Head & Neck Cancer Flashcards

Question

What autoimmune condition is thyroid lymphoma highly associated with?

Answer 1

Highly associated with Hashimoto's thyroiditis

Answer 2

Toxic solitary adenoma Non-functional thyroid adenoma Multinodular goitre Thyroid cyst Cancer

Answer 3

total thyroidectomy followed by radioiodine (I-131) to kill residual cells

Answer 4

Yearly thyroglobulin levels to detect early recurrent disease

Answer 5

Usually contain a mixture of papillary and colloidal filled follicles Histologically tumour has papillary projections and pale empty nuclei They are rarely encapsulated

Answer 6

Solitary thyroid nodule/focal encapsulates lesions

Answer 7

Malignancy can only be excluded on formal histological assessment

Answer 8

May appear macroscopically encapsulated, microscopically capsular invasion is seen. Without this finding the lesion is a follicular adenoma.

Answer 9

Microscopically, capsular invasion seen

Answer 10

Resection where possible Palliation may be achieved through: isthmusectomy and radiotherapy. Chemotherapy is ineffective.

Answer 11

Anaplastic

Answer 12

1. Papillary - cells a mixture of papillary and colloid-filled follicles with papillary projections pale empty nuclei 2. Follicular microscopic capsular invasion 3. Medulary 4. Anaplastic

Answer 13

Female gender Family history - Also includes relevant cancer syndromes (e.g. medullary subtype associated with Multiple Endocrine Neoplasia (MEN) Syndrome type IIa and IIb) Radiation exposure in childhood Full body radiotherapy for bone marrow transplant Hashimoto’s disease (Predisposes to lymphoma subtype)

Answer 14

Rapid growth Pain Cough, hoarse voice, or stridor Multiple enlarged cervical lymph nodes Tethering of the lump to surrounding structures

Answer 15

Thyroid cancers may present as a palpable lump, multiple lumps, or be found incidentally on imaging of the neck. The red flag signs to be aware of with any neck lump that may suggest a malignancy are: - Rapid growth - Pain - Cough, hoarse voice, or stridor - Multiple enlarged cervical lymph nodes - Tethering of the lump to surrounding structures

Answer 16

Benign thyroid adenoma or thyroid cyst Toxic multi-nodular goitre - Toxic refers to excessive productive of thyroid hormone which results in the clinical features of hyperthyroidism Non-toxic multi-nodular goitre Thyroglossal duct cyst* (not in the thyroid itself) - Will move superiorly as the patient sticks out their tongue

Answer 17

Thyroglossal cysts, prior to any suggested removal, should be fully investigated as the as the cyst may be the only functioning thyroid tissue that the patient has therefore would not warrant removal

Answer 18

low TSH raised T3 or T4 Radio-nucleotide imagain showing a ''hot'' nodule No further investigation for malignancy is required - overative nodules are very rarely malignant

Answer 19

Microcalcifications Hypoechongenicity (dark regions, decreased response) Irregular margins

Answer 20

TFTs (if evidence toxic nodule - no further investigation req.) Ultrasound thyroid scan: assess nodule + look for cervical lymphadenopathy FNA cytology if U3-U5 lesion Diagnostic hemithyroidectomy if Thy 3 or Thy 4 on FNAC

Answer 21

US of thyroid A score will be allocated (U1-U5). U1-U2 lesions have low risk of malignancy and will not require fine needle aspiration cytology (FNAC), U3-U5 lesions should undergo FNAC.

Answer 22

If U3-U5 on US, lesions will undergo fine needle aspiration cytology Involves passing a neddle into the thryoid nodule and aspirating cells out of it These cells will be reviewed and the relevant score allocated (Thy1-Thy5) Thy 1- requires further sample Thy 2 - non-malignant, no further action Thy 3 - folicular lesion, requires diagnostic hemithyroidectomy Thy 4 - suspicious, requires diagnostic hemithyroidectomy Thy 5 - malignant and requires work up for appropriate treatment

Answer 23

Thy1 is inconclusive and requires a further sample Thy2 is non-malignant Thy3 is follicular lesion and requires diagnostic hemithyroidectomy for histology to determine between follicular adenoma (benign) or carcinoma Thy4 is suspicious and requires diagnostic hemithyroidectomy Thy5 is malignant and requires work up for appropriate treatment

