Ch07. H&N Cancer Flashcards
1
Q
SCC on histology may look like (false positive)
A
- Necrotizing sialometaplasia
2. Mucoepidermoid carcinoma (esp high-grade variant)
2
Q
IHC markers of lymphoma
A
Leukocyte common antigen (LCA), T-cell and B-cell markers
3
Q
IHC markers of carcinoma
A
Cytokeratin
4
Q
IHC markers of melanoma
A
S-100 (high sens, low spec; also found in neural and cartilaginous tumors)
HMB-45 (sens and spec, does not stain spindle cell type)
MART-1 and melan-A (newer, sens and spec for melanocytes)
5
Q
IHC for neuroendocrine tumors
A
Chromogranin, neuron-specific enolase (NSE), synaptophysin
6
Q
Gold standard for HPV testing
A
HPV DNA in situ hybridization in tumors
7
Q
Grading of malignant neoplasms
A
Grading categorizes the histologic type of cancer according to the degree of differentiation; well-differentiated (G1), moderately well-differentiated (G2), poorly differentiated (G3), undifferentiated (G4); less related to prognosis
8
Q
TX vs T0
A
TX indicates the primary tumor is not fully assessed, T0 indicates no evidence of a primary tumor
9
Q
T1 N0 General overall staging criteria for head and neck cancer (ex NP, salivary, and thyroid)
A
Stage I
10
Q
T2 N0 General overall staging criteria for head and neck cancer (ex NP, salivary, and thyroid)
A
Stage II
11
Q
T3 N0 General overall staging criteria for head and neck cancer (ex NP, salivary, and thyroid)
A
Stage III
12
Q
T4 N0 General overall staging criteria for head and neck cancer (ex NP, salivary, and thyroid)
A
Stage IV
13
Q
T1 N1 General overall staging criteria for head and neck cancer (ex NP, salivary, and thyroid)
A
Stage III
14
Q
T2 N1 General overall staging criteria for head and neck cancer (ex NP, salivary, and thyroid)
A
Stage III
15
Q
T3 N1 General overall staging criteria for head and neck cancer (ex NP, salivary, and thyroid)
A
Stage III
16
Q
T4 N1 General overall staging criteria for head and neck cancer (ex NP, salivary, and thyroid)
A
Stage IV
17
Q
T1 N2 General overall staging criteria for head and neck cancer (ex NP, salivary, and thyroid)
A
Stage IV
Any N2-3, M+ is Stage IV
18
Q
T2 N2 General overall staging criteria for head and neck cancer (ex NP, salivary, and thyroid)
A
Stage IV
Any N2-3, M+ is Stage IV
19
Q
T3 N2 General overall staging criteria for head and neck cancer (ex NP, salivary, and thyroid)
A
Stage IV
Any N2-3, M+ is Stage IV
20
Q
T4 N2 General overall staging criteria for head and neck cancer (ex NP, salivary, and thyroid)
A
Stage IV
Any N2-3, M+ is Stage IV
21
Q
Tumor extension regions considered unresectable
A
Base of skull, nasopharynx, prevertebral fascia, floor of neck, mediastinum, subdermal lymphatics
Carotid artery encasement (>270degrees)
22
Q
Clinical trial designs
A
Phase 0 evaluates pharmacodynamics and pharmacokinetics including oral bioavailability and half-life
Phase 1 defines the dose range and safety as well as side effects
Phase 2 tests the efficacy of the treatment regimen as well as toxicty
Phase 3 are randomized controlled trials that evaluate the new treatment compared to the standard treatment
Phase 4 are performed postapproval and postmarketing to gather additional information such as risks, benefits and optimal use
23
Q
Overall 5-year survival for H&N cancer
A
~62% (SEER database, 1998-2012; vary by subsite)
24
Q
Tumor thickness and survival
A
Poorer prognosis with increased tumor thickness (esp if >4 mm in depth)
25
Cisplatin mechanism of action
Heavy metal that acts as an alkylating agent that covalently binds DNA and RNA
26
Cisplatin side effects
Nausea, nephrotoxicity, peripheral neuropathy, ototoxicity (dose limiting, affects high frequencies, bilateral effects, cumulative toxicity), electrolyte disturbances, anorexia
27
Carboplatin mechanism of action
Heavy metal that acts as an alkylating agent that covalently binds DNA and RNA; less reactive than cisplatin
28
Carboplatin side effects
Better tolerated than cisplatin (less nephrotoxicity, nausea, neurotoxicity, and ototoxicity), but has an increased myelosuppresino risk
29
5-Fluorouracil mechanism of action
Antimetabolite that binds to thymidylate synthetase blocking the conversion of uridinet to thymidine, preventing DNA synthesis in S-phase
30
5-Fluorouracil side effects
Anorexia and nausea, mucositis, diarrhea, alopecia, myelosuppresion, cardiac toxicity
31
5-Fluorouracil indications
Similar to cisplatin (cisplatin and 5-FU is the most studied combination chemotherapy regimen in H&N cancer
32
What is leucovorin?
