunderland Royal Hospital Cumberland Infirmary Darlington Memorial James Cook University Hospital local support provided by Specialist MDT Geographical coverage Northumberland, North Tyneside, Newcastle Sunderland, South Tyneside, North Durham, Washington, Gateshead Carlisle, Whitehaven, North Cumbria South Durham - Darlington, Bishop Auckland, Sedgefield (75%) Teesside North of Tees, South of Tees, Sedgefield (25%), North Yorkshire 50

51 Appendix 1 - Referral Guidelines for Primary Care North of England Cancer Network Referral Guidelines for Primary Care Oral, Non Oral Lesions and Thyroid Developed by Head & Neck Site Specific group & Thyroid Sub-group May 2013 Review date: July 2015 Title: NECN Head and Neck Cancer Primary Care Referral Guidelines Authors: Head and Neck NSSG members Thyroid Subgroup members Circulation List: Primary care medical practices Primary dental practices Designated consultant clinicians Non-designated head and neck consultant clinicians (ENT surgeons, endocrine surgeons, OMFS surgeons, oral medicine specialists, endocrinologists, restorative dentistry consultant) via Cancer Unit Managers Head and Neck NSSG Contact Details: Mrs C McNeill, Peer Review Co-ordinator Claire.mcneill@nhs.net Telephone: Version History: Date: Version: v.05 Review Date: July 2015 Document Control Versio Date Summary Review Date n V Reviewed and no amendments require July 2015 v Head and neck cancers (Oral Lesions)- amended May

52 Referral Guidelines for Primary Care Practitioners - UAT Patients Area Population* Newcastle West 144 Freeman Hospital (FH) Freeman Hospital GDP - FH Mr A Welch Newcastle North & East week wait central office Mr V Paleri Northumberland 316 Fax: Mr D Meikle North Tyneside 202 Choose & Book Mr Adams Tel: Cumbria CCG populations 328 Designated Hospital Cumberland Infirmary Cumberland Infirmary 2 week central office Mr J Elliott Fax: Mr A Robson West Cumberland Hospital Neck Lump Clinic Location West Cumberland Hospital Contact Points Designated Lead Clinicians Mr G Putnam Mr P Counter Sunderland 276 Sunderland Royal Hospital (SRH) Sunderland Royal Appointments Office Mr R Banks Hospital (SRH) Fax: Mr C Hartley North Durham 243 Ms H Cocks Mr I C Martin Mr A Burns Mr J O Hara Haematooncologists Location MDT with direct care sessions timetabled for the clinic Dr A Lennard Dr G Jackson Dr G Jones Dr T Menne (do not attend cliniccontactable by phone /bleep only) H Ob'rien R Oakes Locum (do not attend cliniccontactable by phone/bleep only) V Hervey (does not attend clinic- but contactable as liaison haematologist) Freeman Hospital Thursday AM South Tyneside 149 South Tyneside DH South Tyneside DH Fax: Ms H Cocks Miss J Heaton Palmer Community Hospital Palmer Community Hospital Mr T Leontsinis Mr Pardeshi Mr A Burns V Hervey (does not attend clinic- but contactable as liaison haematologist) SRH Friday AM Gateshead 200 Queen Elizabeth Hospital Queen Elizabeth Hospital Ms K Stone Miss N Jones Choose & Book Mr J Moor Tel: Ms H Cocks S Marshall (does not attend clinicbut contactable by Bleep only) Cancer Booking Team Mr P Arul (within call centre) QE Durham Dales, Easington & Sedgefield 273 Darlington Memorial Hospital Darlington Memorial Hospital Choose & Book Mr S Lester Mr R Wight Darlington 105 Tel: Mr C Edge Col D Bryant South Tees 274 James Cook University Hospital James Cook Tel: Mr C Pace (JCUH) University Hospital Fax: Hartlepool & Stockton 286 (JCUH) Dr D Plews (unable to attend clinic however they are able to see the patient hrs) JCUH Tuesday AM Hambleton, Richmondshire & Whitby 154 * Mid Year Population Estimates 52

