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Hematology, oncology > head and neck cancer > Flashcards

head and neck cancer Flashcards

1
Q

most common locations of HPV-related squamous cell H and N cancer

A

palatine tonsils, lingual, base of tongue

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2
Q

role of EGFR in pathogenesis of SCCHN

A

leads to activation of growth pathways and resistance to apoptosis

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3
Q

virus associated with nasopharyngeal cancer

A

EBV

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4
Q

“field cancerization” concept?

A

diffuse epithelial injury in aerodigestive tract due to chronic exposure to carcinogens

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5
Q

Management of early stage head and neck cancer in general + exception to rule

A

primary surgery or definitive radiation therapy (oral cavity cancers are usually surgery because cure rates are better and less toxic)

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6
Q

current classifications of surgical neck dissection

A

comprehensive and selective

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7
Q

comprehensive surgical neck dissection – structures removed and intent

A

remove all five lymph node levels with curative intent

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8
Q

selective surgical neck dissection – structures removed and intent

A

remove fewer than all five lymph nodes based on common pathways, performed electively to improve staging. Usually reserved for NO (no palpable lymph nodes) or occasionally N1-N2.

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9
Q

new mode of radiation therapy used for head and neck cancer and point

A

intensity-modulated RT (IMRT), decreases toxicity (especially xerostomia)

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10
Q

xerostomia

A

dry mouth due to reduced or absent salivary flow

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11
Q

common SE’s of radiation in head and neck

A

dermatitis, xerostomia, mucositis, loss of taste, dysphagia, loss of hair

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12
Q

role of concomitant chemoradiation as first-line therapy?

A
  • To spare patients with locally advanced from surgery.

- very advanced SCCHN

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13
Q

concomitant vs sequential chemo and radiation for H and N cancer

A

concomitant preferred for organ preservation (except for laryngeal)

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14
Q

Radiation sensitizer + RT dose + schedule for head and neck

A

70 Gy at daily Gy fractions for 7 weeks with cisplatin q 3 weeks

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15
Q

IO drugs approved for head and neck cancer

A

cetuximab, nivolumab, pembrolizumab

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16
Q

role for cetuximab in metastatic head and neck cancer

A

…

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17
Q

Major RF’s for local recurrence

A
  • positive margins

- extracapsular nodal spread of tumor

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18
Q

combination therapy vs monotherapy in head and neck cacner

A

combination therapy is superior

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19
Q

Second line for recurrent/metastatic head and neck cancer

A
  • Immunotherapy –> nivolumab or pembrolizumab
  • If not immunotherapy candidate –> single agent cetuximab, weekly docetaxel, weekly methotrexate
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20
Q

poor prognostic factors for lip cancer

A

Lower lip –> low incidence of mets

Upper lip –> higher incidence of mets

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21
Q

most common presentation of nasopharyngeal carcinoma

A

Neck mass (regional lymph node mets)

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22
Q

Standard therapy for nasopharyngeal carcinoma Stages I and IIA
+ IIB, III, IV

A

Stages I and IIA – Radiation alone
IIB, III, IV – chemoradiation with cisplatin
IVC – cisplatin with gemcitabine or cisplatin with 5-FU or single agent taxane

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23
Q

hypopharyngeal cancer managment

A

Induction therapy w/ cisplatin + 5-FU followed by followed by XRT or cisplatin with XRT
T4A –> total laryngectomy followed by radiation +/- chemotherapy

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24
Q

division of laryngeal cancers + prognosis

A

Supraglottic, glottic, and subglottic

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25
Q

Management of laryngeal cancer, locally advanced

A

resection followed by radiation vs. organ preservation (induction chemo (cisplatin + 5 FU) followed by XRT

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26
Q

management of cancer of nasal cavity and paranasal sinuses

A

Surgical resection generally preferred (but difficult to perform due to advanced presentations), thus most patients treated with chemoradiation

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27
Q

Primary treatment modality for salivary gland tumors

A

complete surgical resection

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28
Q

primary therapy for cancers of oral cavity

A

surgical resection

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29
Q

management of persistent oropharyngeal cancer

A

modified radical neck dissection

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30
Q

CPS (clinical performance score)

A

Score of PD-L1 expression. Number of PD-L1 staining cells (tumor cells, lymphocytes, macrophages) divided by the total number of viable tumor cells, multiplied by 100.

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31
Q

tumors with high somatic mutation burden + relevance to immunotherapy

A

Preliminary data suggest that tumors with high rates of somatic mutations (ie, sun-exposed cutaneous melanoma, NSCLC, bladder cancer, and microsatellite-unstable colorectal carcinomas) have a higher chance of benefiting from immune checkpoint blockade than tumors with lower rates of somatic mutations

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32
Q

staging

A

Contrast CT +/- MRI (depends on what head and neck surgery want)
IF palpable LAD → PET/CT

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33
Q

clinical significance of PNI

A

Mechanism of tumor dissemination that can provide a challenge to tumor eradication and that is correlated with poor survival. Squamous cell carcinoma, the most common type of head and neck cancer, has a high prevalence of PNI.