AKA tetrahydrofolic acid. It is utilized as a "rescue" agent for methotrexate toxicity, competitively overcomes increase in intracellular pools of dUMP (also used with 5-FU)
33
Direct mechanism of radiation injury
Direct damage of radiation to critical elements in a cell (DNA, cell membranes)
34
Indirect mechanism of radiation injury
Secondary damage from direct radiation effects on other cell components, primary mechanism of cell death (DNA injury from production of free radicals)
35
Cell cycle
```
3 stages of interphase and mitosis
Gap1 growth phase cell size doubles (G0 in and out)
Sythesis phase (DNA doubled)
Gap2 growth phase (mito double)
Mitosis and cytokinessis resulting in two identical daughter cells
```
36
WHO grading system for oral mucositis
Grade 1: erythema and unpleasant sensation
Grade 2: erythema and pain but can still eat solids
Grade 3: ulcers, very painful, and can only tolerate liquids
Grade 4: ulcers, severe and intolerable pain, parenteral or enteral feedings by mouth is impossible
37
Xerostomia 2/2 XRT
Salivary acinar cells are extremly sensitive to radiation therapy causing irreversible xerostomia
38
Define ORN
Hypocellularity, hypovascularity, and ischemia or tissue
39
Rx ORN
Initially treat conservatively with antibiotics, analgesics, meticulous oral hygiene, and soft diet.
Debriement may be requirement.
May also consider hyperbaric oxygen.
Free tissue transfer necessary in recalcitrant painful mandibular disease, orocutaneous fistula, and/or pathological fracture.
40
Incidence of dysphagia after XRT
<=26% of patients at 1 year
41
Incidence of nonfunctional larynx after CRT
<=12% patients at 1 year
CRT can cause loss of sensation and movement of the glottis leading to chronic aspiration and inability to phonate, may require tracheostomy
42
Nodal level I
IA submental triangle
| IB submandibular triangle
43
Nodal level II
Upper jugular (between hyoid or carotid bifurcation and base of skull)
IIA anterior
IIB posterior to CN XI
44
Nodal level III
Middle jugular (between hyoid or carotid bifurcation to cricoid or omohyoid)
45
Nodal level IV
Lower jugular (between clavicle and cricoid or omohyoid)
46
Nodal level V
Posterior triangle (VA: superior and VB: inferior to omohyoid)
47
Nodal level VI
Anterior neck/central compartment (between carotid sheaths), includes Delphian (precricoid/prelaryngeal) LNs
48
Nodal level VII
Superior mediastinum (suprasternal notch to anterior mediatsinum)
49
HPV neg cN
```
NX: LN can't be assessed
N0: no regional LN met
N1: single ipsi LN <=3 and ENE-
N2a: single ipsi LN >3 and <=6 and ENE-
N2b: multiple ipsi LNs <=3 and ENE-
N2c: bilat or contralat LNs <=6 and ENE-
N3a: any LN >6cm and ENe-
N3b: any LN and ENE+
```
50
HPV neg pN
Nx: LN can't be assessed
N0: no regional LN met
N1: single ipsi LN <=3 and ENE-
N2a: single ipsi LN >3 and <=6 and ENE-
- OR single ipsi or contra LN <=3 cm and ENE+
N2b: multiple ipsi LNs <=6 cm and ENE-
N2c: bilat or contralat LNs <=6 cm and ENE-
N3a: any LN >6 cm and ENE-
N3b: single ipsi LN>3 cm and ENE+; or multiple ipsi, contra or bilat LN with ENE+
51
When is neck dissection done in cN neck?
Generally indicated if risk of regional metastasis >15-25% (e.g. supraglottis, BOT, tonsil, oral tongue, and advanced staged cancer)
52
What test is done before carotid artery en bloc resection?
