Management of Head and Neck Cancer Indian Medical PG Practice Questions and MCQs
Practice Indian Medical PG questions for Management of Head and Neck Cancer. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Management of Head and Neck Cancer Indian Medical PG Question 1: What is the most common oral cancer?
- A. Transition cell ca
- B. Mucoepidermoid
- C. Adenocarcinoma
- D. Squamous cell ca (Correct Answer)
Management of Head and Neck Cancer Explanation: ***Squamous cell ca***
- **Squamous cell carcinoma (SCC)** accounts for over **90% of all oral cancers**, making it the most prevalent type.
- It arises from the **stratified squamous epithelium** lining the oral cavity.
*Transition cell ca*
- This term is more commonly associated with tumors of the **urinary tract**, such as transitional cell carcinoma of the bladder.
- **Transitional cell carcinomas** are not typically found in the oral cavity.
*Mucoepidermoid*
- **Mucoepidermoid carcinoma** is the most common primary malignant tumor of **salivary glands**, not the oral cavity lining.
- While salivary glands are in the oral region, this type of cancer originates specifically from these glands.
*Adenocarcinoma*
- **Adenocarcinoma** originates from **glandular tissue** and represents a small percentage of oral cancers.
- It is much **less common** than squamous cell carcinoma in the oral cavity.
Management of Head and Neck Cancer Indian Medical PG Question 2: What is the most appropriate treatment after resection of lateral border of tongue carcinoma with high-risk features (positive margins, perineural invasion)?
- A. Systemic chemotherapy
- B. Adjuvant radiotherapy (Correct Answer)
- C. Surgical neck dissection
- D. Postoperative observation
Management of Head and Neck Cancer Explanation: ***Adjuvant radiotherapy***
- **Adjuvant radiotherapy** is the **standard of care** after surgical resection of **oral tongue squamous cell carcinoma** with **high-risk features** such as:
- **Positive or close margins** (<5 mm)
- **Perineural invasion (PNI)**
- **Lymphovascular invasion (LVI)**
- **Deep tumor invasion** (>4 mm depth)
- **Advanced T stage** (T3-T4)
- These features significantly **increase the risk of local recurrence**, and adjuvant radiotherapy improves **locoregional control** and **overall survival**.
- The **tongue** has rich lymphatic drainage making it prone to both local recurrence and regional metastasis, necessitating adjuvant therapy.
*Systemic chemotherapy*
- **Systemic chemotherapy alone** is not used as adjuvant treatment after resection of oral tongue carcinoma.
- It may be combined with radiotherapy (**concurrent chemoradiotherapy**) in cases with **extranodal extension** or multiple positive nodes, but standalone chemotherapy is reserved for **palliative treatment** of distant metastatic disease.
*Surgical neck dissection*
- **Neck dissection** is typically performed **at the same time** as primary tumor resection (concurrent procedure), not as a separate "after treatment."
- It addresses **regional lymph node metastasis** rather than controlling the primary tumor site.
- If not done initially and nodes become clinically positive later, it would be therapeutic neck dissection, but this is not routine adjuvant therapy.
*Postoperative observation*
- **Observation alone** is appropriate only for **very early-stage disease** (T1N0) with **clear margins** (>5 mm), **no depth invasion** (<4 mm), and **absence of adverse features** like PNI or LVI.
- Given the presence of **high-risk features** in this scenario, observation would result in unacceptably high rates of **local recurrence**.
Management of Head and Neck Cancer Indian Medical PG Question 3: Treatment of stage III carcinoma of oral tongue is:
- A. Wide excision
- B. Radiotherapy delivering 7000 cGy
- C. Wide excision with supraomohyoid neck dissection
- D. Wide excision with supraomohyoid neck dissection and post-operative radiotherapy (Correct Answer)
Management of Head and Neck Cancer Explanation: ***Wide excision with supraomohyoid neck dissection and post-operative radiotherapy***
- For **Stage III carcinoma of the oral tongue**, combining **wide excision** of the primary tumor with a **supraomohyoid neck dissection** (for potential lymphatic spread) and **postoperative radiation therapy** is the standard of care for optimal outcomes.
