H&N Evaluation and Management of oral cavity cancer Flashcards Preview

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Flashcards in H&N Evaluation and Management of oral cavity cancer Deck (41)
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1
Q

What environmental risk factors act synergistically
in the formation of oral cavity squamous cell
carcinoma and are the most common risk factors
in the Western world?

A

Tobacco and alcohol

2
Q

In addition to tobacco and alcohol use, what risk
factors place a patient at higher risk for developing
oral cavity cancer?

A
● Betel nut chewing
● Chewing tobacco or other oral tobacco
● Chronic periodontal disease or irritation
● History of head and neck radiation
● History of head and neck cancer
● Immunodeficiency
● Sun exposure (lip)
● Other: Plummer-Vinson syndrome, chronic syphilis
3
Q

Is HPV infection considered a major risk factor in

the development of oral cavity carcinoma?

A

No. Although it is a risk factor, it is not considered a major
risk factor, and its role in carcinogenesis in the oral cavity is
unclear.

4
Q

What is the most common malignancy of the oral

cavity?

A

Squamous cell carcinoma (~95%)
Note: For the hard palate, tumors most commonly arise in
the minor salivary glands.

5
Q

What are the most common squamous cell

carcinoma subtypes found within the oral cavity?

A

● Sarcomatoid carcinoma
● Basaloid carcinoma
● Verrucous carcinoma

6
Q

What are the most common malignancies of the

oral cavity, excluding squamous cell carcinoma?

A

● Lymphoma
● Minor salivary gland tumors: Adenoid cystic carcinoma,
mucoepidermoid carcinoma, polymorphous low-grade
adenocarcinoma, adenocarcinoma
● Sarcoma: Osteosarcoma, chondrosarcoma, malignant
fibrous histiosarcoma, rhabdomyosarcoma, liposarcoma,
Kaposi sarcoma
● Melanoma: Malignant mucosal melanoma

7
Q

What common premalignant lesions are associated with an increased risk of developing an oral
cavity squamous cell carcinoma?

A

● Leukoplakia: White plaque, cannot be wiped off; lower
risk of malignant conversion (< 30%)
● Erythroplakia: Red plaque, not associated with obvious
cause; higher risk of malignant conversion (< 60%)
● Lichen planus: Lacy white pattern on mucosa or atrophic
lesions (red and smooth) or erosive lesions (depressed
margins, covered with fibrinous exudate), more common
in women (40s), < 1% 10-year conversion rate
● Submucosal fibrosis: Thickened and fibrotic buccal
mucosa and deeper structures; associated with betel quid
chewing, poor oral hygiene

8
Q

What premalignant lesion can be mistaken for
verrucous carcinoma but is differentiated on
pathology because it does not invade the lamina
propria?

A

Verrucous hyperplasia. Most commonly occurs on the

buccal mucosa of men in their fourth decade of life.

9
Q

What benign lesion manifests as a butterfly-
shaped ulceration commonly found at the hard–

soft palate junction and is associated with pressure
injuries?

A

Necrotizing sialometaplasia

10
Q

What benign lesion is commonly found in mucosal
or salivary tissue and may resemble squamous cell
carcinoma?

A

Pseudoepitheliomatous hyperplasia

11
Q

What are common benign exostoses that appear
as firm submucosal masses on the anterior lingual
mandible and midline hard palate?

A

Torus mandibularis and torus palatini, respectively

12
Q

What are the most common initial signs and

symptoms associated with oral cavity cancer?

A

Bleeding, pain, halitosis, dysphagia, and dysarthria

13
Q

What is the most common site of oral verrucous

carcinoma?

A

Buccal mucosa

14
Q

What is the most common location of oral tongue

squamous cell carcinoma?

A

Posterolateral oral tongue

15
Q

What is the most common location of buccal

mucosa squamous cell carcinoma?

A

Adjacent to the thirrd mandibular molar

16
Q

When does the NCCN (2013) recommend PET/CT
scan in the workup of patients with oral cavity
cancer?