Pre-op balloon occlusion test and Pt needs to understand the risk of stroke
53
Disadvantages of radical neck dissection
1. Neck deformity (SCM muscle)
2. Shoulder drop (CN XI)
3. Facial edema (IJ)
4. Hypesthesia of the neck and periauricular region
5. Higher incidence of carotid blowouts due to lack of tissue (SCM) covering carotid artery
54
Types of MRND
Type I: spares spinal accessory nerve
Type II: spares IJ and XI
Type III (functional/Bocca): SCM, IJ, XI
55
Course of XI
The only nerve to enter and exit the skull.
From upper spinal cord, enter the skull through the foramen magnum
the nerve travels along the inner wall of the skull towards the jugular foramen
Leaving the skull, the nerve travels through the jugular foramen with the glossopharyngeal and vagus nerves
56
Supraomohyoid neck dissection
Anterolateral neck dissection
Removes nodal levels I-III (expanded supraomohyoid removes level IV)
Larger oral cancers with a N0 or select N1 (mobile) neck
57
Lateral neck dissection
Removes nodal levels II-IV
Indicated for select supraglottic, oropharyngeal, hypopharyngeal cancers
Typically bilateral
58
Posterior lateral neck dissection
Removes nodal levels II-V (also retroauricular and suboccipital nodes)
Indicated for select posterior scalp cancers
59
When to consult thoracic surgery for chyle leak?
Consult for proximal ligation if failed conservative therapy or if output >600 mL/day
60
Horner's syndrome after neck dissection
From damage to sympathetic trunk during carotid artery dissection
Triad of miosis, ptosis, and anhidrosis
Rx: observation as Sx may improve with time
61
Most common site of head and neck cancer
Oral cavity (30% of all H&N cancer)
62
Most common site of second primary H&N cancer
Oral cavity (10-40%)
63
Oral leukoplakia vs erythroplakia malignant potential
5-20% malignant potential
| 25% malignant potential
64
OC subsites
7. lips, oral tongue, buccal mucosa, alveolar ridge, retromolar trigone, hard palate, floor of mouth
65
OC AJCC 8th staging
T1: <=2 cm thickness DOI <=5 mm
T2:<=2 cm thickness DOI >5 <=10; tumor >2 <=4 cm thickness, DOI <=10 mm
T3: > cm thickness OR >10 mm COI
T4a: mod adv local diz: cortical bone of the mandible/maxilla, maxillary sinus or skin of face
T4B: very adv local diz: invasion through masticator space, pterygoid plates, skull base and/or encases ICA
66
Verrucous carcinoma
Variant of SCC
Broad-based, warty growth
MC buccal mucosa, lateral growth, rare mets and deep invasion
Better prognosis
67
OC adjuvant Tx.
| One positive Node, without adverse features
XRT optional
68
OC adjuvant Tx.
| Adverse features such as positive margins or extracapsular spread
CRT (preferred), re-resection, or XRT
69
OC adjuvant Tx.
| Residual tumor post-XRT
Salvage surgery
70
Surgical approach for oral cancer
Anterior and small tumors (<2 cm) may be approached intraorally; larger and more posterior tumors require a transmandibular, transcervical, or transoral robotic approach
71
OP junction
Anterior boundary at junction of hard and soft palate; circumvallate papillae
Superior boundary at level of hard palate
Inferior boundary at the superior surface of the hyoid
72
Subsites of OP
```
5. Tonsil/lateral pharyngeal wall
Posterior pharyngeal wall
Soft palate
Base of tongue
Vallecula
```
73
E6 and E7 of HPV
E6 binds and inactivates p53
E7 binds and inactivates retinoblasttoma (Rb) protein leading to release of E2F transcription factor causing cell cycle progression
74
OP HPV+ AJCC T staging
T1 <= 2 cm
T2 >2 and <=4 cm
T3 >4 or extension to lingual surface of epiglottis
T4: primary tumor invades larynx, extrinsic muscles of tongue, medial pterygoid, or mandible or beyond
75
OP HPV+ AJCC cN staging
N0: no regional LN met
N1: 1+ ipsi LN <= 6 cm
N2: bilat or contralt LN <= 6 cm
N3: any LN >6 cm
76
OP HPV+ AJCC pN staging
N0: no regional LN met
N1: met in <=4 LNs
N2: met in >4 LNs
77
OP cancers other than SCC
Lymphjoepithelioma (subgroup of poorly differentiated carcinoma; may present in the tonsi, exophytic, radiosensitive)
Lymphoma
Sarcoma, salivary gland malignancies, metastatic disease
78
OP T1-T2 N2-3 neck
CRT (preferred), induction chemo followed by XRT or CRT
79
OP T3-T4a any neck
