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ENT > H&N Cancer > Flashcards

H&N Cancer Flashcards

1
Q

Anatomic borders of Level Ia

What nodal group is contained there?

A

Superior: Mandible
Inferior: Hyoid
Lateral: anterior bellies of digastrics

Submental nodes contained there

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2
Q

Anatomic borders of Level Ib

What nodal group is contained there?

A

Superior: Mandible
Anterior: Anterior belly of digastric
Posterior: Stylohyoid or Posterior edge of submandibular gland

Submandibular nodes contained there

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3
Q

Anatomic borders of Level IIa

What nodal group is contained there?

A

Superior: Skull base
Inferior: Inf border of the hyoid
Anterior: Stylohyoid or Posterior edge of submandibular gland
Posterior: CNXI

Jugular nodes contained there

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4
Q

Anatomic borders of Level IIb

What nodal group is contained there?

A

Superior: Skull base
Inferior: Inf border of the hyoid
Anterior: CNXI
Posterior: Posterior border of SCM

Jugular nodes contained there (upper 1/3)

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5
Q

Anatomic borders of Level III

What nodal group is contained there?

A

Superior: Hyoid
Inferior: Inferior border of the cricoid
Anterior: Sternohyoid muscle
Posterior: Posterior border of SCM

Jugular nodes contained there (middle 1/3)

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6
Q

Anatomic borders of Level IV

What nodal group is contained there?

A

Superior: Cricoid
Inferior: Clavicle
Anterior: Sternohyoid muscle
Posterior: Posterior border of the SCM

Jugular nodes contained there (lower 1/3)

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7
Q

Anatomic borders of Level Va

What nodal group is contained there?

A

Anterosuperior: Posterior border of SCM
Posterosuperior: Anterior border of trap
Inferior: Level of cricoid

Spinal accessory, transverse cervical nodes contained there

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8
Q

Anatomic borders of Level Vb

What nodal group is contained there?

A

Superior: Level of cricoid
Inferior: Clavicle
Anterior: Post border of SCM
Posterior: Ant border of trap

Spinal accessory, transverse cervical, supraclavicular nodes contained there

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9
Q

Anatomic borders of Level VI

What nodal group is contained there?

A

Lateral: Carotid arteries
Superior: Hyoid
Inferior: Suprasternal notch

Paratracheal, pretracheal, prelaryngeal, Delphian, parathyroidal nodes contained here

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10
Q

What are the qualifiers to radical neck dissection

A

Modified: Preserves 1+ nonlymphatic structures (SCM, CNXI, IJ)
Selective: Preserves LN group typically removed in RND
Extended: Addition of LN groups or nonlymphatic structures

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11
Q

What is removed in RND?

What LN groups are not removed?

A

Levels I-V, parotid tail nodes, CNXI, SCM, IJ, submandibular gland,

Not removed: Postauricular, suboccipital, perifacial, buccinator, retropharyngeal, central compartment nodal groups

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12
Q

What is preserved in a MRND?

A

Any one or more of CNXI, SCM, IJ

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13
Q

Types of selective neck dissections & the corresponding levels

A

Supraomohyoid (anterolateral) ND: Levels I-III
Lateral ND: Levels II-IV
Posterolateral ND: II-V
Anterior compartment ND: Level VI

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14
Q

What neck dissection is used for OC cancer?

A

Supraomohyoid (anterolateral) ND (Levels I-III)

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15
Q

What neck dissection is used for OP, hypopharyngeal, or laryngeal cancer?

A 
Lateral ND (Levels II-IV)
Can also do central compartment if midline
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16
Q

What are the types of MRND’s?

A

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

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17
Q

What syndrome is caused by injury to CNXI?

A

Shoulder syndrome:

  • Shoulder drop
  • Winged scapula
  • Pain
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18
Q

What side typically sees chylous fistula?

A

Left side (chyLe; 95%)

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19
Q

Borders of oral cavity

A

Lips
Junction of hard/soft palate
Circumvallate papillae

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20
Q

Lymph drainage of the lips

A

Upper lip = unilateral levels I-III

Lower lip = bilateral levels I-III

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21
Q

Most common site of verrucous carcinoma

A

Buccal mucosa

It’s a SCCa varient with lateral warty growth & better prognosis.

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22
Q

Which OC cancers do not require elective supraomohyoid ND?

A

Early-stage hard palate or lower lip

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23
Q

What are the borders of the OP?

