H&N Cancer Flashcards
Anatomic borders of Level Ia
What nodal group is contained there?
Superior: Mandible
Inferior: Hyoid
Lateral: anterior bellies of digastrics
Submental nodes contained there
Anatomic borders of Level Ib
What nodal group is contained there?
Superior: Mandible
Anterior: Anterior belly of digastric
Posterior: Stylohyoid or Posterior edge of submandibular gland
Submandibular nodes contained there
Anatomic borders of Level IIa
What nodal group is contained there?
Superior: Skull base
Inferior: Inf border of the hyoid
Anterior: Stylohyoid or Posterior edge of submandibular gland
Posterior: CNXI
Jugular nodes contained there
Anatomic borders of Level IIb
What nodal group is contained there?
Superior: Skull base
Inferior: Inf border of the hyoid
Anterior: CNXI
Posterior: Posterior border of SCM
Jugular nodes contained there (upper 1/3)
Anatomic borders of Level III
What nodal group is contained there?
Superior: Hyoid
Inferior: Inferior border of the cricoid
Anterior: Sternohyoid muscle
Posterior: Posterior border of SCM
Jugular nodes contained there (middle 1/3)
Anatomic borders of Level IV
What nodal group is contained there?
Superior: Cricoid
Inferior: Clavicle
Anterior: Sternohyoid muscle
Posterior: Posterior border of the SCM
Jugular nodes contained there (lower 1/3)
Anatomic borders of Level Va
What nodal group is contained there?
Anterosuperior: Posterior border of SCM
Posterosuperior: Anterior border of trap
Inferior: Level of cricoid
Spinal accessory, transverse cervical nodes contained there
Anatomic borders of Level Vb
What nodal group is contained there?
Superior: Level of cricoid
Inferior: Clavicle
Anterior: Post border of SCM
Posterior: Ant border of trap
Spinal accessory, transverse cervical, supraclavicular nodes contained there
Anatomic borders of Level VI
What nodal group is contained there?
Lateral: Carotid arteries
Superior: Hyoid
Inferior: Suprasternal notch
Paratracheal, pretracheal, prelaryngeal, Delphian, parathyroidal nodes contained here
What are the qualifiers to radical neck dissection
Modified: Preserves 1+ nonlymphatic structures (SCM, CNXI, IJ)
Selective: Preserves LN group typically removed in RND
Extended: Addition of LN groups or nonlymphatic structures
What is removed in RND?
What LN groups are not removed?
Levels I-V, parotid tail nodes, CNXI, SCM, IJ, submandibular gland,
Not removed: Postauricular, suboccipital, perifacial, buccinator, retropharyngeal, central compartment nodal groups
What is preserved in a MRND?
Any one or more of CNXI, SCM, IJ
Types of selective neck dissections & the corresponding levels
Supraomohyoid (anterolateral) ND: Levels I-III
Lateral ND: Levels II-IV
Posterolateral ND: II-V
Anterior compartment ND: Level VI
What neck dissection is used for OC cancer?
Supraomohyoid (anterolateral) ND (Levels I-III)
What neck dissection is used for OP, hypopharyngeal, or laryngeal cancer?
Lateral ND (Levels II-IV) Can also do central compartment if midline
What are the types of MRND’s?
Type I: Spares CNXI
Type II: Spares CNXI and IJ
Type III: Spares CNXI, IJ, and SCM
Type I spares I, type II spares II, type III spares III
What syndrome is caused by injury to CNXI?
Shoulder syndrome:
- Shoulder drop
- Winged scapula
- Pain
What side typically sees chylous fistula?
Left side (chyLe; 95%)
Borders of oral cavity
Lips
Junction of hard/soft palate
Circumvallate papillae
Lymph drainage of the lips
Upper lip = unilateral levels I-III
Lower lip = bilateral levels I-III
Most common site of verrucous carcinoma
Buccal mucosa
It’s a SCCa varient with lateral warty growth & better prognosis.
Which OC cancers do not require elective supraomohyoid ND?
Early-stage hard palate or lower lip
What are the borders of the OP?
