Term
| What are the most common malignancies seen in the temporal bone? |
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Definition
1) SCC (60-80%)
2) BCC
3) Adenoid cystic
4) Melanoma |
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Term
| The are the cartilaginous and bony tracts in the ear canal for tumor spread? |
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Definition
1) Fissures of santorini in cartilage
2) Foramen of huschke in bone |
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Term
| What is the typical staging system for temporal bone cancers? |
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Definition
Pittsburgh staging system
T1: limited to ear canal without bony erosion or soft tissue involvement
T2) Limited to ear canal with bony erosion but not full thickness and limited soft tissue involvement
T3) Erode through ear canal with limited soft tissue, or involving middle ear or mastoid
T4) Large, erosive tumors and/or facial paralysis
Lower risk of LN mets (10-20%), but when present is advanced sign (stage IV) |
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Term
| How are temporal bone SCCs typically managed by T stage? |
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Definition
- T1/T2 may have lateral TB resection, parotid and neck dissection
- T3 usually would need subtotal TB resection with parotidectomy and neck dissection
- T4 would require total TB resection, sometimes craniotomy, often not worth it
For T3/4 there may be upfront chemo before surgery or treatment with chemoXRT |
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Term
| What are the surgical goals of a lateral temporal bone resection? |
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Definition
1) En bloc removal of ear canal
2) Begin with complete mastoidectomy, open attic to see ossicles, drill away root of zygoma and folow between dura and ear canal until exposed temporomandibular joint (anterior/superior extent of resection)
2) Open wide facial recess and follow facial nerve out to stylomastoid foramen
3) Remove mastoid tip and extend facial recess along facial nerve to inferior tympanic ring. Inferior extent of dissection is where annulus reaches TMJ.
4) Disarticular ossicles, remove incus, divide tensor tympani tendon. |
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Term
What differentiates a subtotal temporal bone resection from a lateral resection?
What about total? |
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Definition
In subtotal, you take the labryrinth and cochlea, as well as sometimes facial nerve.
In total, remove IAC with continuation into anterior petrous apex |
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Term
70M Caucasian patient with a cancer history presents with firm purplish/reddish nodule in the left neck skin, it is solitary and arose fairly rapidly.
What do you suspect is going on and what is the typical pathophysiology? |
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Definition
Merkel cell carcinoma is most common in elderly white males. History of immunosuppression also common
Arise from neural crest cells (neuroendocrine carcinoma of skin technically). Merkel cells are mechanoreceptors in basal layer of epidermis that form synapses with nerve terminals of sensory nerve fibers. 80% of cases driven by viral (Merkel cell polyomavirus) in immunosuppressed patients.
Its a dsDNA virus that begins with asymptomatic infection, fecal oral, with integration into genome of immunosuppressed patients leading to cancer-causing mutations. |
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Term
70M Caucasian patient with a cancer history presents with firm purplish/reddish nodule in the left neck skin, it is solitary and arose fairly rapidly.
You suspect a merkel cell carcinoma. What are the classic pathologic findings? |
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Definition
High grade neuroendocrine tumor.
CK 20 is highly sensitive for Merkel cells (also synaptophysin and chromogranin A)
1) High density of small blue round cells
2) Large nuclei with scant cytoplasm and high mitotic rates |
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Term
What rapidly growing cutaneous malignancy is found most commonly in elderly, white males with history of immunosuppression?
How are these patients typically worked up/staged? |
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Definition
Merkel Cell carcinoma. Rare tumor so no definitive consensus on imaging modality.
SLNB is quite important. Rate of occult neck metastasis in clinically N0 neck is fairly significant. 5 year survival drops to 50% in presence of neck nodes.
Stage 1 is T1N0M0 (<2cm)
Stage 2A are T2 or T3N0M0 (2-5cm, or >5cm)
Stage 2B are T4N0M0
Stage 3A have occult neck met by SLNB
Stage 3B have clinically apparent node disease
Stage 4 have distant mets |
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Term
| What is typical approach to excision of head and neck merkel cell carcinoma? What about non-surgical therapy? |
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Definition
Rapidly growing, aggressive neuroendocrine tumor of cutaneous location.
WLE with 2-3cm margin, SNLB important for prognostication.
