H&N Flashcards
Which nodal levels are included in the CTV when treating a cT2N0 nasopharyngeal carcinoma confined to the nasopharynx?
A. Bilateral retropharyngeal lymph nodes and cervical lymph node levels II, III, and Va
B. Bilateral retropharyngeal lymph nodes and cervical lymph node levels IB, II, III
C. Bilateral cervical lymph node levels IB, II, III, IV and Va
D. Bilateral cervical lymph node levels IB, II and III
A. Bilateral retropharyngeal lymph nodes and cervical lymph node levels II, III, and Va
Current guidelines recommend elective coverage of bilateral retropharyngeal lymph nodes and cervical nodal levels II, III and Va for all patients. Level IB should be considered for tumor that extend to involve the nasal cavity or regions for which level IB is primary echelon lymph node drainage.
A patient presents with nasal congestion, epistaxis, and progressive bilateral cervical lymphadenopathy. Flexible endoscopy demonstrates a mass posterior to the nasal choanae, and biopsy confirms keratinizing squamous cell carcinoma, EBV negative. MRI and PET/CT demonstrates invasion of the nasopharynx, and is confined to the mucosa without parapharyngeal involvement. What is the most appropriate clinical stage for this patient?
A. T2N0
B. T1N1
C. T1N2
D. T2N1
C. T1N2
Based on the information provided in the MRI and PET-CT images, the examinee should recognize that the tumor involves the nasopharynx and is confined to the mucosa without parapharyngeal involvement which is T1. Given a history of bilateral cervical LAD, the N stage is N2. Among the choices provided, the best answer is T1N2 (AJCC VIII).
What is the recommended adjuvant therapy for a patient with a resected oral tongue cancer, pT2N1 cM0 with PNI, LVI, 5mm margin, and depth of invasion 7mm?
A. RT to the primary site and bilateral neck level I-IV
B. RT to the primary site and bilateral neck level I-III
C. RT to the primary site
D. ChemoRT to the primary site and bilateral neck level I-IV
A. RT to the primary site and bilateral neck level I-IV
LVI and PNI are indications for adjuvant treatment. In the absence of ECE (pN2a or N3b) and positive margins concurrent chemotherapy is not indicated. Oral tongue cancer has metastatic skip lesions to level IV ~15% of the time and depth of invasion >4 mm is high risk of lymph node involvement.
For resected oral cavity cancer with extranodal extension, the key benefit of adding concurrent cisplatin to postoperative RT is the reduction of:
A. local-regional recurrence.
B. metastatic disease.
C. second primary cancers.
D. radiation dose.
A. local-regional recurrence.
An improvement in local-regional control is the greatest benefit of adding postoperative chemotherapy to radiation for high-risk patients with positive margins or extranodal extension. The RTOG 9501 and EORTC 22931 trials both showed a significant improvement in local-regional control but with increased grade 3 or higher acute toxicity. Neither trial showed a significant improvement in distant metastases and only the EORTC 22931 trial showed a statistically significant improvement in overall survival.
How does smoking during treatment of oropharyngeal cancer affect OS in the risk stratified RTOG 0129 study?
A. No impact on OS
B. Decreased by ≈5%
C. Decreased by ≈15%
D. Decreased by ≈25%
D. Decreased by ≈25%
In the RTOG 0129 data, patients that continued smoking during treatment had an OS decrease of approximately 25%. An absolute benefit in OS of 24.6% (95% CI, 5.9% to 43.3%) was observed at 5 years.
The ORATOR trial compared RT +/- chemotherapy to transoral robotic surgery and neck dissection with adjuvant treatment as indicated for oropharyngeal squamous cell carcinoma. What did this study show with regards to the primary endpoint, swallowing-related QOL scores 1 year after treatment?
A. Surgery was superior
B. Radiation was superior
C. There was no difference
D. The addition of chemotherapy worsened swallowing scores
B. Radiation was superior
Patients treated with radiotherapy showed superior swallowing-related quality of life (QOL) scores 1 year after treatment. QOL at 1 year was established using the MD Anderson Dysphagia Inventory (MDADI) score. MDADI total scores at 1 year were mean 86.9 (SD 11.4) in the radiotherapy group versus 80.1 (13.0) in the TORS plus neck dissection group (p=0.042).
What is the stage group for a 1 cm thyroid nodule that is fully contained in the lobe on ultrasound, biopsy shows anaplastic thyroid carcinoma, and PET CT indicates no other disease?
A. IA
B. II
C. IIIA
D. IVA
D. IVA
The lowest stage grouping for anaplastic thyroid carcinoma is IVA.
Which treatment offers the highest chance of larynx preservation for locally advanced (T3/T4) larynx cancer?