Anterior: Junction of hard/soft palate & circumvallate papillae
Superior: Hard palate
Inferior: Hyoid
Most common site of OP cancer
Tonsillar fossae
Types of cancers found in the OP
SCCa
Lymphoepithelioma
Lymphoma (BOT & tonsillar fossae)
Management of the cN0 neck in OP cancers
Elective lateral ND
Hypopharynx borders
Hyoid bone to cricopharyngeus
Subsites of hypopharynx & cancer rates
Piriform sinus (70%) Posterior pharyngeal wall (25%) Postcricoid region (
T staging of hypopharyngeal cancer
T1: limited to 1 subsite; 1 subsite or 2-4cm
T3: >4cm or vocal fold fixation or esophageal extension
T4: Invasion of adjacent structures
Where is Reinke’s space?
It is the superifical lamina propria of the true vocal fold
Borders of the supraglottic larynx
Epiglottis to junction of ventricle & true vocal fold
What is the embryologic precursor to the supraglottis?
3rd & 4th branchial arches
What is the embryologic precursor to the glottis & subglottis?
6th branchial arch
T staging of supraglottic cancer
T1: Limited to one subsite; normal cord mobility
T2: Invades mucosa of >1 adjacent subsite or outside of supraglottis; normal cord mobility
T3: Vocal fold fixation or tumor invades postcricoid area, pre-epiglottic space, paraglottic space, or thyroid cartilage
T4: Invasion outside of larynx
What are the subsites of the supraglottis?
Suprahyoid epiglottis Infrahyoid epiglottis* Ayepiglottic folds Arytenoids False cords
*Most common supraglottic site
What are the borders of the glottis?
Superior surface of true cords to 1cm below the true vocal folds
What is the most common site of laryngeal cancer?
Glottis
What is the histology of the laryngeal subsites?
Supraglottis/Subglottis: Pseudostratified ciliated columnar epithelium
Glottis: Stratified squamous epithelium
T staging of glottic cancers
T1: Limited to vocal fold with normal mobility
T1a: one vocal fold
T1b: bilateral vocal folds
T2: Tumor extends to supra/subglottis or impaired vocal fold mobility
T3: Vocal fold fixation or invasion of paraglottic space or thyroid cartilage
T4: Extension outside of the larynx
Borders of subglottis
1cm below true vocal folds to the inferior cricoid cartilage
T staging of subglottic cancers
T1: Limited to subglottis
T2: Involves vocal folds (normal or impaired mobility)
T3: Fixed vocal cord; limited to larynx
T4: Outside of larynx
Which laryngeal cancers do not require elective ND?
T1 or T2 glottic cancers
All others require elective (usually b/l) lateral ND
Most common presentating symptoms of nasopharyngeal cancer
1) Neck mass
2) serous otitis media
Risk factors for nasopharyngeal cancer
Regional distribution (South Asia) EBV infection
Borders of the nasopharynx
Anterior: Choanae
Superior: Skull base
Inferior: Soft palate
Posterior: Superior constrictors
Where is the Fossa of Rosenmuller?
Medial to the medial crura of the eustachian tube orifice
What prevents food from going up your nose when swallowing?
Passavant’s ridge
superior constrictors abut the soft palate
T staging of nasopharyngeal cancer
T1: Confined to nasopharynx/oropharynx/nasal cavity
T2: Parapharyngeal extension
T3: Invasion of bony skull base or paranasal sinuses
T4: Extension into cranium, CN’s, hypopharynx, orbit, infratemporal fossa
Treatment for nasopharyngeal carcinoma
Chemoradiation
No role for surgery except for salvage neck management
What line divides the maxillary sinuses in half?
Ohngren’s line
Line from medial canthus to angle of jaw. Posterosuperior to the line indicates worse prognosis.
Most common paranasal sinuses for cancer
1) Maxillary sinuses
2) Ethmoid sinus
Contents of the pterygopalatine fossa
Foramen rotundum (V2) Vidian n. Sphenopalatine n. Lesser Palatine n. Greater Palatine n. Pterygopalatine ganglion Maxillary artery
Borders of the pterygopalatine fossa
Medial: Perpendicular plate of palatine bone
Lateral: Pterygomaxillary fissure
Anterior: Posterior wall of maxillary sinus
Posterior: Medial/Lateral pterygoid plates
What foramina open up into the infratemporal fossa?
Foramen ovale (V3) Foramen spinosum (middle meningeal a.)
Where is the H-zone of the face?
Why is it important?
Eyes, ears, nose, philtrum, jawline
Skin cancers here portend a worse prognosis because these are embryologic fusion plates
N staging of melanoma
N1: 1 LN
N2: 2-3 LN’s
N3: 4+ nodes or satellites in transit
Vagus schwannoma/neurofibroma:
Unilateral or bilateral?
