H&N principles of staging evaluation and prognosis Flashcards
What oncologic staging system was devised in
1959 by the American Joint Committee on Cancer
(AJCC) to describe the extent of the primary
tumor, involvement of regional lymph nodes, and
metastases to distant sites in an effort to form a cohesive system providing the clinician with an
important tool to predict prognosis, counsel the
patient, chose an intervention, and perform more
consistent clinical research?
Tumor, node, metastasis (TNM) staging system
Using the TNM staging system, how can you
differentiate a clinical stage from a pathologic stage?
● Clinical stage is designated with a “c” and is based on
physical examination or imaging (e.g., cT, cN, or cM).
● Pathologic stage is designated with a “p” and is based on
pathologic analysis of a specimen (e.g., pT, pN, pM).
Which subsites share the following criteria (in
addition to subsite specific criteria) for T staging:
● T1: < 2 cm
● T2: > 2 cm, < 4 cmT3: > 4
● Lips and oral cavity
● Oropharynx
● Hypopharynx (plus additional criteria)
● Major salivary gland (plus additional criteria)
● Well-differentiated thyroid cancer and medullary thyroid
cancer (plus additional division of T1a, T1b)
In the 7th edition of the AJCC, the terms resectable and unresectable were changed to mean “moderately advanced local disease (T4a)” and “very advanced local disease (T4b)” in an effort to predict better the prognosis using current management strategies. What does “very advanced local disease” generally represent?
Very advanced disease correlates with extension into
surrounding critical structures which are largely viewed as
unresectable or incurable.
What two head and neck subsites have a unique
nodal staging system compared with the majority
of subsites?
● Nasopharynx
● Thyroid
Tumor invasion of what subsites are considered by
some as unresectable?
● Nasopharynx ● Prevertebral fascia ● Base of skull ● Intracranial extension ● Mediastinum ● Subdermal lymphatics ● Carotid artery encasement (generally > 270 degrees)
Describe how the American Joint Committee on
Cancer reports the presence or absence of residual
tumor (R) following treatment.
● RX: Residual tumor cannot be assessed
● R0: No residual tumor
● R1: Microscopic residual tumor
● R2: Macroscopic residual tumor
How does the AJCC recommend reporting tumor
grade?
● GX: Grade cannot be assessed ● G1: Well differentiated ● G2: Moderately differentiated ● G3: Poorly differentiated ● G4: Undifferentiated
Patients with head and neck cancer will have
symptoms related to the location and extent of
their tumor that are often subsite specific. What
“red flag” signs or symptoms should be reviewed
with all patients who have concerns for head and
neck cancer?
Pain, cranial neuropathy, bleeding, unintentional weight
loss, lymphadenopathy, malaise, anorexia
What risk factors should be elicited when taking a
history on a patient with potential head and neck
cancer?
● Tobacco* (smoked and smokeless) and alcohol* exposure
● Viral infection (EBV and HPV*)
● Radiation exposure
● Diet low in fruits and vegetables and high in red meats
and processed meats
● Occupational risk factors such as woodworking, textile
exposure, and nickel refining
● Sun exposure
● Personal history of head and neck cancer
● Family history of cancer
● Poor dentition, chronic inflammation, or chronic irritation
● Immunosuppression
● Use of betel (quid or panna) (Asia)
* Major risk factors in developed countries
What risk factors are associated with advanced
head and neck cancer at presentation?
● Low income
● Black race
● Poorly differentiated tumors
● Patient neglect
Define the Eastern Cooperative Oncology Group
(ECOG) performance status system.
● Grade 0: Fully active, able to carry on all predisease
performance without restriction
● Grade 1: Restricted in physically strenuous activity but
ambulatory and able to carry out work of a light or
sedentary nature
● Grade 2: Ambulatory and capable of all self-care but
unable to carry out any work activities. Up and about >
50% of waking hours
● Grade 3: Capable of only limited self-care; confined to
bed more than 50% of waking hours.
● Grade 4: Completely disabled; cannot carry out any self-
care. Totally confined to bed or chair.
● Grade 5: Deceased
During a head and neck examination in an adult patient, you note unilateral serous otitis media. On flexible endoscopic examination, to what anatomical region(s) should you pay particular attention?
Posterior nasal cavity, nasopharynx, fossa of Rosenmuller
and eustachian tube orifice
During fiberoptic or mirror laryngoscopy, what
maneuvers are critical for a complete oncologic
head and neck examination?
● Phonation → assess vocal cord mobility
● Tongue protrusion → full view of the epiglottis and
vallecula
● Puff out cheeks → full view of pyriform sinuses and
postcricoid region
You perform an otoscopic examination on a
patient complaining of otalgia but note no obvious source of pain. Which nerve(s) might be impli-
cated in referred otalgia?
CN V3, IX (via Jacobson nerve), X (via Arnold nerve), and VII
(via the Ramsay Hunt branch of VII), as well as branches
from C2 and C3 through the great auricular nerve
On evaluation of a primary head and neck tumor,
in addition to the location and size of the tumor,
what information can be gained from palpation
that is critical to the workup?
Fixation of the tumor
Note: fixation of nodal metastases should also be noted.
What premalignant lesion can present as a
thickened white patch that can’t be scraped off on
physical exam of the upper aerodigestive tract
mucosa that can progress to invasive carcinoma in
up to 30% of patients over a variable number of
years?
Leukoplakia
What premalignant mucosal lesion can appear as a
flat red patch with a malignant potential of up to
60% over a variable number of years?
Erythroplakia
What common initial screening test evaluates for
pulmonary disease (metastases or primary lung
cancer)?
Chest radiograph. PET/CT is also often ordered now as the
initial screening test for distant metastases.
Which imaging modality is used most often in the
initial workup of head and neck cancer patients?
Contrast-enhanced CT
CT scan of the head and neck is often ordered as a
first-line imaging modality to evaluate the size,
extent, and location of the primary tumor; status
of the vasculature; and nodal disease. Should this
scan be ordered with or without contrast?
With contrast (as patient’s allergies and renal status
permits). In the initial workup of differentiated thyroid
carcinoma, avoidance of iodinated contrast should be
considered.
What are frequently used as radiographic criteria
for a nodal malignancy on CT scan?
● Size > 1 cm
● Evidence of central necrosis (~100% specificity)
● Spherical shape (suggestive)
● Nodal grouping in the predicted drainage pathway, with
nodes > 1 cm
