Management of Head and Neck Cancer — MCQs
What is the most common oral cancer?
What is the most appropriate treatment after resection of lateral border of tongue carcinoma with high-risk features (positive margins, perineural invasion)?
Treatment of stage III carcinoma of oral tongue is:
Treatment of choice for carcinoma larynx T1N0M0 stage -
Identify the marked structure in the given image.
Most common presentation in nasopharyngeal carcinoma is with:
Which of these is the STRONGEST indication for giving adjuvant treatment in oral malignancy after resection and Modified Radical Neck Dissection (MRND)?
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?
Late effects of radiation therapy include:
Carcinoma of pyriform fossa usually presents with :
Management of Head and Neck Cancer Indian Medical PG Practice Questions and MCQs
Question 1: What is the most common oral cancer?
- A. Transition cell ca
- B. Mucoepidermoid
- C. Adenocarcinoma
- D. Squamous cell ca (Correct Answer)
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.
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
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**.
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)
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.
Question 4: 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.
Question 5: Identify the marked structure in the given image.
- A. Electrode
- B. Coil (Correct Answer)
- C. Magnet
- D. Processor
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.
Question 6: Most common presentation in nasopharyngeal carcinoma is with:
- A. Cervical lymphadenopathy (Correct Answer)
- B. Epistaxis
- C. Hoarseness of voice
- D. Nasal stuffiness
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.
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
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.
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
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.
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)
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.
Question 10: Carcinoma of pyriform fossa usually presents with :
- A. Lump in the neck
- B. Cough
- C. Dysphagia (Correct Answer)
- D. Hoarseness
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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