Unlike melanoma, Merkel cell is radiosensitive, can be used in adjuvant setting.
Chemotherapy, on the other hand is not useful |
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Term
| What therapies are utilized in distantly metastasized merkel cell carcinoma? |
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Definition
Checkpoint inhibitors. Avelumab (PD-L1 inhibitor) is first line
Pembrolizumab, Nivolamab, Ipilimumab are also effective. |
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Term
| How do you distinguish oral leukoplakia for erythroplakia from lichen planus and how do their malignant potential differ? |
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Definition
All are premalignant lesions of oral cavity
1) Leukoplakia (white patches or plaques) with 1% annual risk of transformation
2) Erythroplakia (red patch) is bright velvety patch with higher risk compared to leukoplakia
3) Oral Lichen planus- chronic autoimminume inflammation related to description of baal cell layer by cytotoxic T cells presenting as reticular or lacy appearing oral lesion (1-3% overall risk and <1% anual risk) |
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Term
| How is verrucous carcinoma unique as an oral cavity cancer and what are its pathologic features? |
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Definition
1) Appears grossly as broad-based thick plaque that is white or pale in color
2) EPithelial thickening with spires of acanthosis separated by crypts of keratin with pushing borders
3) Very little metastatic potential (<2%) so no elective neck dissection |
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Term
| How does depth of invasion play into T staging oral cavity cancer? |
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Definition
T1 must be <5mm DOI
T2 must be <10mm DOI
Neck dissection indicated for >3-4mm DOI, unless radiation already planned for neck. |
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Term
| How does risk of occult neck metastasis differ by oral cavity subsite for SCC? |
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Definition
Overall risk is 30% in clinically N0 neck. FOM is 60%. RMT and buccal mucosa also higher risk compared to oral tongue or lips.
Lymph nodes typically in supraomohyoid neck levels (think of level IV for oral tongue) |
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Term
| How can pre-malignant dysplastic oral cavity lesions be managed? |
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Definition
1) Typically excise severe dysplasia
2) Laser ablate can be considered for mild to moderate dysplasia |
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Term
| What do head and neck schwannomas look like on histology? |
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Definition
1) Biphasic tumors with Antoni A (palisades)
and Antoni B (Verocay bodies mixed in with myxoid hypocellular component Antomi B)
2) S100+ |
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Term
| How can you differentiate a paraganglioma from a schwanomma on imaging? |
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Definition
1) Paragangliomas enhance on CT with contrast and Schwanommas do not). Schwannoma on CT will appear and well-defined, ovoid mass, avascular, sometimes with cystic components.
2) MRI with gadolinium shows enhancing lesion (can be confused for vascular)
3) Vagal origin (between IJV and Carotid), so carotid gets medial and anterior and IJV gets posterior and lateral
Sympathetic origin (medial to carotid sheath) means both artery and vein will be pressed anterior and lateral. |
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Term
| What is the standard of care management of stages II-IV nasopharyngeal cancer? |
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Definition
| Chemotherapy and radiation concurrent (cisplatin) |
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Term
| What are the major findings of the VA study and RTOG 91-11 in terms of organ preservation in laryngeal cancer? |
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Definition
1) VA: Induction chemo with radiation equivalent survival to surgery followed by radiation and better chance of laryngeal preservation
2) RTOG 91-11: concurrent chemoXRT superior to induction chemo followed by XRT in terms of survival |
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Term
| In what circumstances are PDL-1 inhibitors useful in head and neck cancer? |
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Definition
1) Mestatstic/unresectable HNSCCC
2) Melanoma
3) |
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Term
What are the mechanisms of the following chemotherapy agents?
1) Cisplatin
2) Carboplatin
3) Taxanes
4) 5-FU
5) Methotrexate |
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Definition
1-2: Alkylating agent (nephro, ototoxic, peripheral neuropathy)
2) microtubule destabilizer (neutropenia, alopecia, mucositis)
4) Antimetabolite binds thymidylate synthetatse (musocisit, myleosuppression, cardiac toxicity)
5) Antimetabolite binds DHFR (bone marrow suppression, GI disturbance) |
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Term
What are the mechanisms of the following systemic therapy agents in treatment of HNSCC?
