H&N Evaluation and Management of oral cavity cancer

Question 1

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?

Answer 1

Tobacco and alcohol

Question 2

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

Answer 2

● 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

Question 3

Is HPV infection considered a major risk factor in

the development of oral cavity carcinoma?

Answer 3

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.

Question 4

What is the most common malignancy of the oral

cavity?

Answer 4

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

Question 5

What are the most common squamous cell

carcinoma subtypes found within the oral cavity?

Answer 5

● Sarcomatoid carcinoma
● Basaloid carcinoma
● Verrucous carcinoma

Question 6

What are the most common malignancies of the

oral cavity, excluding squamous cell carcinoma?

Answer 6

● 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

Question 7

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

Answer 7

● 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

Question 8

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

Answer 8

Verrucous hyperplasia. Most commonly occurs on the

buccal mucosa of men in their fourth decade of life.

Question 9

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

soft palate junction and is associated with pressure
injuries?

Answer 9

Necrotizing sialometaplasia

Question 10

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

Answer 10

Pseudoepitheliomatous hyperplasia

Question 11

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

Answer 11

Torus mandibularis and torus palatini, respectively

Question 12

What are the most common initial signs and

symptoms associated with oral cavity cancer?

Answer 12

Bleeding, pain, halitosis, dysphagia, and dysarthria

Question 13

What is the most common site of oral verrucous

carcinoma?

Answer 13

Buccal mucosa

Question 14

What is the most common location of oral tongue

squamous cell carcinoma?

Answer 14

Posterolateral oral tongue

Question 15

What is the most common location of buccal

mucosa squamous cell carcinoma?

Answer 15

Adjacent to the thirrd mandibular molar

Question 16

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

Answer 16

Consider for stage III–IV disease

Question 17

Name four common features of patients with early

stage (stage I or II) oral cavity cancer.

Answer 17

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

Question 18

How is a T4a oral cavity tumor defined?

Answer 18

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).

Question 19

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

Answer 19

False

Question 20

How are T4b oral cavity tumors defined?

Answer 20

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

Question 21

What pathologic factors directly relate to prog-

nosis in oral cavity cancer?

Answer 21

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

Question 22

Which has a worse prognosis: upper or lower lip

cancer?

Answer 22

Upper lip cancer tends to be more aggressive and to have

early metastatic potential.

Question 23

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

Answer 23

● 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

Question 24

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

Answer 24

● 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

Question 25

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)?

Answer 25

● 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

Question 26

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?

Answer 26

● 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

Question 27

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

Answer 27

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

Question 28

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

Answer 28

● 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

Question 29

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

Answer 29

● 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.

Question 30

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

Answer 30

44 to 64 Gy

Question 31

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

Answer 31

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.

Question 32

What is the recommended adjuvant radiation | recommended for oral cavity cancer?

Answer 32

● 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

Question 33

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

Answer 33

Concurrent cisplatin (100 mg/m2 every 3 weeks)

Question 34

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?

Answer 34

● 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

Question 35

What local flap using the facial artery can be used | to close intraoral defects?

Answer 35

Facial artery musculomucosal (FAMM) flap

Question 36

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?

Answer 36

Tethered tongue

Question 37

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

Answer 37

Skin graft or free tissue transfer

Question 38

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

Answer 38

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

Question 39

What is the reconstruction of choice for patients who | have greater than 50% of the oral tongue resected?

Answer 39

Fasciocutaneous free flap, radial forearm free flap

Question 40

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

Answer 40

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.

Question 41

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?

Answer 41

Prosthetic obturator