Cathy's Class

Front 1

Multiple tumor types are included in H&N region. Which type is most common?

Back 1

Squamous Cell Carcinoma

Front 2

The primary lymphatic drainage of the lower lip would be?

Back 2

Submental nodes

Front 3

What normal tissue would be at most risk of radiation damage when treating maxillary antrum?

Back 3

The Eye

Front 4

The most common sign symptom of oral cancer is?

Back 4

Ulceration

Front 5

The most common involved group of nodes in the oropharyngeal cancer is?

Back 5

Jugulogastric nodes

Front 6

A tumor confined to the larynx with cord fixation is in glottic cancer is staged at?

Back 6

T3

Front 7

Palpation of the cricoid cartilage indicates the inferior boarder of the?

Back 7

Larynx

Front 8

For pt's with carious teeth, when is dental work recommended when anticipating oral cavity irradiation?

Back 8

Before Tx

Front 9

Post cricoid cancer occur predominantly in women?

Back 9

True

Front 10

Tumors of the H&N may involve the cranial nerves that control out major senses. this may lead to signs and symptoms that can point to a possible location of a tumor. The Cranial nerve that may be involved in facial paralysis is cranial nerve?

Back 10

Cranial Nerve #7

Front 11

Which us not a common symptom for H&N Cancer

Back 11

Weight Loss

Front 12

For Tx of the Maxillary sinus?

Back 12

Angle the beam posteriorly to 15 degrees

Front 13

What is the stage if one cord is fixed?

Back 13

T3

Front 14

What if it extends to the Pharynx?

Back 14

T4

Front 15

Spreads to....but has normal mobility?

Back 15

T1

Front 16

What is the superior boarder while treating the nasopharynx?

Back 16

Base of Skull

Front 17

What is the most common cause for reassurance of laryngeal cancer?

Back 17

Geographic Miss

Front 18

How do we treat small tumors of tongue?

Back 18

Surgery or RT

Front 19

How does paranasal sinus spread?

Back 19

Direct invasion

Front 20

Vocal Cord Question: Normal voice depends on:
a. normal mobility of the cord
b. symmetrical closing and opening of the cord
c. Stream of Air
d. All of the above

Back 20

D. All of the Above

Front 21

What is the most common tx for parotid gland?

Back 21

Surgery

Front 22

If the pt is coughing persistently while on the tx table, what do you do?

Back 22

Call the doctor or nurse

Front 23

What are the structures do we observe the tolerance dose for in nasopharynx?

Back 23

Retina, Temporal lobe and optic nerve

Front 24

What is the most common etiology for H&N cancers?

Back 24

Tobacco

Front 25

What is the most common radiation side effect?

Back 25

Osteoradionecrosis (Bone Death)

Front 26

Why do supraglottis cancers have a poorer prognosis than Glottic cancers?

Back 26

Because the supraglottis has a very good lymphatic drainage system as apposed to the glottic

Front 27

With oral cavity cancers, we mostly see?

Back 27

Ulcerations

Front 28

If a pt has H&N cancer, then the pt has a greater chance of getting ?

Back 28

Lung cancer because both have the same etiology

Front 29

How do we treat posterior 2/3 of tongue?

Back 29

EBRT

Front 30

Relative to the vertebral bodies, where is the larynx located?

Back 30

C3-C6

Front 31

Which is part of the True Cord?

Back 31

Anterior Commissure

Front 32

Waldyer's ring is composed of?

Back 32

Lymphatic Tissue

Front 33

What is Moniliasis?

Back 33

A fungal infection caused by fungi of the genus Monilia or Candida

Front 34

What does Leukoplakia on skin of lips indicate?

Back 34

It indicates that the pt may be at risk for cancer

Front 35

Nodes that are palpable...

Back 35

Are nodes that be felt by touch due to the inflammation of the node

Front 36

What is nodal involvement on the same side of the disease called?

Back 36

Ipsilateral nodes

Front 37

WHAT IS THE DOSE TO THE NASOPHARYNX?

Back 37

75 Gy

Front 38

Which H&N cancers is the anterior field not tx?

Back 38

Maxillary sinus and True Cord (because they have poor lymphatic drainage)

Front 39

When using wedges, what is the orientation?

Back 39

Heel up to avoid anterior hot spots

Front 40

What are Wedged paired techniques used for?

