Kj Lee 10Th Ed - Chapter 32 - Carcinoma Of The Oral Cavity, Pharynx, And Esophagus

Front 1

90% of malignant neoplams arising within the oral cavity and pharynx are _____________________

Back 1

SCCA

Front 2

What are the second most common type of oral cavity cancers?

Back 2

those arising from minor salivary glands

Front 3

Tobacco and alcohol have a multiplicative rather than additive effect resulting in a ___-fold increased risk for developing these cancers

Back 3

15

Front 4

Which virus increases risk of nasopharyngeal carcinoma?

Back 4

EBV

Front 5

Which genetic disease has been implicated in oral cavity carcinoma's?

Back 5

Li-Fraumeni syndrome

Front 6

What are the borders of the oral cavity?

Anterior
Posterior
Superior
Inferior

Back 6

Anterior - cutaneous-vermilion junction of the lips
Posterior - anterior tonsillar pillars
Superior - junction of hard & soft palate
Inferior - circumvallate papillae

Front 7

What are the subsites within the oral cavity?

Back 7

SEVEN subsites:
Lips
Oral tongue, anterior 2/3rds
Floor of Mouth
Buccal mucossa
Gingivas/Alveolar Ridges
Retromolar trigone
Hard palate

Front 8

What are the borders of the Oropharynx?

Anterior
Posterior
Superior
Inferior

Back 8

Anterior - anterior tonsillar pillars
Posterior - soft palate, tonsillar fossa posterior pharyngeal wall & BOT
Superior - inferior surface of the soft palate at the junction of the hard-soft palate
Inferior - superior surface of the hyoid bone

Front 9

What are the subsites within the oropharynx?

Back 9

FOUR subsites:
Soft palate and uvula
BOT
Tonsillar fossa
Pharyngeal wall (lateral and posterior)

Front 10

What are the borders of the hypopharynx?
Superior
Inferior

Back 10

Superior - superior border of the hyoid
Inferior - lower border of the cricoid cartilage

Front 11

What are the subsites within the hypopharynx?

Back 11

THREE subsites:
Pyriform sinuses (or fossa), left & right
Posterior hypopharyngeal wall
Postcricoid region
- this region extends from the arytenoid cartilages to the inferior aspect of the cricoid and connects the two pyriform sinuses, thus forming the anterior wall of the hypopharynx.

Front 12

What are the borders of the nasopharynx?
Anterior
Posterior
Inferior

Back 12

anterior - posterior edge of the choanae
posterior - free edge of the soft palate
inferior - free edge of the soft palate

Front 13

What are the subsites within the nasopharynx?

Back 13

THREE subsites:
Lateral walls (including the fossa of Rosenmuller (aka posterolateral recess) and eustachian tube orifices)
Vault of roof
Posterior wall

Front 14

Early stage (stage I-II) carcinoma of the oral cavity and pharynx (excluding nasopharynx) can be tx with what?

Back 14

Surgery or XRT

Front 15

Early stage (stage III - IV) carcinoma of the oral cavity and pharynx (excluding nasopharynx) can be tx with what?

Back 15

combination of chemotherapy and radiation or surgery and postop radiation

Front 16

What is the treatment of choice for nasopharyngeal carcinoma?

Back 16

XRT with OR without chemo

Front 17

What are the options for management of the N0 neck in pts with oral cavity and pharynx cancers?

Back 17

Several tx options are advocated:
1) expectant management
2) elective cervical lymphadenectomy
3) elective radiotherapy of the neck

Front 18

What is the incidence of second primary?

Back 18

Incidence of second primary SCCA is 5-10%
- 50% of second primaries arise in the H&N, while the lung is the next most common site (20%)

Front 19

Distant mets develops in ___% of pts with H&N cancer

Back 19

15%

Front 20

What are the factors which increase rate of distant mets?

Back 20

Higher nodal stage
Number of luymphatic mets
Advanced T stage
Hypopharynx as primary tumor site

Front 21

What is the typical follow-up schedule after definitive treatment for H&N cancer?

Back 21

Recurrences usually present in the first 2 years after tx.
For the first year - q4-6 weeks
For the second year - q3 months
For the third-fifth years - q6 months
Then q6-12 months for life

Front 22

What is the most common site of cancer in the oral cavity?

Back 22

lips

Front 23

What is the most common type of cancer of the lip?

Is there preference for upper or lower lip?

Back 23

95% are SCCA

95% lower lip, 5% upper lip
(BCC in general occurs on the upper lip than lower lip, but SCCA is still the overall most common ca of the upper lip)

Front 24

Is there is sex predilection for cancer of the lip?

Back 24

20-35:1 male to female ratio for the lower lip
5:1 male to female ratio for the upper lip

Front 25

What are the RF for cancer of the lip?