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34
Q

TORS meaning

A

transoral robotic surgery. innovative, minimally invasive treatment option to remove head and neck cancers through the mouth, especially those related to the human papilloma virus (HPV)

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35
Q

MRND meaning

A

Modified radical neck dissection

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36
Q

ENE clinical significance

A
  • Presence of ENE in squamous cell carcinoma of the head and neck, found postoperatively, is associated with higher rates of locoregional recurrence, distant metastasis, and poorer survival.
  • Critical importance because determines need for chemo.
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37
Q

adverse features defined as:

A

Presence of ENE in squamous cell carcinoma of the head and neck, found postoperatively, is associated with higher rates of locoregional recurrence, distant metastasis, and poorer survival.

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38
Q

management of locally advanced head and neck cancer

A

IF PS good → Primary surgery +/- Radiation
IF declined surgery → concurrent chemo + RT
IF positive surgical margins OR nodal mets with extracapsular extension → chemo (usually cetuximab or cisplatin)

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39
Q

oral cavity vs oropharynx

A

The oral cavity lies anterior to the oropharynx and is separated from it by the circumvallate papillae; soft palate; and anterior tonsillar pillars, which make up its posterior boundary. The oral cavity is bounded superiorly by the hard palate, laterally by the cheek, and inferiorly by the mylohyoid muscle.

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40
Q

clinical relevance of HPV vs non HPV head and neck cancers

A

no data at present to indicate that human papilloma virus (HPV) associated cancers should be treated differently than other squamous cell carcinomas arising in the oropharynx, although several reports suggest that patients with HPV associated cancer have improved survival rates relative to patients with HPV negative cancers

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41
Q

what is CPS?

A

Combined Positive Score (CPS), which is the number of PD-L1 staining cells (tumor cells, lymphocytes, macrophages) divided by the total number of viable tumor cells, multiplied by 100.

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42
Q

cellular origin of squamous cells

A

epithelial lineage or characteristics.[citation needed] SCCs arise from squamous cells, which are flat cells that line many areas of the body

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43
Q

where does nasopharyngeal cancer typically present?

A

Fossa of Rosenmuller

44
Q

Effect of HPV vaccination on incidence of HPV-related SCCHN

A

Hasn’t been demonstrated yet…

45
Q

Basic staging system based on…

A

Tumor size, nodal involvement, mets

46
Q

Presentation of nasopharyngeal cancer

A

Persistent nasal congestion and fullness

47
Q

Presentation of laryngeal cancer

A

hoarseness

48
Q

Why field cancerization topic is important

A
  • Diffuse epithelial injury within aerodigestive tract may lead to second metachronous and synchronous cancers of aerodigsestive tract.
  • Mandates chest imaging because of risk of concurrent lung malignancy
49
Q

How does presence of palpable lymph nodes in neck effect survival rate compared to patients with the same T stage

A

Decreases survival rate by 50%

50
Q

Importance of timing in SCCHN cancer

A

IMPORTANT. Shouldn’t be any delays in staging and therapy, which can decrease survival.

51
Q

Sequence of interventions in SCCHN

A

Depends on cancer center location and expertise – surgery followed by radiation/chemo OR chemoradiotherapy followed by surgery

52
Q

Involvement of which structures makes SCCHN tumor unresectable

A
  • tumor extension to skull base
  • direct tumor extension to superior nasopharynx or Eustachian tube
  • encasement of common or internal carotid artery
  • direct extension to mediastinum, prevertebral fascia, or cervical vertebra
  • direct extension of neck disease to external skin
  • involvement of pterygoid muscles
53
Q

major advantage of radiation therapy in SCCHN

A

organ preservation

54
Q

What is organ preservation approach

A

Induction chemo (cisplatin + 5 FU) followed by XRT

55
Q

Which laryngeal cancers have the best and worst prognosis?

A

Supraglottic have worst prognosis

Glottic have best prognosis

56
Q

Clinical presentation of oral cavity tumors

A

Mouth pain, nonhealing mouth ulcers, dysphagia, odynophagia, weight loss, bleeding, otalgia

57
Q

Clinical presentation of tongue cancer

A

Pain, with or without dysarthria

58
Q

Clinical presentation of oropharyngeal tumors

A

Dysphagia, pain, OSA or snoring, bleeding, or a neck mass

59
Q

Clinical presentation of hypopharyngeal tumors

A

Usually remain asymptomatic for a long period and present late

60
Q

Clinical presentation of laryngeal cancer

A
  • persistent hoarseness, later on – dysphagia, otalgia, chronic cough, hemoptysis, stridor
61
Q

Histology of head and neck cancer

A

pretty much all squamous cell (90-95%)

62
Q

Preferred method for determining HPV tumor status

A

p16 IHC

63
Q

Term for exam ENT usually does to examine laryngeal and hypopharyngeal malignancies

A

EUA (examination under anesthesia)

64
Q

Biopsy type for neck mass

A

FNA

65
Q

Management if FNA from suspicious neck node is initially negative

A

Repeat FNA before excisional bx

66
Q

How is pathologic LAD defined radiographically with head and neck cancer?

