Head and Neck Tumors Flashcards
t/f head and neck cancer is more common in females, except for thyroid malignancy
false, more common in males
signs for benign mass
- younger age
- shorter duration
- symptoms of inflammation
- exposure to farm animals, tb, fungus
signs for malignant mass
- older age group
- chronic duration
- fast growth
- compressive or obstructive symptoms
- family hx
- exposure to ionizing radiation
- smoker, betel nut chewer
- alcoholic beverage drinker
- hpv infection (oropharyngeal cancer)
- ebv (nasopharyngeal cancer)
differentiating between benign and malignant masses on pe
benign: smooth, non-ulcerating, movable, well-defined borders
malignant: firm to hard, rough or irregular, ulcerative, friable or fragile, erythroplakia
types of biopsy
needle aspiration: deep tumors with intact skin (fnab)
punch biopsy: exophytic tumors
incision biopsy: for intact skin
excision biopsy: removal of entire tumor
most common histology for h&n malignancies is __
squaca
distant metastases work-up
- chest xray or lung ct
- hbt uts or whole abdomen uts
- alkaline phosphatase or bone scan
- pet/ct is superior for identifying distant metastases and posttreatment recurrence
tenets of reconstruction
- complete removal of tumor
- function > form
- goal: match size, skin color, texture, and thickness of donor site tissue
- put incisions on relaxed skin tension lines
what is primary closure
- for small defects
- you can close primarily but it depends on the laxity of the skin
- pediatric and elderly are amenable
what is wound healing by secondary intention
- defects will not be closed
- used in superficial defects
- causes unwanted contracture of wound edges
skin grafts vs flaps
graft: no direct blood supply, less contracture than secondary
flaps: has its own blood supply
what is split thickness skin grafts
- epidermis + dermis
- better perfusion and viability
- poor color match, more contractures
what are full thickness skin grafts
- epidermis + dermis + subcutaneous tissues
- good color match, less contractures, better form
- high probability of nonviability
factors that affect graft viability
- blood supply to recipient bed
- vascularity of the donor graft tissue
- contact between graft and recipient bed
- patient’s overall health
what are not good beds for skin graft
bare bone, irradiated tissue, infected tissue
sutures to give good contact between graft and bed
- pie crust slits prevent blood accumulation between the graft and bed
- basting sutures
- bolster or pressure dressing to improve non movement
flaps according to location
local: tissue immediately adjacent to the defect
regional: flap from a site not immediately adjacent to the defect
distant: far from the area/defect
flaps according to blood supply
axial pattern: there is a named artery that supplies the flap
random: based on the rich perforating vascular plexus of the skin
t/f all regional and pedicle flaps are random flaps, all local flaps are axial pattern flaps
false!!!
all regional and pedicle flaps are axial patter
all local flaps are random flaps
flap used for extensive defects
pectoralis major myocutaneous flap: skin and muscle flap
examples of regional flaps
- paramedian forehead flap (supratrochlear artery)
- deltopectoral flap (perforating branches of the internal mammary artery)
what is an anterolateral thigh free flap
- thicker with more subcutaneous fat
- blood: lateral circumflex artery
signs of a healthy flap
- pink, warm, slightly edematous
- capillary refill within 3 seconds
- pinprick will produce bright red blood
signs of bad flap
- arterial thrombosis: no blood supply, pale and cold to touch, doesn’t bleed on pinprick
- venous thrombosis: leads to congestion, violaceous, bleeds on pinprick but blood is dark
___ is an option for those who are medically unfit for another surgery or refuses surgery
prosthesis
warning signs for skin lesions
Asymmetry Border irregularity Color variation Diameter greater than 6 mm Evolving changes
most common malignancy in humans around the world
basal cell carcinoma
what is basal cell carcinoma
- slow growing epithelial malignancy
- most frequent in sun exposed skin
- rarely metastasizes
- aberrant activation of hedgehog signaling pathway
presentation and tx for basal cell carcinoma
- raised, rolled border with central ulceration and may be pruritic
- tx: dermabrasion, cryosurgery, mohs surgery, wide excision with/without reconstruction
- vismodegib: hedgehog inhibitor
t/f intermittent recreational sun exposure is at higher risk than cumulative uv radiation
true
malignant epidermal tumor from keratinocytes with a locally destructive and metastatic potential, 2nd most common skin cancer
squamous cell ca
high risk for multiple skin cancers
immunocompromised and xenoderma pigmentosum
management for squaca