1) Cetuximab
2) Ipilimumab
3) Nivolumab/Pembrolizumab
4) Vemurafenib
5) Vismodegib |
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Definition
1) EGFR inhibitor
2) CTLA-4 inhibitor
3) PD-1 inhibitor
4) Inhibitors MAP kinase pathway in tumors with B600 BRAF
5) Hedgehob inhibitor used in metastatic or locally advanced BCC that recurred following surgery |
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Term
| When should elective neck dissection in clinically N0 neck be considered in HNSCC? |
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Definition
If risk of occult metastasis is >15-25%
Oral tongue with DOI>3-4mm, Supraglottis, base of tongue, tonsil, FOM |
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Term
| What side is chylous fistula during surgery most likely? How do you manage? |
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Definition
1) Left (thoracic duct)
2) Pressure, head elevation, MCTGL diet, consider sclerosis therapy versus surgical re-exploration vs. thoracic surgery consult if output >600ml/day |
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Term
| What are most common sites of oral cancer? |
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Definition
1) Lips, 90$ 5-year survival I <2cm, 90% HNSCC
2) 90% on lower lip (2-15% regional mets, ipsilateral drainage to I-III) |
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Term
| What is 8th AJCC staging of oral cavity cancer? |
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Definition
| T1 (<2cm, <5mm DOI), T2 (2-4cm, 5-10 DOI), T3 (>4cm or DOI>10mm), T4 (moderately advanced local) |
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Term
| When would adjuvant radiation and/or chemo be considered after surgery for oral cavity SCC? |
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Definition
1) T1-2 disease, 1 positive node without adverse features, RT alone could be considered
2) T1-2 disease, Positive margins or ENE, needs chemoXRT
3) PNI, LVI, adjuvent radiation
3) |
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Term
| What are the molecular mechanisms of HPV pathogenesis in oropharyngeal cancer? |
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Definition
Types 16, 18 most common pathogenic (16>18)
1) E6 bindings p53 tumor suppressor gene
2) E7 binds Rb |
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Term
| What is the N staging for HPV positive oropharyngeal SCC? |
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Definition
N0- none
N1- one or more <6cm
N2- bilateral or contralateral <6cm
N3- >6cm
Pathologic is N1 < 4 LNs, N2 >4 LNs |
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Term
| What is the T staging for HPV positive oropharyngeal SCC? |
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Definition
1) T1 <2cm
2) T2 2-4cm
3) T3 >4cm or extension onto lingual surface of epiglottis
4) T4 Locally invasive |
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Term
| What are the anatomic subsites of the hypopharynx and their probabilities of being effected by SCC? |
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Definition
Hyoid to cricopharyngeus, concern for submucosal skip lesions
1) Piriform sinus (most common site 65-75%)
- 75% have regional mets
2) Posterior pharyngeal wall (20-25%)
3) Postcricoid (rare <5%) |
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Term
| What is the T staging for hypopharyngeal SCC? |
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Definition
1) 1 subsite, <2cm
2) >1 subsite or 2-4cm
3) >4cm, VC fixation or esophageal extension
4a) Adjacent structures |
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Term
| What are the contraindications to laryngeal preservation in management of hypopharyngeal cancer? |
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Definition
1) Involvement of thyroid cartilage
2) Apex of piform sinus
3) Postcricoid region
4) Interarytenoid
5) Cervical esophagus
6) VF fixation |
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Term
| What are the anatomical barriers to spread in laryngeal SCC? |
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Definition
1) Quadrangular membrane: supports epiglottis, extends along lateral epiglottis and arytenoid, inferior border is vestibular ligament, superior is AE fold (resists spread of supraglottic tumors)
2) Conus elasticus: supports vocal cord, extends from cricoid to murge with vocal ligament (resists spread of glottic and subglottic tumors)
3) Broyle's tendon: insertion of vocalis tendon on thyroid cartilage, used as the basis for transoral surgery of laryngeal cancer |
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Term
| What is the T staging 8th AJCC edition for supraglottic laryngeal cancer? |
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Definition
T1) 1 subsite of supraglottis
T2) Invades mucosa of 1 additional subsite without VF fixation
T3) VF fixation or tumor in postcricoid area, pre-epiglottic space, paraglottic space or inner cortex of thyroid cartilage
T4) Advanced local disease |
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Term
