Head and Neck Cancer

A patient presents with numbness of left lower lip and a mass in floor of mouth. Examination demonstrates 2.5-cm biopsy-proven squamous cell carcinoma (SCC) of the floor of mouth with invasion of the mandible on CT scan and no lymph node involvement or distant metastases. According to the TNM classification, how would you stage this patient?

T4aN0M0 (stage IVA). Based upon size this would be a T2 tumor, however, invasion of the mental nerve (numbness) and through mandibular cortex makes this a T4 tumor.

Which surgical procedures are available for treating the mandible of the patient in Question 1?

Segmental mandibulectomy. Marginal mandibulectomy can be used when the tumor abuts the mandibular cortex but does not directly invade it.

How would you treat the neck of the patient in Question 1?

The options are surgery +/− radiotherapy versus radiotherapy alone. Traditionally for midline T4 tumors, bilateral neck dissections with postoperative radiotherapy to the both primary and bilateral necks.

What are the risk factors for increased risk of lymph node metastases?

High-grade histology, large lesions (T4), spread involving the nonkeratinized (wet) mucosa of the lip or buccal mucosa in patients with recurrent disease, and invasion of the orbicularis oris muscle. These patients all need elective lymph node radiation or neck dissection.

How would you treat the surgical defect if a segmental mandibulectomy were required for tumor clearance?

Free fibula flap for bone reconstruction taken with a cutaneous skin paddle to reconstruct the floor of mouth defect.

How would you treat the surgical defect if a rim/marginal resection only were required for tumor clearance?

A free radial forearm flap or anterolateral thigh flap for intraoral lining.

A 50-year-old patient presents with 1.5-cm tumor of the anterior tonsillar pillar with biopsy-proven SCC. The patient has no clinically palpable nodes or evidence of metastasis on work-up. How would you stage this tumor?

T1N0M0 (stage I).

What will be your treatment strategy?

Radiation or surgical resection is equally effective in stage I and II oropharyngeal cancers. Elective cervical lymph node dissection should be considered in anterior tonsillar pillar, tonsil and base of tongue lesions as the incidence of lymph node metastases is up to 70%.

What level of lymph nodes is the first to be involved?

Level 2 (jugulodigastric nodes) followed sequentially by levels III, IV, and V.

A 50-year-old patient presents with a 2-cm nonpulsatile mass in the level III of the neck. What is your management plan?

FNA biopsy and CT scan of head and neck.

If both CT and FNA are negative in the patient above, what is your plan?

Open biopsy with frozen sectioning and progression to neck dissection if diagnosis of SCC is obtained. Pan endoscopies of naso/oro/hypo-pharynx, larynx, esophagus, stomach. If all look normal, multiple biopsies are performed including tonsils, base of tongue, nasopharynx, and piriform fossa. Treatment of the primary depends on the results of these biopsies.

A patient presents with a 1-cm biopsy-proven tongue SCC and a palpable node in level II with no distant metastases. According to the TNM classification, how would you stage this patient clinically?

T1N1M0.

Following surgical excision pathological evaluation the tumor margins in the above patient were clear and the patient was staged as pT1N1M0. Would you perform radiotherapy to either the primary or the neck?

No, unless there is presence of extracapsular spread.

What are the indications for postoperative radiotherapy to the neck?

More than one neck node involved or evidence of extracapsular nodal disease.

What type of head and neck cancer is associated with Epstein–Barr viral infection?

Nasopharynx. Most commonly with a nonkeratinizing undifferentiated carcinoma. These tumors are rare in the United States but endemic in East Asia and Africa. Treatment is usually with chemotherapy and radiation with surgery reserved for recurrent cancer.

An 18-year-old male presents with progressive bilateral nasal obstruction and recurrent epistaxis. Anterior rhinoscopy demonstrates a soft, compressible purplish mass filling bilateral nasal cavities. What is the diagnosis?

Nasopharyngeal angiofibroma occurs most commonly in adolescent males with unilateral or bilateral nasal obstruction and recurrent epistaxis. Advanced lesions can deform the nose, face, and orbits and may even erode into the cranial cavity causing diplopia from pressure on the optic chiasm.

What is the treatment?

Preoperative embolization and estrogen hormonal therapy to limit intraoperative blood loss followed by surgical resection. Postoperative radiation is usually given in cases with intracranial extension. These should never be biopsied in the office due to risk of bleeding.

A patient requires segmental bony reconstruction of the mandible. This can be achieved by which methods?

Reconstructive plate with no bone, reconstruction with nonvascularized bone, and reconstruction with vascularized bone (free flap or pedicle flap).

When would you use a reconstruction plate?

For patients in whom no other reconstruction is possible, where good soft tissue exists, and/or when radiotherapy has not been performed and is not planned.

What types of vascularized bone on a pedicle flap exist?

Clavicle on the sternocleidomastoid flap, rib on the pectoralis major muscle, and scapula on the trapezius muscle.

What types of vascularized bone as a free flap would you consider?

Deep circumflex iliac artery (iliac crest) flap, radial forearm flap, free fibula flap, and free scapula flap.

Which free vascularized bone flap is most anatomically similar to a hemimandible?

Deep circumflex iliac artery (iliac crest) flap. Typically used for defects less than 5 cm.

Which free vascularized bone flap could you place osseointegrated implants into?

Fibula flap and deep circumflex iliac artery flap. Survival rate for osseointegrated dental implants in a nonirradiated free fibular flap is 95%.

Which free vascularized bone flap provides the longest length of bone?

Fibula flap. This is important if you are performing more than one osteotomy. Multiple osteotomies may be easily performed without disrupting the blood supply to the fibula given its segmental distribution.

A patient presents with a 2-cm mass in the parotid gland. Is the mass likely to be benign or malignant?