A

Anterior: Junction of hard/soft palate & circumvallate papillae
Superior: Hard palate
Inferior: Hyoid

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24
Q

Most common site of OP cancer

A

Tonsillar fossae

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25
Q

Types of cancers found in the OP

A

SCCa
Lymphoepithelioma
Lymphoma (BOT & tonsillar fossae)

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26
Q

Management of the cN0 neck in OP cancers

A

Elective lateral ND

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27
Q

Hypopharynx borders

A

Hyoid bone to cricopharyngeus

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28
Q

Subsites of hypopharynx & cancer rates

A 
Piriform sinus (70%)
Posterior pharyngeal wall (25%)
Postcricoid region (
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29
Q

T staging of hypopharyngeal cancer

A

T1: limited to 1 subsite; 1 subsite or 2-4cm
T3: >4cm or vocal fold fixation or esophageal extension
T4: Invasion of adjacent structures

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30
Q

Where is Reinke’s space?

A

It is the superifical lamina propria of the true vocal fold

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31
Q

Borders of the supraglottic larynx

A

Epiglottis to junction of ventricle & true vocal fold

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32
Q

What is the embryologic precursor to the supraglottis?

A

3rd & 4th branchial arches

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33
Q

What is the embryologic precursor to the glottis & subglottis?

A

6th branchial arch

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34
Q

T staging of supraglottic cancer

A

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

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35
Q

What are the subsites of the supraglottis?

A 
Suprahyoid epiglottis
Infrahyoid epiglottis*
Ayepiglottic folds
Arytenoids
False cords

*Most common supraglottic site

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36
Q

What are the borders of the glottis?

A

Superior surface of true cords to 1cm below the true vocal folds

37
Q

What is the most common site of laryngeal cancer?

A

Glottis

38
Q

What is the histology of the laryngeal subsites?

A

Supraglottis/Subglottis: Pseudostratified ciliated columnar epithelium

Glottis: Stratified squamous epithelium

39
Q

T staging of glottic cancers

A

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

40
Q

Borders of subglottis

A

1cm below true vocal folds to the inferior cricoid cartilage

41
Q

T staging of subglottic cancers

A

T1: Limited to subglottis
T2: Involves vocal folds (normal or impaired mobility)
T3: Fixed vocal cord; limited to larynx
T4: Outside of larynx

42
Q

Which laryngeal cancers do not require elective ND?

A

T1 or T2 glottic cancers

All others require elective (usually b/l) lateral ND

43
Q

Most common presentating symptoms of nasopharyngeal cancer

A

1) Neck mass

2) serous otitis media

44
Q

Risk factors for nasopharyngeal cancer

A 
Regional distribution (South Asia)
EBV infection
45
Q

Borders of the nasopharynx

A

Anterior: Choanae
Superior: Skull base
Inferior: Soft palate
Posterior: Superior constrictors

46
Q

Where is the Fossa of Rosenmuller?

A

Medial to the medial crura of the eustachian tube orifice

47
Q

What prevents food from going up your nose when swallowing?

A

Passavant’s ridge

superior constrictors abut the soft palate

48
Q

T staging of nasopharyngeal cancer

A

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

49
Q

Treatment for nasopharyngeal carcinoma

A

Chemoradiation

No role for surgery except for salvage neck management

50
Q

What line divides the maxillary sinuses in half?

A

Ohngren’s line

Line from medial canthus to angle of jaw. Posterosuperior to the line indicates worse prognosis.

51
Q

Most common paranasal sinuses for cancer

A

1) Maxillary sinuses

2) Ethmoid sinus

52
Q

Contents of the pterygopalatine fossa

A 
Foramen rotundum (V2)
Vidian n.
Sphenopalatine n.
Lesser Palatine n.
Greater Palatine n.
Pterygopalatine ganglion
Maxillary artery
53
Q

Borders of the pterygopalatine fossa

A

Medial: Perpendicular plate of palatine bone
Lateral: Pterygomaxillary fissure
Anterior: Posterior wall of maxillary sinus
Posterior: Medial/Lateral pterygoid plates

54
Q

What foramina open up into the infratemporal fossa?

A 
Foramen ovale (V3)
Foramen spinosum (middle meningeal a.)
55
Q

Where is the H-zone of the face?

Why is it important?

A

Eyes, ears, nose, philtrum, jawline

Skin cancers here portend a worse prognosis because these are embryologic fusion plates

56
Q

N staging of melanoma

A

N1: 1 LN
N2: 2-3 LN’s
N3: 4+ nodes or satellites in transit

57
Q

Vagus schwannoma/neurofibroma:
Unilateral or bilateral?
Flow voids?

A

Unilateral

No flow voids present

58
Q 
Cervical paraganglioma (carotid body tumor):
Unilateral or bilateral?
Flow voids?
A

Single or bilateral

Strongly enhancing with flow voids

59
Q

How does internal jugular thrombosis look on CT?