Back 40

Parotid Gland [Mixed beam is used as well]

Front 41

What side effects, for H&N cancers, can a pt receive from radiation?

Back 41

Trismus [effect Temporal mandibular joint/lockjaw]

Front 42

What is not involved in tx volume of the nasopharynx?

Back 42

Optic Chiasm

Front 43

Why do we check for flash when treating larynx?

Back 43

To ensure the anterior structures are in the beam.

Front 44

How do we treat late stage larynx?

Back 44

Surgery and RT

Front 45

What does erythroplaisa in the floor of the mouth indicate?

Back 45

The Tumor has invaded.

Front 46

What side effects, for H&N cancers, can a pt receive from radiation?

Back 46

Trismus [effect Temporal mandibular joint/lockjaw]

Front 47

What is not involved in tx volume of the nasopharynx?

Back 47

Optic Chiasm

Front 48

What type of biopsy can be performed for parotid tumors?

Back 48

FNA (Fine Needle Aspiration), although an open biopsy can instigate the tumor causing it to become more aggressive.

Front 49

Why do we check for flash when treating larynx?

Back 49

To ensure the anterior structures are in the beam.

Front 50

What % of pt, nasopharyngeal cancer, have bilateral nodal involvement?

Back 50

50%

Front 51

How do we treat late stage larynx?

Back 51

Surgery and RT

Front 52

What is the uppermost node in the retropharyngeal group is?

Back 52

Node of Rouviere

Front 53

What does erythroplaisa in the floor of the mouth indicate?

Back 53

The Tumor has invaded.

Front 54

What type of biopsy can be performed for parotid tumors?

Back 54

FNA (Fine Needle Aspiration), although an open biopsy can instigate the tumor causing it to become more aggressive.

Front 55

Of the H&N cancers which plays the biggest role when treating with Chemo?

Back 55

Nasopharynx

Front 56

What % of pt, nasopharyngeal cancer, have bilateral nodal involvement?

Back 56

50%

Front 57

Where do most cancers originate in H&N?

Back 57

Mucus Membrane

Front 58

What is the uppermost node in the retropharyngeal group is?

Back 58

Node of Rouviere

Front 59

Of the H&N cancers which plays the biggest role when treating with Chemo?

Back 59

Nasopharynx

Front 60

Where do most cancers originate in H&N?

Back 60

Mucus Membrane

Front 61

What side effects, for H&N cancers, can a pt receive from radiation?

Back 61

Trismus [effect Temporal mandibular joint/lockjaw]

Front 62

What is not involved in tx volume of the nasopharynx?

Back 62

Optic Chiasm

Front 63

Why do we check for flash when treating larynx?

Back 63

To ensure the anterior structures are in the beam.

Front 64

How do we treat late stage larynx?

Back 64

Surgery and RT

Front 65

What does erythroplaisa in the floor of the mouth indicate?

Back 65

The Tumor has invaded.

Front 66

What type of biopsy can be performed for parotid tumors?

Back 66

FNA (Fine Needle Aspiration), although an open biopsy can instigate the tumor causing it to become more aggressive.

Front 67

What % of pt, nasopharyngeal cancer, have bilateral nodal involvement?

Back 67

50%

Front 68

What is the uppermost node in the retropharyngeal group is?

Back 68

Node of Rouviere

Front 69

Of the H&N cancers which plays the biggest role when treating with Chemo?

Back 69

Nasopharynx

Front 70

Where do most cancers originate in H&N?

Back 70

Mucus Membrane

Front 71

How does cancer behave without doing anything?

Back 71

Locally invasive, common lymph spread, not blood born, if it does spread through lymph it is mostly predictable. Rarely distant Mets

Front 72

Symptoms of H&N Cancers

Back 72

Sore throat, Cankered sore, Otitis Media, Odynophagia (painful swallowing, Hoarseness (if symptoms do not go away in 2 wks, it should be investigated)

Front 73

Who are the population with cx

Back 73

2/3 men

Front 74

Average age of H&N pt's

Back 74

40's

Front 75

What are the increased risk factors for cigarette smokers to develop H&N Cx

Back 75

Lung, Pancreas, Esophageal, and bladder.

Front 76

What are some factors that can predict lymphatic spread?

Back 76

1. The differentiation ((how close the cell resembles cell of the tumor) histology grade)) of the tumor
2. Size of the primary lesion
3. The presence of vascular space invasion, if it near or pressing on a blood vessel

Front 77

Is there a difference if a pt is tx with RT or Surgery when it comes to distant mets?