Back 25

Sunlight exposure
Lack of pigmented layer
Tobacco smoking

Front 26

How are small (T1, T2) lesions of the lip treated?

How are large (T3, T4) lesions of the lip treated?

Back 26

Small = radiation or surgery only

Large = combined modality therapy

Front 27

How is the lower lip closed if the size of the defect is less than 1/4 to 1/3 of the lip?

Back 27

Primary closure, facilipated by V-shaped excision

Front 28

How is the lower lip closed if the size of the defect is 1/4 to 1/2 of the lip?

Back 28

Bilateral advancement flaps or "lip-switch" flaps:
1) Abbe - when close to oral commissure (image)
2) Estlander - when involving the oral commissure

Front 29

How is the lower lip closed if the size of the defect is 1/2 to 2/3 of the lip?

Back 29

Karapandzic flap

Front 30

How is the lower lip closed if the size of the defect is 2/3 to total of the lip?

Back 30

Local flap reconstruction (Bernard-Burrow or Gillies fan flap) or free tissue transfer

Front 31

What is the overall 5-year survival rate for pts with lip cancer?

Back 31

About 91%
- lower as stage increases

Front 32

What is the second most common tumor of the oral cavity?

Back 32

tongue (30%) - most often arises along the lateral borders of the tongue

Front 33

What are the RF for tongue ca?

Back 33

Tobacco
Alcohol
Immunosuppression
Possibly poor oral hygiene

Front 34

What is the most common form of early SCCA on the tongue?

Back 34

erythroplakia

Front 35

What are the tx options for T1-T2 tongue ca?

Back 35

Partial glossectomy is indicated with reconstruction by primary closure, secondary intention or skin graft

External beam radiation with or without brachytherapy may be used in these pt's that are not suitable for or refuse surgery.

Front 36

What are the tx options for extensive tongue ca?

Back 36

Near-total or total glossectomy may be necessary
- even with flap reconstruction, there is significant morbidity associated with deglutition and maintenance of an adequate airway
- Aspiration may be a chronic problem, thus laryngectomy may be necessary
- In select pts, total glossectomy may be possible w/o total laryngectomy

Chemo may be considered for T4 tongue cancers, however, bone involvement usually requires surgical excision.

Front 37

How is the mandible managed in pts with tumors extending superficially to the gingiva?

How about if the tumor involves the periosteum?

Back 37

periosteum as the deep margin

if tumor involves the periosteum, may require at least a marginal mandiubulectomy with a horizontal cuff of alveolar ridge or saggital resection of the inner or outer cortex.

Front 38

Which nodes does tongue ca typically spread to?

Back 38

upper jugular nodes (73%) (ie. jugulodigastric)
submandibuar nodes (18%)
middle jugular nodes (18%)
submental nodes (9%)

Front 39

Elective tx of the neck with either surgery or radiation is recommended for primary tumors of which depth of invasion?

Which cervical levels should be dissected?

Back 39

2-4mm depth
typically at least a level I-III dissection is needed
bilateral neck dissection should be performed for midline dorsum or ventral tongue cancers

Front 40

What are 5-year survival rates for tongue ca?

Back 40

Stage I, II = 60-75%
Stage III, VI = 25-40%

Front 41

What is the 3rd most common site for oral cavity tumor?

Back 41

floor of the mouth

Front 42

Cervical mets from the floor of the mouth is typically seen in which nodes?

Back 42

Submandibular (64%)
Upper jugular (43%)
Submental nodes (7%)

Bilateral spread is not uncommon

Front 43

What is the rate of recurrance of FOM cancers?

Back 43

Recurrence at the primary site (41%) is more than twice as common as failure in the neck (19%)

Front 44

Retromolar cancers often have involvement of which nerve?

Back 44

Inferior alveolar nerve (V3) due to its close proximity to the mandibular foramen

Front 45

What is the lymphatic drainage of the retromolar trigone?

Back 45

predominately to the upper jugular LN

Front 46

What is the tx for stage I and II retromolar trigone tumors?

Back 46

Surgery and radiation are EQUALLY effective
If only soft tissue involvement - radiotherapy may result in less morbidity than surgery, but advanced-stage lesions often require BOTH

Front 47

If retromolar trigone tumor involves the mandible, what are the reconstruction options?

Back 47

Mandible defects <5cm = mandibular reconstruction bar to span the bony defect and a soft tissue flap

Mandibular defects >5cm - usually require a composite flap such as fibular osteocutaneous free flap

Front 48

What is the lymphatic drainage of cancers of the alveolar ridge?

Back 48

Most often to levels I and II

Front 49

Why is radiation therapy as the primary modality is not recommended for alveolar ridge tumors?

