Laryngeal Cancer — MCQs
65 year old man with carcinoma of tongue of > 4 cm size and multiple lymph nodes of > 6 cm noted. What is the AJCC staging?
A patient presents with hoarseness and laryngoscopy reveals a warty, cauliflower-like growth on the vocal cord. Identify the most likely lesion.
All the following statements about laryngeal carcinoma are true except:
Stage IVa with thyroid cartilage invasion in laryngeal carcinoma is treated with:
What is the name of the nerve block technique shown in the image?
A 50-year-old smoker presents with hoarseness, dysphagia, and weight loss. Flexible laryngoscopy shows a mass on the vocal cords. What is the next best step?
Descending order of cancer prevalence in males in India?
Treatment of resectable T4N0M0 stage of head and neck carcinoma is?
Inspiratory stridor is due to lesions of:
Treatment of choice for carcinoma larynx T1N0M0 stage -
Laryngeal Cancer Indian Medical PG Practice Questions and MCQs
Question 1: 65 year old man with carcinoma of tongue of > 4 cm size and multiple lymph nodes of > 6 cm noted. What is the AJCC staging?
- A. T3 N3 M0 (Correct Answer)
- B. T2 N3 M0
- C. T3 N2 M0
- D. T2 N2 M0
Explanation: ***T3 N3 M0*** - The primary tumor (T) is classified as **T3** because its greatest dimension is greater than 4 cm (or any tumor with depth of invasion > 10 mm). - The nodal involvement (N) is classified as **N3** (specifically **N3a**) because any lymph node greater than 6 cm, regardless of number, qualifies as N3a per **AJCC 8th Edition** staging. - This is the correct staging based on the clinical findings provided. *T2 N3 M0* - This is incorrect because a tumor > 4 cm automatically classifies as **T3**, not T2. - **T2** is reserved for tumors > 2 cm but ≤ 4 cm with depth of invasion ≤ 10 mm, or tumors ≤ 2 cm with depth of invasion > 5 mm and ≤ 10 mm. - While the N3 classification is correct, the T staging is wrong. *T3 N2 M0* - This is incorrect because although **T3** is correct for a tumor > 4 cm, the nodal classification is wrong. - Any lymph node > 6 cm is classified as **N3a**, not N2. - **N2** classifications require all involved nodes to be ≤ 6 cm in size. *T2 N2 M0* - This is incorrect as both the T and N classifications are inaccurate. - A tumor > 4 cm is **T3**, not T2. - Lymph node(s) > 6 cm are **N3a**, not N2. - This represents understaging of both the primary tumor and nodal disease.
Question 2: A patient presents with hoarseness and laryngoscopy reveals a warty, cauliflower-like growth on the vocal cord. Identify the most likely lesion.
- A. Laryngeal papilloma (Correct Answer)
- B. Laryngeal malignancy
- C. Tracheomalacia
- D. Reinke’s edema
Explanation: ***Laryngeal papilloma*** - **Hoarseness** and a **warty, cauliflower-like growth** on the vocal cord are classic descriptions of a laryngeal papilloma, often caused by **HPV infection**. - These lesions can be solitary or multiple, and while benign, they can recur and cause voice changes and respiratory obstruction. *Laryngeal malignancy* - While hoarseness is a common symptom of laryngeal malignancy, the description of a **"warty, cauliflower-like growth"** is more characteristic of a papilloma than most typical carcinomas, which might appear more ulcerative or infiltrative. - Malignancies are more commonly associated with risk factors like **smoking and alcohol use**, and often present with other symptoms like dysphagia or weight loss. *Tracheomalacia* - **Tracheomalacia** refers to softening of the tracheal cartilage, leading to airway collapse, typically causing stridor or respiratory distress. - It does not present as a **discrete growth** on the vocal cords but rather as a diffuse structural weakness of the trachea. *Reinke’s edema* - **Reinke's edema** (polypoid corditis) is characterized by a **gelatinous or fluid-filled swelling** of the vocal cords, usually associated with chronic irritation like smoking. - It presents as a swollen, boggy appearance of the vocal cords, not a warty or cauliflower-like growth.
