Head and Neck Flashcards
Indications for post op radiation
- Advanced stage disease, pT3 or pT4
- Multiple positive nodes
- Close or positive surgical margins: reresection preferable if possible, concurrent CRT if resection not possible
- Perineural invasion
- Lymphovascular invasion
- Extracapsular extension (gets CRT)
Timing of radiation therapy
Adjuvant: 4-6 weeks after surgery
Primary: 2 weeks after any necessary dental extractions
Complications of radiation therapy
- Mucositis
- Xerostomia
- Dental caries
- Osteoradionecrosis
- Chondroradionecrosis of larynx
- Soft tissue fibrosis
- Dysphagia
- Cranial neuropathy
- Atherosclerosis and long term risk of stroke
- Long term risk of secondary malignancies
Risk factors for ORN after radiation
- Radiation dose > 60 Gy
- Poor oral hygiene or poor dentition
- Location of primary tumor: posterior mandible most commonly affected
- Extent of mandible in radiation field
- Poor nutritional status
- Concurrent chemoradiation
Cisplatin
Most common chemotherapy agent used. Leads to DNA crosslink formation.
- Regimen: high dose q3 weeks protocol (delivered every 3 weeks for 3 weeks) or low dose week protocol (better tolerated)
- Side effects: nephrotoxicity, ototoxicity, alopecia, nausea and vomiting, neutropenia
Carboplatin
Similar mechanism of action as cisplatin (DNA crosslinking). More myelosuppressive, better tolerated than cisplatin. Less ototoxic.
5 Flurouracil
Causes derangements in DNA synthesis and repair. Causes severe mucositis.
- Irreversibly binds to thymidylate synthetase, blocking conversion of uridine to thymidine thereby preventing DNA synthesis
Taxanes
Stabilize microtubules and arrest cells in G2/M phase. In induction chemo addition of taxanes to cisplatin and 5-FU leads to better outcomes than cisplatin and 5-FU alone.
Cetuximab
Monoclonal antibody that binds to epidermal growth factor receptor (which is overexpressed in HNSCC). Improved survival when given concurrently with radiation compared to radiation alone.
When to give chemo concurrently with radiation
When extracapsular extension or positive margins
Radical neck dissection
Resection of levels I-V with sacrifice of internal jugular vein, SCM and spinal accessory nerve
Modified radical neck dissection
Resection of levels I-V with sparing of at least one of the nonlymphatic structures taken in a radical dissection.
Selective neck dissection
- Supraomohyoid: levels I-III
- Lateral neck dissection: levels II-IV
- Posterolateral: levels II-V, suboccipital nodes
- Central neck : level VI
Anatomic landmarks of level Ia
Bounded by anterior bellies of digastric laterally, mandible superiorly, hyoid inferiorly, mylohyoid deep
Anatomic landmarks of level Ib
Bounded anteriorly by anterior belly of digastric, superiorly by body of mandible, posteriorly by posterior belly of digastric
Anatomic landmarks of level II
Upper jugular nodal group extending from skull base superiorly to hyoid inferiorly
IIa - Bordered by posterior belly of digastric superior/anteriorly, anterior to spinal accessory nerve, inferior border is hyoid bone or bifurcation of carotid
IIb- Bordered by spinal accessory nerve anteriorly to posterior border of SCM posteriorly, inferior border level of hyoid bone
Anatomic landmarks of level III
Midjugular nodal group that extends from carotid bifurcation (or hyoid, radiographic landmark) to the junction of the omohyoid and internal jugular vein (or inferior border of cricoid, radiographic landmark)
Anatomic landmarks of level IV
Lower jugular nodal group that extends from junction of omohyoid muscle with internal jugular vein (or inferior border of cricoid) to the clavicle
Anatomic landmarks of level V
Posterior triangular nodes bordered by trapezius posteriorly, and posterior border of SCM anteriorly, inferior border is clavicle
Va- nodes located above a horizontal plane at inferior border of cricoid cartilage
Vb- nodes located below a horizontal plane at inferior border of cricoid cartilage
When to do a neck dissection in the N0 neck
Management (surgery or radiation) indicated when risk of nodal involvement reaches 20% (when depth of invasion > 4mm)
Types of neck dissections that should be done in head and neck cancer when RT is not already planned for T1/T2 N0 cancer
Oral cavity: supraomohyoid (levels I-III), consider bilateral dissection for midline lesions (floor of mouth and tongue)
Oropharynx: Ipsilateral dissection for tonsil primary (at least levels II-IV), bilateral dissection for base of tongue
Supraglottis: bilateral levels II-IV
Hypopharynx: ipsilateral vs bilateral levels II-IV
Type of neck dissection in the T3/T4 N0 neck
- Surgical management of primary should include neck dissection
- Ipsilateral dissection: lateral tongue not crossing midline, retromolar trigone, buccal mucosa, lateral alveolar ridge, tonsil
- Bilateral dissection: oral tongue crossing midline, anterior floor of mouth, soft palate, base of tongue, supraglottis, glottis, hypopharynx
Complications of neck dissections
- Nerve injury: spinal accessory, vagus, hypoglossal, RLN, phrenic, sympathetic chain, brachial plexus, marginal mandibular branch of facial
- Hematoma
- Infection
- Seroma
- Chyle leak
- lymphatic leak
- Skin flap necrosis
- Carotid rupture
Subsites of oral cavity
- Lips
- Buccal mucosa
- Oral tongue
- Floor of mouth
- Hard palate
- Alveolar ridge
- Retromolar trigone
Oral cavity T staging
T1: tumor < 2cm in greatest dimension, and DOI ≤ 5 mm
T2: tumor ≤ 2 cm, DOI > 5 mm and ≤ 10 mm or tumor > 2 cm and ≤ 4 cm and DOI ≤ 10 mm
T3: > 4cm or any tumor with DOI > 10 mm
T4a: Tumor invades adjacent structures only (e.g., through cortical bone of mandible or maxilla, or involves the maxillary sinus or skin of the face; for lip it invades through the cortical bone, inferior alveolar nerve, floor of mouth or skin of face)
T4b: Tumor invades masticator space, pterygoid plates, or skull base and/or encases the internal carotid artery
Oral cavity N staging
Clinical assessment:
NX: Regional lymph nodes cannot be assessed
N0: No regional lymph node metastasis
N1: Metastasis in a single ipsilateral lymph node, ≤ 3 cm and ENE-
N2a: Metastasis in a single ipsilateral lymph node > 3 cm and ≤ 6 cm and ENE
N2b: Metastases in multiple ipsilateral lymph nodes, ≤ 6 cm and ENE-
N2c: Metastases in bilateral or contralateral lymph nodes, ≤ 6 cm and ENE-
N3a: Metastasis in a lymph node > 6 cm and ENE-
N3b: metastasis in any lymph node(s) with ENE+ clinically
Pathologically remainder of above is the same except for -
N2a: Metastasis in a single ipsilateral lymph node, ≤ 3 cm and ENE+; or metastasis in a single ipsilateral lymph node > 3 cm and ≤ 6 cm and ENE-
N3b: Metastasis in a single ipsilateral node larger than 3 cm in greatest dimension and ENE+; or multiple ipsilateral, contralateral, or bilateral nodes, any with ENE+; or a single contralateral node of any size and ENE+
Retromolar trigone
- Mucosal space between third mandibular molar and maxillary tuberosity
- Continuous with buccal mucosa, hard and soft palate, anterior tonsillar pillar, maxillary tuberosity and upper and lower alveolar ridges
Borders: superior - maxillary tuberosity; anterior: posterior aspect of second mandibular molar; lateral - buccal mucosa; medial- anterior tonsillar pillar
Most common site of verrucous carcinoma in head and neck
Buccal
Subsite of the oropharynx
- Palatine tonsils
