Neoplastic Flashcards
Which of these subtypes is associated with a more aggressive disease course?
11
What is the mean age of presentation of MTC in patients with MEN Ila?
27
What percent of thyroid nodules are malignant?
What are the two types of temporal bone paragangliomas?
Glomus jugulare involving the adventitia of the jugular bulb and glomus tympanicum involving Jacobson’s nerve (Jugulo-tympanic glomus if unable to discern site of origin).
What were the treatment arms in the VA trial for laryngeal cancer?
- Surgery.
-
- Two cycles of cisplatinum and s-fluorouracil.
- a. Responders received a 3rd cycle followed by XRT.
- b. Nonresponders had surgery+/- postoperative XRT.
What are the three most well-known prognostic systems for well-differentiated thyroid cancer?
- GAMES (Memorial Sloan Kettering): Grade, Age, Metastases, Extent, Size
- AMES (Lahey Clinic; Cohort of 814 patients): Age, Metastases, Extent (extrapyramidal invasion), Size
- AGES: Age, Gade, Extent, Size
What is Shamblin’s classification system for carotid body tumors?
- Group I: Small and easily excised.
- Group II: Adherent to the vessels; resectable with careful subadventitial dissection.
- Group III: Encase the carotid; require partial or complete vessel resection
Which five salivary gland tumors have the worst prognosis?
- High-grade mucoepidermoid
- adenocarcinoma
- squamous cell undifferentiated carcinoma
- carcinoma ex-pleomorphic adenoma
What were the three treatment arms in the Head and Neck Intergroup R91-11 trial?
- Induction chemotherapy (cisplatin and s-FU)
- radiation alone
>* concomitant cisplatin and radiation therapy
for the treatment of potentially resectable stage III and IV cancer of the larynx.
What is the incidence of stomal papilloma recurrence rate after tracheostomy for RRP?
>50%.
What is the incidence of nodal metastases if the depth of the tumor is >4.0 mm?
>70%.
What percent of thyroid cancers are well differentiated?
>80%.
What is conventional fractionated radiotherapy?
1.8-2.5 Gy every day, five fractions every week, for 4-8 weeks (total dose 60-65 Gy for small tumors, 65-70 Gy for larger tumors).
What percent of carotid body tumors are multicentric?
10% (30-40% in the hereditary form).
What percent of patients with a tumor in the EAC will present with cervical metastases?
10%.
What is the risk of developing esophageal cancer in patients who smoke and drink compared with those who do not?
100 times higher.
What percent of patients with a primary laryngeal cancer will eventually develop a 2nd primary?
10-20%.
What percent of squamous cell carcinoma arising in areas of scar or chronic inflammation metastasize?
10-30%.
What is the incidence of nasopharyngeal cancer among native-born Chinese compared with that among Caucasians?
118 times higher.
What is the incidence of vestibular schwannoma in patients with unilateral SNHL?
1-2%.
What is the incidence of regional metastasis in synovial sarcomas of the head and neck?
12.5%.
What is the incidence of recurrence after resection of inverting papilloma via lateral rhinotomy/medial maxillectomy?
13-15%.
What is the risk of melanomatous transformation of giant congenital nevi?
14%.
What percent of patients with RRP require tracheostomy?
15%.
What is the incidence of patients with Hiirthle cell carcinoma who present with distant metastases?
15%.
What is the average lag time between radiation exposure and development of thyroid cancer?
15-25 years.
How many years does it take for a former smoker to have the same probability of developing an oral cavity cancer as a nonsmoker?
16 years.
What percent of patients undergoing supraglottic laryngectomy and unilateral neck dissection will fail in the contralateral neck?
16%, despite receiving radiation therapy to the area.
What percent of malignant thyroid nodules are suppressible by exogenous TSH?
16%.
What percent of malignant tumors of the parotid gland present with facial nerve weakness or paralysis?
20%.
What percent of melanomas occur in the head and neck?
20%.
Nasopharyngeal cancer accounts for what percent of all cancers diagnosed in the Kwangtung province of southern China?
20%.
What percent of patients with a tumor in the middle ear will present with facial nerve palsy?
20-40%.
What percent of benign thyroid nodules are suppressible by exogenous TSH?
21%.
What percent of glottic tumors display perineural and vascular invasion?
25%.
What percent of these tumors will metastasize to the cervical lymph nodes?
25%.
What is the incidence of skull base erosion in patients with nasopharyngeal carcinoma?
25%.
When, after XRT or radiation therapy, is a positive biopsy a reliable indicator of persistent disease?
3 months after treatment.
What percent of patients with xeroderma pigmentosa develop melanoma?
3%.
What is a typical word discrimination score in a patient with a vestibular schwannoma?
-30% in >50% of patients with an acoustic neuroma.
What is the 5-year survival of patients with Merkel cell carcinoma?
30%.
What is the s-year survival of patients with WHO I disease?
30%.
What is the incidence of positive cervical nodes in patients with T3 glottic tumors?
30-40%.
What is the incidence of cervical metastasis of mucoepidermoid carcinomas?
30-40%.
What percent of thyroid nodules are malignant in patients with a history of radiation exposure?
30-50%.
What percent of squamous cell carcinoma arising in areas of actinic change metastasize?
3-5%.
For SCCA of the tongue, invasion beyond is associated with a significantly higher incidence of lymph node metastasis.
4 mm (30% vs. 7% if 4 mm or less invasion).
What is the chance that a patient cured of an oral cavity cancer will develop a 2nd primary if they continue to smoke?
40%.
What percent of cervical paragangliomas are associated with an encoding underlying germline mutation in the gene succinate dehydrogenase (SDH)?
40%.
What percent of Hodgkin’s lymphoma cases are associated with EBV?
40%.
What is the 5-year survival rate of synovial sarcoma of the head and neck?
40-50%.
What is the maximum dose of radiation to the spinal cord?
45 Gy (increased risk of radiation myelitis above this level).
What percent of patients have had well-differentiated cancer before developing anaplastic thyroid cancer?
47%.
What percent of people with gastroesophageal reflux disease have Barrett’s esophagus and what percent of these people will develop adenocarcinoma?
5% and 5-10%, respectively.
What percent of laryngeal tumors are primarily subglottic?
5%.
What is the incidence of malignancy in adults with asymmetric tonsils with normal-appearing mucosa and no cervical lymphadenopathy?
