Head and Neck Oncology Flashcards
what makes up 90% of oral cancers
squamous cell carcinomas
is oral cancer a disease of deprivation
yes
what are 3/4 of head and neck cancers attributable to
cigarettes and alcohol use
synergistic
what other factors leads to head and neck cancers
Betel/pan - Not common within UK
oral hygiene,
diet,
HIV,
EBV
and HPV
what sites are high risk for cancer in the oropharynx
○ Base of tongue
○ Tonsil
Soft palate
what sites are high risk for cancer in the oral cavity
○ Buccal mucosa
○ Retromolar trigone
○ Alveolus
○ Hard palate
○ Anterior 2/3 tongue
○ Floor of mouth
Lip mucosa
what are red flags in cancer
1) Ulcer persists (t > 2 weeks) despite removal of any obvious causation
2) Rolled margins, central necrosis
○ Abnormal area
○ Feel for the raised peripheral areas which are firm
3) Speckled (erythroleukoplakia) appearance
○ Red and white patches
4) Cervical lymphadenopathy
○ enlarged (size > 1cm) - Particularly one that is unilateral
○ firm,
○ fixed,
○ tethered,
○ non-tender
5) Worsening pain
○ neuropathic - Sharp
○ dysaethesia,
○ paraesthesia)
6) Referred pain
○ ear,
○ throat,
○ mandible
7) Weight loss
○ local / systemic effects
how do divide the anterior and posterior triangles of the neck into levels when talking about cancer
- Divide into levels of 1, 2, 3 and 4 which form part of the anterior triangle of neck
○ Level 5 is posterior triangle of the neck
○ These are subdivided anatomically based on certain important aspects of the anatomy- Level 1
○ Level 1 A = submental nodes
○ Level 1 B = submandibular nodes - Level 2 = upper jugular chain
○ Divided into A and B in relation to the accessory spinal nerve which also subdivides the posterior triangle into level 5 A and B - Level 3 = mid jugular chain
Level 4 = lower jugular chain
- Level 1
look up picture from lecture if this doesnt make sense it has each of the levels labelled
what investigations can be carried out
- CT scans
- OPT (to assess dentition)
- biopsy
what do you need to provide a TNM staging
- Tissue
○ Histology - Imaging
○ CT
MRI for primary site and CT chest
what is TNM staging
○ Tumour = description of the primary tumour
§ In terms of size and depth of invasion
§ The deeper the tumour = increased risk of metastasis
○ Nodes = involved lymph nodes in the neck
§ In terms of whether there is one or more
§ Or whether it is unilateral or bilateral
§ Has the tumour breached the peripheral capsule of the lymph node
□ ENE = extra-nodal extension
□ Or sometimes ECS = extra=capsular spread
○ M = metastasis
Most common for head and neck cancer is the thorax
what are the treatment options for head and neck cancer
- Curative Vs Palliative Vs Best Supportive Care
- Nil
- Surgery alone
- Radiotherapy alone
- Chemo-radiotherapy
Dual or triple modality
what are 3 options for the primary site
Resection and packing
Resection and primary closure
Resection and reconstruction
in terms of reconstruction, what 3 flaps may be suitable
○ Local flap,
§ Can be a local reconstruction = utilise flaps from inside the mouth
□ Or for the floor of the mouth in an edentulous patient you can borrow a bit of the buccal mucosa with the facial artery
○ Pedicled flap
§ Still attached to its original blood supply ie it has not been detached from its original blood supply and is rotated into the area required in reconstruction
○ or free flap
§ Where tissue (whether skin, fascia, muscle, bone, combination) actually detach with their blood vessels from the blood supply and move to another part of the body and anastomose to the local blood supply
Form majority of reconstructive attempts
why reconstruct?
- To restore form and function
- Thin and pliable flaps are very suitable for tongue reconstructions
If we want to reconstruct the mandible then a bony reconstruction functions better than just a soft tissue reconstruction
- Thin and pliable flaps are very suitable for tongue reconstructions
what is needed for reconstruction
Planning with 3D CT
+ / - model / mirror image if asymmetric tissue loss
Cutting guides & templates
where are possible donor sites for reconstruction
Radial forearm
Rectus abdominus - don’t tend to use now because of the risk of pneumonia
Latissimus dorsi
Anterolateral thigh
DCIA
Fibula
Composite scapula
when is the radial forearm used
- used in tongue reconstructions
when is the rectus abdominus used
- Don’t tend to use now a days
Try to avoid operating on abdomens because they can cause pneumonias when it is painful for the patient to breath after the operation
what is the advantage of using the latissimus dorsi
Good for bulk
Big area of skin, fat and muscle and reliable blood supply
Very limited mobility associated with this site
what is anterolateral thigh commonly used for
Commonly used for intra-oral and extra-oral
what is the problems with the DCIA
- Some bone and muscle and skin
- Not an easy flap to have because of associated mobility
- Short pedicle
Question of the quality of the bone long term particularly if the paitent has radiotherapy
What is probably the most common site
fibula
what is osteoradionecrosis (ORN)
Necrotic bone in a previously radiotherapised field
Hypoxia, hypocellular and hypovascularity
when does osteoradionecrosis occur
- Radiotherapy > 70 Gy
Mandible > maxilla
what is the management of osteoradionecrosis
Management mainly preventative if you can
what is ORN class I
asymptomatic exposed bone