A

Consider for stage III–IV disease

17
Q

Name four common features of patients with early

stage (stage I or II) oral cavity cancer.

A

● Primary tumor < 4 cm (T1–2)
● No evidence of invasion into adjacent structures
● No evidence of cervical metastases (N0)
● No distant metastases (M0)

18
Q

How is a T4a oral cavity tumor defined?

A

Moderately advanced local disease:

● Lip: It invades through the cortical bone, inferior alveolar
nerve, floor of mouth, or skin of face.
● Oral cavity: Tumor invades adjacent structures (e.g.,

through cortical bone, extrinsic (deep) tongue muscu-
lature, maxillary sinus, skin of face).

19
Q

True or False. Superficial erosion bone or tooth
socket alone meets the criteria for staging a tumor
as T4a.

A

False

20
Q

How are T4b oral cavity tumors defined?

A

● Very advanced local disease
● Tumor invades masticator space, pterygoid plates, or
skull base, and/or encases the internal carotid artery.

21
Q

What pathologic factors directly relate to prog-

nosis in oral cavity cancer?

A

● Tumor thickness (> 5 mm = increased risk of occult nodal
disease, decreased recurrence free and overall survival
rates)
● Differentiation
● Angiolymphatic invasion

22
Q

Which has a worse prognosis: upper or lower lip

cancer?

A

Upper lip cancer tends to be more aggressive and to have

early metastatic potential.

23
Q

What are the adverse risk features considered by
the NCCN (2011) in their algorithm for oral cavity
cancer management?

A
● Extracapsular nodal spread
● Positive margins
● pT3 or pT4 primary
● N2 or N3 nodal disease
● Nodal disease in levels IV or V
● Perineural invasion
● Vascular embolism
24
Q

What treatment strategy recommended by the
NCCN (2013) for early stage (stage I and II) oral
cavity cancer?

A

● Surgical resection ± neck dissection as indicated by tumor
thickness and location (preferred):
○ No adverse risk factors→ Surveillance
○ One positive node without adverse risk features→
Optional adjuvant radiation

○ Extracapsular spread and/or positive margin→ Che-
moradiation (preferred) versus reexcision versus radia-
tion therapy

○ Other adverse risk features→ Radiation therapy versus
chemoradiation therapy.
● Radiation therapy ± brachytherapy

25
Q

For patients with advanced stage disease (T1–
3N1–3; T3N0; T4a, any N), excluding T4b or
unresectable nodal disease, what is the primary
treatment strategy recommended by the NCCN
(2013)?

A

● Surgical resection with ipsilateral or bilateral neck
dissection (N2c or high risk to contralateral neck)
● No adverse features: Radiation therapy (optional)
● Extracapsular spread and/or positive margin: Chemo-
radiation therapy (preferred) vs reexcision versus radiation therapy
● Other risk features: Radiation therapy versus chemo-
radiation therapy
● Multimodality clinical trials

26
Q

How can the mandible be managed if an oral
cavity cancer appears to invade the periosteum,
cortex, or medullary space, either intraoperatively
or on preoperative workup?

A

● Marginal or rim mandibulectomy: Periosteum or super-
ficial cortical invasion
● Segmental mandibulectomy: More than superficial cort-
ical invasion, medullary invasion, invasion from perineural spread via the mandibular or mental foramen, hypoplastic/atrophic/edentulous mandible making rim mandibulectomy unsafe, invasion of periodontal ligament or tooth socket

27
Q

When performing osteotomy for mandibulotomy, which is preferable: straight or stepwise osteot-
omy? Median or paramedian placement?

A

● Stepwise mandibulotomy: Provides better alignment and
stability
● Paramedian: Minimizes trauma to the genioglossus,
geniohyoid, and digastric muscles

28
Q

Describe the extent of neck dissection recommended by the NCCN (2013) for oral cavity cancer
based on clinical nodal staging.