5%.
What percent of cervical paragangliomas secrete catecholamines?
5%.
What percent of tumors are not pigmented (amelanotic)?
5%.
What is the chance that a patient with melanoma will develop a second melanoma?
5%.
What percent of patients with recurrent respiratory papillomatosis (RRP) develop distal tracheal and pulmonary spread of papillomas?
5%.
What is the incidence of patients with vestibular schwannomas who have normal hearing at presentation?
5%.
What percent of T3/T4 tumors of the tonsil can be salvaged after failing primary XRT?
50%.
After having a basal or squamous cell carcinoma of the skin, what are the chances of developing another one within 5 years?
50%.
What percent of solitary thyroid nodules in children are malignant?
50%.
What percent of MTCs secrete CEA?
50%.
What percent of patients have had benign thyroid disease before developing anaplastic cancer?
53%.
What is the incidence of a 2nd primary at the time of diagnosis in patients with hypopharyngeal cancer?
5-8%.
What are the most common subtypes of HPV isolated from RRP?
6 and 11 (found in >95%).
What is the incidence of cervical metastases at the time of presentation of pyriform sinus tumors? What percent are bilateral or fixed?
60%; 25%.
What is the incidence of local recurrence?
60-80%, usually within 2 years.
What is the incidence of recurrence after excision of odontogenic keratocyst?
62% in the first 5 years.
What is the incidence of cervical metastases from base of tongue, tonsil, and soft palate SCCA?
70%, 6o%, and 40%, respectively.
What is the s-year survival of patients with WHO II or III disease?
70%.
What is the incidence of multicentric disease on pathological examination of the entire thyroid in patients with papillary carcinoma (> 1 em)?
70-80%.
What percentage of MTC occurs sporadically?
70-80%.
What percent of head and neck paragangliomas are familial?
7-10%.
What percent of parotid gland tumors are benign?
75-80%.
What percent will fail if bilateral neck dissections are performed?
8%.
What percent of squamous cell carcinoma arising de novo metastasize?
8%.
What is the incidence of nodal metastases if the depth of the tumor is
8%.
What is the survival rate after complete excision of lesions in children
80%.
What percent of patients with distal spread have had a previous tracheostomy?
85%.
How should a lesion suspicious for melanoma be biopsied?
A sample should be taken of the tumor and the underlying tissue so that depth can be ascertained; a shave biopsy should never be performed.
What are the two categories of altered fractionation?
Accelerated and hyperfractionated.
What is the difference between Accelerated and hyperfractionated altered fractionation radiotherapy regimens?
Accelerated: Total dose is the same as conventional treatment, but overall treatment time is decreased. Hyperfractionated: Overall treatment time is the same as conventional treatment, but total dose is increased, dose per fraction is decreased, and the number of fractions is increased.
What is the most common salivary gland malignancy to occur bilaterally?
Acinic cell.
Which type of melanoma occurs on palms, soles, nail beds, and mucous membranes?
Acrallentiginous melanoma.
What is the most common premalignant skin lesion of the head and neck?
Actinic keratosis.
What is the primary problem with concomitant chemoradiation?
Acute toxicities are markedly increased and result in patient noncompliance.
Name the tumour. Second most common malignant sinonasal tumor; tend to be located superior to Ohngren’s line
Adenocarcinoma
What is the second most common malignant tumor of the minor salivary glands?
Adenocarcinoma.
What is the 2nd most common malignant sinonasal neoplasm?
Adenocarcinoma.
Which salivary gland tumor has a high propensity for perineural invasion?
Adenoid cystic carcinoma.
What is the most common tumor of glandular origin to involve the EAC or middle ear?
Adenoid cystic carcinoma.
What is the most common malignancy of the submandibular and minor salivary glands?
Adenoid cystic.
What type of tumor comprises so% of all lacrimal gland neoplasms?
Adenoid cystic.
What factor best correlates with the presence of lymph node metastases in papillary carcinoma?
Age.
In what age groups is rhabdomyosarcoma most common?
Ages 2-5 and 15-19.
What are the indications for adjuvant thyroid hormone in patients with well-differentiated thyroid carcinoma?
All patients with well-differentiated carcinoma should be treated with thyroid hormone to suppress TSH for life, regardless of the extent of their surgery.
Where does a radicular or periapical cyst occur?
Along the root of a nonviable tooth, as the liquefied stage of a dental granuloma.
Name the tumour. Metastasizes to the brain more frequently than any other soft-tissue sarcoma
Alveolar soft part sarcoma
What are the three most common odontogenic tumors?
Ameloblastoma, cementoma, and odontoma.
Which parts of the glottis are most difficult to treat with radiation?
Anterior commissure, posterior 1/3 of the vocal cord.
Extension into which space is associated with the worst prognosis in patients with nasopharyngeal carcinoma?
Anterior masticator space.
What is the incidence of subclinical neck disease with adenoid cystic arcinoma of the parotid gland?
Approximately 10%.
What is the risk of cervical metastases in patients with T1, T2, T3, and T4 tumors of the supraglottis?
Approximately 20%, 40%, 60%, and 80%, respectively.
Where do dentigerous cysts develop?
Around the crown of an unerupted, impacted tooth.
What is the usual cause of death from esophageal cancer?
Aspiration pneumonia.
What is the inheritance pattern of familial carotid body tumors?
Autosomal dominant but only the genes passed from the paternal side are expressed (maternal genomic imprinting).
What is basal cell-nevoid syndrome?
Autosomal dominant disorder characterized by multiple basal cell carcinomas, odontogenic keratocysts, rib abnormalities, palmar and plantar pits, and calcification of the falx cerebri.
What are the characteristics of familial MTC?
Autosomal dominant inheritance pattern; not associated with any other endocrinopathies.
Which UV light is most responsible for acute actinic damage?
B.
An olfactory neuroblastoma involving the ethmoid sinuses would be classified as what stage by the Kadish system?
B.
Involvement of which areas of the body also increases the risk of metastases?
BANS: back, arms, neck, and scalp.
Metaplasia of the distal esophagus is otherwise known as what?
Barrett’s esophagus.
Multiple odontogenic keratocysts are a manifestation of what syndrome?
Basal cell nevus syndrome.
What are the four types of monomorphic adenomas?