Question 3: All the following statements about laryngeal carcinoma are true except:
- A. Laryngeal carcinoma is more common in males.
- B. Laryngeal carcinoma is associated with smoking.
- C. Laryngeal carcinoma is more common in individuals over 40 years of age.
- D. Laryngeal carcinoma has a poor prognosis. (Correct Answer)
Explanation: ***Laryngeal carcinoma has a poor prognosis.*** - While prognosis depends on stage and treatment, laryngeal carcinoma, especially when detected early, often has a **relatively good prognosis** compared to other head and neck cancers, with overall survival rates exceeding 50-60%. - Many patients, particularly those with early-stage disease, can be cured with **surgery or radiation therapy** while preserving laryngeal function. *Laryngeal carcinoma is more common in males.* - **Laryngeal carcinoma** demonstrates a significant **male predominance**, with incidence rates typically 4 to 5 times higher in men than in women. - This disparity is largely attributable to historically higher rates of **smoking and alcohol consumption** among men. *Laryngeal carcinoma is associated with smoking.* - **Smoking** is the most significant and well-established **risk factor** for laryngeal carcinoma, with the risk directly correlated to the intensity and duration of tobacco use. - Exposure to **carcinogens in tobacco smoke** directly damages laryngeal epithelial cells, leading to dysplasia and eventual malignant transformation. *Laryngeal carcinoma is more common in individuals over 40 years of age.* - The incidence of **laryngeal carcinoma** significantly increases with age, with the majority of cases diagnosed in individuals **over the age of 50 or 60 years**. - This age distribution reflects the cumulative exposure to **environmental carcinogens** like tobacco and alcohol over a longer lifespan.
Question 4: Stage IVa with thyroid cartilage invasion in laryngeal carcinoma is treated with:
- A. Total laryngectomy
- B. Radiotherapy
- C. Total laryngectomy with radiotherapy (Correct Answer)
- D. Hemilaryngectomy
Explanation: ***Total laryngectomy with radiotherapy*** - **Stage IVa laryngeal carcinoma** with **thyroid cartilage invasion** is considered advanced disease requiring aggressive treatment. - **Multimodal therapy** combining surgical resection (total laryngectomy) to remove the tumor and adjuvant radiotherapy to address microscopic disease and reduce recurrence is the standard of care. *Total laryngectomy* - While a **total laryngectomy** is necessary to remove the primary tumor with cartilage invasion, it often requires additional (adjuvant) therapy like radiation to improve local control and survival rates. - Relying solely on surgery for **Stage IVa disease** may not adequately address potential microscopic spread, leading to higher recurrence rates. *Radiotherapy* - **Radiotherapy alone** is typically reserved for early-stage laryngeal cancers or as a palliative measure for advanced, unresectable disease. - In Stage IVa with **thyroid cartilage invasion**, radiation alone is insufficient due to the bulk of the disease and high risk of local recurrence. *Hemilaryngectomy* - A **hemilaryngectomy** is a partial removal of the larynx, suitable for much smaller, early-stage tumors that are confined to one side of the larynx, without cartilage invasion. - It is inadequate for **Stage IVa disease** with cartilage invasion due to the extensive nature of the tumor.
Question 5: What is the name of the nerve block technique shown in the image?