A

Size (node greater than 10 mm in maximal diameter)

Central necrosis

67
Q

Other features that suggest pathological lymph nodes

A
  • Rounded shape
  • loss of normal fatty hilum
  • increased or heterogeneous contrast enhancement
  • lymph node clustering
68
Q

To be aware of with lymphadenopathy and head and neck cancer

A

Microscopic or occult nodale adenopathy is not uncommon

69
Q

most commonly used agent for PET/CT in

A

fluorodeoxyglucose (FDG)

70
Q

Test characteristics + main utility of PET/CT for head and neck cancer + comparison to surgical dissection

A
  • Reliable for detecting occult cervical mets but not as sensitive as neck dissection
  • Main utility is in finding occult distant mets + unknown primary lesions + synchronous second primary tumors
71
Q

Most common sites of mets in head and neck cancer

A

Lungs followed by the liver and bone

72
Q

Incidence of second and multiple primaries

A

Relatively more common in head and neck cancer, particularly in those with strong tobacco and alcohol use or FH

73
Q

Early stage means

A

Stage I or II

74
Q

Efficacy of RT vs. surgery for early stage

A
  • similar rates of local control and survival
75
Q

Behavior or oral cavity tumors

A

Aggressive – high rates of locoregional recurrence

76
Q

Organ-sparing approach is typically used for which type of head and neck cancer

A

Oropharnyx, hypopharynx, and larynx

77
Q

Management of persistent nodal involvement

A

salvage surgery

78
Q

term for toxicity arising a ways out from treatment for cancer

A

delayed toxicity

79
Q

Problem with obtaining PET/CT to early after head and neck treatment

A

Increases rate of false-positive results

80
Q

Initial evaluation of locoregionally recurrent head and neck cancer

A

Restage to look for distant mets

81
Q

Other clinically defining feature of HPV associated head and neck cancer aside from improved prognosis

A

Frequent nodal involvement

82
Q

Difference in management between HPV associated and HPV not associated head and neck cancer

A

None for now. There are trials underway looking at deintensification of treatment.

83
Q

Management of locoregional nasopharyngeal cancer in general

A
  • RT is the mainstay
  • chemo integral for stage III and IV
  • No surgery typically (due to deep location of nasopharynx and close proximity to critical neurovascular structures and base of skull)
84
Q

Management of oropharyngeal cancers with bony involvement

A
  • surgery (mandibulectomy) over RT (mandibular invasion is difficult to cure with nonsurgical approaches)
85
Q

Preffered chemo for chemoradiotherapy

A

Cisplatin

86
Q

Localized Oropharyngeal cancer management in elderly patient who is not ideal candidate for chemoRT

A

Definitive RT

87
Q

Oropharyngeal cancer chemo for patient who isn’t cisplatin eligible

A

Carboplatin

88
Q

Typical management of locally advanced oropharyngeal cancer

A
  • organ-preservation approaches using chemoradiation are more commonly used than primary surgery
89
Q

How synchronous vs. metachronous is typically defined

A
  • Synchronous cancers = occurring within 6 months of the first primary cancer
  • metachronous cancers = occurring more than 6 months later (12).
90
Q

Why carboplatin is not first line

A

Considered less effective than cisplatin (but little direct evidence)

91
Q

Higher toxicity of carboplatin vs cisplatin

A

carboplatin causes more myelosuppression

92
Q

Immunotherapy for head and neck cancer?

A

Pembro and nivo both approved for patients who have been treated previously with platinum-based chemo for metastatic or recurrent SCC

93
Q

Other active chemo agents aside from platinum-based

A

taxanes

94
Q

Targeted therapies for head and neck cancer?

A

Cetuximab

95
Q

Second line

A

Immunotherapy with pembro or nivo (if eligible for immunotherapy)

96
Q

Repeating cytotoxic chemotherapy after initial trial?

A

Never done because objective response is uncommon

97
Q

Mechanism of palbociclib

A

CDK inhibitor

98
Q

Management of locally recurrent disease

A
  • salvage surgery and/or reirradiation
99
Q

workup of head and neck cancer/staging

A
  • CT head and neck
  • Chest CT
  • FDG PET/CT
100
Q

locoregional head and neck cancer with nodal involvement surgery

A

Ipsilateral or bilateral neck dissection

101
Q

Preferred interval between resection and postoperative RT

A

6 weeks or less

102
Q

Role for IO in metastatic head and neck cancer?

A

CPI’s approved for patients who’ve progressed on platinum-based chemo

103
Q

backbone of most chemo regimens in metastatic head and neck cancer

A

cisplatin and carboplatin

104
Q

chemo with activity in metastatic head and neck cancer

A
  • platinums
  • taxanes
  • 5-Fu
105
Q

Management of metastatic head and neck with poor PS

A

Palliative RT or palliative debulking

106
Q

Preferred radiation sensitizer for concurrent chemoRT of locally advanced disease

A

1) high dose cisplatin

2) carboplatin/5-Fu

107
Q

Preferred induction systemic therapy for metastatic with good PS

A

Docetaxel + cisplatin + 5-Fu

Hematology, oncology (218 decks)

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