- Base of tongue (posterior to circumvallate papillae)/ lingual tonsils
- Soft palate and uvula
- Anterior and posterior tonsillar pillars
- Posterior pharyngeal wall
- Vallecula
T Staging for HPV + Oropharynx
T1: Tumor ≤ 2 cm
T2: Tumor > 2 cm and ≤ 4 cm
T3: Tumor > 4 cm or extension to lingual surface of the epiglottis
T4: Moderately advanced local disease; tumor invades larynx, extrinsic muscle of tongue, medial pterygoid, hard palate, or mandible or beyond
N Staging for HPV+ Oropharynx
Clinical-
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 One or more ipsilateral lymph nodes ≤ 6 cm
N2 Contralateral or bilateral lymph nodes ≤ 6 cm
N3 Lymph node(s) > 6 cm
Pathologic -
pNX Regional lymph nodes cannot be assessed
pN0 No regional lymph node metastasis
pN1 Metastasis in 4 or fewer lymph nodes
pN2 Metastases in more than 4 lymph nodes
Layers of Vocal fold
squamous epithelium -> superficial lamina propria -> intermediate lamina propria -> deep lamina propria -> vocalis muscle
Sites of larynx
Supraglottis
Glottis
Subglottis
Subsites of supraglottis
Epiglottis
AE folds
Arytenoid cartilages
False vocal folds
Subsites of glottis
True vocal folds
Anterior commissure
Posterior commissure
Ventricle
Laryngeal carcinoma barriers to spread
- Quadrangular membrane (for supraglottis)
- Conus elasticus (for glottis and subglottis)
- Cricothyroid membrane
- Thyrohyoid membrane
- Inner perichondrium
Laryngeal carcinoma pathways to spread
- Broyle’s tendon: vocalis tendon inserted into thyroid cartilage
- Preepiglottic space
- Paraglottic space
T staging for Supraglottis
T1: Tumor limited to one subsite of supraglottis with normal vocal cord mobility
T2: Tumor invades mucosa of more than one adjacent subsite* of supraglottis or glottis or region outside the supraglottis (e.g., mucosa of base of tongue, vallecula, or medial wall of pyriform sinus) without fixation of the larynx
T3: Tumor limited to larynx with vocal cord fixation and/or invades any of the following: postcricoid area, pre-epiglottic tissues, paraglottic space, and/or minor thyroid cartilage erosion (e.g., inner cortex)
T4a: Tumor invades through the thyroid cartilage, and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of the neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus)
Note: extrinsic muscles of the tongue are: genioglossus, hyoglossus, styloglossus, and palatoglossus
T4b: Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures
T staging for Glottis
T1: Tumor limited to the vocal cord(s), which may involve anterior or posterior commissure, with normal mobility
T1a: Tumor limited to one vocal cord
T1b: Tumor involves both vocal cords
T2: Tumor extends to supraglottis and/or subglottis and/or with impaired vocal cord mobility
T3: Tumor limited to the larynx with vocal cord fixation and/or invades paraglottic space, and/or minor thyroid cartilage erosion (e.g., inner cortex)
T4a: Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck, including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus)
Note: extrinsic muscles of the tongue are: genioglossus, hyoglossus, styloglossus, and palatoglossus
T4b: Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures
T staging for subglottis
T1: Tumor limited to the subglottis
T2: Tumor extends to vocal cord(s) with normal or impaired mobility
T3: Tumor limited to larynx with vocal cord fixation
T4a: Tumor invades cricoid or thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck, including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus)
Note: extrinsic muscles of the tongue are: genioglossus, hyoglossus, styloglossus, and palatoglossus
T4b: Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures
Supraglottic laryngectomy
- Can be done for T1, T2 and limited T3 tumors of the supraglottis
- Remove epiglottis, AE folds, false cords, preepiglottic space, portions of hyoid and thyroid cartilage
- Spares the arytenoids and true cords
Supracricoid laryngectomy with criohyoidopexy/cricoepiglottopexy
- Can be done for select T3/T4 glottic and supraglottic cancers
- Must not have arytenoid fixation, cricoid cartilage contact/incision, major preepiglottic space involvement, invasion of thyroid cartilage, perichondrum, hyoid and posterior arytenoid mucosal involvement
- Remove entire thyroid cartilage, bilateral true and false vocal cords, one arytenoid and the paraglottic space
- Spare cricoid, hyoid and at least one arytenoid
Endoscopic cordotomy
- Can be done for T1 glottic cancers located in the mid third
When can laryngofissure and cordectomy be utilized
- Can be done for T1 glottic cancers located in the mid third
Vertical partial laryngectomy
- Done for T1-T2 glottic cancers if the tumor does not extend beyond one third of the opposite cord; < 10mm anterior subglottic extension; <5mm posterior subglottic extension; no posterior commissure, cricoarytenoid joint, AE fold, posterior surface of arytenoids or paraglottic space involvement; FEV1 > 50%
- remove one vocal fold from the arytenoid cartilage to vocal process, false cord, ventricle, paraglottic space and overlying thyroid cartilage
- Vertical height of the larynx is maintained by the retained contralateral thyroid ala
Contraindications for vertical partial laryngectomy
- Fixed TVF
- > 10mm anterior subglottic extension or > 5 mm posterior subglottic extension
- Involvement of posterior commissure
- Bulky transglottic lesions
- Lesions invading thyroid cartilage
- Poor pulmonary function
Contraindications for a supraglottic partial laryngectomy
- Cricoid or thyroid cartilage invasion
- Arytenoid mucosa involvement
- Posterior or anterior commissure involvement
- Impaired TVC motion
- Impaired base of tongue motion
- BOT invasion < 1cm from circumvallate papillae
- Invasion of FOM via vallecular involvement
Contraindications for Supracricoid partial laryngectomy-cricohyoidopexy
- Arytenoid fixation
- > 1.5cm extension anteriorly (cricothyroid membrane) and > 0.5cm posterolaterally
- Cricoid involvement
- Extensive preepiglottic space invasion with bulging beneath the vallecular or extension to the thyrohyoid membrane
- Hyoid bone involvement
- External perichondrial thyroid cartilage involvement or extralaryngeal spread
Contraindications for partial laryngectomy
- Fixed cords
- Cartilage invasion
- Subglottic extension
- Interarytenoid invasion
- Subglottic invasion
- Cervical metastasis (relative contraindication)
Indications for total laryngectomy
- T3/T4 tumors with thyroid cartilage destruction
- Posterior commissure or bilateral arytenoid involvement
- Circumferential submucosal disease
- Subglottic extension with cricoid cartilage involvement
- RT or chemoradiation failures
- Hypopharygneal tumors that spread to the postcricoid mucosa
- Thyroid tumors that invade both sides of the larynx
- Radiation necrosis of the larynx
- Severe irreversible aspiration
Ways to prevent laryngectomy stomal stenosis
- Bevel tracheal cuts
- Minimize tracheal tension
- Cut medial heads of SCM
- Minimize suctioning
- Minimize lary tube use
Complications from total laryngectomy
- Early complications: drain failure, hematoma, infection, pharyngocutaneous fistula, wound dehiscence, hypoglossal nerve injury
- Late complications: stomal stenosis, pharyngoesophageal stenosis or stricture, hypothyroidism
What percentage of patients with prior RT have a pharyngocutaneous fistula after laryngectomy?