A. RT alone
B. Induction chemotherapy followed by RT
C. RT followed by chemotherapy
D. Concurrent chemoRT
D. Concurrent chemoRT
RTOG 91-11 was a 3-arm trial comparing larynx preservation approaches: RT alone vs induction chemotherapy followed by RT vs concurrent chemoRT. Larynx preservation was highest in the concurrent chemoRT arm (10-yr 81.7%, HR 0.58; 95% CI, 0.37 to 0.89) compared to induction chemo followed by RT (10-yr 67.5%, p=0.0050) and over RT alone (10-yr 63.8%, p<0.001). The sequential approach of 1-3 cycles of induction chemotherapy for selection of patients for larynx preservation with chemoRT requires more data to be considered a standard option.
Twelve weeks after chemoRT for a cT3N1 larynx cancer, a patient has a complete response on office examination and PET-CT with IV contrast. What is the MOST appropriate next step?
A. Neck dissection
B. Repeat PET-CT in 4 weeks
C. Clinical monitoring
D. Exam under anesthesia
C. Clinical monitoring
The 2018 ASCO Larynx Preservation Guideline Update emphasizes that patients with clinically involved lymph nodes that have a post-treatment complete response on imaging and examination, do not require elective neck dissection.
A patient presents with progressive hoarseness and odynophagia. CT of the neck demonstrates extrathyroidal extension with cortical breakthrough of the thyroid cartilage. There is no lymphadenopathy or distant metastases. Which treatment would provide the optimal tumor control?
A. RT to 70 Gy in 35 Fx
B. Induction chemotherapy followed by RT to 70 Gy in 35 Fx
C. Concurrent cisplatin-based chemoRT to 70 Gy in 35 Fx
D. Total laryngectomy and adjuvant (chemo)RT based on pathologic findings
D. Total laryngectomy and adjuvant (chemo)RT based on pathologic findings
The purpose of this question is to identify optimal treatment of resectable clinical stage T4a larynx cancer. The patient has significant extrathyroidal extension with cortical breakthrough of the thyroid cartilage. Although controversial to some, the best level of evidence indicates optimal local control and survival with definitive surgical treatment.
What were the OS outcomes in the EORTC 24891 which randomized patients with locally advanced hypopharynx squamous cancer to surgical resection followed by RT versus a larynx preservation approach (3 cycles induction chemotherapy followed by RT in complete responders)?
A. Better with larynx preservation approach
B. Worse with larynx preservation approach
C. Non-inferior with larynx preservation approach
D. Not the primary endpoint of the trial
C. Non-inferior with larynx preservation approach
End points of EORTC 24891 were overall survival, progression-free survival, and survival with a functional larynx. The larynx preservation approach with induction chemotherapy did not compromise disease control or survival and allowed more than half of the survivors to retain their larynx.
A 52 year-old non-smoker presents with a single right level II lymph node that measures 2.5 cm. His history, physical exam, and fiberoptic laryngoscopy are negative for a primary site. What are the next steps for work-up?
A. FNA, HPV testing, contrast-enhanced CT, PET-CT, exam under anesthesia
B. Nodal excision, HPV testing, contrast-enhanced CT, exam under anesthesia, PET-CT
C. Core needle biopsy, HPV testing, contrast-enhanced CT, exam under anesthesia, PET-CT
D. FNA, HPV testing, MRI, exam under anesthesia, PET-CT
A. FNA, HPV testing, contrast-enhanced CT, PET-CT, exam under anesthesia
PET-CT should always be done prior to examination under anesthesia, as PET may guide biopsies and PET after examination under anesthesia with biopsies may result in false positives. FNA is appropriate, if lymphoma can always do excisional after.
Which salivary malignancy is MOST likely to be HER2+?
A. Adenoid cystic carcinoma
B. Hyalinizing clear cell carcinoma
C. Low grade mucoepidermoid carcinoma
D. Salivary ductal carcinoma
D. Salivary ductal carcinoma
Salivary duct carcinoma is an aggressive high-grade salivary malignancy with a high rate of HER2 overexpression compared with other salivary malignancies. There is controversy regarding the potential use of HER2-directed therapy for recurrent or metastatic HER2-overexpressing salivary cancers.
A patient has an enlarging lesion in the left hard palate and nasal cavity. The patient endorses numbness of the medial portion of the left nasolabial fold indicating involvement of which nerve?
A. Vidian nerve
B. Greater and lesser palatine nerves
C. Infraorbital nerve
D. Mental nerve
C. Infraorbital nerve
Adenoid cystic carcinoma is recognized for its propensity for perineural spread and is the most likely diagnosis for a younger nonsmoker with indolent tumor growth. Regardless, the purpose of the question is for the examinee to recognize upper lip innervation by the infraorbital nerve, an important clinical pearl in sinonasal tumors.
What is included in the postoperative radiation volume for a 5.1 cm Merkel cell carcinoma of the left temple after wide local excision of the primary?
A. Surgical bed
B. Surgical bed, left parotid
C. Surgical bed, left parotid and neck
D. Surgical bed and left neck
C. Surgical bed, left parotid and neck
Skin on the temple drains to the parotid lymph nodes and then to level Ib-III. Adjuvant radiation of Merkel cell carcinoma would include the surgical bed and draining nodal regions.
