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Pasha > Ch07. H&N Cancer > Flashcards

Ch07. H&N Cancer Flashcards

1
Q

SCC on histology may look like (false positive)

A
  1. Necrotizing sialometaplasia

2. Mucoepidermoid carcinoma (esp high-grade variant)

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2
Q

IHC markers of lymphoma

A

Leukocyte common antigen (LCA), T-cell and B-cell markers

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3
Q

IHC markers of carcinoma

A

Cytokeratin

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4
Q

IHC markers of melanoma

A

S-100 (high sens, low spec; also found in neural and cartilaginous tumors)
HMB-45 (sens and spec, does not stain spindle cell type)
MART-1 and melan-A (newer, sens and spec for melanocytes)

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5
Q

IHC for neuroendocrine tumors

A

Chromogranin, neuron-specific enolase (NSE), synaptophysin

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6
Q

Gold standard for HPV testing

A

HPV DNA in situ hybridization in tumors

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7
Q

Grading of malignant neoplasms

A

Grading categorizes the histologic type of cancer according to the degree of differentiation; well-differentiated (G1), moderately well-differentiated (G2), poorly differentiated (G3), undifferentiated (G4); less related to prognosis

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8
Q

TX vs T0

A

TX indicates the primary tumor is not fully assessed, T0 indicates no evidence of a primary tumor

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9
Q

T1 N0 General overall staging criteria for head and neck cancer (ex NP, salivary, and thyroid)

A

Stage I

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10
Q

T2 N0 General overall staging criteria for head and neck cancer (ex NP, salivary, and thyroid)

A

Stage II

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11
Q

T3 N0 General overall staging criteria for head and neck cancer (ex NP, salivary, and thyroid)

A

Stage III

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12
Q

T4 N0 General overall staging criteria for head and neck cancer (ex NP, salivary, and thyroid)

A

Stage IV

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13
Q

T1 N1 General overall staging criteria for head and neck cancer (ex NP, salivary, and thyroid)

A

Stage III

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14
Q

T2 N1 General overall staging criteria for head and neck cancer (ex NP, salivary, and thyroid)

A

Stage III

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15
Q

T3 N1 General overall staging criteria for head and neck cancer (ex NP, salivary, and thyroid)

A

Stage III

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16
Q

T4 N1 General overall staging criteria for head and neck cancer (ex NP, salivary, and thyroid)

A

Stage IV

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17
Q

T1 N2 General overall staging criteria for head and neck cancer (ex NP, salivary, and thyroid)

A

Stage IV

Any N2-3, M+ is Stage IV

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18
Q

T2 N2 General overall staging criteria for head and neck cancer (ex NP, salivary, and thyroid)

A

Stage IV

Any N2-3, M+ is Stage IV

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19
Q

T3 N2 General overall staging criteria for head and neck cancer (ex NP, salivary, and thyroid)

A

Stage IV

Any N2-3, M+ is Stage IV

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20
Q

T4 N2 General overall staging criteria for head and neck cancer (ex NP, salivary, and thyroid)

A

Stage IV

Any N2-3, M+ is Stage IV

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21
Q

Tumor extension regions considered unresectable

A

Base of skull, nasopharynx, prevertebral fascia, floor of neck, mediastinum, subdermal lymphatics
Carotid artery encasement (>270degrees)

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22
Q

Clinical trial designs

A

Phase 0 evaluates pharmacodynamics and pharmacokinetics including oral bioavailability and half-life
Phase 1 defines the dose range and safety as well as side effects
Phase 2 tests the efficacy of the treatment regimen as well as toxicty
Phase 3 are randomized controlled trials that evaluate the new treatment compared to the standard treatment
Phase 4 are performed postapproval and postmarketing to gather additional information such as risks, benefits and optimal use

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23
Q

Overall 5-year survival for H&N cancer

A

~62% (SEER database, 1998-2012; vary by subsite)

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24
Q

Tumor thickness and survival

A

Poorer prognosis with increased tumor thickness (esp if >4 mm in depth)

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25
Q

Cisplatin mechanism of action

A

Heavy metal that acts as an alkylating agent that covalently binds DNA and RNA

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26
Q

Cisplatin side effects

A

Nausea, nephrotoxicity, peripheral neuropathy, ototoxicity (dose limiting, affects high frequencies, bilateral effects, cumulative toxicity), electrolyte disturbances, anorexia

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27
Q

Carboplatin mechanism of action

A

Heavy metal that acts as an alkylating agent that covalently binds DNA and RNA; less reactive than cisplatin

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28
Q

Carboplatin side effects

A

Better tolerated than cisplatin (less nephrotoxicity, nausea, neurotoxicity, and ototoxicity), but has an increased myelosuppresino risk

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29
Q

5-Fluorouracil mechanism of action

A

Antimetabolite that binds to thymidylate synthetase blocking the conversion of uridinet to thymidine, preventing DNA synthesis in S-phase

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30
Q

5-Fluorouracil side effects

A

Anorexia and nausea, mucositis, diarrhea, alopecia, myelosuppresion, cardiac toxicity

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31
Q

5-Fluorouracil indications

A

Similar to cisplatin (cisplatin and 5-FU is the most studied combination chemotherapy regimen in H&N cancer

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32
Q

What is leucovorin?