Back 77

There is no difference, both have the same chance for metastatic disease.

Front 78

Where are the risk for distant mets?

Back 78

Neck Stage and location of involved nodes in the low neck than to primary stage.

Front 79

What is the risk for N0 or N1?

Back 79

Less than 10%

Front 80

What happens if a person is diagnosed with N3?

Back 80

They are offered Chemo to help systemically control the spread.

Front 81

What organ does H&N cancer tend to metastatically go to?

Back 81

Lung

Front 82

1/2 metastases are recognized by....

Back 82

9 months, 80% by 2yrs, 90% by 3 yrs.

Front 83

What is the aim of Tx to H&N pt's

Back 83

To keep local control and avoid spread

Front 84

What is the complication when it comes to dose to H&N?

Back 84

The dose we want to give the pt cannot tolerate b/c of where the primary site is. `

Front 85

What would be done if the pt developed the inability to swallow on their own?

Back 85

Unfortuantky the pt would get a PEG to be fed. Although pt's are encouraged to swallow as to not lose the function.

Front 86

What do you think the most difficult thing for a PEG pt to swallow?

Back 86

Believe it or not its THIN LIQUIDS

Front 87

In Summary

Back 87

- Locally invasive
- likelihood of lymph nodes
- Unlikelihood of distant mets, some factors may change that.
- Common histology of Squamous Cell
- T2 do well (is cut off)
- Each organ site has its own staging b/c move a cm, you are in a different organ)
- T4 i common to have no mets,

Front 88

What is Epidemiology and Histology of the Oral cavity and Oropharynx?

Back 88

- Most common are Squamous Cell
- Occur after the age of 45
- Are associated with the use of tobacco and alcohol
- Cx of the lip is associated w/ sun exposure and pipe smoking

Front 89

Anatomy of the Lips

Back 89

- Anterior Boarder of oral cavity: the Vermillion (outside of lips)
- Posterior Boarder: the soft palate meet the hard palate (uval)
- Superior Boarder: The Mucosa of the hard palate
- Inferior Boarder: Floor of Mouth
- Lateral Boarder: Buccal Mucosa
- Contains: 2/3 tongue, gums, teeth, mucosa, glands (sublingual, salivary, perriatal)

Front 90

The Do's and Don't with oral cavity cancer.

Back 90

- Do-Use salin & baking soda (balance ph)
- Don't- Eat spicy Food
- Do- Use a baby toothbrush
- Don't- Use commercial mouthwash b/c of the alcohol

Front 91

Histopathology of the lip

Back 91

- Good blood & nerve supply
- BCC can start in the skin of the lip and may secondarily invade the vermilion
- Can have Begin lesions such as hemangioma, fibromas, and cysts.
-

Front 92

What is Keratoacanthoma and where does it form/?

Back 92

Occurs on the skin of the lip (from the sun and develops on the lower lip)

Front 93

What are some surgical approaches to lip cancer?

Back 93

- Cosmetically not wonderful
- W shape incision
- Quick solution for small cx
- Good for small cold sore

Front 94

Treatment with RT

Back 94

- better done with low energy photons
- for larger lesions it is recommended for a fractionation scheme of 50-55 Gy in 4-6 weeks ( that's is aggressively speaking)

Front 95

Outcomes of RT

Back 95

- Either RT or Surgery yield a five yr survival of about 90% (only 10% don't do well cause of sential node involvement)
- Cosmetic effects is generally better with RT
- Better survival rate for lower lip tumors

Front 96

Cancers of the interior oral cavity

Back 96

- Floor of Mouth (FOM)
- anterior 2/3 tongue
- buccal mucosa
- Retromolar Trigone

Front 97

Epidemiology of internal oral cavity

Back 97

- Malignant tumors of about 30% of all H&N and including lymph
- More Common in males

Front 98

Floor of Mouth (anatomic)

Back 98

- U-shaped area, sublingual glands geniohyoid muscles
- The tongue is a muscle

Front 99

Signs and symptoms

Back 99

- Leukoplakia-white spots
- 20% of cases
- Erythrophasia
- 50% are on the floor of the mouth

Front 100

Work up

Back 100

- examination of the mouth, nose and throat
- Chest x-ray, because if there are mets the first place it'll go is the lung
- CT & MRI to see if there is any disease.