- A. Intra-arterial anesthesia (Correct Answer)
- B. Bier's block
- C. Regional anesthesia
- D. Axillary block
Explanation: ***Intra-arterial anesthesia*** - The image shows a **cannula inserted directly into an artery**, indicated by the blood reflux and the context of anesthesia, suggesting direct drug delivery into the arterial system. - This method is used for specific types of regional pain management or diagnostic procedures where direct arterial access is required for **localized drug distribution**. *Bier's block* - A Bier's block, or **intravenous regional anesthesia**, involves injecting local anesthetic into a **vein** in an extremity after it has been exsanguinated and isolated by a tourniquet. - The image clearly shows a **bright red blood flash**, characteristic of arterial cannulation, not venous. *Regional anesthesia* - This is a broad term referring to the **anesthesia of a specific region** of the body and encompasses various techniques. - While intra-arterial anesthesia is a type of regional anesthesia, "regional anesthesia" itself is too general to specifically describe the technique shown. *Axillary block* - An **axillary block** is a type of peripheral nerve block targeting the brachial plexus in the axilla to anesthetize the arm. - The image does not depict the axillary region or the characteristic needle placement for an axillary block; instead, it shows direct vascular access.
Question 6: A 50-year-old smoker presents with hoarseness, dysphagia, and weight loss. Flexible laryngoscopy shows a mass on the vocal cords. What is the next best step?
- A. Direct laryngoscopy with biopsy (Correct Answer)
- B. MRI of neck
- C. CT scan of neck
- D. Radiotherapy
Explanation: ***Direct laryngoscopy with biopsy*** - A definitive diagnosis of a vocal cord mass requires **histological examination** to rule out malignancy, especially given the patient's risk factors (age, smoking) and symptoms (hoarseness, dysphagia, weight loss). - **Direct laryngoscopy** allows for a thorough, magnified view of the mass and precise biopsy collection, which is superior to flexible laryngoscopy alone for definitive diagnosis and staging. *MRI of neck* - While MRI can provide excellent soft tissue detail for **staging** a known malignancy, it cannot provide a **histological diagnosis**. - It would typically be performed after a biopsy confirms malignancy to assess the extent of the tumor and potential spread. *CT scan of neck* - A CT scan is useful for evaluating **bony involvement**, lymph node status, and tumor extension for **staging purposes**, but it is not a diagnostic tool for identifying the specific type of tissue or cell pathology. - Like MRI, a CT scan would generally follow a biopsy confirming malignancy. *Radiotherapy* - **Radiotherapy** is a treatment modality for laryngeal cancer, not a diagnostic step. - Initiating treatment without a definitive histological diagnosis of malignancy would be inappropriate and potentially harmful.
Question 7: Descending order of cancer prevalence in males in India?
- A. Oral > lung > pharynx > esophagus
- B. Pharynx > lung > oral > esophagus
- C. Lung > oral > pharynx > esophagus (Correct Answer)
- D. Esophagus > oral > stomach > lung
Explanation: ***Lung > oral > pharynx > esophagus*** - This order represents the **most common cancer prevalence pattern** in Indian males according to **ICMR-NCDIR** population-based cancer registries. - **Lung cancer** ranks highest nationally, strongly associated with **smoking** (bidi and cigarette use). - **Oral cavity cancer** is extremely prevalent in India due to **tobacco chewing, betel quid, and gutka consumption**. - **Pharyngeal cancer** and **esophageal cancer** follow, also linked to tobacco and alcohol use. - Regional variations exist, but this order reflects **national-level data** for Indian males. *Oral > lung > pharynx > esophagus* - While **oral cancer prevalence is very high** in India (competing with lung cancer in some regions), at the **national aggregate level**, lung cancer typically ranks first. - This order may be accurate for **specific regions** with high tobacco chewing prevalence but does not represent the overall national pattern. *Pharynx > lung > oral > esophagus* - **Pharyngeal cancer** is less prevalent than both **lung and oral cancers** in Indian males. - This sequence incorrectly places pharyngeal cancer at the top, which contradicts **Indian cancer registry data**. *Esophagus > oral > stomach > lung* - This order is incorrect as **esophageal and stomach cancers** are significantly less prevalent than **lung and oral cancers** in Indian males. - **Lung cancer consistently ranks at or near the top** in Indian male cancer statistics, making this order epidemiologically inaccurate.