Answer 24

Thyroid cancer should be managed by a multi-disciplinary team, including endocrinologists, histopathologists, radiologists, oncologists, and ENT surgeons, alongside of specialist nurses and speech and language therapists. The management varies depending on the type of cancer as well as the stage. Management options include surgical, chemotherapy, radiotherapy, and radio-iodine therapy. Surgical: hemi or total thyroidectomy - neck dissection to remove groups of lymph nodes from surrounding region Non surgical: radioiodine therapy, external beam raidotherapy

Answer 25

Hemi-thyroidectomy – This involves removing half of the thyroid that contains the lesion, however is only suitable for certain tumours (e.g. small low grade non-metastatic malignancy) Total thyroidectomy – Most malignant disease will require a total thyroidectomy, which involves removing the whole thyroid (including the isthmus); patients will always need to take thyroid hormone replacement following this surgery Locally advanced disease may also require neck dissection, to remove groups of lymph nodes from the surrounding region, both to aid diagnosis and attempt to reduce disease spread.

Answer 26

Radioiodine therapy involves administration of a radioactive iodine solution, which is taken up preferentially by residual thyroid tissue, acting a focal radiation targeting the malignancy (used for papillary or follicular carcinomas). Only effective after total thyroidectomy. External beam radiotherapy can be used as primary or adjunct therapy (curative or palliative). Chemotherapy can be used as primary or adjunct therapy (curative or palliative) - classically lymphomas usually responding well to chemotherapy, and symptoms can improve within a few doses. Anaplastic tumours do not respond well to chemotherapy

Answer 27

can be used as primary or adjunct therapy (curative or palliative) classically lymphomas respond well anaplastic carcinoma does not respond to chemotherapy

Answer 28

Haematogenous spread

Answer 29

Papillary or follicular carcinomas Only effective after total thyroidectomy

Answer 30

Haematoma formation beneath the skin, potentially causing airway obstruction (must be opened and drained on ward and return to theatre to stop bleeding) Damage or removal of parathyroid gland - hypocalcaemia Unilateral RLN damage - vocal cord paralysis - hoarse voice Bilateral RLN damage - vocal cord paralysis - life threatening stridor

Answer 31

Clinical features of hypocalcaemia, such as paraesthesia or tetany. PTH and serum calcium levels must be checked the next day (however levels can become significantly low within hours post-operatively) Because, Hypocalcaemia may occur if there is damage to or removal of the parathyroid glands.

Answer 32

Paraesthesia - usually of fingers, toes, cicumoral regions, cause be increase neuromuscular irritability Tetany (involuntary contraction of muscles leading to painful cramps, spasms and neurological reflexes) Chvostek's sign - twitching of circumoral muscles in response to gentle tapping of the facial nerve just anterior to the ear Trousseau's sign - carpal spasm induced by inflation of a blood pressure cuff to 20 mmHg above the patient's systolic blood pressure for 3 min Prolonged QT interval Bronchospasam

Answer 33

The recurrent laryngeal nerves run close to the thyroid gland, hence care during surgery must to taken to prevent damage causing vocal cord paralysis. Unilateral palsy will result in a hoarse voice however a bilateral paralysis can result in a life-threatening stridor and tracheostomy may be warranted.

Answer 34

Bleeding immediately after the operation can result in a haematoma forming beneath the skin. Large haematomas can cause airway obstruction, which is an emergency. In this situation the surgical wound must be re-opened (on the ward!) to allow drainage of the haematoma and the patient will need to go back to theatre to stop the bleeding The recurrent laryngeal nerves run close to the thyroid gland, hence care during surgery must to taken to prevent damage causing vocal cord paralysis. Unilateral palsy will result in a hoarse voice however a bilateral paralysis can result in a life-threatening stridor and tracheostomy may be warranted.

Answer 35

Bleeding immediately after the operation can result in a haematoma forming beneath the skin. Large haematomas can cause airway obstruction, which is an emergency. In this situation the surgical wound must be re-opened (on the ward!) to allow drainage of the haematoma and the patient will need to go back to theatre to stop the bleeding

Answer 36

When nodal or metastatic spread is seen.