Flow voids?
Unilateral
No flow voids present
Cervical paraganglioma (carotid body tumor): Unilateral or bilateral? Flow voids?
Single or bilateral
Strongly enhancing with flow voids
How does internal jugular thrombosis look on CT?
Round, expanded hypodense lumen
What potential spaces are seen behind the pharynx?
Retropharyngeal space (buccopharyngeal & alar fascia) Danger space (alar & prevertebral fascia) Prevertebral space
Retropharyngeal space has a midline raphe, danger space does not
MR appearance of cystic hygroma
aka Lymphangioma
T2 bright, T1 isointense
Most often found in posterior cervical space
What portions of the larynx come from which bronchial arches?
Supraglottis - 3rd & 4th
Glottis - 6th
Subglottis - 6th
3/4, 6, 6
What is the minimum SUV cutoff to be suspicious for cancer?
2.5 SUV’s
How does Warthin’s tumor appear on MRI?
Restricted diffusion often
T1 hyperintense
Can be bilateral or multiple sites in 1 parotid
What imaging characteristics point toward a malignant parotid mass?
Spiculated
T2 hypointense
If both present then 80% PPV of malignancy.
What H&N cancer goes to the retropharyngeal LN’s?
Nasopharyngeal Ca
**can be a normal finding in children
Best series to see LN’s on MRI?
T2 fat suppressed
Best diagnostic modality for salivary gland masses
FNA
Incisional biopsy is contraindicated
What is the most common salivary gland malignancy?
Mucoepidermoid carcinoma
True of both children and adults
What is the most common malignancy of the submandibular and minor glands?
Adenoid cystic carcinoma
How is the neck managed with mucoepidermoid carcinoma in a salivary gland?
Low grade: ND only if clinical nodes present
High grade: Elective supraomohyoid ND
What salivary gland malignancy has a predilection for perineural spread?
Adenoid cystic carcinoma
What are the histologic subtypes of adenoid cystic carcinoma?
Low grade: Cribriform, Cylindromatous
High grade: Solid
How is the neck managed with adenoid cystic carcinoma in a salivary gland?
Clinically positive nodes only
What are the markers used to identify the facial nerve while performing parotidectomy?
Tragal pointer (lies 1cm inferior & anterior)
Tympanomastoid suture line (lies deep to the inf end)
Digastric attachment
What causes Frey’s syndrome?
AKA gustatory sweating
Caused by injury to the auriculotemporal nerve (supplies the parotid). Sweating & reddening of the affected area.
What US characteristics of thyroid nodules are predictive of malignancy?
Hypoechogenicity Height > Width Irregular borders Microcalcifications Hypervascularity
5y survival rates for HNSCCa for local, locoregional, and distant mets
Local = 80% Locoregional = 45% Distant = 35%
What is the mechanism of cisplatin?
Alkylating agent –> DNA cross-linking
What are the major toxicities of cisplatin?
Renal toxicity Ototoxicity Peripheral neuropathy Myelosuppression Increased liver enzymes N/V
What is the mechanism of Cetuximab (Erbitux)?
mAb that blocks EGFR
What are the major toxicities of Cetuximab (Erbitux)?
Peripheral neuropathy Desquamation and acne Electrolyte abnormalities Neutropenia/Infections Transaminitis Cardiac arrest (2%)
What is the mechanism of Pembrolizumab (Keytruda)?
mAb blocks PD-1 receptor and inhibits cell death on T-cells –> reverses T-cell suppression & induces antitumor response
What are the major toxicities of Pembrolizumab (Keytruda)?
Hyperglycemia & DM
Electrolyte abnormalities
Myelosuppression
Edema
What are the major toxicities of Paclitaxel (Taxol)?
Peripheral neuropathy
Alopecia
Pancytopenia
Hypersensitivity
Subsites of the oropharynx
Tonsil BOT Soft palate Posterior wall Vallecula
What percent of OP cancers are P16 positive but HPV negative?
10-20%
What malignancies are seen in the oropharynx?
SCCa (majority)
Lymphoepithelioma (tonsil)
Lymphoma
Sarcoma, salivary gland
What ND is used for oropharyngeal cancer?
Levels II-IV
Ipsilateral or bilateral
