Head & Neck MDT

Head & Neck MDT

Patient Details

• Arthur Pendelton
• 14/05/1962
• NHS: 482 910 3847

Clinical History

• 6-week Hx of painless R-sided neck lump and mild odynophagia. No weight loss or night sweats.
• HTN, T2DM, GORD.
• Laparoscopic cholecystectomy (2015).
• Ramipril 5 mg PO OD, metformin 500 mg PO BD, omeprazole 20 mg PO OD. No herbal supplements.
• NKDA.
• Ex-smoker (15 pack-years, quit 2010). Alcohol: 14 units/week. Retired carpenter, lives with wife.

Examination Findings

• ECOG 0, BMI 26.4 kg/m², vital signs stable, chest clear.
• Asymmetrical enlargement of R palatine tonsil with ulceration. Firm, mobile 2.5 cm R level II cervical lymph node. Flexible nasendoscopy (FNE): normal base of tongue, larynx, and pyriform fossae; vocal cords mobile bilaterally.

Investigations

• MRI Neck (02/10/2023): 22 mm enhancing mass in R tonsillar fossa, no deep parapharyngeal space invasion. Enlarged necrotic R level IIa node measuring 26 x 18 mm. CT Thorax (04/10/2023): No distant metastases or synchronous pulmonary lesions.
• R tonsil biopsy and US-guided FNA of R level II node (28/09/2023): Moderately differentiated squamous cell carcinoma (SCC), strongly p16-positive.
• Hb 142 g/L, WCC 6.8 x 10^9/L, Plt 245 x 10^9/L, eGFR > 90 mL/min/1.73m², LFTs normal, HbA1c 48 mmol/mol.

Diagnosis

• T2 N1 M0 (AJCC 8th Edition) p16-positive squamous cell carcinoma of the right oropharynx (tonsil).
• Hypertension, Type 2 Diabetes Mellitus.

Management Plan

• Not for primary surgery; prophylactic RIG tube insertion prior to treatment if required per dietitian.
• Concurrent cisplatin 100 mg/m² IV every 3 weeks (Days 1, 22, 43) alongside radiotherapy, subject to baseline audiogram and formal renal clearance.
• Radical intensity-modulated radiotherapy (IMRT): 65 Gy in 30 fractions over 6 weeks to primary site and involved R level II node; 54 Gy in 30 fractions to elective nodal levels.
• Weekly on-treatment review in combined Head & Neck clinic. Post-treatment PET-CT at 12 weeks post-completion of chemoradiotherapy.

Discussion Points

• Discussed merits of transoral robotic surgery (TORS) + neck dissection vs primary concurrent chemoradiotherapy (CRT). Given nodal size and patient preference to avoid surgery, consensus reached that radical CRT offers optimal single-modality-equivalent outcomes and avoids trimodality toxicity.

Recommendations

• Proceed with radical concurrent chemoradiotherapy with curative intent.
• Pre-treatment dental assessment, Speech and Language Therapy (SALT) review, and dietetics input.

Next Steps

• Outpatient clinic appointment booked for 16/10/2023 with Clinical and Medical Oncology to discuss MDT outcome and obtain consent.
• Urgent referral sent to restorative dentistry and baseline audiometry requested.