| What is the T staging AJCC 8th edition of the most common site of laryngeal cancer? |
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Definition
Glottic is 60-65%, rarely metastatic compared to supraglottis
T1) Focal folds with normal mobility (T1b is bilateral VF involvement)
T2) Subglottis or supraglottis or impaired mobility of VF
T3) VF fixation or invasion of paraglottic space or inner cortex thyroid cartilage
T4) Advanced local disease |
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Term
| What are the classic histopathalogic descriptions of verrucous laryngeal cancer? |
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Definition
Benign appearing well-differentialted squamous epithelium with extensive hyperkeratosis, in tact basement membrane and "pushing margins"
Exophytic warty lesion grossly with excellent prognosis |
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Term
| When should elective neck dissection be considered in N0 neck of laryngeal cancer? |
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Definition
Supraglottic (elective bilateral or radiation, especially if T3/4 lesion)
Glottic does not require this if T1/2. For T3/4, necks elective ispilateral dissection |
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Term
| What are the indications and contraindications for vertial partial laryngectomy (hemilaryngectomy) |
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Definition
1) indicated for T1-2 glottic carcinomas in certain cases (rare given TLM)
2) Not if tumor extends beyond 1/3 of contralateral VF, >10mm anterior subglottic extension, <5mm posteiror subglottic extension, CA joint, AE fold or paraglottic space involvement
Risk of aspiration is significant**, requires FEV1/FVC>50-60% |
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Term
| When can you not consider a supracricoid laryngectomy? |
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Definition
Select T3-4 glottic and supraglottic space tumors that can involve pre-epiglottic space, paraglottic sace, ventricle, thyroid cartilage
1) Arytenoid fixation
2) Infraglottic extent that reaches upper border of cricoid |
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Term
| What are the useful molecular markers for nasopharyngeal cancer? |
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Definition
EBV association, also south asian descent
1) Early intracellular antigen (EA): specific
2)_Viral capsule antigen (VCA): late, sensitive
**Higher antibody titers predict better prognosis**
3) EBV RNA: useful for non-keratinizing or undifferentiated NPC, can predict prognosis
4) EBV DNA can be used for post-treatment monitoring |
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Term
| Describe the T and N staging AJCC 8th edition of nasopharyngeal cancer |
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Definition
1) T staging
- T1 (nasopharynx or oropharynx/nose without parapharyngeal involvement)
- T2 (parapharyngeal space or pterygoids/prevertebral muscles)
- T3 (bony invasion)
- T4 (intracaranial or cranial nerve involvement, orbit, parotid)
2) N staging
- N1 (unilateral cervical or bilateral retropharyngeal, <6cm and above cricoid caudal border)
- N2 (bilateral cervical above caudal border of cricoid)
- N3 (>6cm and/or extension below caudal border of cricoid) |
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Term
| What are the major WHO types of nasopharyngeal cancer? |
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Definition
1) Type 1: Keratinizing SCC, smoking, not EBV, sporadic, worse prognosis, less radiosensitive
2) Type 2 Non-keratinizing: EBV, endemic, radiosensitive, better prognosis
3) Type 3: Undifferentiated: lymphoepithelioma, EBC association, endemic, better prognosis, radiosensitive |
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Term
| What is the management of Nasopharyngeal cancer? |
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Definition
1) Stage 1-2: radiation to primary site and bilateral necks (regardless of nodal status)
2) Stage 3-4: chemoXRT (cisplatin/5-FU) followed by adjuvant chemotherapy
**limited surgical role) |
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Term
| What are the important contents of the PPF and the ITF? |
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Definition
1) PPF contains V2 (rotundum), vidian, pterygopalatine ganglion (sphenopalatine), maxillary artery)
2) ITF contains foramen ovale (V3), foramen spinosum (middle meningeal vessels), pterygoid muscles. |
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Term
| What are the clinical (Kadish) and pathalogical staging for Esthesioneuroblastoma? |
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Definition
Olfactory epithelium origin, bimodal frequency (teenagers, elderly)
T1 is nasal cavity + sinus but not superior ethmoid or sphenoid
T2 is sphenoid and/or cribriform
T3 is orbit and/or extradural cranial fossa
T4 is brain
2) Pathologic is Homer-Wright pseudorossetes (early) or Flexner-Wintersteiner (later) rossettes