A

AKA tetrahydrofolic acid. It is utilized as a “rescue” agent for methotrexate toxicity, competitively overcomes increase in intracellular pools of dUMP (also used with 5-FU)

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33
Q

Direct mechanism of radiation injury

A

Direct damage of radiation to critical elements in a cell (DNA, cell membranes)

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34
Q

Indirect mechanism of radiation injury

A

Secondary damage from direct radiation effects on other cell components, primary mechanism of cell death (DNA injury from production of free radicals)

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35
Q

Cell cycle

A 
3 stages of interphase and mitosis
Gap1 growth phase cell size doubles (G0 in and out)
Sythesis phase (DNA doubled)
Gap2 growth phase (mito double)
Mitosis and cytokinessis resulting in two identical daughter cells
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36
Q

WHO grading system for oral mucositis

A

Grade 1: erythema and unpleasant sensation
Grade 2: erythema and pain but can still eat solids
Grade 3: ulcers, very painful, and can only tolerate liquids
Grade 4: ulcers, severe and intolerable pain, parenteral or enteral feedings by mouth is impossible

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37
Q

Xerostomia 2/2 XRT

A

Salivary acinar cells are extremly sensitive to radiation therapy causing irreversible xerostomia

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38
Q

Define ORN

A

Hypocellularity, hypovascularity, and ischemia or tissue

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39
Q

Rx ORN

A

Initially treat conservatively with antibiotics, analgesics, meticulous oral hygiene, and soft diet.
Debriement may be requirement.
May also consider hyperbaric oxygen.
Free tissue transfer necessary in recalcitrant painful mandibular disease, orocutaneous fistula, and/or pathological fracture.

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40
Q

Incidence of dysphagia after XRT

A

<=26% of patients at 1 year

41
Q

Incidence of nonfunctional larynx after CRT

A

<=12% patients at 1 year
CRT can cause loss of sensation and movement of the glottis leading to chronic aspiration and inability to phonate, may require tracheostomy

42
Q

Nodal level I

A

IA submental triangle

IB submandibular triangle

43
Q

Nodal level II

A

Upper jugular (between hyoid or carotid bifurcation and base of skull)
IIA anterior
IIB posterior to CN XI

44
Q

Nodal level III

A

Middle jugular (between hyoid or carotid bifurcation to cricoid or omohyoid)

45
Q

Nodal level IV

A

Lower jugular (between clavicle and cricoid or omohyoid)

46
Q

Nodal level V

A

Posterior triangle (VA: superior and VB: inferior to omohyoid)

47
Q

Nodal level VI

A

Anterior neck/central compartment (between carotid sheaths), includes Delphian (precricoid/prelaryngeal) LNs

48
Q

Nodal level VII

A

Superior mediastinum (suprasternal notch to anterior mediatsinum)

49
Q

HPV neg cN

A 
NX: LN can't be assessed
N0: no regional LN met
N1: single ipsi LN <=3 and ENE-
N2a: single ipsi LN >3 and <=6 and ENE-
N2b: multiple ipsi LNs <=3 and ENE-
N2c: bilat or contralat LNs <=6 and ENE-
N3a: any LN >6cm and ENe-
N3b: any LN and ENE+
50
Q

HPV neg pN

A

Nx: LN can’t be assessed
N0: no regional LN met
N1: single ipsi LN <=3 and ENE-
N2a: single ipsi LN >3 and <=6 and ENE-
- OR single ipsi or contra LN <=3 cm and ENE+
N2b: multiple ipsi LNs <=6 cm and ENE-
N2c: bilat or contralat LNs <=6 cm and ENE-
N3a: any LN >6 cm and ENE-
N3b: single ipsi LN>3 cm and ENE+; or multiple ipsi, contra or bilat LN with ENE+

51
Q

When is neck dissection done in cN neck?

A

Generally indicated if risk of regional metastasis >15-25% (e.g. supraglottis, BOT, tonsil, oral tongue, and advanced staged cancer)

52
Q

What test is done before carotid artery en bloc resection?

