Workup/Staging

Question 1

A pt presents with tongue deviation to the left. What CN is involved?

Answer 1

The left CN XII (hypoglossal) is involved with left tongue deviation (deviation is toward the involved nerve).

Question 2

A pt presents with an OC lesion and ipsi ear pain. What nerve is responsible?

Answer 2

The auriculotemporal nerve (branch of CN V3) causes ear pain in OCC.

Question 3

Which lesions in the OC are most and least likely to present with +LNs?

Answer 3

Most likely: tongue, FOM

Least likely: lips, buccal mucosa, gingiva

Question 4

What are some common presenting signs with OC lesions?

Answer 4

Asymptomatic red/raised lesion, ill-fitting dentures, bleeding mass, pain, dysphagia (d/t tongue fixation), trismus (pterygoid/masticator space involvement), and otalgia

Question 5

What does the typical workup of OC lesions entail?

Answer 5

OC lesion workup: H&P with palpation, mirror/fiber optic exam, Bx, CBC, CMP, CT/MRI H&N, chest imaging, consider PET/CT for stage III or greater.

Question 6

What is the DDx for lesions of the OC?

Answer 6

SCC, minor salivary gland tumors, lymphoma, melanoma, sarcoma, plasmacytoma, and ameloblastoma

Question 7

What defines T categories of the OC (AJCC 8th edition)?

Answer 7

T1: ≤2 cm, ≤5 mm DOI (DOI is NOT tumor thickness)

T2: ≤2 cm, DOI >5 mm and ≤10 mm, or >2 cm but ≤4 cm and DOI ≤10 mm

T3: >4 cm or DOI >10 mm

T4a: LIP: invasion of bone or involved inf alveolar nerve, FOM, skin of face

OC: invasion of adjacent structures (bone, deep tongue muscles, maxillary sinus, skin)

T4b: very advanced (invasion of masticator space, pterygoid plates, skull base, carotid artery), typically unresectable

Question 8

What is the clinical nodal staging OCC (AJCC 8th edition)?

Answer 8

N1: single ipsi, ≤3 cm, ENE(–)

N2a: single ipsi >3 cm and ≤6 cm ENE(–)

N2b: multiple ipsi, ≤6 cm and ENE(–)

N2c: bilat or contralat, ≤6 cm and ENE(–)

N3a: >6 cm and ENE(–)

N3b: clinically overt ENE(+)

Question 9

What is the pathologic nodal staging OCC (AJCC 8th edition)?

Answer 9

N1: single ipsi, ≤3 cm, ENE(–)

N2a: single ipsi ≤3 cm and ENE(+) or single ipsi >3 cm and ≤6 cm ENE(–)

N2b: multiple ipsi, ≤6 cm and ENE(–)

N2c: bilat or contralat, ≤6 cm and ENE(–)

N3a: >6 cm and ENE(–)

N3b: single ipsi >3 cm ENE(+) or multiple ipsi/contra/bilat nodes any with ENE(+)

Question 10

Are radiographic findings alone sufficient for ENE?

Answer 10

No. Radiographic evidence alone is insufficient. Exam findings are required (e.g., skin involvement, tethering to adjacent structures, CN findings, etc.), though radiographic evidence should be in support of the physical exam.

Question 11

What is the OCC group staging?

Answer 11

Stage I: T1 N0

Stage II: T2 N0

Stage III: T3 N0 or N1 (T1–T3)

Stage IVA: T4a or N2

Stage IVB: T4b or N3

Stage IVC: M1

Question 12

If RT is anticipated for OCC, what should be done and when should it be done before starting Tx?

Answer 12

Dental evaluation (teeth extractions, fluoride trays) should be done 10–14 days before RT.

Question 13

What is the most common location involved in oral tongue cancers?

Answer 13

The lat undersurface of the tongue in the middle to post 3rd is most commonly involved.

Question 14

What is the overall bilat nodal involvement rate for oral tongue cancers?

Answer 14

5% of oral tongue cancers present with bilat neck Dz (most nodal Dz is ipsi). If N+, there is an ∼30% risk for bilat Dz.

Question 15

What 2 factors are most predictive of nodal involvement in oral tongue cancers?

Answer 15

DOI and tumor thickness are most predictive of LN mets in oral tongue cancers.

Question 16

What are the 2 most important prognostic factors after Sg alone for buccal mucosa cancers?

Answer 16

DOI ≥3 mm or tumor thickness ≥6 mm are the most important prognostic factors for buccal mucosa cancers. (Urist MM et al., Am J Surg 1987)