head and neck oncology and maxillofacial surgery

Question 1

oral/oropharyngeal cancer
prevalance and incidence

Answer 1

1200 new registrations per year in Scotland. 600 Rx in WoS. (6% of all cancers, 5% of all cancer deaths worldwide)

Increasing incidence (younger, both sexes)

90% Squamous Cell Carcinoma

Disease of deprivation

3/ 100,000 male deaths

5 year survival worldwide 46%

75% oral/oropharynx. 25% laryngeal Ca

Question 2

main risk factor for oral/oropharyngeal cancer

Answer 2

¾ of head and neck cancers attributable to cigarettes and alcohol use.
* Synergistic (16x more likely to get SCC)

Other factors: Betel/pan, oral hygiene, diet, HIV, EBV and HPV.

Biggest risk is prev SCC (4% per year)

Question 3

classic sites in oropharynx

Answer 3

base of tongue

tonsil

soft palate

Question 4

classic sites in oral cavity

in order of prevalence

Answer 4

Lateral/Anterior 2/3 of tongue

Floor of mouth

Retromolar trigone

Buccal mucosa

Hard palate

Alveolus

Lip mucosa

Question 5

7 red flags

URGENT REFERRAL TO MAXFAX

Answer 5

1) Ulcer perists (t > 2 weeks) despite removal of any obvious causation
2) Rolled margins, central necrosis (firm raised edges – concern)
3) Speckled (erythroleukoplakia) appearance
4) Cervical lymphadenopathy (enlarged (size > 1cm), firm, fixed – to skin or muscle, tethered – hard to move, non-tender, esp unilateral)
5) Worsening pain (neuropathic (nerve root pain, sharp), dysaethesia, paraesthesia)
6) Referred pain (ear, throat, mandible)
7) Weight loss (local / systemic effects – cachectic appearance, inc metabolic demands)

Question 6

describe

Answer 6

area of shallow ulceration, pseudomembranous slough in central aspect, erythematous border, expect to feel soft (here it is a traumatic ulcer)

Question 7

describe

Answer 7

white patch on left border of tongue, approx. 2-3cm in length and 1cm in width, not uniformly white – non-homogenous leukoplakia, rest of tongue looks normal

Refer to MaxFax

Question 8

describe

Answer 8

lateral tongue border to ventral tongue/FOM, larger, irregular border, erytheroleukoplakia (high risk for malignant transformation when red/white patch mix)

urgent referral

Question 9

describe

Answer 9

lesion on lateral/ventral surface of tongue, irregular, raised with depressed areas of necrosis in it (lumpy), erytheroleukoplakia

Question 10

describe

Answer 10

attached gingivae in upper left quadrant, erytholeukoplakia, not normal, suspicion of progressive restiform leucoplakia – high malignant transformation rate

Question 11

describe

Answer 11

EO, crusting region on lower right lip, differential dx: neoplastic process further down compared to infective (recurrent herpes simplex labialis virus), review in week time and see if resolved

Question 12

describe

Answer 12

left oral commissure has white that enters onto buccal mucosa – raised, irregular, possible firm, suture present (biopsy taken), malignancy or chronic hyperplastic candidiasis (debatable premalignant condition) – referral to check for dysplasia

Question 13

describe

Answer 13

left border of tongue, large area that is irregular, central ulceration, white and red patches, tongue may have limited movement, likely tender to touch

Question 14

lymph nodes in neck

Answer 14

always examine

learn name/number as communication aid

1a – submental
1b – submandibular
2 – upper jugular chain (divided by spinal accessory nerve)
3 – middle jugular chain
4 – lower jugular chain
5 – posterior triangle (divided by spinal accessory nerve)

Question 15

1a lymph node

Answer 15

submental

Question 16

1b lymph node

Answer 16

submandibular

Question 17

2 lymph node

Answer 17

upper jugular chain (divided by spinal accessory nerve)

Question 18

3 lymph node

Answer 18

middle jugular chain

Question 19

4 lymph node

Answer 19

lower jugular chain

Question 20

5 lymph node

Answer 20

posterior triangle (divided by spinal accessory nerve)

Question 21

describe

Answer 21

level 1b lymphadenopathy, oval shaped enlargement 2-2.5cm by 1cm (large than should be), angle of mandible

Question 22

describe

Answer 22

level 2 lymphadenopathy, oval shaped approx. 4mcm by 2cm

Question 23

describe

Answer 23

posterior triangle enlarged lymphadenopathy Va

Question 24

what to check lymph nodes for

6

Answer 24

• Fixed
• Tethered to underlying structures
• painful
• Symmetrical (uni or bilateral)
• Firm
• If intraoral cause

Question 25

inc lymphadnopathy description in referral?