A

Pre-op balloon occlusion test and Pt needs to understand the risk of stroke

53
Q

Disadvantages of radical neck dissection

A
  1. Neck deformity (SCM muscle)
  2. Shoulder drop (CN XI)
  3. Facial edema (IJ)
  4. Hypesthesia of the neck and periauricular region
  5. Higher incidence of carotid blowouts due to lack of tissue (SCM) covering carotid artery
54
Q

Types of MRND

A

Type I: spares spinal accessory nerve
Type II: spares IJ and XI
Type III (functional/Bocca): SCM, IJ, XI

55
Q

Course of XI

A

The only nerve to enter and exit the skull.
From upper spinal cord, enter the skull through the foramen magnum
the nerve travels along the inner wall of the skull towards the jugular foramen
Leaving the skull, the nerve travels through the jugular foramen with the glossopharyngeal and vagus nerves

56
Q

Supraomohyoid neck dissection

A

Anterolateral neck dissection
Removes nodal levels I-III (expanded supraomohyoid removes level IV)
Larger oral cancers with a N0 or select N1 (mobile) neck

57
Q

Lateral neck dissection

A

Removes nodal levels II-IV
Indicated for select supraglottic, oropharyngeal, hypopharyngeal cancers
Typically bilateral

58
Q

Posterior lateral neck dissection

A

Removes nodal levels II-V (also retroauricular and suboccipital nodes)
Indicated for select posterior scalp cancers

59
Q

When to consult thoracic surgery for chyle leak?

A

Consult for proximal ligation if failed conservative therapy or if output >600 mL/day

60
Q

Horner’s syndrome after neck dissection

A

From damage to sympathetic trunk during carotid artery dissection
Triad of miosis, ptosis, and anhidrosis
Rx: observation as Sx may improve with time

61
Q

Most common site of head and neck cancer

A

Oral cavity (30% of all H&N cancer)

62
Q

Most common site of second primary H&N cancer

A

Oral cavity (10-40%)

63
Q

Oral leukoplakia vs erythroplakia malignant potential

A

5-20% malignant potential

25% malignant potential

64
Q

OC subsites

A
  1. lips, oral tongue, buccal mucosa, alveolar ridge, retromolar trigone, hard palate, floor of mouth
65
Q

OC AJCC 8th staging

A

T1: <=2 cm thickness DOI <=5 mm
T2:<=2 cm thickness DOI >5 <=10; tumor >2 <=4 cm thickness, DOI <=10 mm
T3: > cm thickness OR >10 mm COI
T4a: mod adv local diz: cortical bone of the mandible/maxilla, maxillary sinus or skin of face
T4B: very adv local diz: invasion through masticator space, pterygoid plates, skull base and/or encases ICA

66
Q

Verrucous carcinoma

A

Variant of SCC
Broad-based, warty growth
MC buccal mucosa, lateral growth, rare mets and deep invasion
Better prognosis

67
Q

OC adjuvant Tx.

One positive Node, without adverse features

A

XRT optional

68
Q

OC adjuvant Tx.

Adverse features such as positive margins or extracapsular spread

A

CRT (preferred), re-resection, or XRT

69
Q

OC adjuvant Tx.

Residual tumor post-XRT

A

Salvage surgery

70
Q

Surgical approach for oral cancer

A

Anterior and small tumors (<2 cm) may be approached intraorally; larger and more posterior tumors require a transmandibular, transcervical, or transoral robotic approach

71
Q

OP junction

A

Anterior boundary at junction of hard and soft palate; circumvallate papillae
Superior boundary at level of hard palate
Inferior boundary at the superior surface of the hyoid

72
Q

Subsites of OP

A 
5. Tonsil/lateral pharyngeal wall
Posterior pharyngeal wall
Soft palate
Base of tongue
Vallecula
73
Q

E6 and E7 of HPV

A

E6 binds and inactivates p53
E7 binds and inactivates retinoblasttoma (Rb) protein leading to release of E2F transcription factor causing cell cycle progression

74
Q

OP HPV+ AJCC T staging

A

T1 <= 2 cm
T2 >2 and <=4 cm
T3 >4 or extension to lingual surface of epiglottis
T4: primary tumor invades larynx, extrinsic muscles of tongue, medial pterygoid, or mandible or beyond

75
Q

OP HPV+ AJCC cN staging

A

N0: no regional LN met
N1: 1+ ipsi LN <= 6 cm
N2: bilat or contralt LN <= 6 cm
N3: any LN >6 cm

76
Q

OP HPV+ AJCC pN staging

A

N0: no regional LN met
N1: met in <=4 LNs
N2: met in >4 LNs

77
Q

OP cancers other than SCC

A

Lymphjoepithelioma (subgroup of poorly differentiated carcinoma; may present in the tonsi, exophytic, radiosensitive)
Lymphoma
Sarcoma, salivary gland malignancies, metastatic disease