Basal cell, trabecular, canalicular, and tubular.
What are the seven different types of squamous cell aberrations occurring in the larynx?
Benign hyperplasia, benign keratosis (no atypia), atypical hyperplasia, keratosis with atypia or dysplasia, intraepithelial carcinoma, microinvasive squamous cell carcinoma (SCCA), and invasive SCCA.
What prognostic significance does the presence of microcalcifications have?
Better prognosis.
When do patients with synovial sarcoma usually present?
Between ages 25 and 36.
Where do posterior pharyngeal wall tumors metastasize?
Bilaterally to level II cervical nodes, mediastinum, and superiorly to the nodes of Ronviere at the skull base.
In what age group is olfactory neuroblastoma typically seen?
Bimodal distribution-people in their 20s and 50s.
In what age groups is Hodgkin’s lymphoma most common?
Bimodal peak incidence, with one peak in the 15- to 34-year-old age group and another in later adulthood.
What is the most common site of metastasis from follicular thyroid cancer?
Bone.
What is the most common site of distant metastases?
Bones.
What mutation has been found in more than half of malignant melanomas?
BRAF somatic missense mutations; a single substitution CV599E) accounts for 50% of these.
What are the most common sites of origin of metastatic tumors of the temporal bone?
Breast, lung, and kidney.
Which lymphoma accounts for so% of childhood malignancies in equatorial Mrica?
Burkitt’s lymphoma.
What is Marjolin’s ulcer?
Burn or ulcer associated with the development of malignancy.
When is prophylactic thyroidectomy recommended in patients with the RET mutation?
By age 5 or 6.
How is the definitive diagnosis of follicular thyroid cancer made?
By demonstration of capsular invasion at the interface of the tumor and the thyroid gland.
What is a Pindborg tumor?
Calcified epithelial odontogenic tumor that is less aggressive than ameloblastoma and is associated with an impacted tooth.
What is the second leading cause of death among children ages 1-14?
Cancer.
What is the most common paraganglioma of the head and neck?
Carotid body tumor.
What is the best treatment for primary non-Hodgkin’s lymphoma of the thyroid gland?
Chemoradiation.
What is the nature of vertigo in the majority of patients with a vestibular schwannoma?
Chronic disequilibrium with self-limiting episodes of vertigo.
What are the indications for neck dissection in the treatment of salivary gland malignancies?
Clinical metastasis, submandibular tumor, SCCA, undifferentiated carcinoma, size >4 em, and high-grade mucoepidermoid carcinoma.
Where do most basal cell carcinomas of the EAC arise?
Concha.
What is the standard treatment protocol for stage III and IV nasopharyngeal carcinoma?
Concomitant cisplatin and XRT followed by adjuvant chemotherapy with cisplatin and s-FU.
Which arm had the best outcome?
Concomitant cisplatinum and radiation therapy significantly increased the time to laryngectomy.
What are the four types of growth patterns of adenoid cystic carcinoma and which is most common?
Cribriform (most common-looks like Swiss cheese), tubularjductular, trabecular, and solid.
Which of these is a variant of nodular basal cell carcinomas and produces pigment?
Cystic.
SNUC tumors have antibodies to what substances?
Cytokeratin, epithelial membrane antigen, and neuron-specific enolase.
What is the appropriate management for a patient with an anaplastic thyroid carcinoma?
Debulking and tracheostomy may be performed for palliation of airway obstruction.
What is the role of large-dose fraction radiotherapy in the management of melanoma?
Decreases incidence of locoregional recurrence among No patients.
What is the most important prognostic indicator of follicular thyroid cancer?
Degree of angio-invasion.
What chromosomal abnormality do osteosarcoma and retinoblastoma have in common?
Deletion of the long arm of chromosome 13.
What is the most important prognostic factor of melanomas?
Depth of invasion.
How does treatment failure usually manifest in nasopharyngeal carcinoma?
Disease at both the primary site and cervical lymph nodes.
What is the most common form of hereditary cutaneous melanoma?
Dysplastic nevus syndrome.
Which types of radiation beams are used for superficial tumors and why?
Electron beams; their finite range spares deeper tissues.
Smooth, submucosal nasopharyngeal masses located in the midline are most often what?
Embryologic remnants (Thornwaldt’s cysts, pharyngeal bursa remnants).
What are odontomas composed of?
Enamel, dentin, cementum, and pulp.
What is the differential diagnosis of a small cell sinonasal tumor?
Esthesioneuroblastoma, plasmacytoma, melanoma, lymphoma, sarcoma, poorly differentiated squamous cell carcinoma, Ewing’s sarcoma, peripheral neuroectodermal tumor (PNET), and SNUC.
Which type of cancer is most sensitive to radiation therapy: exophytic, infiltrative, or ulcerated?
Exophytic.
What is the most common site of ear and temporal bone tumors?
External auditory canal (EAC).
What factors are predictors of occult regional disease in parotid cancer?
Extracapsular extension, preoperative facial paralysis, age >54 years, and perilymphatic invasion.
Name the tumour. May progress to multiple myeloma
Extramedullary plasmacytoma
True/False: The size of the primary lesion is related to the incidence of lymph node metastases in tumors of the hypopharynx.
False.
True/False: Follicular cell carcinoma is more aggressive than Hiirthle cell.
False.
True/False: Cells undergoing DNA synthesis in the S phase are much more radiosensitive than cells in other phases of the cell cycle.
False: They are much more radioresistant in the S phase.
Which of these has the best prognosis?
Familial.
What are the risk factors for developing melanoma?
Family history, multiple atypical or dysplastic nevi, Hutchinson’s freckle, presence of large congenital nevi, blond or red hair, marked freckling on upper back, history of three or more blistering sunburns prior to age 20, presence of actinic keratoses.
Name the tumour. Benign tumor,most commonly seen in patients less than 20 years old and has a ground glass appearance on X-ray
Fibrous dysplasia
What is the most common thyroid nodule?
Follicular adenoma.
What are the three types of well-differentiated thyroid malignancies?
Follicular, papillary, and Hiirthle cell.
Which of these is associated with iodine deficiency?
Follicular.
Which of these is more likely to be seen in a pregnant woman?
Follicular.
What is unique about the path of growth of basal cell carcinomas?
Follow the path of least resistance, which is typically along embryonic fusion planes.