Back 49

because of the close proximity of tumor to the underlying bone, unless the pt is an unsuitable operative candidate

Front 50

Which tumor types are present in hard palate cancers?

Back 50

About 50% are SCCA
Minor salivary gland tumors

Front 51

Which benign dz process of the hard palate can be mistaken for malignancy?

Back 51

Necrotizing sialometaplasia

Front 52

What are the tx options for cancers of the hard palate?

Back 52

Although radiation can be used to tx carcinomas of this site, surgery is preferred. Radiation is more commonly reserved for adjuvant

Front 53

How is the neck managed with hard palate cancer?

Back 53

elective tx of the neck is generally not performed because of the low rate of occult mets

Front 54

What is the 5-year survival rate for hard palate cancers?

Back 54

44-75%

Front 55

Which product caused an oral cancer epidemic in India?

Back 55

"Pan" chewing, a combination of betel nut, lime and tobacco

Front 56

Which varient of SCCA has a predilection for the buccal mucosa?

Back 56

Verrucous carcinoma

Front 57

What are tx options for ps with carcinoma of the buccal mucosa?

Back 57

Surgical resection is the preferred method
Radiation alone or as adjuvant

Front 58

What are the number one and number two most common types of malignancies in the oropharynx?

Back 58

1) SCCA
2) Lymphoma - due to abudantly present lymphoid tissue in the oropharynx as part of Waldeyer's ring (mc sites are palatine tonsils and the BOT)

Front 59

Which HPV subtype has been shown to be prevalent in oropharyngeal carcinoma?

Back 59

HPV 16

Front 60

Soft palate tumors most frequently occur where?

Back 60

on the oral surface of the soft palate

Front 61

Where is the lymphatic drainage of soft palate cancers?

Back 61

upper jugular nodes (level II)

Front 62

What is the most common site for carcinoma of the oropharynx?

Back 62

tonsils

Front 63

What is the tx of choice for carcinoma of the tonsil and tonsillar pillars?

Back 63

Radiation or combined chemoradiation is generally the tx of choice

Front 64

What are the surgical options for carcinoma of the tonsil and tonsillar pillars?

Back 64

1) transoral excision - limited to very small lesions

2) anterior mandibulotomy with mandibular swing - useful for tonsil and BOT cancers w/o bony invasion. avoids sacrifice of inferior alveolar nerve and preserves sensation to lip and lower face.

3) composite resection - en bloc resection of posterior mandible and primary tumor.

Front 65

What is more aggressive, carcinoma of the oral tongue or BOT?

Back 65

BOT

Front 66

What are the mc presenting signs of BOT carcinoma?

Back 66

referred otalgia and odynophagia

Front 67

Which neck zones are most common for the lymph node mets in BOT carcinoma?

Back 67

levels II-IV (20% are bilateral)

Front 68

What is the primary treatment method for BOT carcinoma?

Back 68

like with other cancers of the oropharynx, XRT or chemoradiation are used

(surgery is used for small primary tumors or for salvage following XRT or chemorads)

Front 69

List some surgical procedures for BOT carcinoma

Back 69

Mandibular swing or composite resection
Median mandibuloglossotomy
Suprahyoid pharyngotomy - through a neck incision
Transoral laser resection

Front 70

Which syndrome is associated with hypopharyngeal carcinoma?

Back 70

Plummer-Vinson syndrome - IDA, dysphagia, mucosal webs, wt loss, angular stomatitis, and atrophic glossitis. affects women

Front 71

In the US, cancer of which hypopharynx site predominates?

Back 71

Pyriform sinus carcinoma

Front 72

A characteristic feature of hypopharyngeal cancer is its tendency for ___________________

Back 72

submucosal spread

Front 73

What is the primary modality in the tx of T1 and selected T2 lesions of the hypopharynx?

Back 73

XRT alone
(adjuvant postop XRT plays an important role in advanced-stage cancers of the hypopharynx)

Front 74

What role does surgery play if cancer of the hypopharynx involves the posterior hypopharyngeal wall?

Back 74

selected tumors can be resected with laryngeal preservation if there is no fixation to the preverterbral fascia
approach via transhyoid or median labiomandibular glossotomy

Front 75

What role does surgery play if cancer of the hypopharynx involves the postcricoid mucosa?

Back 75

usually present at an advanced stage and therefore require total laryngopharyngectomy
these lesions can involve the cervical esophagus and require laryngopharyngoesophagectomy.

Front 76

What role does surgery play if cancer of the hypopharynx involves the pyriform sinus?

Back 76

Extended partial laryngopharyngectomy
Supracricoid hemilaryngopharyngectomy
Total laryngopharyngectomy

Front 77

What are the THREE types of WHO classifications of nasopharynx carcinoma?