78
Q

OP T1-T2 N2-3 neck

A

CRT (preferred), induction chemo followed by XRT or CRT

79
Q

OP T3-T4a any neck

A

CRT (preferred) vs excision of primary tumor with primary recon vs induction chemo followed by XRT and CRT

80
Q

De-escalation of therapy in HPV-associated OP carcinoma

A

Due to improved prognosis with HPV association, several clinical trials are investigating de-escalating (de-intensifying) chemoradiation to decrease side effects and morbidity

81
Q

Transcervical/visor flap for OP SCC

A

Consider for large tumors of the base of tongue or tonsil, access OP from a transoral incision of the floor of mouth, preserves mandibular integrity, poor exposure, chin numbness

82
Q

Mandibulectomy for OP SCC

A

Indicated for larger lesions, mandible extension, or multiple sites (composite resection)
May be approached laterally or medially with a lip-splitting incision (mandibular swing)
Provides excellent exposure, easier soft tissue closure, risk of malocclusion and plate extrusion

83
Q

Mandibulotomy for OP SCC

A

Spares mandible ,may be approached laterally or midline with a lip-splitting incision, osteotomy is performed in a stepwise fashion to create a favorable repair followed by rigid fixation
Provides excellent exposure, less risk of malocclusion

84
Q

Lateral pharyngotomy for OP SCC

A

Consider for small base of tongue or posterior pharyngeal wall tumors
Enters pharynx between CN XII and superior laryngeal nerves
Limited exposure, spares mandible, avoids lip-splitting incision

85
Q

Transhyoid pharyngotomy for OP SCC

A

Consider for small base of tongue or posterior pharyngeal wall tumors without significant superior or tonsillar extension
Enters pharynx above or through hyoid bone
Spares mandible, avoids lip-splitting incision, vallecula must be free of tumor, poor exposure superiorly

86
Q

Hypopharynx boundarise

A

Level of hyoid bone to cricopharyngeus (upper esophageal sphincter), lies behind and aroudn th larynx

87
Q

Hypopharynx subsites

A
  1. Piriform sinus, posterior pharyngeal wall, postcricoid region
88
Q

Hypopharynx AJCC T staging

A

T1: tumor limited to 1 subsite <= 2 cm
T2: tumor invades more than 1 subsite/adjacent site or >2 cm and <=4 cm and without fixation of hemilarynx
T3: tumor >4 cm or vocal fold fixation or extension into esophagus
T4: tumor invades adjacent structures; T4a mod adv local dz (invasion of thyroid/cricoid cartilage, hyoid bone, thyroid gland, or central compartment soft tissue=prelaryngeal strap muscles and subQ fat); T4b: very advanced local dz (invasion of prevertebral fascia, encases carotid artery, or involves mediastinal structures)

89
Q

Supraglottis boundaries

A

From the epiglottis to the junction of the ventricle and true vocal cord

90
Q

Subsites of supraglottis

A
  1. Suprahyoid epiglottis, infrahyoid epiglottis (MC), aryepiglottic folds, arytenoids, false cords
91
Q

Supraglottic cancer AJCC T staging: T1

A

Limited to 1 subsite of supraglottis

92
Q

Supraglottic cancer AJCC T staging: T2

A

Invades mucosa of more than 1 adjacent subsite (even BOT, vallecula, medial wall of piriform sinus) without vocal cord fixation

93
Q

Supraglottic cancer AJCC T staging: T3

A

Vocal fold fixation or primary tumor invades postcricoid area, pre-epiglottic space, paraglottic space, or inner cortex of thyroid cartilage

94
Q

Supraglottic cancer AJCC T staging: T4

A

further invasion.
T4a: mod adv local diz: invasion through thyroid cartilage or tissues beyond the larynx
T4b: very adv local diz (invades prevertebral space, encases carotid artery, or invades mediastinal structures)

95
Q

Glottic cancer anatomic boundaries

A

From the superior surface of the true vocal fold to 1 cm below the true vocal folds

96
Q

Glottic cancer AJCC T staging: T1

A

Tumor limited to vocal folds with normal mobility
T1a: one vocal fold
T1b: bilateral vocal fold involvement

97
Q

Glottic cancer AJCC T staging: T2

A

tumor extends to subglottis or supraglottis, or impaired vocal fold mobility

98
Q

Glottic cancer AJCC T staging: T3

A

Vocal fold fixation or invasion of paraglottic space or invasion of inner cortex of thyroid cartilage

99
Q

Glottic cancer AJCC T staging: T4

A

Further invasion.
T4a: mod adv local diz (invades through outer cortex of thyroid cartilage or invades tissue beyond the larynx)
T4b: very advanced local disease (invades prevertebral space, encases carotid artery, or invades mediastinal structures)

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