30%
Hypopharyngeal SCC is associated with what syndrome?
Plummer Vinson (dysphagia, iron deficiency anemia, hypopharyngeal webs)
- Can see an increased risk in nonsmoking women in their 3rd-5th decades of life
- Most commonly associated with hyopharyngeal cancers in the postcricoid region
Subsites of hypopharynx
- Pyriform sinuses
- Postcricoid space
- Posterior pharyngeal wall
Borders of pyriform sinus
Medial border: AE fold
Lateral border: thyroid cartilage
Superior border: glossoepiglottic fold
Inferior border: cricopharyngeus muscle/ esophageal introitus
Posterior border: lateral pharyngeal wall
Anterior: junction of pyriform sinuses in postcricoid region
Borders of postcricoid space
Superior border: posterior arytenoid cartilages
Inferior border: esophageal introitus
Lateral border: tracheoesophageal groove
Borders of paraglottic space
Anterolateral: thyroid cartilage
Inferiomedial: conus elasticus
Medial: ventricle and quadrangular membrane
Posterior: pyriform sinus
Plummer Vinson syndrome
- Specifically associated with postcricoid SCC
- Primarily affects post menopausal women (85%)
- Dysphagia, iron deficiency anemia, hypopharyngeal/esophageal webs, atrophic gastritis, angular stomatitis
- Chronic irritation from webs progresses to carcinoma
- Syndrome etiology likely the result of nutritional deficiency
Indications for total laryngopharyngectomy
- Cancer involves postcricoid mucosa
- Cancer extends beyond the midline
- Advanced cancer or the posterior hypopharyngeal wall
Nasopharyngeal carcinoma risk factors
- Genetics: 15-20% of nasopharyngeal carcinoma pt have a first degree family member with NPC, HLA-b,c and D haplotypes associated with increased risk
- Environment: high nitrosamine diet of salted fish, eggs and vegetables
- EBV
- Male sex 3:1 ratio
Juvenile nasopharyngeal angiofibroma Chandler staging
Stage I: tumor confined to nasopharynx
Stage II: tumor extends to nasal cavity or sphenoid
Stage III: tumor involves maxillary sinus, ethmoid sinus, infratemporal fossa, orbit, cheek and cavernous sinus
Stage IV: tumor is intracranial
Nasopharyngeal Cancer T staging
T1: Tumor confined to the nasopharynx, or extension to oropharynx and/or nasal cavity without parapharyngeal involvement
T2: Tumor with extension to parapharyngeal space, and/or adjacent soft tissue involvement (medial pterygoid, lateral pterygoid, prevertebral muscles)
T3: Tumor with infiltration of bony structures at skull base, cervical vertebra, pterygoid structures, and/or paranasal sinuses
T4: Tumor with intracranial extension, involvement of cranial nerves, hypopharynx, orbit, parotid gland, and/or extensive soft tissue infiltration beyond the lateral surface of the lateral pterygoid muscle
Nasopharyngeal Cancer N Staging
N1: Unilateral metastasis in cervical lymph node(s) and/or unilateral or bilateral metastasis in retropharyngeal lymph node(s), 6 cm or smaller in greatest dimension, above the caudal border of cricoid cartilage
N2: Bilateral metastasis in cervical lymph node(s), 6 cm or smaller in greatest dimension, above the caudal border of cricoid cartilage
N3: Unilateral or bilateral metastasis in cervical lymph node(s), larger than 6 cm in greatest dimension, and/or extension below the caudal border of cricoid cartilage
Most common site of sinonasal malignancies
- Maxillary sinus (50-70%)
- Nasal cavity (15-30%)
- Ethmoid sinus (10-20%)
Risk factors of sinonasal malignancies
- Wood dust exposure (adenocarcinoma)
- Leather related occupational exposure (adenocarcinoma)
- Smoking (SCC)
- Nickel exposure (SCC)
Kadish system for esthesioneuroblastoma
Kadish A: confined to the nasal cavity
Kadish B: extends to the paranasal sinuses
Kadish C: extends beyond the nasal cavity and paranasal sinuses
Kadish D: lymph node or distant metastasis
Sinonasal carcinoma subsites
- Paranasal sinuses
- Nasal cavity
- Anterior cranial fossa
- Pterygopalatine fossa
- Infratemporal fossa
- Orbital cavity
Most common sinonasal malignancies
Epithelial: SCC, adenocarcinoma, adenoid cystic carcinoma
Nonepithelial: lymphoma, esthesioneuroblastoma, sinonasal undifferentiated carcinoma, mucosal melanoma
Contraindications for endoscopic surgery for sinonasal cancer
- Facial soft tissue extension
- Anteriolateral frontal sinus involvement
- Palate involvement
- Dural involvement beyond midpupillary line
- Mandible involvement
- Orbital extension
Distribution of salivary neoplasms
- 70% in parotid (75% benign)
- 22% in submandibular gland (57% benign)
- 8% minor salivary gland (85% malignant)
Symptoms of deep lobe parotid or parapharyngeal space involvement
Decreased gag reflex (CN IX and X)
Aspiration (CN IX and X)
Asymmetric palate elevation (CN X)
Hoarseness (CNX)
Dysphagia (CNX)
Shoulder weakness (CN XI)
Tongue atrophy/paresis (CN XII)
Ptosis (sympathetic chain)
MRI characteristics in salivary tumors
- Bilateral high T2 signal that does not enhance: more likely Warthin’s tumor
- Unilateral high T2 signal that enhances: more likely pleomorphic adenoma
- Intermediate to low T2 signal: more likely malignant
Mucoepidermoid carcinoma
- Most common salivary gland malignancy (adult and pediatric)
- Can look similar to necrotizing sialometoplasia (hard palate) and adenosquamous carcinoma on FNA
- Grading: low, intermediate, high (higher component of squamous cells to mucus cells)
- Grading correlates to clinical aggressiveness and adjuvant treatment
- MECT1-MAML2 t(11;19) (q21;p13) translocation
Adenoid Cystic Carcinoma
- Second most common salivary malignancy in the parotid gland. Most common malignant tumor of submandibular gland or minor salivary galnd
- Patterns: tubular, cribiform, solid (shows groups of cuboidal cells)
- Slowly progressive, infiltrative growth with distant mets developing over years
- Tendency for perineural invasion
- MYB-NFIB t(6;9) translocation
- Good 5 year, poor 10 year survival
Polymorphous low grade adenocarcinoma
- Arises mainly from minor salivary glands; most commonly from hard/soft palate junction
- Second most common minor salivary gland carcinoma
- Low grade malignancy with excellent prognosis
Acinic cell carcinoma
- Arises mainly in the parotid gland (90% of cases)
- Second most common childhood salivary gland malignancy
- Low grade malignancy but 33% will recur
- 10-15% will develop regional or distant mets
Salivary duct carcinoma
- One of the most aggressive salivary gland cancers
- Generally presents with rapidly growing parotid mass