A

Round, expanded hypodense lumen

60
Q

What potential spaces are seen behind the pharynx?

A 
Retropharyngeal space (buccopharyngeal & alar fascia)
Danger space (alar & prevertebral fascia)
Prevertebral space

Retropharyngeal space has a midline raphe, danger space does not

61
Q

MR appearance of cystic hygroma

A

aka Lymphangioma
T2 bright, T1 isointense
Most often found in posterior cervical space

62
Q

What portions of the larynx come from which bronchial arches?

A

Supraglottis - 3rd & 4th
Glottis - 6th
Subglottis - 6th

3/4, 6, 6

63
Q

What is the minimum SUV cutoff to be suspicious for cancer?

A

2.5 SUV’s

64
Q

How does Warthin’s tumor appear on MRI?

A

Restricted diffusion often
T1 hyperintense
Can be bilateral or multiple sites in 1 parotid

65
Q

What imaging characteristics point toward a malignant parotid mass?

A

Spiculated
T2 hypointense

If both present then 80% PPV of malignancy.

66
Q

What H&N cancer goes to the retropharyngeal LN’s?

A

Nasopharyngeal Ca

**can be a normal finding in children

67
Q

Best series to see LN’s on MRI?

A

T2 fat suppressed

68
Q

Best diagnostic modality for salivary gland masses

A

FNA

Incisional biopsy is contraindicated

69
Q

What is the most common salivary gland malignancy?

A

Mucoepidermoid carcinoma

True of both children and adults

70
Q

What is the most common malignancy of the submandibular and minor glands?

A

Adenoid cystic carcinoma

71
Q

How is the neck managed with mucoepidermoid carcinoma in a salivary gland?

A

Low grade: ND only if clinical nodes present

High grade: Elective supraomohyoid ND

72
Q

What salivary gland malignancy has a predilection for perineural spread?

A

Adenoid cystic carcinoma

73
Q

What are the histologic subtypes of adenoid cystic carcinoma?

A

Low grade: Cribriform, Cylindromatous

High grade: Solid

74
Q

How is the neck managed with adenoid cystic carcinoma in a salivary gland?

A

Clinically positive nodes only

75
Q

What are the markers used to identify the facial nerve while performing parotidectomy?

A

Tragal pointer (lies 1cm inferior & anterior)
Tympanomastoid suture line (lies deep to the inf end)
Digastric attachment

76
Q

What causes Frey’s syndrome?

A

AKA gustatory sweating

Caused by injury to the auriculotemporal nerve (supplies the parotid). Sweating & reddening of the affected area.

77
Q

What US characteristics of thyroid nodules are predictive of malignancy?

A 
Hypoechogenicity
Height > Width
Irregular borders
Microcalcifications
Hypervascularity
78
Q

5y survival rates for HNSCCa for local, locoregional, and distant mets

A 
Local = 80%
Locoregional = 45%
Distant = 35%
79
Q

What is the mechanism of cisplatin?

A

Alkylating agent –> DNA cross-linking

80
Q

What are the major toxicities of cisplatin?

A 
Renal toxicity
Ototoxicity
Peripheral neuropathy
Myelosuppression
Increased liver enzymes
N/V
81
Q

What is the mechanism of Cetuximab (Erbitux)?

A

mAb that blocks EGFR

82
Q

What are the major toxicities of Cetuximab (Erbitux)?

A 
Peripheral neuropathy
Desquamation and acne
Electrolyte abnormalities
Neutropenia/Infections
Transaminitis
Cardiac arrest (2%)
83
Q

What is the mechanism of Pembrolizumab (Keytruda)?

A

mAb blocks PD-1 receptor and inhibits cell death on T-cells –> reverses T-cell suppression & induces antitumor response

84
Q

What are the major toxicities of Pembrolizumab (Keytruda)?

A

Hyperglycemia & DM
Electrolyte abnormalities
Myelosuppression
Edema

85
Q

What are the major toxicities of Paclitaxel (Taxol)?

A

Peripheral neuropathy
Alopecia
Pancytopenia
Hypersensitivity

86
Q

Subsites of the oropharynx

A 
Tonsil
BOT
Soft palate
Posterior wall
Vallecula
87
Q

What percent of OP cancers are P16 positive but HPV negative?

A

10-20%

88
Q

What malignancies are seen in the oropharynx?

A

SCCa (majority)
Lymphoepithelioma (tonsil)
Lymphoma
Sarcoma, salivary gland

89
Q

What ND is used for oropharyngeal cancer?

A

Levels II-IV

Ipsilateral or bilateral

ENT (10 decks)

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