When is stereotactic radiosurgery contraindicated in the treatment of recurrent glomus jugulare tumors?
For larger tumors (>3.0-4.0 cm).
What is the most common site of origin of nasopharyngeal cancer?
Fossa of Rosenmiiller.
What environmental factor is most strongly linked to nasopharyngeal carcinoma?
Frequent consumption of dried salted fish.
Name the tumour. Comprises only 3% of Schneiderian papillomas Cylindrical papil oma Most common type of Schneiderian papilloma,typically seen on the nasalseptum
Fungiform papilloma
What are the three subtypes of Schneiderian papillomas?
Fungiform, inverting, and cylindrical.
What are the five histopathologic types of squamous cell carcinoma?
Generic, adenoid, bowenoid, verrucous, and spindle-pleomorphic.
Which of these typically arises in areas of actinic change?
Generic.
What is the most common site of laryngeal cancer?
Glottis.
Name the tumour. Well-circumscribed, mobile, painless benign lesion most commonly found on the tongue that has malignant potential and histopathology shows polygonal cells with abundant eosinophils
Granular cell tumor
What is the significance of the number of pathologically positive nodes on prognosis?
Greater than 3 pathologically positive nodes is a negative prognostic indicator.
Which of these are classically associated with adenocarcinoma?
Hardwood dusts and leather tanning substances.
Name the tumour. Arise from pericytes of Zimmerman and considered neither benign nor malignant
Hemangiopericytoma
What are the indications for postoperative radiotherapy post-parotidectomy?
High probability of residual microscopic disease; positive margins; advanced stage; high grade; deep lobe tumors; recurrent tumors; the presence of regional metastases; and angiolymphatic invasion.
Radiation is not as effective for tumors with which characteristics?
High volume, cartilage destroying, with bulky lymph node disease.
What is the most common type of hearing loss in patients with a vestibular schwannoma?
High-frequency unilateral SNHL.
Which of these is relatively unresponsive to ablation with radioactive iodine?
Hiirthle cell.
What are the risk factors for developing osteosarcoma in the mandible or maxilla?
History of ionizing radiation, fibrous dysplasia, retinoblastoma, and prior exposure to thorium oxide (radioactive scanning agent).
What are other risk factors for development of ear and temporal bone tumors?
History of radiation to the head and neck, chronic chromate burns secondary to using matchsticks to clean the ear canal.
Which virus is thought to play a role in the etiology of sinonasal tumors?
Human papilloma virus (HPV), particularly types 6 and 12.
Where are most synovial sarcomas of the head and neck located?
Hypopharynx and parapharyngeal space.
What is the stage of a JNA eroding the skull base with uniniunal intracranial extension?
IIIA
What is Ohngren’s line and how is it significant?
Imaginary line from the medial canthus to the angle of the mandible; tumors below the line have a better prognosis than tumors above the line (with the palate as an exception).
Which malignancies most commonly cause paraneoplastic cerebellar degeneration?
In adults, ovarian, uterine, breast, and small cell lung cancer. In children, neuroblastoma.
What are the two most common reasons for tumor recurrence after hemilaryngectomy?
Inability to recognize the inferior tumor margin and spread of tumor through the cricothyroid membrane.
What is the difference in incidence of malignancy between solitary and multiple nodules?
Incidence of malignancy in solitary nodules is 5-12%; incidence is 3% in multiple nodules.
What is the best organ-sparing treatment for a patient with stage III SCCA of the supraglottis?
Induction chemotherapy followed by radiation therapy.
In the staging system described by Ho, poorer prognosis is associated with cervical metastases to which area of the neck?
Inferior to a plane spanning from the contralateral sternal head of the clavicle to the ipsilateral superior margin of the trapezius muscle.
That being said, which areas of the face are most susceptible to basal cell carcinomas?
Inner canthus, philtrum, mid-lower chin, nasolabial groove, preauricular area, and retroauricular sulcus.
Tumors that metastasize to the temporal bone via the meninges most often traverse what structure?
Internal auditory canal.
Where does the main blood supply to Juvenile Angiofibroma tumours come from?
Internal maxillary artery or the ascending pharyngeal artery.
What is the most common cause of death in osteosarcoma of the head and neck?
Intracranial extension.
What is “microinvasive” SCCA of the vocal cord?
Invades through the basement membrane but not into the vocalis muscle.
Name the tumour. 2-13% of these benign sinonasaltumors have malignant potential
Inverting papilloma
What is the most common benign sinonasal neoplasm?
Inverting papilloma.
What are the clinical features of Plummer-Vinson syndrome?
Iron-deficiency anemia, upper esophageal web, hypothyroidism, glossitis/cheilitis, gastritis, and dysphagia.
What happens to the carotid sheath with deep lobe parotid tumors extending into the parapharyngeal space?
It is displaced posteriorly.
How does metastasizing pleomorphic adenoma differ from carcinoma ex-pleomorphic adenoma?
It is histologically benign, lacking malignant epithelial components.
Is melanoma radiosensitive?
It may be sensitive to large dose fractions (600 cGy) but not to standard fractionation radiotherapy (180-200 cGy).
Why is aspergillus infection a risk factor for ear and temporal bone tumors?
It produces aflatoxin B, a known carcinogen.
When SCCA grossly invades the adventitia of the carotid artery, how will resection of the artery affect survival?
It will not improve long-term survival.
Where does supraglottic carcinoma most often begin?
Junction of the epiglottis and false cords.
After benign lymphoid hyperplasia, what is the most common benign nasopharyngeal tumour?
Juvenile nasopharyngeal angiofibroma (JNA).
What is the name of the skin lesion, most commonly located on the nose, characterized by rapid growth with a central area of ulceration followed by spontaneous involution?
Keratoacanthoma.
Which of these is the most aggressive?
Keratotic.
High expression of which nuclear antigen is significantly associated with distal tracheobronchial spread and increased frequency of recurrences?
Ki-67.
What are the indications for postoperative radioiodine ablation therapy?
Known distant metastases, gross extrathyroidal extension of tumor, tumors larger than 4 em, tumors 1-4 em when T and N status, age, and histological features predict an intermediate to high rate of recurrence.
What are the two types of anaplastic thyroid cancer?
Large cell and small cell.
Which is more common?
Large cell.
What EBV product is likely to play a role in malignant transformation of nasopharyngeal epithelium?