- Minority present with facial nerve paresis
- High grade by definition (30-40% develop local recurrence, 50-75% develop distant mets)
- Significant minority positive for ERBB2 (Her2/neu) receptors
- Typically negative for estrogen and progesterone receptors
Landmarks to identify facial nerve during parotidectomy
- Tragal pointer (1-1.5cm deep and inferior)
- Tympanomastoid suture line (6-8mm deep)
- Retrograde dissection (marginal mandibular branch at mandible superficial to facial vessels; buccal branch deep to parotidomasseteric fascia, parallel to parotid duct)
- Posterior belly of digastric
Complications of parotidectomy
- Seroma
- Hematoma
- Facial nerve paresis/paralysis
- Frey syndrome
- First bite syndrome
- Salivary fistula
Frey syndrome
Gustatory sweating
- Aberrant cross innervation between postganglionic secretomotor parasympathetic fibers (parotid) to postganglionic sympathetic fibers (sweat glands to the skin)
- Estimated incidence 35-60%
- Diagnosis: minor starch/iodine test
- Treatment: antiperspirant, glycopyrrolate, tympanic neurectomy, botox
First bite syndrome
- Most common after deep lobe parotidectomy with instrumentation in parapharyngeal space
- Characterized by severe cramping or spasm int he parotid with first bite of a meal
- Likely because of loss of sympathetic innervation, causing denervation supersensitivity activated by parasympathetic hyperactivation
- Stimulates exaggerated myoepithelial cell contraction through the parotid
- Treatment: pain meds, acupuncture, botox, time
Desmoplastic melanoma
- Rare overall (<4%) but makes up >50% of desmoplastic melanomas occur in head and neck
- Features: majority are amelanotic, locally aggressive and highly infiltrative, up to 50% with local recurrence, perineural and endoneural infiltration, greater tumor thickness at time of diagnosis
- Pure and mixed variants
Subtypes of melanoma
- Superficial spreading (70%)
- Nodular (15-30%)
- Lentigo maligna
- Desmoplastic (4%)
- Unknown primary (2-8%)
Biopsy of melanoma
- Recommend complete excisional biopsy with 1-2 mm margins
- If can’t do excisional then punch or incisional biopsy through thickest or darkest portion
- FNA, shave biopsy, frozen section not recommended
(prevents evaluation of tumor thickness which dictates treatment)
Melanoma T staging
T1: <1mm thickness
T2: > 1-2mm thickness
T3: > 2-4mm thickness
T4: > 4mm thickness
a - no ulceration
b- ulceration present
Satellite metastasis in melanoma
Defined as a nest of metastatic tumor > .05mm in diameter that is separate from the primary lesion by <2cm
In transit metastasis in melanoma
Defined as a metastatic tumor that is separate from the primary lesion by > 2cm but not in the lymph node basin
Melanoma N staging
N1: one node
N2: 2-3 nodes
N3: Four + notes
a: microscopic (clinically occult)
b: macroscopic (clinically detected)
c: presence of satellite or intransit mets
Indications for SLNB in melanoma
- T2-T4 melanomas
- Some patients with T1b
Histopathologic markers for melanoma
- S100
- Melan-A (MART-1)
- HMB-45
Pathway of right RLN
- Exits vagus nerve at base of neck
- Loops around right subclavian artery
- Returns deep to innominate artery and back to thyroid bed diagonally
- Non-recurrent RLN may rarely occur on right side and enter from lateral course, associated with aberrant retroesophageal subclavian artery
Pathway of left RLN
- Exits vagus nerve at level of aortic arch and ligamentum arteriosum, lateral to the obliterated ductus arteriosus
- Returns to thyroid bed along tracheoesophageal groove at a more medial and vertical course than right RLN
- Crosses deep to inferior thyroid artery 70% of time
Location of parathyroid glands
- Superior parathyroid glands: at the level of the cricoid cartilage, medial/cranial to the intersection of the RLN and inferior thyroid artery
- Inferior parathyroid glands: lateral or posterior surface of lower thyroid pole
Superior glands are deep to the RLN and inferior glands are superficial to the RLN
Thyroid vascular supply
Inferior thyroid artery (branch of the thyrocervical trunk)
Superior thyroid artery (branch of the external carotid artery)
Superior, middle and inferior thyroid veins (drain to the internal jugular or innominate veins)
Genetic alterations in thyroid cancer
Papillary (RET, BRAF, RAS) - BRAF V600E is specific for PTC and found in 70-80% of tall cell variants, RET/PTC arrangements can be seen commonly in pts with history of radiation
Follicular (RAS, PPARG)
Poorly differentiated (RAS, BRAF, TP53)
Anaplastic (TP53, RAS, BRAF, PIK3CA)
Medullary (RET 95% in MEN2)
Thyroid T staging
T1: Tumor ≤ 2 cm in greatest dimension limited to the thyroid
T1a: Tumor ≤ 1 cm in greatest dimension limited to the thyroid
T1b: Tumor > 1 cm but ≤ 2 cm in greatest dimension limited to the thyroid
T2: Tumor > 2 cm but ≤ 4 cm in greatest dimension limited to the thyroid
T3: Tumor > 4 cm limited to the thyroid or gross extrathyroidal extension invading only strap muscles
T3a: Tumor > 4 cm limited to the thyroid
T3b*: Gross extrathyroidal extension invading only strap muscles (sternohyoid, sternothyroid, thyrohyoid or omohyoid muscles) from a tumor of any size
T4: Includes gross extrathyroidal extension into major neck structures
T4a: Gross extrathyroidal extension invading subcutaneous soft tissues, larynx, trachea, esophagus or recurrent laryngeal nerve from a tumor of any size
T4b: Gross extrathyroidal extension invading prevertebral fascia or encasing carotid artery or mediastinal vessels from a tumor of any size
Thyroid N staging
N0: No evidence of regional lymph node metastasis
N0a: One or more cytologic or histologically confirmed benign lymph nodes
N0b: No radiologic or clinical evidence of locoregional lymph node metastasis
N1: Metastasis to regional nodes
N1a: Metastasis to level VI or VII (pretracheal, paratracheal, prelaryngeal / Delphian or upper mediastinal) lymph nodes; this can be unilateral or bilateral disease
N1b*: Metastasis to unilateral, bilateral or contralateral lateral neck lymph nodes (levels I, II, III, IV or V) or retropharyngeal lymph nodes
Thyroid cancer staging
Differentiated thyroid cancer:
Age at diagnosis < 55 years
Stage I: any T any N M0
Stage II: any T any N M1
Anaplastic thyroid cancer: staging automatically starts at IVa
Types of cancer that metastasizes to the thyroid
Kidney, breast, lung, skin (melanoma and SCC)
What % of thyroid FNAs are nondiagnostic or inadequate?