CRT (preferred) vs excision of primary tumor with primary recon vs induction chemo followed by XRT and CRT
80
De-escalation of therapy in HPV-associated OP carcinoma
Due to improved prognosis with HPV association, several clinical trials are investigating de-escalating (de-intensifying) chemoradiation to decrease side effects and morbidity
81
Transcervical/visor flap for OP SCC
Consider for large tumors of the base of tongue or tonsil, access OP from a transoral incision of the floor of mouth, preserves mandibular integrity, poor exposure, chin numbness
82
Mandibulectomy for OP SCC
Indicated for larger lesions, mandible extension, or multiple sites (composite resection)
May be approached laterally or medially with a lip-splitting incision (mandibular swing)
Provides excellent exposure, easier soft tissue closure, risk of malocclusion and plate extrusion
83
Mandibulotomy for OP SCC
Spares mandible ,may be approached laterally or midline with a lip-splitting incision, osteotomy is performed in a stepwise fashion to create a favorable repair followed by rigid fixation
Provides excellent exposure, less risk of malocclusion
84
Lateral pharyngotomy for OP SCC
Consider for small base of tongue or posterior pharyngeal wall tumors
Enters pharynx between CN XII and superior laryngeal nerves
Limited exposure, spares mandible, avoids lip-splitting incision
85
Transhyoid pharyngotomy for OP SCC
Consider for small base of tongue or posterior pharyngeal wall tumors without significant superior or tonsillar extension
Enters pharynx above or through hyoid bone
Spares mandible, avoids lip-splitting incision, vallecula must be free of tumor, poor exposure superiorly
86
Hypopharynx boundarise
Level of hyoid bone to cricopharyngeus (upper esophageal sphincter), lies behind and aroudn th larynx
87
Hypopharynx subsites
3. Piriform sinus, posterior pharyngeal wall, postcricoid region
88
Hypopharynx AJCC T staging
T1: tumor limited to 1 subsite <= 2 cm
T2: tumor invades more than 1 subsite/adjacent site or >2 cm and <=4 cm and without fixation of hemilarynx
T3: tumor >4 cm or vocal fold fixation or extension into esophagus
T4: tumor invades adjacent structures; T4a mod adv local dz (invasion of thyroid/cricoid cartilage, hyoid bone, thyroid gland, or central compartment soft tissue=prelaryngeal strap muscles and subQ fat); T4b: very advanced local dz (invasion of prevertebral fascia, encases carotid artery, or involves mediastinal structures)
89
Supraglottis boundaries
From the epiglottis to the junction of the ventricle and true vocal cord
90
Subsites of supraglottis
4. Suprahyoid epiglottis, infrahyoid epiglottis (MC), aryepiglottic folds, arytenoids, false cords
91
Supraglottic cancer AJCC T staging: T1
Limited to 1 subsite of supraglottis
92
Supraglottic cancer AJCC T staging: T2
Invades mucosa of more than 1 adjacent subsite (even BOT, vallecula, medial wall of piriform sinus) without vocal cord fixation
93
Supraglottic cancer AJCC T staging: T3
Vocal fold fixation or primary tumor invades postcricoid area, pre-epiglottic space, paraglottic space, or inner cortex of thyroid cartilage
94
Supraglottic cancer AJCC T staging: T4
further invasion.
T4a: mod adv local diz: invasion through thyroid cartilage or tissues beyond the larynx
T4b: very adv local diz (invades prevertebral space, encases carotid artery, or invades mediastinal structures)
95
Glottic cancer anatomic boundaries
From the superior surface of the true vocal fold to 1 cm below the true vocal folds
96
Glottic cancer AJCC T staging: T1
Tumor limited to vocal folds with normal mobility
T1a: one vocal fold
T1b: bilateral vocal fold involvement
97
Glottic cancer AJCC T staging: T2
tumor extends to subglottis or supraglottis, or impaired vocal fold mobility
98
Glottic cancer AJCC T staging: T3
Vocal fold fixation or invasion of paraglottic space or invasion of inner cortex of thyroid cartilage
99
Glottic cancer AJCC T staging: T4
Further invasion.
T4a: mod adv local diz (invades through outer cortex of thyroid cartilage or invades tissue beyond the larynx)
T4b: very advanced local disease (invades prevertebral space, encases carotid artery, or invades mediastinal structures)