Answer 25

yes will be check on Ultrasound or if still unsure a fine needle aspirate of the lump

Question 26

possible investagations

Answer 26

CT scan of primary sites, neck and thorax * sagittal, coronal, axial views OPT – assess dentition to see if dentally fit (remove poor prognosis) prior to radiotherapy US Scan of enlarged node in neck – check cells of lymphadenopathy if no obv primary site (US guided FNB) Punch biopsy

Question 27

describe CT scan

Answer 27

Left maxilla is abnormal (different to RHS) Loss of zygomatic buttress, maxillary sinus and subcutaneous swelling towards left cheek, possible invading ethomoidal sinus 3D * bony window - left maxilla eaten away by pathology – likely malignant neoplasm * vascular window – supply to tumours and recon purposes

Question 28

lymph nodes on CT

Answer 28

yes check for large/abnormal lymph nodes and metastases

Question 29

unsure on extent of disease in theatre?

Answer 29

stain with Loogals iodine staining in theatre, highlights dysplastic tissue dysplasia is associated with premalignancy – abnormal cells that can go onto to be malignant

Question 30

TNM staging

Answer 30

T - tumour - size, depth of invasion (inc risk of metastasis) N – nodes – involved lymph nodes in neck (number and uni or bilateral), breached extra-nodule capsule of lymph node (clinically, radiology, pathology confirmed)* ENE extra-nodal expression or ECS extra-capsular spread* M – metastases – distant metastases, most common site for H&N cancer is thorax

Question 31

tx plan process for head and neck oncology cases

Answer 31

* Examination * Imaging (CT or MRI for primary site and CT Chest) * Tissue (Histology) * Provides a TNM staging * Present at MDT and produce management plan

Question 32

6 tx options for head and neck oncology

Answer 32

* Curative vs Palliative vs Best Supportive care * Nil * Surgery alone * Radiotherapy alone * Chemo radiotherapy * Dual or Triple Modality WHO guidance has performance status ranking which helps determine which Tx option pt can manage with

Question 33

primary sites surgical options | 4

Answer 33

- Resection and packing - Resection and Primary closure - Resection and reconstruction - Local flap, pedicled flap or free flap

Question 34

what are local flaps

Answer 34

FOM cancer edentulous and use buccal mucosa to repair FANN flap, Pedicle flap – still attached to original blood supply rotated into area it is needed in (pectoralis major commonly used), Free flaps – tissue is detatched with their blood supply and moved to another part of body and anstamosed to new blood supply – mainly used

Question 35

why reconstruct

Answer 35

restore form and function

Question 36

how to plan reconstruction

Answer 36

* Planning with 3-D CT * +/- Model/mirror image if asymmetric tissue loss * Cutting guides & templates Resection Planning * tumour in anterior mandible, invading lower lip, FOM, tongue can create cutting guides from plans

Question 37

possible donor sites for head and neck oncology | 7

Answer 37

* **Radial Forearm** - common for tongue recon * Rectus Abdominus - avoid, pneumonia post op risk * Latissimus Dorsi - good for bulk *** Anterolateral Thigh -** common for intra and extra oral lesions * DCIA - avoid, mobidity risk, hard to harvest * **Fibula** - most common composite site (combo soft tissue and bone) * Composite Scapula

Question 38

multiple flaps....

Answer 38

inc risk and complications

Question 39

Osteoradionecrosis

Answer 39

side effect of head and neck cancer Necrotic bone in a previously radiotherapised field * Hypoxia, hypocellular and hypovascualrity Radiotherapy > 70 Gy, mandible > maxilla * Incidence not decreasing despite IMRT All new OSCC patients see restorative specialists Management mainly preventative

Question 40

classification of ORN

Answer 40

I asymptomatic exposed bone II III cutaneous fistulisation +/- pathological fracture Hard to manage when progress to III