15%
Characteristics of suspicious lymph nodes
- Loss of fatty hilum
- Increased vascularity
- Round nodule configuration
- Solid nodule with hypoechogenicity
- Microcalcifications
PTC Management
- Thyroglobulin level monitoring
- Routine neck ultrasound monitoring
- Elective lateral neck dissection not recommended until N+ disease documented
- Central neck disection recommended for N+ disease, palpable or visualized disease during surgery
Follicular thyroid carcinoma
- Cervical lymphadenopathy less common than PTC
- Classically hematogenous spread
- Distant mets more common than PTC
- FNA cannot distinguish between follicular adenoma and carcinoma
Medullary thyroid cancer
- Arises from parafollicular C cells and secretes calcitonin
- Distant mets present in 50% of patients on presentation
- 30% are familial
- Workup: calcitonin, RET mutation testing (if negative don’t need to test for MEN), serum calcium to test for hyperparathyroidism, 24hr urinary metanephrines and catecholamines and abdominal MRI to assess for pheo
- Surgery: any pheo should be removed first, total thyroidectomy, central neck dissection strongly considered with lateral neck if central +, when primary lesion >1cm ipsilateral lateral neck strongly considered because 60% will have nodal mets
- Surveillence: calcitonin
- RAI no effective
MEN2 syndromes
MEN2A - MTC, pheochromocytoma, hyperparathyroidism
MEN2B: MTC, pheochromocytoma, mucosal neuromas, Marfanoid body habitus
Adjuvant treatment for thyroid cancer
- TSH suppresion: goal TSH of <0.1 for intermediate to high risk patients, goal TSH of 0.1-0.5 for low risk
- RAI: for higher risk PTC and FTC. Indications include any primary tumor >4cm, extrathyroidal extension, distant mets, high risk features. Need TSH elevated > 30ml/L since RAI uptake stimulated by TSH
PTH
- Half life of 3-5 minutes
- Cleared by liver and kidney
- Increase resportion of calcium and decreases resorption of phosphorus
- Converts 25 hydroxyvitamin d3 (calcifediol) to 1,25 OH D3 (calcitriol)
- Stimulates osteoclast activity via osteoblast modulation
- Increases calcium absorption through vitamin D
Calcitonin
- Secreted by parafollicular cells in thyroid gland
- Inhibits bone resoption
Location of superior parathyroid
- Cricothyroid junction approximately 1cm cranial to the juxtaposition of the RLN and inferior thyroid artery
- Paraesophageal location in 1% of cases
- Embyrologically deep to RLN
Location of inferior parathyroid
- Inferior pole of thyroid along the thyrothymic ligament
- Migratory pathway into the anterior superior mediastinum (where up to 33% of missed parathyroid glands are found)
- More variable position compared to superior glands
Arterial supply of parathyroids
- Inferior thyroid artery supply 80% of inferior and posterior glands
- Additional vascularization from plexus of vessels
- Superior thyroid artery may provide dominant arterial supply for superior glands in 10-20% of patients
Key elements of biochemical diagnosis of primary hyperparathyroidism
- High calcium
- Elevated PTH
- Normal creatinine
- Low or low normal phosphate
- Urinary calcium > 125mg/ 24hrs
- Normal 25 OH vitam D and 1,25 OH vitamin D
Symptoms of hypercalcemia
- Nephrolithiasis, urolithiasis (most stones are calcium oxalate)
- Osteitis fibrosis cystica (bone pain, pathologic fractures, cystic bone change), osteoporosis (spares trabecular bone)
- Muscle weakness, fatigue
- Anxiety, psychosis, depression, deafness, dysphagia,
- Peptic ulcer, pancreatitis, cholelithiasis
- Hypertension
Causes of primary hyperparathyroidism
- Parathyroid adenoma
- Parathyroid lipoadenoma
- Parathyroid hyperplasia
- Parathyroid carcinoma
Causes of secondary hyperparathyroidism
- Insufficient calcium intake, decreased calcium absorption, vitamin D deficiency
- Renal insufficiency or failure
Tertiary hyperparathyroidism
Long standing renal insufficiency or failure leading to autonomous parathyroid hyperfunctioning
Hypercalcemia of malignancy
- PTH related protein secretion (lung, esophagus, head and neck, renal cell, ovarian, bladder, pancreatic)
- Ectopic PTH secretion by small cell lung cancer, small cell ovarian cancer, squamous cell lung cancer
- Ectopic 1,25 OH production by B cell lymphoma and Hodgkin disease
- Lytic bone mets (multiple myeloma, lymphoma, breast cancer and sarcoma)
- Tumor cytokines
Familial hypercalcemic hypocalciuria
- Autosomal dominant disorder
- Inactivating mutations in the calcium sensing receptor of the parathyroid gland
- Low 24 hour urine calcium relative to their hypercalcemia
Indications for surgery for asymptomatic primary hyperparathyroidism
- Serum calcium >1mg/dL above the upper limit of normal
- Creatinine clearance reduced > 60ml/min
- Age < 50
- Surgery requested by patient and patient unsuitable for surveillence
Ectopic parathyroid locations
- Mediastinum and thymus
- Retroesophageal
- Intrathyroidal
- Carotid sheath
Medical management of hyperparathyroidism
- Hydration
- Furosemide
- Bisphosphonates
- Estrogen
- Calcitonin
- Calcimimetics (sensitizes PTH receptor to calcium)
5 basic phases of cell cycle
G0: resting state
G1: preparation for cell division; increase in transcription/translation and doubling of macromolecules
S: synthesis phase, replication of chromosomes
G2: continued cellular growth
M: mitosis phase, chromosomes are separated and two daughter cells result
What is the term given to cells in permanent cell cycle arrest
Senescent
What are the key checkpoints within the cell cycle?
G1/S checkpoint: prevent entry into S phase, rate limiting step
Intra S phase checkpoint: halt progression of S phase if damaged DNA is detected
G2/M checkpoint: prevent entry into M phase
M checkpoint: ensure correct replication of DNA and avoid mitotic exit if errors exist
If an error is identified at a cell cycle checkpoint what processes can be activated?
Recruitment of DNA repair effector complexes
Temporary cell cycle arrest, which can lead to senescence or apoptosis depending on the cell and the lesion
What key tumor suppressor protein controls progression through the G1/S checkpoint and the G2/M checkpoint?
p53 (activates p21-> inhibits cyclin and cyclin dependent kinase (CDK) complexes)
What two key classes of molecules regulate a cell’s progress through the cell cycle?
- Cdks: catalytic subunit, require cyclin for activation; result in phosphorylation (activates/inactivates molecules necessary for progression through the cell cycle)
- Cyclines: regulatory subunit that activates Cdk molecules when bound to form a heterodimer
The classic retinoblastoma tumor suppressor protein (pRB) functions to inhibit what key transcription factors, effectively preventing formation of cell cycle related proteins and arresting the cell in G0 phase?
E2F factors
What genes are considered members of the INK4a family of tumor suppressor genes and in what phase of the cell cycle do they inhibit cyclin-CDk complexes?
p16 and p19, G1 phase
The phases G1, S, G2 are collectively referred to as what?
Interphase
Five stages of mitosis
Prophase: condensation of chromatin, polarization of centrosomes and initiation of mitotic spindle formation
Prometaphase: nuclear envelope breaks down, mitotic spindle microtubules attach to chromosomes
Metaphase: alignment of chromosomes at metaphase plate
Anaphase: separation of sister chromatids
Telophase: cytoplasmic division into two daughter cells; chromatid decondensation
What is the estimated average time required for the accumulation of enough genetic alterations to produce traditional head and neck SCC?
20-25 years
Field cancerization
Term used to describe histopathologic changes seen in mucosa surrounding invasive carcinoma and result in an increased incidence of second primary tumors. Thought to be due to abnormal and genetically unique clones that form independently at multiple sites due to exposure to similar environmental changes or due to a single tumoral clone that forms and subsequently migraes via lateral movement through the mucosa.
Why might alcohol function as a synergistic carcinogen with other environmental carcinogens?
It may decrease the effectiveness of both local and systemic detoxification enzymes (cytochrome P450)
Describe the cell cycle dysregulation that is commonly seen in patients with environmentally related head and neck cancer.
- Loss of p16 (normally inhibits cyclin D)
- upregulation of cyclin D
- loss of p53 (normally inhibits cell cycle progression and promotes apoptosis)
- upregulation of EGFR (enhances mitogenic signaling)
- upregulation of COX-2 (increased angiogenesis, decreased apoptosis)
- increased chromosomal instability (increased aneuploidy)
What genetic conditions are related to an increased risk of head and neck cancer?