- This multimodal approach addresses both the primary tumor and regional nodal disease, reducing recurrence risk and improving survival in advanced stages.
*Wide excision*
- While essential for local control of the primary tumor, **wide excision alone** is insufficient for **Stage III disease** as it fails to address potential regional lymphatic involvement.
- Stage III oral tongue carcinoma often indicates a higher likelihood of **nodal metastases**, which wide excision does not treat.
*Radiotherapy delivering 7000 cGy*
- **Radiotherapy** alone as a primary treatment for resectable Stage III oral tongue carcinoma is generally not the preferred approach.
- While radiation is a crucial component, it is typically used **adjuvantly** to surgery, not as a sole definitive treatment for such advanced resectable tumors.
*Wide excision with supraomohyoid neck dissection*
- This combination effectively targets the **primary tumor** and potential **regional lymph node metastases** in the neck.
- However, for **Stage III disease**, the risk factors for local or regional recurrence are significant enough to warrant **adjuvant postoperative radiotherapy** to sterilize any residual microscopic disease, making this option incomplete.
Management of Head and Neck Cancer Indian Medical PG Question 4: Treatment of choice for carcinoma larynx T1N0M0 stage -
- A. External beam radiotherapy (Correct Answer)
- B. Surgery
- C. Radioactive implants
- D. Surgery & radiotherapy
Management of Head and Neck Cancer Explanation: ***External beam radiotherapy***
- For **early-stage laryngeal cancer (T1N0M0)**, both **radiotherapy and surgery are considered equally effective first-line treatments** with excellent local control rates (>90%).
- EBRT offers the advantage of being **completely non-invasive** while preserving vocal function and avoiding surgical risks.
- Treatment duration is typically **6-7 weeks**, requiring patient compliance with daily fractions.
- Preferred when patient prefers non-invasive approach or has comorbidities making surgery high-risk.
*Surgery*
- **Transoral laser microsurgery (TLS)** or endoscopic **cordectomy** are equally effective surgical options for T1 glottic cancer with cure rates comparable to radiotherapy.
- Modern laser techniques provide excellent **voice preservation** with minimal morbidity.
- Advantages include **shorter treatment time** (single procedure), obtaining tissue for histopathology, and preserving radiotherapy as salvage option.
- Both **surgery and radiotherapy are Category 1 recommendations** for T1N0M0 disease; choice depends on institutional expertise, patient preference, and individual factors.
*Radioactive implants*
- **Brachytherapy (radioactive implants)** can be used for early-stage glottic cancer at specialized centers.
- However, **external beam radiotherapy** is more commonly employed due to greater accessibility and extensive outcome data.
*Surgery & radiotherapy*
- **Combined modality treatment** is indicated for **locally advanced disease** (T3-T4) or **node-positive disease** (N+).
- For **T1N0M0 disease**, single modality (either surgery OR radiotherapy) is sufficient and preferred to minimize treatment-related morbidity.
Management of Head and Neck Cancer Indian Medical PG Question 5: Identify the marked structure in the given image.
- A. Electrode
- B. Coil (Correct Answer)
- C. Magnet
- D. Processor
Management of Head and Neck Cancer Explanation: ***Coil***
- The marked structure appears to be a **cochlear implant's internal coil**, which is common in X-ray imaging of these devices.
- The **cochlear implant internal coil** is crucial for transmitting processed sound signals via electromagnetic induction to the electrode array within the cochlea.
*Electrode*
- An **electrode array** is typically a thin, flexible wire with multiple contacts inserted into the cochlea, which is not what the arrow is pointing to directly.
- While electrodes are part of a cochlear implant, the marked structure's shape and position are more consistent with the **internal coil** that connects to the electrode array.
*Magnet*
- A **magnet** is present in a cochlear implant system, typically in both the external processor and internal receiver, to hold these two components together through the skin.
- Magnets usually appear as dense, circular structures in X-rays, often seen more anteriorly or superiorly to the coil for external component alignment.
*Processor*
- The **processor** for a cochlear implant is an external device worn behind the ear, not an implanted component visible on an X-ray. It processes sound and sends it to the internal coil.
- The structures seen in the X-ray are **implanted components** of the cochlear implant, not the external sound processor.