Answer 37

For anaplastic cancer, there is a very poor prognosis with a 1 year survival of 10-20%

Answer 38

The tumour has spread beyond the gland

Answer 39

Anterior triangle Posterior triangle (These two triangles are on either side of the sternocleidomastoid muscle) Midline (vertically along the centre of the neck)

Answer 40

Superior: (inferior border) mandible Medial: (saggital line down the) midline of neck Lateral: (anterior border of) the sternocleidomastoid

Answer 41

Anterior: (posterior border) of the sternocleidomastoid Posterior: (anterior border) trapezius muscle. Inferior: (middle 1/3 of) the clavicle

Answer 42

Normal structures (e.g., bony prominence - hyoid bone, mastoid process, transverse processes of C1) Skin abscess Lymphadenopathy (enlarged lymph nodes) Tumour (e.g., squamous cell carcinoma or sarcoma) Lipoma Goitre (swollen thyroid gland) or thyroid nodules Salivary gland stones or infection Carotid body tumour Haematoma (a collection of blood after trauma) Thyroglossal cysts Branchial cysts

Answer 43

Cystic hygromas Dermoid cysts Haemangiomas Venous malformation

Answer 44

General information about the symptoms (e.g., when the lump first appeared and how quickly it has grown) Features that suggest or exclude a particular diagnosis (e.g., night sweats indicating lymphoma) Risk factors for that condition (e.g., family history, age and smoking status) General fitness for further investigations and treatment (e.g., co-morbidities and medications such as anticoagulants)

Answer 45

Location (anterior triangle, posterior triangle or midline) Size Shape (oval, round or irregular) Consistency (hard, soft or rubbery) Mobile or tethered to the skin or underlying tissues Skin changes (erythema, tethering or ulceration) Warmth (e.g., infection) Tenderness (e.g., infection) Pulsatile (e.g., carotid body tumours) Movement with swallowing (e.g., thyroid lumps) or sticking their tongue out (e.g., thyroglossal cysts) Transilluminates with light (e.g., cystic hygroma – usually in young children)

Answer 46

Ear, nose and throat infections (e.g., reactive lymph nodes) Weight loss (e.g., malignancy or hyperthyroidism) Skin pallor and bruising (e.g., leukaemia) Focal chest sounds (e.g., lung cancer) Clubbing (e.g., lung cancer) Hepatosplenomegaly (e.g., leukaemia)

Answer 47

2ww referral for: - An unexplained neck lump in someone aged 45 or above - A persistent unexplained neck lump at any age

Answer 48

They recommend considering an urgent ultrasound scan in patients with a lump that is growing in size. Within 2 weeks in patients 25 and older and Within 48 hours in patients under 25. They require a two week wait referral if the ultrasound is suggestive of soft tissue sarcoma.

Answer 49

FBC and blood film for leukaemia and infection HIV test Monospot test or EBV antibodies for infectious mononucleosis Thyroid function tests for goitre or thyroid nodules Antinuclear antibodies for systemic lupus erythematosus Lactate dehydrogenase (LDH) is a very non-specific tumour marker for Hodgkin’s lymphoma

Answer 50

Ultrasound is often the first-line investigation for neck lumps CT or MRI scans Nuclear medicine scan (e.g., for toxic thyroid nodules or PET scans for metastatic cancer)

Answer 51

Fine needle aspiration cytology – aspirating cells from the lump using a needle Core biopsy – taking a sample of tissue with a thicker needle Incision biopsy – cutting out a tissue sample with a scalpel Removal of the lump – the entire lump can be removed and examined

Answer 52

Supraclavicular - . They may be caused by malignancy in the chest or abdomen and require further investigation.

Answer 53

Unexplained (e.g., not associated with an infection) Persistently enlarged (particularly over 3cm in diameter) Abnormal shape (normally oval shaped where the length is more than double the width) Hard or “rubbery” Non-tender Tethered or fixed to the skin or underlying tissues Associated symptoms, such as night sweats, weight loss, fatigue or fevers

Answer 54

Lymphadenopathy refers to enlarged lymph nodes. There are a long list of causes of enlarged lymph nodes, which can be generally grouped into: Reactive lymph nodes (e.g., swelling caused by viral upper respiratory tract infections, dental infection or tonsillitis) Infected lymph nodes (e.g., tuberculosis, HIV or infectious mononucleosis) Inflammatory conditions (e.g., systemic lupus erythematosus or sarcoidosis) Malignancy (e.g., lymphoma, leukaemia or metastasis)

Answer 55

Graves disease (hyperthyroidism) Toxic multinodular goitre (hyperthyroidism) Hashimoto’s thyroiditis (hypothyroidism) Iodine deficiency Lithium

Answer 56

Benign hyperplastic nodules Thyroid cysts Thyroid adenomas (benign tumours the can release excessive thyroid hormone) Thyroid cancer (papillary or follicular) Parathyroid tumour

Answer 57

Parotid glands Submandibular glands Sublingual glands

Answer 58

Stones blocking the drainage of the glands through the ducts (sialolithiasis) Infection Tumours (benign or malignant)

Answer 59

The carotid body is a structure located just above the carotid bifurcation (C3–5 vertebra, where the common carotid splits into the internal and external carotids). It contains glomus cells, which are chemoreceptors that detect the blood’s oxygen, carbon dioxide, and pH. Groups of these glomus cells are called paraganglia.