Back 77

Type I - keratinizing SCCA (25%)
Type II - nonkeratinizing SCCA (12%)
Type III - undifferentiated carcinoma (63%)

Front 78

Which nasopharyngeal carcinoma types are endemic and which are sporadic? What are the risk factors of these groups?

Back 78

Endemic = WHO Type II and III
- EBV, genetic predisposition, environmental factors (certain food preservatives)

Sporadic = WHO type I
- tobacco and alcohol exposure

Front 79

At which decades does NPC peak?

Back 79

Fifth and sixth decades
20% present in pts under the age of 30 (young pts more likely to have WHO III (undifferentiated))

Front 80

What is the role of EBV in nasopharyngeal carcinoma (NPC)?

Back 80

EBV is a double-stranded DNA virus that is part of the human herpesvirus family.
It establishes persistent, chronic infection, usually in B lymphocytes.
90-95% of the populations have demonstrable EBV Ab's by adulthood
Molecular cytogenetic studies have confirmed that EBV infection is an early, possibly initiating event in the development of NPC

Front 81

What is the primary tx modality for NPC?

Back 81

Radiation therapy or chemoradiation is the primary tx modalities
Chemotherapy concurrently with XRT for NPC has been shown to improve overall survival rates recently

Front 82

What role does surgery place in NPC?

Back 82

Resection is technically difficult due to architecture and inaccessibility of the anterosuperior skull base
Reserved for highly selected pts in cases of radiation failure or tumor recurrence.

Front 83

What are the local and regional control rates of NPC with radiation? How about with radiation with concurrent chemotherapy?

Back 83

XRT - 60%
Radiation with concurrent chemotherapy - 70-80%

Front 84

What are the 5-year survival rates of NPC with radiation? How about with radiation with concurrent chemotherapy?

Back 84

XRT - 36-58%
Radiation with concurrent chemotherapy - 70-80%

Front 85

Which subsite within the head and neck region that has the highest rate of distant mets?

Back 85

Cancers of the nasopharynx - 25-30% of pts
- whereas local and regional failure previously accounted for most morbidity and mortality, distant mets now is a frequent mode of failure and death

Front 86

What types of cancer is prevalent in esophageal cancer?

Back 86

SCCA or adenocarcinoma

Front 87

Where does adenocarinoma occur in the esophagus?

Where does SCCA occur in the esophagus?

Back 87

>75% of adenocarcinomas occur in the distal esophagus.

SCCA is more EVENLY distributed throughout the esophagus

Front 88

What is the most common site of primary esophageal cancer?

Back 88

distal third > middle third > proximal third

Front 89

What are the RF for SCCA of the esophagus?

Back 89

Tobacco
Alcohol use
Achalasia
Caustic injury
Plummer-Vinson syndrome
Hx of H&N cancer
Hx of radiation therapy to the mediastinum
Low socioeconomic status
Nonepidermolytic palmoplantar keratoderma (tylosis; image)

Front 90

What are the RF for adenocarcinoma of the esophagus?

Back 90

Barrett's esophagus
Weekly acid reflux
Tobacco use
Hx of radiotherapy to the mediastinum

Front 91

What is the annual rate of malignant transformation in Barrett's esophagus?

Back 91

0.5% annually

Front 92

At the time of diagnosis of esophageal cancer, what % of patients have distant mets or an unresectable primary tumor?

Back 92

50%

Front 93

What role does surgery play in esophageal cancer?

Back 93

Early-stage dz is tx with a transthoracic or transhiatal approach for partial or total esophagectomy
Transcervical approach for upper cervical esophagus or inferior extension from hypopharynx
Laryngectomy with or without partial tracheal resection may be necessary for upper cervical esophageal cancer
Endoscopically placed stents may be deployed for palliative tx of dysphagia in advanced dz

Front 94

What role does radiation play in esophageal cancer?

Back 94

Primary radiotherapy may be used an alternative tx in pts with medical comorbidities that prevents surgical resection
No improvement in survival has been demonstrated with preop XRT
Postop XRT improved local dz control and is useful in pts at high risk for recurrence, tracheoesophageal fistula, or presence of residual dz

Front 95

What role does chemotherapy play in esophageal cancer?

Back 95

Preop chemo may result in a reduction in primary tumor size as well as tx regional and distant mets, but no survival benefit has been demonstrated
Postop chemo may also tx regional and distant mets but results in increased toxicity, morbidity and no improvement in survival

Front 96

What role does chemoradiation play in esophageal cancer?

Back 96

Increased toxicity bu better tumor response
If utilized preoperatively, the reduction in tumor size may allow for complete surgical resection
No clear survival benefit when used preop

Front 97

What is the overall 5-year survival rate for esophageal cancer?

Back 97

14%