Latent membrane protein (LMP-1).
Where do these tumors most often originate?
Lateral nasal wall, adjacent to the middle turbinate.
Where do inverting papillomas most commonly arise?
Lateral nasal wall.
What is the most common site of recurrent/persistent nasopharyngeal carcinoma?
Lateral wall of the nasopharynx.
What factors, described by Ho and Neel, are regarded as importantadverse prognostic indicators in patients with nasopharyngeal carcinoma?
Length and symptomatology of disease, extension of tumor outside of the nasopharynx, presence of inferior cervical adenopathy, keratinizing Histologic architecture, cranial nerve and skull base extension, presence of distant metastases, and low ADCC titers.
How do most glomus jugulare tumors respond to external beam radiation?
Less than 50% show tumor regression radiographically; lack of tumor growth is more common.
Other than UV light and genetics, what are some other factors that increase the risk of cutaneous malignancy?
Long-term immunosuppression after organ transplantation, long-term treatment of psoriasis with photosensitizing chemicals, chronic ulcers, and low-dose irradiation.
How is an altered fractionated schedule different?
Lower dose per fraction, two or more fractions every day, decreased overall treatment time, with total dose same or higher.
What is the primary advantage of stereotactic radiosurgery for treatment of recurrent glomus jugulare tumors compared with surgery and conventional radiation?
Lower incidence of cranial nerve injury.
What is the most common cause of death from synovial sarcoma of the head and neck?
Lung metastases.
What is the most common site of distant metastasis for adenoid cystic carcinoma?
Lung.
What is the most common site of distant metastasis from laryngeal carcinoma?
Lungs.
What is the commonest head and neck tumour of children?
Lymphoma.
What is the most common type of skin sarcoma?
Malignant fibrous histiocytoma.
Which nasal masses should not be biopsied in the clinic?
Masses in children or adolescents and masses suspicious for angiofibroma-some also recommend delaying biopsy of any nasal mass until after imaging has been obtained.
Where is fibrous dysplasia most commonly found in the head and neck?
Maxilla.
What are the most common locations of sinonasal squamous cell carcinoma?
Maxillary sinus, followed by the nasal cavity, then ethmoid sinuses.
What cells are melanomas composed of?
Melanocytes, which are derived from neural crest cells.
Which of these presents earliest?
MEN IIb (mean age 19).
Which adnexal skin carcinoma arises from a pluripotential basal cell within or around the hair cells?
Merkel cell carcinoma.
What virus is strongly associated with Merkel cell carcinoma that is known to cause cancer in animals?
Merkel cell polyomavirus.
What factor is most related to the chance of recurrence for inverting papilloma?
Method of removal.
In which areas of the world is the incidence of esophageal cancer highest?
Middle East, southern and eastern Mrica, and northern China.
What is the most common site of a malignant salivary gland neoplasm?
Minor salivary glands (60%; of these, 40% occur on the palate).
In patients who undergo resection of inverting papilloma via lateral rhinotomy / medial maxillectomy, what is the most important factor related to risk for recurrence?
Mitotic index.
How does nasal melanoma differ from cutaneous melanoma?
More aggressive with a worse prognosis and an unpredictable course-local recurrence is the most common cause of failure.
How do glomus tumors differ clinically from carotid body tumors?
More common in females, less likely to secrete catecholamines or metastasize, and are more radiosensitive.
What is the significance of size with thyroid nodules?
More likely to be malignant if >4 cm in diameter.
What is the significance of age with thyroid nodules?
More likely to be malignant in women over so and men over 40 and in both men and women under 20.
Which of these commonly resembles a scar?
Morpheaform.
What are the clinical features of salivary duct carcinomas?
Most commonly involve the parotid gland and present as an asymptomatic mass; higher incidence in males; distant metastases are the most common cause of death.
What is the most common malignant tumor of the parotid gland in adults?
Mucoepidermoid carcinoma.
Which salivary gland tumor is more common in women with a history of breast cancer?
Mucoepidermoid carcinoma.
What are the two most common malignant tumors of the parotid gland in children younger than 12?
Mucoepidermoid is the most common, followed by acinic cell.
What is the most common salivary gland malignancy following radiation?
Mucoepidermoid.
What is the treatment for rhabdomyosarcoma?
Multimodality; primary chemoradiation followed by surgery for recurrent or residual disease.
What are the three most common malignant bone tumors of the paranasal sinuses?
Multiple myeloma, osteogenic sarcoma, chondrosarcoma.
What are the indications for postoperative radiation after neck dissection?
Multiple nodes or extracapsular spread.
How does metastatic disease to the lungs normally present?
Multiple small lesions less than 3 mm that are difficult to detect on X-ray.
What genetic mutation is associated with medullary thyroid cancer?
Mutation of the RET proto-oncogene.
Where is melanoma most commonly found in the nose and paranasal sinuses?
Nasal septum.
What are the precursor cells of neuroblastouna?
Neural crest cells.
Name the tumour. Encapsulated,benign tumor that arises from the surface of nerve fibers
Neurilemoma
What is the most common solid malignant tumour in infants
Neuroblastoma.
Name the tumour. Unencapsulated tumor that arises from within a nerve;15% become malignant (when associated with von Recklinghausen’s disease)
Neurofibroma
~diag008~ Below are axial MRI views of the CPA in an 18-year-old man with bilateral hearing loss. He has no skin lesions or subcutaneous nodules. What disease does he most likely have?
Neurofibromatosis type 2.
Which type of radiation therapy does adenoid cystic carcinoma respond best to?
Neutron beam.
Which substances are thought to predispose to sinonasal neoplasms?
Nickel, chromium, isopropyl oils, volatile hydrocarbons, organic fibers from wood, shoe, and textile refineries.
Which of these is classically associated with SCCA?
Nickel.
What was the outcome of this study?
No significant difference in survival among the three arms.
What is the role of induction chemotherapy for treatment of nasopharyngeal carcinoma?
No survival advantage has been proven.
Are elective neck dissections warranted in patients with sinonasal squamous cell carcinoma?
No, as the incidence of occult cervical metastases is 10%.
A 36-year-old woman presents with a 3 cm papillary carcinoma and no clinical evidence of lymph node involvement, no intrathyroidal vascular invasion, and no gross or microscopic multifocal disease. She has no history of neck radiation and no family history of thyroid cancer. She was treated with a total thyroidectomy. Is radioiodine ablation therapy indicated?