Answer 60

They present with a slow-growing lump that is: In the upper anterior triangle of the neck (near the angle of the mandible) Painless Pulsatile Associated with a bruit on auscultation Mobile side-to-side but not up and down

Answer 61

Carotid body tumours are formed by excessive growth of the glomus cells. They are also called paragangliomas. Most are benign Carotid body tumours may compress the glossopharyngeal (IX), vagus (X), accessory (XI) or hypoglossal (XII) nerves. Pressure on the sympathetic nerves may result in Horner syndrome, with a triad of: Ptosis Miosis Anhidrosis (loss of sweating)

Answer 62

A characteristic finding on imaging investigations is splaying (separating) of the internal and external carotid arteries (lyre sign).

Answer 63

Surgical removal

Answer 64

Lipomas are benign tumours of fat (adipose) tissue. They can occur almost anywhere on the body where there is adipose tissue. On examination, lipomas are typically: Soft Painless Mobile Do not cause skin changes They are typically treated conservatively with reassurance (after excluding other pathology). Alternatively, they can be surgically removed.

Answer 65

Thyroglossal cysts occur in the midline of the neck. They are: Mobile Non-tender Soft Fluctuant Thyroglossal cysts move up and down with movement of the tongue. This is a key feature that demonstrates a midline neck lump is a thyroglossal cyst. This occurs due to the connection between the thyroglossal duct and the base of the tongue.

Answer 66

During fetal development, the thyroid gland starts at the base of the tongue. From here, it gradually travels down the neck to the final position in front of the trachea, beneath the larynx. It leaves a track behind called the thyroglossal duct, which then disappears. When part of the thyroglossal duct persists, it can give rise to a fluid-filled cyst. This is called a thyroglossal cyst.

Answer 67

Ultrasound or CT scan can confirm the diagnosis.

Answer 68

A branchial cyst is a congenital abnormality that arises when the second branchial cleft fails to form properly during fetal development. This leaves a space surrounded by epithelial tissue in the lateral aspect of the neck. This space can fill with fluid. This fluid-filled lump is called a branchial cyst. Branchial cysts arising from the first, third and fourth branchial clefts are possible, although they are much rarer.

Answer 69

Branchial cysts present as a round, soft, cystic swelling between the angle of the jaw and the sternocleidomastoid muscle in the anterior triangle of the neck. Branchial cysts tend to present after the age of 10 years, most commonly in young adulthood when the cyst becomes noticeable or infected. Management of a branchial cyst is either: Conservative, without any active intervention, where it is not causing problems Surgical excision where recurrent infections are occurring, there is diagnostic doubt, or it is causing other problems

Answer 70

They are usually squamous cell carcinomas arising from the squamous cells of the mucosa.

Answer 71

Nasal cavity Paranasal sinuses Mouth Salivary glands Pharynx (throat) Larynx (epiglottis, supraglottis, vocal cords, glottis and subglottis)

Answer 72

Head and neck cancers usually spread to the lymph nodes first. Squamous cell carcinoma cells may be found in an enlarged, abnormal lymph node (lymphadenopathy), and the original tumour cannot be found. This is called cancer of unknown primary.

Answer 73

Head and neck cancers usually spread to the lymph nodes first. Squamous cell carcinoma cells may be found in an enlarged, abnormal lymph node (lymphadenopathy), and the original tumour cannot be found. This is called cancer of unknown primary.

Answer 74

Smoking Chewing tobacco Chewing betel quid (a habit in south-east Asia) Alcohol Human papillomavirus (HPV), particularly strain 16 Epstein–Barr virus (EBV) infection HPV also causes cervical cancer. The HPV vaccine (Gardasil) protects against strains 6, 11, 16 and 18.

Answer 75

Lump in the mouth or on the lip Unexplained ulceration in the mouth lasting more than 3 weeks Erythroplakia or erythroleukoplakia Persistent neck lump Unexplained hoarseness of voice Unexplained thyroid lump

Answer 76

Treatment may involve any combination of: Chemotherapy Radiotherapy Surgery Targeted cancer drugs (i.e., monoclonal antibodies) Palliative care Cetuximab is an example of a monoclonal antibody used in treating squamous cell carcinomas of the head and neck. It may also be used to treat bowel cancer. It targets epidermal growth factor receptor, blocking the activation of this receptor and inhibiting the growth and metastasis of the tumour.