Front 101

Staging

Back 101

T1, N0, T2, N0 do well
T3 or any Nodal involvement worsens the staging,

Front 102

What is the most common cell type with lip cx?

Back 102

- SCC with usually moderate Grade
- 5% are adenoid cystic and mucoepidermoid

Front 103

What happens when local extension is done?

Back 103

- 90% of the tumor, especially FOM arise in midline-not lateral
- Lesion mucosa (best prognosis); deep structure (worse prognosis)

Front 104

Lymphatic spread of the oral cavity?

Back 104

- 30% of pt's have cliniaclly positive nodes
- only 4% will have bilateral positive nodes
-Spread in an orderly fashion (n1,2,3,)
- First nodes involved are the submandibular (lvl 1) and Subdigastic (Lvl II) nodes,

Front 105

How should all H&N cancers be tx, curative or palliative?

Back 105

- Should be treated with a Curative intent
- Primary tumors should be treated radically, w/ a carful evaluation of the neck nodes,

Front 106

Types of treatment for Oral Cavity and Oropharynx.

Back 106

Surgical resection or RT works well for stages I &II, but the problem is the Pt is receiving Tx for 6-7 wks through the Jaw; even with IMRT ; most Pt will go with surgery

Stages III & IV do poorly w/ either modality alone. Therefore in most cases a combination of RT and Surgery are done. If the tumor is too large to remove surgically first then RT will be done to shrink the tumor in order to make it more accessible to the surgeons.

Front 107

Other Treatment Options for Oral Cavity and Oropharynx...

Back 107

- Chemotherapy will normally be used in combination with RT with the consideration on a large tumor.

- Preoperative RT and neoadjuvant chemotherapy are considered in Tx of huge masses
-If you do per-op RT, then you cannot do RT post-op

Front 108

How are Superficial T1 cx pt's?

Back 108

What is used is Brachytherapy(nasty but quick tx) or intraoral cone irradiation to ~65 Gy and the neck is observed

Front 109

How are larger lesions Tx with EBRT?

Back 109

Tx with EBRT to 40-45 Gy over 5 wks (depend on how big the lesion is (bigger the lesion, larger dose is needed)) followed by a boost though brachytherapy (interstitial implant for an additional 20-30 Gy)

Front 110

What could be a possibility RT will have poor results?

Back 110

The lesion are usually modernly well-differentiated which predict that they are not that radiosensitive.

Front 111

Why should a Pt see a dental consultation b4 RT Tx?

Back 111

WIth the RT the jaw can and probably will become soft or infected.
Minimum of 3 wks are necessary for healing before starting Tx

Front 112

Conventional 3 Field for floor of mouth and oral tongue

Back 112

Conventional 3 Field for floor of mouth and oral tongue

Front 113

How has IMRT corrected the problem with 3 field tx?

Back 113

Match Line

Front 114

Before Match lines what was the tx setup?
And what customized tx to the neck?

Back 114

- There were couch kicks, tilt gantry
- IMRT

Front 115

What is the MOST important this when setting up a H&N pt?

Back 115

- The positioning of the pt is MOST important
- For example, even with the best Tx planning it means nothing if the Pt is not set up correctly....probably the biggest concern is GEOGRAPHIC MISS

Front 116

When does IGRT tract target?

Back 116

Before Tx, NOT DURING

Front 117

What machine can track the target during Tx ?

Back 117

Cyber-Knife, it is so dynamic, continually x-raying Pt and making adjustments all at the same time

Front 118

Why is it important for maintaing positioning for small field Tx

Back 118

Because the margins are soo small you can have a geographic miss and when treating such a small field, usually will have a high dose (cGy)

Front 119

What dose does the Neck usually get?

Back 119

50 Gy and that is in consideration of lymph node involvement, regardless if positive nodes were or were not found they still treat to ensure sterilization.

Front 120

What was the problem during the 3 field tx prescription?

Back 120

The match line was either over dose or under dose. So pt was getting being either over tx or they RT was geographically missing the target.

Front 121

What are some of the impacts of the outcome of Oral Cavity and Oropharynx?

Back 121

-Survival is down with every stage, so nodes have a HUGE impact on pt survival.

Front 122

Now with IMRT what is a benefit?

Back 122

Because of the IMRT, it allows to spare the parotids and the Pt will not get Xerostomia (dry mouth)