Management of Head and Neck Cancer Indian Medical PG Question 6: Most common presentation in nasopharyngeal carcinoma is with:
- A. Cervical lymphadenopathy (Correct Answer)
- B. Epistaxis
- C. Hoarseness of voice
- D. Nasal stuffiness
Management of Head and Neck Cancer Explanation: ***Cervical lymphadenopathy***
- **Cervical lymphadenopathy** is the most frequent initial symptom, with over 75% of patients presenting with a palpable neck mass, often a **painless, firm mass** in the upper deep cervical chain.
- This is due to the rich lymphatic drainage of the nasopharynx to the cervical lymph nodes, leading to early metastasis.
*Epistaxis*
- While **epistaxis** (nosebleeds) can occur in nasopharyngeal carcinoma, it is generally not the most common presenting symptom.
- It usually presents as recurrent, mild **epistaxis** or bloody discharge rather than severe bleeding.
*Hoarseness of voice*
- **Hoarseness of voice** is typically associated with laryngeal involvement or recurrent laryngeal nerve palsy, which is a less common and usually later manifestation of nasopharyngeal carcinoma.
- Primary nasopharyngeal tumors do not directly cause hoarseness unless they extend significantly or metastasize to structures affecting vocal cord function.
*Nasal stuffiness*
- **Nasal stuffiness** or obstruction can be a symptom due to tumor growth within the nasopharynx.
- However, it is a less specific symptom and often overshadowed by the more prominent presentation of cervical lymphadenopathy.
Management of Head and Neck Cancer Indian Medical PG Question 7: Which of these is the STRONGEST indication for giving adjuvant treatment in oral malignancy after resection and Modified Radical Neck Dissection (MRND)?
- A. Extranodal extension (Correct Answer)
- B. Multiple lymph node metastasis
- C. T3 tumor
- D. Close margin
Management of Head and Neck Cancer Explanation: ***Extranodal extension***
- **Extranodal extension (ENE)** is the strongest adverse pathological feature (APF) indicating the highest risk of recurrence and significantly impacting prognosis.
- ENE is associated with increased likelihood of regional and distant metastasis.
- The presence of ENE mandates **adjuvant concurrent chemoradiotherapy** (not radiotherapy alone), as landmark trials (EORTC 22931, RTOG 9501) demonstrated survival benefit with combined modality treatment.
- ENE and positive surgical margins are the two most critical features requiring intensified adjuvant therapy.
*Multiple lymph node metastasis*
- Multiple positive lymph nodes (≥2 nodes) indicate high risk of recurrence and warrant **adjuvant radiotherapy**.
- While this is a significant adverse feature, it does not mandate chemoradiotherapy unless accompanied by ENE or positive margins.
- Considered a high-risk feature but not as strong an indication as ENE.
*T3 tumor*
- T3 tumor indicates significant local invasion but is a clinical staging parameter, not a pathological adverse feature.
- The decision for adjuvant therapy depends primarily on pathological findings (margins, lymph node status, ENE) rather than T-stage alone.
- T3 status without adverse pathological features may not require adjuvant treatment after complete resection.
*Close margin*
- Close margin (tumor within 1-5 mm of resected edge) is a high-risk feature warranting **adjuvant radiotherapy** due to increased local recurrence risk.
- However, it is less critical than ENE in terms of overall survival and regional control.
- A **positive margin** (<1 mm or tumor at ink) would be equivalent to ENE as an indication for chemoradiotherapy, but a close margin typically requires radiotherapy alone.
Management of Head and Neck Cancer Indian Medical PG Question 8: A patient presents with a cheek cancer of 2.5 cm size, which is close to and involves the alveolus, and is associated with a single mobile cervical lymph node of 6 cm size. What is the TNM staging?
- A. T3 N2
- B. T4 N2 (Correct Answer)
- C. T3 N3
- D. T4 N3
Management of Head and Neck Cancer Explanation: ***T4 N2***
- The primary tumor involving the **alveolus (cortical bone invasion)** is classified as **T4a** regardless of size according to AJCC TNM staging for oral cavity cancers.