A

● No neck dissection: It can be considered for T1N0 lower-
lip cancer, T1–T2N0 oral tongue with < 2 mm of invasion,
T1–T2N0 upper alveolar ridge and hard palate tumors.
For lesions 2- to 4-mm thick, elective neck dissection is
used when appropriate (patient reliability, other risk
factors, and so forth).
● N0: Select neck dissection. Supraomohyoid (levels I–III)
recommended for oral cavity tumors > 4 mm; level IIB
dissection is controversial; can consider preserving for
early stage disease. Consider suprahyoid dissection (levels
IA and IB) for T2 lower-lip tumors.
● N1–N2c: Select or comprehensive neck dissection as
indicated
● N3: Comprehensive neck dissection

29
Q

What is regimen is recommended by the NCCN
(2013) for definitive radiation therapy for oral
cavity cancer with gross lymphadenopathy?

A

● Conventional fractionation: 66–74 Gy, Monday through
Friday for 7 weeks
● Altered fractionation:
○ Six fractions/week accelerated: 66 to 74 Gy (gross
disease), 44 to 64 Gy (subclinical disease)
○ Concomitant boost accelerated: 72 Gy for 6 weeks
(boost given during a second daily fraction for the last
12 days of treatment)
○ Hyperfractionation: 81.6 Gy x 7 weeks given twice daily
Monday through Friday.

30
Q

What radiation dose is typically given to uninvolved nodal levels at risk for occult disease in oral cavity cancer undergoing definitive radiation?

A

44 to 64 Gy

31
Q

When should adjuvant radiation or chemoradia-
tion begin after surgical resection for oral cavity
cancer?

A

Six weeks or less (often around 3 to 4 weeks). Ideally all
treatment will be completed within 12 weeks from
diagnosis. Given 6 weeks of typical adjuvant therapy, this
gives 6 weeks from diagnosis to initiation of adjuvant
therapy.

32
Q

What is the recommended adjuvant radiation

recommended for oral cavity cancer?

A

● Primary site: 60 to 66 Gy, daily Monday through Friday for
6 weeks
● N(+) levels: 60 to 66 Gy
● N(-) levels: 44 to 64 Gy

33
Q

What chemotherapeutic regimen is recommended when adjuvant chemoradiation therapy is planned for oral cavity cancer?

A

Concurrent cisplatin (100 mg/m2 every 3 weeks)

34
Q

What is the reconstruction of choice for lower-lip
defects smaller than one-third the length of the
lip, between one-third and two-thirds, greater
than two-thirds?

A

● Less than one-third: Primary closure
● One-third to two-thirds: Abbe-Estlander flap
● More than two-thirds: Karapandzic flap, Webster-Bernard
flap, or radial forearm free flap with palmaris longus
tendon

35
Q

What local flap using the facial artery can be used

to close intraoral defects?

A

Facial artery musculomucosal (FAMM) flap

36
Q

In a patient with a floor of mouth or oral tongue
tumor, resection followed by primary closure of a

large defect can result in what long-term compli-
cation?

A

Tethered tongue

37
Q

What reconstructive options are best used to avoid
trismus in defects of the buccal mucosa larger
than 3 cm in diameter?

A

Skin graft or free tissue transfer

38
Q

What is the reconstruction of choice for patients
with segmental resection of the anterior mandi-
ble?

A

Free tissue transfer with vascularized bone (i.e., fibula free
flap)

39
Q

What is the reconstruction of choice for patients who

have greater than 50% of the oral tongue resected?

A

Fasciocutaneous free flap, radial forearm free flap

40
Q

What reconstruction options are best in patients
with segmental mandibulectomy who are not
candidates for free tissue transfer?

A

Soft tissue pedicled flap with or without a reconstruction
bar. Reconstruction bars should be used with caution
without underlying bone. They are prone to fracture,
exposure, and infection.

41
Q

What is an adequate nonsurgical method for
rehabilitation of speech and swallow function after
resection of a hard palate or maxillary alveolar ridge
tumor with resultant oronasal or oroantral fistula?

A

Prosthetic obturator