Question 8: Treatment of resectable T4N0M0 stage of head and neck carcinoma is?
- A. Radiotherapy alone
- B. Surgery and Radiotherapy (Correct Answer)
- C. Chemoradiation
- D. Surgery alone
Explanation: ***Surgery and Radiotherapy*** - For **resectable T4N0M0 head and neck carcinoma**, the standard treatment is **surgical resection** of the primary tumor followed by **adjuvant radiotherapy**. - This approach achieves optimal **local control** for advanced primary tumors without nodal involvement. - **Adjuvant radiotherapy** is essential for T4 tumors due to high risk of microscopic residual disease and local recurrence. - Surgery allows for complete tumor removal with negative margins, while radiotherapy addresses subclinical disease. *Radiotherapy alone* - Radiotherapy alone is **insufficient as monotherapy** for T4 tumors due to the large tumor burden and extensive local invasion. - Single modality radiation cannot reliably achieve adequate tumor control for advanced primary lesions. - Generally reserved for early-stage disease or patients unfit for surgery. *Chemoradiation* - **Definitive chemoradiation** is an alternative for **unresectable T4 tumors** or when organ preservation is desired (e.g., laryngeal cancer). - For **resectable** T4N0M0 disease, surgery with adjuvant RT is preferred as it provides better local control and allows pathological staging. - Chemoradiation may be used postoperatively if high-risk features are found (positive margins, perineural invasion, extranodal extension). - In this **N0 case with resectable tumor**, upfront surgery is the preferred initial approach. *Surgery alone* - While surgical resection is crucial for T4 tumors, **surgery alone is inadequate** due to high risk of locoregional recurrence. - T4 classification indicates extensive local invasion, necessitating **adjuvant radiotherapy** to eradicate microscopic disease. - Combined modality treatment (surgery + RT) significantly improves local control and survival compared to surgery alone.
Question 9: Inspiratory stridor is due to lesions of:
- A. Supraglottis
- B. Trachea
- C. Bronchi
- D. Subglottis (Correct Answer)
Explanation: ***Subglottis*** - **Inspiratory stridor** is classically associated with **subglottic lesions**, such as **croup (laryngotracheobronchitis)** and **subglottic stenosis**. - The **subglottis** is the **narrowest part of the pediatric airway**, making it particularly susceptible to significant obstruction from inflammation or narrowing. - During inspiration, the negative intrathoracic pressure causes **dynamic collapse** of the subglottic region when narrowed, producing characteristic **high-pitched inspiratory stridor**. - Common causes: **Croup**, subglottic stenosis, subglottic hemangioma. *Supraglottis* - Supraglottic lesions (epiglottis, aryepiglottic folds) can also cause **inspiratory stridor**, particularly in **acute epiglottitis**. - However, supraglottic pathology more commonly presents with **muffled voice** (hot potato voice), **dysphagia**, **drooling**, and **tripod positioning**. - The stridor from supraglottic lesions tends to be **lower-pitched** and is often accompanied by more prominent systemic symptoms. *Trachea* - Tracheal lesions typically produce **biphasic stridor** (both inspiratory and expiratory phases) due to fixed obstruction in the main conducting airway. - The trachea is a more rigid structure; obstruction produces a **harsh, lower-pitched** sound heard in both respiratory phases. - Examples: tracheal stenosis, tracheomalacia, tracheal tumors. *Bronchi* - Bronchial lesions cause **expiratory wheezing** rather than stridor, due to dynamic collapse of small airways during exhalation. - Bronchial obstruction affects the lower airways and presents as **polyphonic wheeze** rather than the monophonic sound of stridor.
Question 10: Treatment of choice for carcinoma larynx T1N0M0 stage -
- A. External beam radiotherapy (Correct Answer)
- B. Surgery
- C. Radioactive implants
- D. Surgery & radiotherapy
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.
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