No.
What are the five main types of basal cell carcinomas?
Nodular, cystic, superficial multicentric, morpheaform, and keratotic.
Which of these is most common?
Nodular.
What is the most common type of lymphoma of the nose and paranasal sinuses?
Non-Hodgkin’s lymphoma.
What is the pathophysiology of fibrous dysplasia?
Normal medullary bone is replaced by collagen, fibroblasts, and osteoid.
Which mandibular tumor or cyst produces white, keratin-containing fluid?
Odontogenic keratocyst.
Name the tumour. Arise from stem cells of neural crest origin that differentiate into olfactory sensory cells;Homer Wright rosettes are characteristic
Olfactory neuroblastoma or esthesioneuroblastoma
What percent of patients with carcinoma in situ of the vocal cord will develop invasive SCCA after a single excisional biopsy?
One in six (16.7%).
What is a “nonchromaffin” paraganglioma?
One that does not secrete significant amounts of catecholamines.
What proportion of incompletely excised basal cell cancers will recur?
One-third.
What type of nystagmus is often seen in children with neuroblastouna?
Opsoclonus.
Involvement in which area of the head and neck by rhabdomyosarcoma has the best prognosis?
Orbit.
What are the poor prognostic factors for SNUC tumors?
Orbital involvement and neck metastases; tumors in the paranasal sinuses have a worse prognosis than those arising in the nasal cavity.
Name the tumour. Has a predilection for the mandible and a sunray appearance on X-ray
Osteogenic sarcoma
Name the tumour. Benign tumor most commonly found in the frontal sinus
Osteoma
What are the complications from radiation overdosage in the treatment of nasopharyngeal carcinoma?
Osteoradionecrosis, brain necrosis, transverse myelitis, hearing loss, hypopituitarism, hypothyroidism, and optic neuritis.
Where is adenoid cystic carcinoma of the head and neck most commonly found?
Palate, followed by major salivary glands, then paranasal sinuses.
What is the most common type of well-differentiated thyroid carcinoma in children?
Papillary.
Which of these is more likely to be seen in a 30-year-old?
Papillary.
Which of these is the most common type of thyroid cancer?
Papillary.
Which of these has the best prognosis?
Papillary.
What is the most common benign neoplasm of the larynx in children?
Papillomas.
Severe cerebellar symptoms with a normal MRI suggests what condition?
Paraneoplastic cerebellar degeneration.
What is the primary site of lymphatic drainage from subglottic tumors?
Paratracheal nodes.
What is the least common site of a malignant salivary gland neoplasm?
Parotid gland (32%).
What is the most common site of a salivary gland neoplasm?
Parotid gland (73%).
Which salivary gland has the best prognosis for malignant tumors?
Parotid gland.
Tumors that metastasize to the temporal bone hematogenously most often involve which area of the temporal bone?
Petrous apex.
What other disorders are present in patients with MEN IIb?
Pheochromocytoma, multiple mucosal neuromas, marfanoid body habitus.
What other disorders are present in patients with MEN Ila?
Pheochromocytoma, parathyroid hyperplasia.
What is the most common tumor of the parotid gland?
Pleomorphic adenoma in adults, hemangioma in children.
What is the most common tumor of the parapharyngeal space?
Pleomorphic adenoma.
What are the most common respiratory complications of distal RRP?
Pneumatocele, abscess, and tracheal stenosis.
Which compartment are neurogenic tumors most likely to arise in?
Pos1styloid compartment.
What test should be ordered in the workup of Merkel cell carcinoma?
Positron emission tomography scan.
Which site of the hypopharynx drains bilaterally into levels IV and VI?
Postcricoid area.
In patients with Plummer-Vinson syndrome, where is squamous cell carcinoma of the esophagus most likely to occur?
Postcricoid area.
What is the treatment for SNUC?
Preoperative chemoradiation, followed by surgical resection for those tumors without distant metastases or extensive intracranial involvement.
Parapharyngeal tumors arising from the deep lobe of the parotid will involve which compartment?
Prestyloid compartment of the paraphayrngeal space.
What are the differences between primary and secondary subglottic tumors?
Primary tumors are less common, usually present with stridor or dyspnea and at a more advanced stage, and have a worse survival time than secondary tumors.
What features of hypopharyngeal tumors distinguish them from other head and neck tumors?
Propensity for early submucosal spread and skip lesions.
What are the most common and least common sites of tumor involvement in the hypopharynx?
Pyriform sinus is the most common site (75%); postcricoid area is the least common site (3-4%).
What is the primary treatment modality for nasopharyngeal cancer?
Radiation therapy to the nasopharynx (66-70 Gy) and neck (6o Gy).
What is the primary modality of treatment for extramedullary plasmacytomas?
Radiation.
What are the three most common odontogenic cysts?
Radicular cyst (65%), odontogenic keratocyst, and dentigerous cyst.
How are patients with MTC managed postoperatively?
Receive L-thyroxine and 2 weeks of calcium and vitamin D supplementation; serial measurements of calcitonin and CEA.
Which medication improves quality of life when preparing patients for radioiodine scanning and ablation therapy?
Recombinant TSH stimulation (rTSH).
What are the most common presenting symptoms in patients with tumor of the retromolar trigone?
Referred otalgia and trismus.
What are the treatment options for recurrent/persistent nasopharyngeal carcinoma at the primary site?
Reirradiation with larger therapeutic dose than initial treatment; stereotactic radiotherapy; brachytherapy with split palate implantation of radioactive gold grains; surgical resection.
Name the tumour. Most common tumor to metastasize to the sinonasal area
Renal cell
Which nodal groups does nasopharyngeal cancer spread to?
Retropharyngeal nodes of Rouviere, jugulodigastric nodes, spinal accessory chain.
What are the most common types of sarcoma of the temporal bone?
Rhabdomyosarcoma, chondrosarcoma, and osteosarcoma.
What is the most common soft tissue sarcoma of the head and neck in children?
Rhabdomyosarcoma.
Which sinonasal neoplasms remodel rather than erode bone?
Sarcomas, minor salivary gland carcinomas, hemangiopericytomas, extramedullary plasmacytomas, large cell lymphomas, and olfactory neuroblastomas.