- A single mobile ipsilateral cervical lymph node of **6 cm** is classified as **N2a** (single ipsilateral node, 3-6 cm in greatest dimension).
- Therefore, the correct staging is **T4 N2**.
*T3 N2*
- **T3 classification is incorrect** as alveolar involvement (cortical bone invasion) automatically upgrades the tumor to T4a.
- While N2 is correct for a single 6 cm node, the T-stage is underestimated.
*T4 N3*
- While **T4 is correct** due to alveolar bone involvement, **N3 is incorrect**.
- **N3a requires lymph nodes >6 cm** (greater than 6 cm), not equal to 6 cm.
- A single 6 cm node falls within the N2a category (3-6 cm range).
*T3 N3*
- **Both T3 and N3 are incorrect** for this presentation.
- Alveolar involvement mandates T4 staging, and a 6 cm node is N2a, not N3.
Management of Head and Neck Cancer Indian Medical PG Question 9: Late effects of radiation therapy include:
- A. Mucositis, Enteritis, Nausea and vomiting, Pneumonitis
- B. Enteritis, Nausea and vomiting, Pneumonitis, Somatic mutations
- C. Mucositis, Nausea and vomiting, Pneumonitis, Somatic mutations
- D. Mucositis, Enteritis, Pneumonitis, Somatic mutations (Correct Answer)
Management of Head and Neck Cancer Explanation: ***Mucositis, Enteritis, Pneumonitis, Somatic mutations***
- **Somatic mutations** leading to **secondary malignancies** are a classic late effect of radiation (occurs years after exposure due to DNA damage) [1]
- **Radiation pneumonitis** progressing to **pulmonary fibrosis** is a well-recognized late complication (typically 1-3 months to years post-treatment) [1]
- **Chronic radiation enteritis** with fibrosis and vascular damage can occur months to years after abdominal/pelvic radiation [1]
- **Chronic mucositis** with fibrosis can persist as a late effect, though mucositis is more commonly acute
- This option represents the **most comprehensive list of late effects** among the choices
*Mucositis, Enteritis, Nausea and vomiting, Pneumonitis*
- **Nausea and vomiting** are predominantly **acute side effects** occurring during or immediately after radiation therapy, not late effects
- While mucositis and enteritis can have chronic forms, including nausea/vomiting makes this option incorrect
*Enteritis, Nausea and vomiting, Pneumonitis, Somatic mutations*
- Incorrectly includes **nausea and vomiting** as a late effect
- Though it includes somatic mutations (correct late effect), the presence of an acute symptom invalidates this choice
*Mucositis, Nausea and vomiting, Pneumonitis, Somatic mutations*
- Incorrectly includes **nausea and vomiting** as a late effect
- Omits enteritis, which can manifest as chronic radiation enteritis with fibrosis and strictures
**References:**
[1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Central Nervous System Synapse, pp. 437-439.
Management of Head and Neck Cancer Indian Medical PG Question 10: Carcinoma of pyriform fossa usually presents with :
- A. Lump in the neck
- B. Cough
- C. Dysphagia (Correct Answer)
- D. Hoarseness
Management of Head and Neck Cancer Explanation: ***Dysphagia***
- Carcinoma of the **pyriform fossa** is a type of hypopharyngeal cancer, and given its anatomical location, it commonly interferes with swallowing [1].
- The pyriform fossa lies immediately lateral to the laryngeal inlet, and involvement here directly impacts the ability to form a **food bolus** and propel it into the esophagus.
*Lump in the neck*
- A neck lump can occur, especially if there is **lymph node metastasis**, but it's often a later symptom [1].
- **Dysphagia** usually precedes the development of a palpable neck mass as the primary tumor expands within the pyriform fossa [1].
*Cough*
- While aspiration might lead to coughing, it's not the primary presenting symptom.
- Cough is more commonly associated with laryngeal involvement or **tracheal invasion**, which can occur with advanced disease.
*Hoarseness*
- **Hoarseness** is a prominent symptom if the **vocal cords** or recurrent laryngeal nerve are directly involved [2].
- The pyriform fossa is adjacent but distinct from the vocal cords, so hoarseness is not typically the initial or most common symptom unless the tumor extends medially.
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