- Fanconi anemia (autosomal recessive, DNA repair gene mutation)
- Cowden syndrome (autosomal dominant, TPEN hematoma tumor syndrome; PTEN is a tumor suppressor gene)
- Mutations in cyp P450 enzymes
The HPV DNA encodes 9 open reading frames (genes) on a single strand of its double stranded circular DNA. 7 are considered early phase genes (E) and two are considered late phage genes (L). What are the general functions of E and L genes?
E: regulate transcription of viral DNA
L: encode capsid proteins involved in viral spread
Name the two viral onco-proteins in HPV related tumorigenesis and identify the two genes that control the transcription of these viral proteins?
- E6/E7: onco genes
- E1/E2: transcriptional regulators
When HPV DNA integrates into host DNA the process can result in deletion or loss of function of the E1 and E2 viral genes. This in turn results in what?
Loss of regulation of E6 and E7 and subsequent transcription of these viral genes
What HPV protein functions to inhibt the function of p53 by targeting it for ubiquitin dependent degradation and what is the result?
E6. Results in progressiong though G1 checkpoint and inhibition of apoptosis.
What HPV protein phosphorylates pRb and thus targest it for ubiquitin dependent degradation? What is the primary result?
E7. Results in releast of pRb inhibition of E2F, activation of cell cycle related transcription and progression through the G1 checkpoint.
In addition to E2F related transcription, the degradation of p53 results in over expression of what important protein and what impact does this have on the cell cycle progression?
p16. Normally inhibitics Cdk4/6, but with the loss of p53, pRb, does not meaningfully result in cell cycle control. Can be used as a biomarker of HPV activity.
In addition to HPV what viruses have been associated with head and neck cancer?
- EBV (nasopharyngeal carcinoma)
- HIV (increased risk of all head and neck cancers)
- merkel cell polyomavirus (merkel cell carcinoma)
- Human T lymphotrophic virus (HTLV-1, human T cell lymphoma/leukemia)
- Kaposi sarcoma associated herpesvirus (Kaposi sarcoma)
EGFR is a transmembrane glycoprotein that when activated by binding an extracellular ligand results in dimerization, tyrosine kinase activation and a complex downstream pathway that ultimately results in what major outcomes?
- Cellular growth and proliferation
- Apoptosis
- Angiogenesis
- Invasion
- Metastasis
How does EGFR expression relate to prognosis in head and neck cancer
Increased expression and amplification are related to decreased recurrence free survival and cancer specific survival rates.
What strategies have been used to target aberrant signaling in head and neck SCC based on better understanding of EGFR signaling?
- Tyrosine kinase inhibitors (geftinib)
- Monoclonal antibodies inhibiting dimerization (cetuximab)
- Antisense oligodeoxynucleotide or small interfering mRNA inhibition of mRNA expression
What inflammatory mediator is elevated in head and neck cancer cells
Prostaglandins as a result of the upregulation of COX-1 and 2
What nerves might be implicated in referred otalgia?
CN V3, IX (via Jacobsons nerve), X (via Arnold nerve), and VII as well as branches of C2 and C3 through the great auricular nerve.
What premalignant lesion can present as a thickened white patch that can’t be scarped off on physical exam of mucosa that can progress to invasive carcinoma in up to 30% of patients?
Leukoplakia
What premalignant lesion can appear as a flat red patch with a malignant potential of up to 60% over a variable number of years?
Erythroplakia
What are frequently used as radiographic criteria for a nodal malignancy on CT scan?
- Size > 1cm
- Evidence of central necrosis (~100% specificity)
- Spherical shape (suggestive)
- Nodal grouping in the predicted drainage pathway, with nodes > 1cm
In what situations is evaluation with MRI most useful during the workup for head and neck cancer?
- Soft tissue tumor
- Intracranial extension or skull base involvement
- Paranasal sinus disease
- Nasopharyngeal tumors
- Temporal bone
- Assessment of perineural invasion
What head and neck tumors have either variable/inconsistent or no FDG avidity?
- Well differentiated thyroid cancer
- Medullary thyroid cancer
- Indolent lymphomas
- Neuroendocrine tumors
- Teratomas
- Soft tissue sarcomas
What might result in a false positive result on a PET/CT?
- Infection
- Normal physiologic activity (brain, kidneys)
- Inflammation (after radiation, surgical resection, aspiration/biopsy)
- Osteoradionecrosis
- Granulomatous disease
- Patient movement
What is one of the major limitations of PET/CT which can result in a false negative?
It is unreliable for lesions <1cm in diameter
Which immunohistochemical marker is associated with carcinomas and papillomas?
Cytokeratin
Which immunohistochemical marker is most commonly associated with neural/cartilaginous tumors, melanoma and Langerhans cell histiocytosis?
S-100
Which immunohistochemical marker is associated with neuroendocrine tumors?
- Neuron specific enolase (NSE)
- Chromogranin
- Synaptophysin
Which immunohistochemical marker is most commonly associated with lymphoma?
- Leukocyte common antigen (LCA/CD45)
- CD 20 -> B cell specificity
- CD2 -> T cell specificity
Which tumors stain positive for vimentin and for desmin?
Vimentin -> sarcomas, lipomas, myomas
Desmin -> sarcomas, myomas
What sybtype of SCC is commonly seen in HPV+ oropharyngeal tumors and are more likely to present at an advanced stage owing to early nodal and distant metastasis?
- Basaloid carcinoma
- Despite early regional mets, these tumors are failry sensitive to tx and therefore have better prognosis than conventional SCC
Histopathology for spindle cell carcinoma
Also called carcinosarcoma or pseudosarcoma because it includes a squamous cell lesion on the surface and a more notable underlying malignant spindle cell component. Currently it is thought it arises from epithelial cells and undergoes mesenchymal differentiation
Why are spindle cell carcinomas also known as sarcomatoid, carcinosarcoma or pseudosarcoma?
- Contains a superficial squamous cell lesion and a deeper malignant spindle cell component
- Stain positive for both cytokeratin (epithelial cells) and vimentin (mesenchymal cells)
- Arises from epithelial cells and then undergoes mesenchymal differentiation
How can adenosquamous carcinoma be distinguished from mucoepidermoid carcinoma?
Mucoep doesn’t include a mucosal component. Adenosquamous carcinoma has a predominant mucosal squamous cell component and a deeper adenocarcinoma component.
What squamous cell subtype manifests as slow growing, velvety, exophytic, warty mass in elderly patients and what pathologic feature determines prognosis?
- Verrucous carcinoma
- Focal areas of high grade SCC
Most common sites of metastasis for head and neck SCC
- lungs (66%)
- bone (22%)
- liver (10%)
- less often skin, mediastinum and bone marrow
Traditionally, what single prognostic factor has been shown to decrease overall survival by as much as 50%?
Regional nodal disease
When considering nodal disease what factors have been considered negative prognostic features?
- Presence of nodal disease
- Increasing nodal size
- Extracapsular spread
- Bilateral neck disease
- Matted lymph nodes
- Disease in levels IV and V
- “Skipped” levels
- Invasion of local structures by nodal disease
- Confluence of primary disease and nodal disease
- Total number of involved lymph nodes
What tumor markers can be used to help determine prognosis in head and neck cancer?