- wide excision with or without reconstruction and neck dissection
- more aggressive: adjuvant radiation and/or systemic therapy (cetuximab, pd1, pdl1 inihibitors)
most lethal form of skin cancer
cutaneous melanoma
risk factors for cutaneous melanoma
sun exposure, light skin, atypical nevi
manifestation of cutaneous melanoma
- potentially metastatic when it reaches vertical growth phase
- satellite lesions: discrete nests of melanoma cells that are clearly separated from body of tumor
management of cutaneous melanoma
- wide excision with neck dissection if with regional metastases
- radiation may be given post-surgery for pts with extra-capsular spread or multiple node involvement
- immunotherapy (stage 4): dacarbazine, il2, ipilimumab, vemurafenib, pd1-i
type of biopsy to be done in salivary gland neoplasms
fnab
most common salivary gland tumor, least malignant: ___
least common salivary gland tumor, most malignant: ___
most common salivary gland tumor, least malignant: parotid
least common salivary gland tumor, most malignant: sublingual
incidence of histology of malignant salivary gland neoplasms
most common: mucoepidermoid
adenoid cystic, adenocarcinoma
benign vs malignant salivary gland tumors
benign: slow, mobile, no facial nerve paralysis, no overlying ulceration of skin
malignant: fast, fixed to underlying tissue, facial nerve paralysis (parotid), constant pain, tongue numbness (submandibular), cervical lymphadenopathy
mgt for salivary gland tumor
- mri, ct to rule out bone involvement
- surgical resection
- adjuvant radiationi
risk factors for nasopharyngeal cancer
- chinese descent (guangdong province)
- fish, ebv, smoking
- highest indicence: southern china, hk, guangzhou province
histology of nasopharyngeal ca
- most common: nonkeratinizing undifferentiated ca
histologies of npca
most common: nonkeratiniing
undifferentiated
keratinizing squamous cell ca, basaloid squamous cell ca
diagnostics for npca
- biopsy: histology
- imaging: extent (cct for base of skull, mri for intracranial)
mgt for npca
- stage 1 and 2: radiation only
- stage 3 and 4: concurrent chemo
- local and regional recurrency: surgical
most common site for paranasal sinus ca
most common histology for paranasal sinus ca
maxillary sinus
adult: squaca
pedia: rhabdomyosarcoma
diagnostics for paranasal sinus ca
- ct for skull base involvement
- mri for intracranial involvement
- biopsy: intranasal or into sinus
- ohngren’s line: above has poorer prognosis, blow has better prognosis
mgt of paranasal sinus ca
surgical only
- endoscopic or open
contraindications for endoscopic mgt of paranasal sinus ca
- dura involvement beyond mid pupillary line
- anterior/lateral frontal sinus involvement
- facial/orbital soft tissue extension
- palatal involvement
- gross brain parenchyma involvement
contraindication for open surgery for paranasal ca
- gross invasion of the brain
- invasion of orbits
- carotid encasement
- invasion of cavernous sinus
- significant comorbidities
- extension to nasopharynx or pterygoid fossa
presentation for laryngeal and hypopharyngeal cancers
- hypopharyngeal and supraglottic ca: dysphagia
- glottic cancer: hoarseness
- subglottic cancer: dyspnea
- squaca: MOST COMMON HISTOLOGY
important subset of laryngeal tumors with aggressive behavior and high risk of lymphatic metastasis
transglottic tumors
diagnostics for laryngeal and hypopharyngeal cancers
- laryngeal exam
- ct scan of the neck with contrast!!!
- imaging before operative endoscopy and biopsy
mgt of laryngeal and hypopharyngeal ca
goals: cure the pt, preserve larynx, minimize tx morbidity
early (stage 1 and 2): surgery, radio (single modality)
advanced (3 and 4): surgery and radio with/wo chemo post op, concurrent chemo-radio without surgery
surgery = wide excision w/wo neck dissection, w/wo radio or chemo-radio
presentation of oral cavity ca
- ulcerative exophytic lesions
- involvement of adjacent structures
- dysarthria (tongue involvement)
- teeth mobility
- neck nodes are usual
diagnostics for oral cavity ca
- ct: cortical bone erosion and ln metastases
- mri: extent
- punch biopsy or periphery and/or fna of regional metastases
mgt of oral cavity ca
- surgery!!
- advanced stage: combined modality (surgery and radio)
most common histology of oropharyngeal ca
scc
signs of hpv-associated opscc
- younger (40-60), male > female
- minimal/ no addication habit
- nonkeratiinizing scc, poorly differentiated
- small/unknown primary with bulky, cystic, or multiple odes
- good 5 year survival
mgt of oropharyngeal ca
- early: single modality
- advanced: multimodal (with surgery)
synchronous vs metachronous lesion
synchronous: tumor detected simultaneously or within 6 mos of initial primary tumor
metachronous: second primary lesion >6 mos after index tumor