53 Area CCG populations Population* Designated Hospital Thyroid Clinic Location Contact Points Designated Lead Clinicians MDT Location/MDT Co-ordinator Contact Newcastle West 144 Freeman Hospital Freeman Hospital GDP - FH Mr A Welch Newcastle North & East 143 Royal Victoria Infirmary Royal Victoria Infirmary 2 week wait central office Mr V Paleri Mr R Bliss Choose & Book Tel: Northumberland 316 North Tyneside Hospital North Tyneside Fax: Mr M Carr Hospital North Tyneside 202 Wansbeck General Mr S Aspinall Hospital Cumbria 328 Cumberland Infirmary Cumberland Infirmary 2 week central office Mr M Williams Fax: Mr L Barthelmes Sunderland 276 Sunderland Royal Hospital Sunderland Royal Appointments Office Hospital Easington (60%) 56 Sacriston, Durham Fax: Mr T Leontsinis Royal Victoria Infirmary Wednesday PM Ms H Cocks South Tyneside 149 Palmer Community Hospital Palmer Community Fax: Ms H Cocks Hospital Miss J Heaton Mr T Leontsinis Mr Pardeshi Gateshead 200 Queen Elizabeth Hospital Queen Elizabeth Choose & Book Mr J Moor Hospital Tel: Ms H Cocks Cancer Booking Team (within call centre) QE Durham Dales, Easington & Sedgefield (excl Easington 60%) 217 Darlington Memorial Hospital Darlington Memorial Hospital Choose & Book Mr V Shanker Darlington 105 Tel: Mr S Lester North Durham 243 University Hospital of North Durham Shotley Bridge Hospital University Hospital of North Durham Shotley Bridge Hospital Choose & Book Tel: Mr G Tervitt Mr A Bhatti South Tees 274 James Cook University Hospital James Cook Tel: Mr W M Elsaify University Hospital Fax: Dr S Nag Hambleton, Richmondshire & Whitby 154 Stockton 193 University Hospital of North Tees University Hospital of North Tees Tel: Mr J Kurup Hartlepool 93 University Hospital of Hartlepool Dr S Jones James Cook University Hospital Last Friday of each month pm Source - Mid-2013 Population Estimates for Clinical Commissioning Groups (CCGs) in England - ONS.gov.uk 53

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60 Appendix 2 - NSSG Guidelines for Teenage and Young Adults Teenage and Young Adults Peer Review Measures Topic 11-1C (Functions of the Network Site Specific Groups for TYA) 1. Teenage and Young Adult Pathway for initial Management The NSSG has received the document named NECN Teenage and Young Adult Cancer Pathway Guidance Paper and agrees to follow the generic TYA Pathway with any site specific variations to be documented. Please see Appendix 1 for pathway. 2. Teenage and Young Adult Pathway for Follow up on completion of first line treatment Patients aged years will adopt the site specific adult follow up pathway on completion of first line treatment. It is acknowledged by both the CYPCG and NSSGs across NECN that further work is required to develop these pathways for this age group and partly in response a TYA working group has been established to take this work forward. If advice is required regarding the follow up care of a year old patient, then the Lead TYA Clinician at the designated hospital or PTC should be contacted. Please see Appendix 2 for contact details. Patients age years will continue to adopt the paediatric and adolescent follow up protocol of the PTC and all advice should be sought direct from the On Call Paediatric Oncologist at Royal Victoria Infirmary Paediatric Follow Up Protocols can be found on the CCLG website (2005 second edition) with the exception of trial specific protocols which can be requested via the Children s Trial Co-ordinator based at the RVI. 3. Pathways for cases involving Specialised NHS services (Only Gynae and Sarcoma) The Gynae NSSG and SAG reviewed and agreed the Specialised NHS Service pathway for patient s age years. This is attached in Appendix 3. 60

61 Appendix 3 Teenage and Young Adult Pathway for initial Management 61