- EGFR amplification and overexpression
- HPV status
- Loss of heterozygosity (suggests loss of tumor suppressor gene function)
- Aneuploidy
Neoadjuvant/induction therapy
Treatment approaches uses chemotherapy and or radiation therapy before definitive therapy
Concurrent therapy
Aka concomitant therapy, uses chemo and radiation together as primary treatment modality
Adjuvant therapy
Treatment apporahc that uses radiation therapy with or without chemoptheray after primary surgical management
Describe the three phases of clinical trials
- Phase I: defines maximum tolerated dose or safety of a drug or invasive medical device
- Phase II: includes more patients than phase I; assess the efficacy and side effects or toxicity associated with the intervention of interest
- Phase III: randomized prospective trial comparing the intervention of interest with standard of care
What % of patients with locally advanced head and neck SCC die from recurrent locoregional disease within 5 years of initial treatment?
30-50%
Median length of survival for a patient diagnosed with locally advanced or metastatic head and neck SCC?
6-9 months
General surveillance schedule for exam and imaging for head and neck cancer patients?
Year 1: see every 1-3 months
Year 2: see every 2-4 months
year 3-5: see every 4-6 months
> 5 years: see 6-12 months
Imaging: within 6 months of treatment end for T3-4 or N2-3 cancers of oropharynx, hypopharynx, glottic/supraglottic larynx and nasopharynx. Additional imaging based on concerning signs and symptoms
When should you check a patient’s TSH level after completion of tx for head and neck cancer?
If the neck was irradiated check every 6-12 months
What 3 major categories should be considered when determining candidacy for surgical intervention for head and neck cancer patients?
Physiologic: cardiorespiratory fitness, coag status, immune status, weight loss
Anatomical: surgical acess to subsite of interest
Oncologic: ability to achieve surgical margins, acceptable morbidity with complete resection
Why is it clinically important from both a prognostic and management standpoing to identify the site of origin for an unknown primary tumor?
Failure to identify origin results in significant decrease 5 year overall survival and results in the need for wide field radiation therapy with increase in associated morbidity
At what point during the cell cycle are cells most radiosensitive and radioresistant?
Radiosensitive: M phase and G2
Radioresistant: S phase
How does radiation result in cell killing?
Radiation therapy produces intracellular ionization -> breaks chemical bonds, creates free radicals -> DNA damage -> cell death. Double strand breaks are the most important and deadly injury imposed by radiation
Althogh radiation can result in rapid cell death some cells don’t diet until they attempt mitosis and others continue to divide several times before celld eath. What is this delayed cell killing called?
Mitotic cell death. This is why tumors do not shrink immediately after radiation and may take weeks to demonstrate the full effects of radiation treatment.
Common acute (days to week) toxicities associated with radiation to head and neck?
- Mucositis
- Dermatitis
- Xerostomia
- Hoarseness
- Odynophagia
- Dysphagia
- Weight loss
Common delated (months to years) toxicities associated with radiation treatment
- Xerostomia
- Dental caries/decay
- Osteoradionecrosis, chondronecrosis
- Fibrosis
- Hypothyroidism
- Neurologic damage
What class of chemotherapeutic agents target DNA and cause cross linking, double strand breaks, or substitutions, therby interfering with DNA replication and ultimately causing mutation and or cell death?
Alkylating agents
What inorganic platinum chemotherapeutic agent results in DNA cross links, denaturation of strands, covalend bonds with DNA bases and DNA intrastrand cross links?
Cisplatin
What common side effects are associated with cisplatin administration?
Nephrotoxicity, ototoxicity, neurotoxicity, nausea/vomting, electrolyte disturbances, myelotoxicity
Second generation platinum agent that binds with DNA to create intrastrand and intrastrand cross links and protein DNA cross links that ultimately result in interruption of the cell cycle and apoptosis
Carboplatin
Methotrexate
Binds to dihydrofolate reductase which is necessary for de novo synthesis of thymidine and purine synthesis
Cultured Streptomyces spp produce compounds that function as antibiotic chemotherapeutic agents. Name three of these antitumor antibiotics and their mechanism of action
-Doxorubicin - results in intercalation between base pairs
- Bleomycin: form complexes with iron, thus reducing oxygen to superoxide and hydroxyl radicals which result in DNA strand breaks
- Mitomycin: results in DNA cross linking, alkylation and oxygen radiacals
What class of chemo agents bind to free tubulin dimers and result in disruption of microtubule polymerization or depolymerization and ultimate disruption of the cell cycle
Alkaloids
- VincristingL binds irreversibly to microtubules and spindle proteins in S phase and interferes with the mitotic spindle -> arrest in metaphase
- Vinblastine: binds to tubulin and inhibits microtubule formation, disrupts mitotic spindle -> arrest in M phase
Class of chemo agents that cause stabilization of microtubules inhibiting normal cell cycle by preventing microtubule disassembly and arrest in G2/M phase?
Taxanes
- Docetaxel
- Paclitaxel
What recombinant humanized monoclonal antibody targets EGFR and is currently being investigated in head and neck cancer?
Bevacizumab
What are some of the attributes that definie high risk disease in head and neck cancer patients that benefits from adjuvant chemotherapy?
- Positive surgical margins
- Extracapsular extension
- T3/T4 primary
- Higher nodal stage
- Perineural invasion
- Angiolymphatic invasion
- Involvement of level IV or V lymph nodes
How is level IB distinguished from level IIA surgically and radiographically?
Posterior edge of the submandibular gland
How is the lateral border of level IIA defined radiographically
Posterior border of the internal jugular vein
What anatomical structure divides lymph node level II into IIA and IIB surgically
Spinal accessory nerve (CN XI)
How are the superior and inferior boundaries of level IIA surgically definited?
Superior: skull base
Inferior: carotid bifurcation
What are the radiographic and surgical landmarks that separate neck levels II and III?
Radiographic: inferior border of the hyoid bone Surgical: carotid bifurcation
What are the superior and inferior borders of level III radiographically
Superior: inferior border of hyoid
Inferior: inferior border of cricoid
What are radiographic and surgical landmarks that separate level III and IV
Radiographic: inferior border of cricoid cartilage
Surgical: omohyoid muscle
What anatomic structure divides lymph node level V into Va and Vb
A horizontal plane from the inferior border of the cricoid cartilage
Level VA includes spinal accessory nodes, VB includes transverse cervical nodes and supraclavicular nodes. Just inferior to the clavicle lies the sentinel node or Verchow node
What are the surgical landmarks that define level VI
Hyoid bone superiorly, suprasternal notch inferiorly, common carotid arteries laterally
Level VI nodes are at greatest risk for metastasis from which primary locations?
- Glottic and subglottic
- Pyriform sinus
- Cervical esophagus
- Thyroid gland
What are the major divisions of cervical fascia in the neck?
Superficial cervical fascia
Deep cervical fascia: superficial (investing), middle (visceral) and deep layers
What layer of cervical fascia covers the superficial surface of the platysma and is continuous with the SMAS superiorly?
Superficial cervical fascia
Which layer of cervical fascia arises from the vertebral spinous processes, wraps around the SCM and trapezius muscles, covers the mylohyoid muscle and anterior bellies of the digastric, attaches to the hyoid bone and forms the floor of the submandibular and posterior triangle?
Superficial layer of the deep cervical fascia
What are the two subdivisions of the middle layer of the deep cervical fascia?
Muscular division: surrounds infrahyoid strap muscles, attached superiorly to the hyoid bone and thyroid cartilage and inferiorly to the sternum
Visceral division: surrounds the thyroid, trachea and esophagus and extends into the mediastinum to connect with the fibrous pericardium. Superiorly, the fascia may blend with the buccopharyngeal fascia (controversial)
Name the fascial layers that line the inner (pharyngeal) and outer (cervical) surface of the pharyngeal constrictor muscles.