Name the tumour. More than 90% will have invaded through at least one wall of the involved sinus at presentation
SCCA
What is the differential diagnosis of a CPA tumor?
Schwannoma, meningioma, epidermoid, lipoma, arachnoid cyst, cholesterol granuloma.
What is the incidence of nasopharyngeal cancer among North American-born Chinese compared with that among Caucasians?
Seven times higher.
What impact does hyperfractionated therapy have on locoregional control and survival rates compared with conventional therapy?
Significantly higher locoregional control and survival rates.
What is a SNUC?
Sinonasal undifferentiated carcinoma-a very aggressive small cell sinonasal tumor.
Which of these is usually responsive to radiation therapy?
Small cell.
Which of these is the least common?
Spindle-pleomorphic.
In what four settings does medullary thyroid carcinoma (MTC) arise?
Sporadic, familial, and in association with multiple endocrine neoplasia (MEN) Ila or IIb.
Which of these has the worst prognosis?
Sporadic.
Which of these tends to occur unilaterally?
Sporadic.
What is Bowen’s disease?
Squamous cell carcinoma in situ of the skin.
What is the most common malignant sinonasal neoplasm?
Squamous cell carcinoma, comprising 50% of malignant sinonasal neoplasms.
Cancer of the cervical esophagus is usually what type?
Squamous cell carcinoma.
What is the most common histologic type of tumor involving the EAC or middle ear?
Squamous cell carcinoma.
Involvement of two or more lymph node sites on the same side of the diaphragm is designated as which stage according to the Ann Arbor system?
Stage II.
What is the most important prognostic factor for malignant salivary gland neoplasms?
Stage.
Compared with supraglottic and glottic tumors, subglottic tumors are at a much higher risk for developing what?
Stomal recurrence.
Why is the clinically negative neck treated?
Studies have shown improved local control and disease-free survival for prophylactic irradiation of the clinically negative neck in patients with nasopharyngeal carcinoma.
What is the least common site of a salivary gland neoplasm?
Submandibular gland (11%).
Which salivary gland has the worst prognosis for malignant tumors?
Submandibular gland.
Which of these is more commonly found on the extremities or trunk?
Superficial multicentric.
What are the four types of melanoma?
Superficial spreading, lentigo maligna, acrallentiginous, and nodular sclerosing.
Which is the most common?
Superficial spreading.
Which has the best prognosis?
Superficial spreading.
Which type of laryngeal cancer is mostly likely to metastasize distally?
Supraglottic.
What is the optimal treatment for osteosarcoma of the head and neck?
Surgery and radiation therapy.
What is the stage of a transglottic tumor without vocal cord fixation, cartilage invasion, or extension beyond the larynx?
T2.
What histological subtypes of thyroid tumors are associated with an increased risk of local recurrence and metastasis?
Tall cell, columnar, insular, solid variant, and poorly differentiated.
What were the results from the EORTC 22851 study comparing accelerated split-course XRT with conventional XRT?
The accelerated course resulted in significantly higher late side effects without significant locoregional control or survival advantage.
What are the advantages of postoperative XRT or radiation therapy?
The anatomic extent of the tumor can be determined surgically, making it easier to define the treatment portals required; a greater dose can be given postoperatively than preoperatively; the total dose to be given can be determined on the basis of residual tumor burden after surgery; surgical resection is easier and healing is better in nonirradiated tissue.
What conclusions can be made based on meta-analysis of VA, GETTEC, and EORTC studies?
The surgical patients had slightly higher (but not significant) survival advantage (6%). Among patients receiving chemotherapy, 58% were able to keep their larynx. Better outcomes were seen in patients with hypopharyngeal cancer who underwent chemotherapy than in those with laryngeal cancer.
What was the first published randomized trial for organ preservation in head and neck cancer?
The VA trial for SCCA of the larynx.
What were the results from the RTOG 9003 study evaluating accelerated treatments with concomitant boost?
This protocol resulted in significantly higher locoregional control and survival rates with somewhat higher rate of late side effects compared with conventional XRT.
Which patients are more likely to benefit from adjuvant chemotherapy?
Those with high-risk tumors (extracapsular extension, carcinoma-in-situ, close surgical margins) and those with locally advanced nasopharyngeal cancer.
What is the most common route of spread of tumors in the cartilaginous portion of the EAC?
Through the fissures of Santorini.
What is the primary role of concomitant chemoradiation in the treatment of head and neck cancer?
To improve local and regional control in patients with unresectable disease.
What are the risk factors for developing esophageal cancer?
Tobacco, alcohol, achalasia, Plummer-Vinson syndrome, prior head and neck cancer, tylosis, and Barrett’s disease.
What is the treatment of choice for primary subglottic cancer?
Total laryngectomy, bilateral neck dissection, near total thyroidectomy, paratracheal node dissection, and postoperative radiation to the superior mediastinum and stoma; if the anterior cervical esophageal wall is involved, then laryngopharyngectomy with cervical esophagectomy instead of total laryngectomy.
What is the treatment of choice for metastatic cutaneous SCCA to the parotid?
Total parotidectomy with preservation of VII (unless invaded by tumor) and postoperative radiation therapy to the parotid area and ipsilateral neck.
A 44-year-old man presents withascm thyroid nodule. FNA returns fluid, the nodule disappears, and the cytology is benign. What is the next step in management?
Total thyroid lobectomy with isthmusectomy should be considered because there is an increased chance of malignancy in large cysts.
A 56-year-old man with no risk factors presents with a thyroid nodule. The FNA is nondiagnostic. What is the treatment of choice?
Total thyroid lobectomy with isthmusectomy.
A 65-year-old woman presents with a cervical lymph node that is found to have well-differentiated thyroid tissue but the thyroid has no palpable abnormality. What is the next step in management?
Total thyroidectomy and modified radical neck dissection.
What is the surgical treatment for MTC?
Total thyroidectomy with central node dissection, lateral cervical lymph node sampling of palpable nodes, and a modified radical neck dissection, if positive.
From which site in the nasopharynx do Juvenile angiofibromas develop?
Trifurcation of the palatine bone, horizontal ala of the vomer, and the root of the pterygoid process (basisphenoid)
True/False: The dose of radiation necessary to kill hypoxic cells is 2.5-3.0 times greater than that required to kill well-oxygenated cells.