**Management is surgery usually with post-operative radiation (consider neo or adjuvent chemo) |
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Term
| What is the key pathological finding for midline lesion of clivus/skull base? |
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Definition
| Chordoma, physaliferous cells |
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Term
| What are types of basal cell skin cancers, their relative prevalence and prognosis? |
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Definition
1) Nodular: most common, rolled appearance, good prognosis
2) Superficial: rare in H & neck, scaly/waxy
3) Morpheaform (sclerosing): flat or depressed, looks like scleroderms, agressive, worst prognosis
4) Pigmented: similar to nodular, more pigmented |
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Term
| What are types of melanoma, their relative prevalence and prognosis? |
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Definition
1) Superficial spreading (most common), 70% from junctional nevi
2) Nodular (very aggressive, worst prognosis)
3) Lentigo Maligna (elderly, sun-exposure), decent prognosis
4) Acral Lentiginous: hands/soles of feet (african americans) |
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Term
| What are the clark levels of melanoma depth? Breslow thickness? |
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Definition
1) Clark (oudated)
- epidermis (1), basal cell layer (2), papilllary dermis (3), reticular dermis (4), subcutaneous (5)
2) Breslow
- Outdated, depth in mm
**usually use AJCC staging** |
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Term
| What are T staging for melanoma? |
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Definition
1) T1a; <0.8mm without ulceration
2) T1b; 0.8-1mm with ulceration or <0.8 with ulceration
3) T2; 1-2mm
4) T3; 2-4mm
5) T4: >4mm |
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Term
| What is the N staging for melanoma? |
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Definition
a; occult, b; clinically detected c; in-transit, satellite or microsatellite mets
N1a: occult detect on SNLB
N1b: clinically
N1c: no node but in-transit met
N2a: 2-3 clinically occult
N2b: 2-3 clinically detected
N2c: 1 occult or detect LN with c
N3: >4 nodes (with a-c denotions) |
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Term
| What margins to you need for excision of melanoma by T stage? |
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Definition
1) Tis: 2-5mm
2) T1: 1cm
3) T2: 1-2cm
4) T3-4: 2cm margins
**consider delay in recon if margins are close** |
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Term
| When is SNLB indicated in melanoma management? |
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Definition
**adjuvent systemic options include interferon a-2b**
T1 lesions
1) <0.8mm with ulceration
2) 0.8-1mm with or without ulceration
T2/3 lesions
1) N0 neck, do SLNB, BRAF testing, if positive node, do ND |
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Term
| Which systemic agents are useful in metastatic melanoma? |
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Definition
1) Dacarbazine
2) PDL-1 inhibitors (Ipilimumab, nivolumab, vemurafenib)
3)_For IIb-III, consider IFN a-2b |
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Term
What are the most common sites of origin for mucosal melanoma?
How is it staged? |
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Definition
1) Nasal cavity and sinuses (70-80%)
2) Starts at T3 (mucosal disease). Anything more is T4
Very poor prognosis. |
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Term
| For Hodgkin's Lymphoma, what are the treatment approaches, and most common regimens? |
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Definition
1) Stage 1-2, consider single modality radiation
2) Stage III-IV, multimodality chemoXRT. MOP(P): mechlorethamine, oncovin, prednisone, procarbazine)
ABVD (adriamycin, bleomycin, vinblastine, DTIC) |
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Term
| Describe the anatomical boundaries of the parapharyngeal space. |
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Definition
Superior: skull base
Inferior: Junction of posterior digastric and greater corneu of hyoid
Medial: Lateral pharyngeal wall
Lateral: pterygoids
Posterior: prevertebral fascia, carotid sheath |
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Term
| Contents of pre- and post-styloid parapharyngeal space and associated lesions. |
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Definition
1) pre-styloid
- lymph nodes, parotid, max artery, inferior alveolar and lingual nerves (V3)
- most often salivary gland tumors
2) post-styloid
- carotid sheath, sympathetic chain, CN IX, X, XI, XIII
- Lesions are neurogenic or vascular |
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Term
| What are the major neuroendocrine malignancy types? |
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Definition
MR SLEEP
- melanoma, rhabdomyosarcoma, SNUC/sarcoma/small cell, Lymphoma, Ewings, Esthesio, PNET |
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