Inner: pharyngobasilar fascia
Outer: buccopharyngeal fascia
What are the two names divisions of the deep layer of the deep cervical fascia?
Prevertebral fascia: fuse to the transverse processes of the vertebral bodies with extension medially to cover the prevertebral musculature and vertebral bodies. Continues posteriorly to cover the extensor muscles and insert onto the vertebral spinous processes.
Alar fascia: located between the prevertebral fascia and the visceral division of the middle layer of the deep cervical fascia
What layers of the cervical fascia from the carotid sheath?
The superficial (investing), middle (visceral) and deep layers of the deep cervical fascia
What is enveloped by the superficial (investing) layer of the deep cervical fascia?
- Two muscles (SCM and trapezius)
- Two glands (parotid and submandibular gland)
- Two spaces (posterior triangle, suprasternal space of Burns)
What is the vascular supply and innervation of the platysma muscle
Innervation: cervical branch of the facial nerve (VII)
Arterial supply: submental branch of the facial artery and suprascapular artery
What is the innervation and blood supply of the SCM
Innervation: spinal accessory nerve (CN XI), ventral rami of C2-4
Arterial supply: occipital and posterior auricular arteries, superior thyroid artery, suprascapular artery
Innervation and arterial supply of anterior and posterior bellies of digastric
Innervation: anterior belly -> mylohyoid branch of inferior alveolar nerve (V3); posterior belly -> facial nerve
Arterial supply: anterior belly -> submental branch of facial artery; posterior belly -> posterior auricular and occipital arteries
What is the predominant innervation and vascular supply to the infrahyoid straps
Innervation: ansa cervicalis (C1-3)
Arterial supply: superior thyroid artery and lingual artery
What muscle can be found in the lateral neck extending from the transverse processes of C3-C6 to the first rib, passing just posterior to the phrenic nerve, just anterior to the subclavian artery, and just medial to the brachial plexus?
Anterior scalene muscle
What spinal nerve provide sensory innervation to the cervical skin?
Ventral rami of C2-4
-Lesser occipital nerve (C2): posterior scalp and ear
-Greater auricular nerve (C2,C3): anterior branch -> skin over parotid gland; posterior branch -> mastoid area, lower ear and lobule
-Transverse cutaneous nerve (C2, C3): Ascending/descending branches ->anterolateral neck skin
-Supraclavicular nerve (C3, C4): Medial, intermediate and lateral (posterior) branches -> supraclavicular skin from second rib to shoulder
What anatomical location describes the point where the cutaneous nerves of the cervical plexus exit posterior to the SCM and what is the relationship between this point and the spinal accessory nerve (CN XI)?
Erb’s point
- The spinal accessory nerve (CN XI) passes approximately 1cm superior and deep to the SCM muscle and Erb’s point.
What are the muscular branches that constitute the cervical plexus?
- Phrenic nerve (C3-C5)
- Inferior branch of ansa cervicalis (C1-3)
- Segmental branches including cervical branches of the spinal accessory nerve (C1-4)
What structure travels deep to the deep cervical fascia and superficial to the anterior scalene and can be found when dissecting levels III and IV?
Phrenic nerve
The submandibular duct passes between what two nerves
Hypoglossal and lingual nerves
The sympathetic trunk travels deep and medial to the carotid sheath and is just superficial to the prevertebral fascia and what muscle?
Longus colli
Pathway of right recurrent laryngeal nerve
Branches off vagus at approximately T1-2, wraps around the subclavian artery from anterior to posterior, ascends in the neck along the tracheoesophageal groove, generally posterior to the inferior thyroid artery, and enters the larynx at a 30-45 degree angle by passing under the inferior constrictor muscle and through the cricothyroid joint space
Pathway of left recurrent laryngeal nerve
Wraps around the aortic arch before passing superiorly in the neck in the tracheoesophageal groove to enter the larynx at 0-30 degree angle by passing under the inferior constrictor muscle and through the cricothyroid
Describe the classic relationship between the inferior thyroid artery and the recurrent laryngeal nerve
50%: nerve passes deep to artery
25%: nerve passes between arterial branches
25%: nerve passes anterior to artery
This relationship is extremely variable and may not represent a reliable landmark for identifying the nerve
What is the incidence of right nonrecurrent inferior/recurrent laryngeal nerve?
.05-1%
What anomaly is associated with a right aberrant retroesophageal subclavian artery? Situs inversus?
- Right nonrecurrent inferior/recurrent laryngeal nerve
- Left nonrecurrent inferior/ recurrent laryngeal nerve
What structure is formed by the anastamoses of the posterior (dorsal) recurrent laryngeal nerve fibers and the posterior (dorsal) fibers of the infernal branch of the SLN?
Galen anastamosis (aka ramus anastomaticus)
What artery branches from the aortic arch, passes over the trachea from left to right and branches into the right common carotid artery and right subclavian artery?
Innominate (brachiocephalic) artery
What artery branches off the first part of the subclavian artery, ascends in the neck by passing through the foramina of the transverse processes of C1-C6 and enters the foramen magnum and joins with its paired contralateral vessel to form the basilar artery?
Vertebral artery
What are the three arteries that arise from the first part of the subclavian artery?
- Vertebral artery
- Thyrocervical trunk
- Inferior thoracic artery
Name the branches of the thyrocervical trunk that branch off the first part of the subclavian artery at approximately the medial border of the anterior scalene muscle?
- Inferior thyroid artery
- Suprascapular artery
- Superficial/transverse cervical artery
What vessels come off the costocervical trunk?
- Deep cervical artery
- Superior intercostal artery
At what vertebral level is the carotid bifurcation in the majority of people?
C3-C4 (at the level of the superior border of the thyroid cartilage)
What bony skull base structure runs between the internal and external carotid arteries?
Styloid process
What are the branches of the external carotid artery?
- Superior thyroid
- Ascending pharyngeal
- Lingual
- Facial
- Occipital
- Posterior auricular
- Internal maxillary artery
- Superficial temporal
Named branches of superior thyroid artery
Infrahyoid, superior laryngeal, cricothryoid and SCM arteries
Named branches of ascending pharyngeal artery
Pharyngeal, inferior tympanic, meningeal arteries
Named branches of lingual artery
suprahyoid, dorsal lingual, sublingual arteries
Named branches of facial artery
Ascending palatine, tonsillar, submental, labial arteries
Named branches of occipital artery
upper and lower branches to the SCM
Named branches of posterior auricular artery
Stylomastoid artery
Named branches of superficial temporal artery
Frontal and parietal branch
Course of the facial artery
Arises at the level of the greater cornu of the hyoid bone from the external carotid, runs deep to the posterior belly of the digastric muscle and stylohyoid muscle, turns at the middle constrictor to follow the posterior boundary of the submandibular gland and medial border of the medial pterygoid muscle and then winds around the mandible at the level of the facial notch
What artery often transverses level IIB in the neck and “tethers” the hypoglossal nerve in level IIA
Occipital artery
What are the three parts of the internal maxillary artery?
- First part: mandibular portion - arises between the ramus of the mandible and sphenomandibular ligament, passes posterior to the lateral pterygoid muscle
- Second part: pterygoid portion - within the lateral pterygoid muscle
- Third part: pterygopalatine portion - peterygopalatine fossa