True, as free radical formation requires oxygen.
True/False: Once invasion of the laryngeal framework occurs, the ossified portions of cartilage have the least resistance to tumor spread.
True.
True/False: Stage I lesions of the supraglottis can be controlled equally well with radiotherapy or surgery.
True.
True/False: Chemosensitive tumors are usually radiosensitive.
True.
True/False: The cells responsible for acute radiation injuries are rapidly cycling.
True.
True/False: Disease-free, but not overall, survival is improved in patients with early oral tongue cancer who undergo elective neck dissection.
True.
True/False: The involvement of the medial (as opposed to lateral) wall of the pyriform sinus significantly increases the likelihood of bilateral cervical metastasis.
True.
True/False: Due to the high incidence of cervical metastases, treatment of the neck is necessary in all patients with hypopharyngeal cancer.
True.
True/False: There is a much lower risk of distant metastases with osteosarcoma of the head and neck than that of the long bones.
True.
True/False: A patient with T3N2aMo SCCA of the base of tongue has a complete response to external-beam radiation therapy both at the primary site and the neck. A planned neck dissection should be done to increase the rate of regional control.
True.
True/False: Adnexal carcinomas of the skin are very aggressive and have a poor prognosi•s.
True.
True/False: squamous cell carcinomas arising in sun-exposed areas tend to behave less aggressively than those arising de novo.
True.
True/False: Women with melanoma have a better prognosis than men regardless of tumor depth.
True.
True/False: The presence of unilateral compared with bilateral nodal disease in patients with nasopharyngeal carcinoma has no prognostic significance.
True.
True/False: Smoking by itself is not a significant etiologic factor for sinonasal tumors.
True.
True/False: Axillary, inguinal, and Waldeyer’s ring involvement is uncommon in patients with Hodgkin’s lymphoma.
True.
True/False: Microscopic lymph node involvement does not change the long-term survival in patients with papillary thyroid cancer.
True.
True/False: All patients with MEN Ila will have MTC.
True.
True/False: Multifocal well-differentiated thyroid tumors less than 1em without high-risk features do not require postoperative radioiodine ablation therapy.
True.
True/False: Hypopharyngeal cancer has the worst prognosis of all head and neck cancers.
True: 70% of patients present with advanced disease (stage III and IV) and the s-year disease-specific survival is only 33%.
True/False: XRT or radiation therapy should not be delayed in the presence of a fistula, open wound, or bony exposure.
True: As long as the carotid artery is not exposed, radiation treatments should never be delayed.
What are the two most important factors predicting lymph node metastasis in laryngeal cancer?
Tumor size and location.
What factors increase the likelihood of regional metastasis of squamous cell carcinoma?
Tumors arising on the ear, diameter >2 em or >4 mm thickness, poorly differentiated histology, and recurrent tumors.
How does the behavior of pyriform sinus tumors differ from postcricoid and posterior pharyngeal wall tumors?
Tumors of the pyriform sinus tend to infiltrate deeply at early stages, whereas those of the postcricoid area and posterior pharyngeal wall tend to remain superficial until achieving an advanced stage.
What factors increase the likelihood of recurrence for squamous cell carcinoma?
Tumors on the midface, diameter > 2 em or thickness > 4 mm, perineural invasion, or regional metastases.
What tumor factor, other than depth, influences regional metastasis in melanoma?
Ulceration.
Which kinds of supraglottic cancers are more likely to extend inferiorly to the anterior commissure or ventricle-ulcerative or exophytic?
Ulcerative lesions.
What can be said of the presence of level V cervical metastases from SCCA of the upper aerodigestive tract?
Uncommon (7%) and, if present, most likely to occur in the presence of level IV metastases.
What is the most common presentation of tumors of the EAC?
Unremitting pain and serosanguinous otorrhea.
What are the advantages of planned preoperative XRT or radiation therapy?
Unresectable tumors may be made resectable; the extent of surgical resection may be diminished; the treatment portals preoperatively are usually smaller than those used postoperatively; microscopic disease is more radiosensitive preoperatively due to better blood supply; the viability of tumor cells that may be disseminated by surgical manipulation is diminished.
What percentage of sinonasal tumors can be attributed to occupational exposures?
Up to 44%.
What are the three major randomized studies on organ preservation as treatment for laryngeal cancer?
VA, GETTEC, and EORTC.
What anatomic structure serves as a natural barrier to the inferior extension of supraglottic cancers?
Ventricle (embryologic development is completely separate from the false cord).
Which of these is more common in the oral mucosa?
Verrucous
What is Ackerman’s tumor?
Verrucous carcinoma, thought to be less radiosensitive and less likely to metastasize than SCCA.
What is the most common tumor of the cerebellopontine angle (CPA)?
Vestibular schwannoma.
What are the two primary subtypes of paraneoplastic cerebellar degeneration?
Vestibulocerebellar syndrome and opsoclonus-myoclonus syndrome.
Adenocarcinoma of the endolymphatic sac is more common in patients with what disease?
Von Hippel-Lindau disease.
What is the primary mode of treatment for synovial sarcoma of the head and neck?
Wide surgical excision and postoperative radiation therapy.
What significance do these features have on treatment?
Wide surgical margins (4-6 em inferior to gross, 2-3 em superior to gross) and wide radiation therapy ports are necessary.
What are the disadvantages of planned preoperative XRT or radiation therapy?
Wound healing is more difficult, and the dose that can be safely delivered preoperatively is less than that which can be given postoperatively.
What are some other genetic disorders that are associated with a high risk of cutaneous malignancies?
Xeroderma pigmentosum, albinism, epidermodysplastic verruciformis, epidermolysis bullosa dystrophica, and dyskeratosis congenital.
How do XRT or radiation therapy failures differ from surgical failures in site of recurrence?
XRT or radiation therapy failures often occur in the center of areas that were grossly involved with cancer initially, whereas surgical failures often occur at the periphery of the original tumor.
Should the No neck be treated in patients with Merkel cell carcinoma?
Yes.
Your patient has a mucoepidermoid carcinoma of the parotid gland. Histologic evaluation of the biopsy specimen reveals a scant amount of mucin. There is no clinical evidence of regional metastasis. Do you treat the neck?
Yes. Low mucin suggests high-grade mucoepidermoid which has a high incidence of occult neck disease.
