13 Cancer of the Head and Neck

Douglas R. Adkins, Jessica C. Ley and Loren Michel

QUESTIONS

Each of the numbered items below is followed by lettered answers. Select the ONE lettered answer that is BEST in each case unless instructed otherwise.

Question 13.1 A 65-year-old man with a 40 pack-year history of smoking presented with hoarseness and a neck mass. The patient did not aspirate and had not lost weight. The patient was found to have T4N2cM0 squamous cell carcinoma (SCC) of the glottic larynx. T4 classification was based on limited cortical erosion of the thyroid cartilage. A total laryngectomy and bilateral neck dissections followed by adjuvant radiation therapy was recommended by the otolaryngologist. However, the patient preferred a chance to preserve the larynx. Which treatment approach offers the best chance to preserve the patient’s larynx and prevent disease recurrence?

A. Radiation therapy alone

B. Induction chemotherapy followed by radiation therapy

C. Concurrent chemotherapy and radiation therapy

D. Chemotherapy alone

Question 13.2 Which of the following statements about the epidermal growth factor receptor (EGFR) in head and neck SCC (HNSCC) is TRUE?

A. Randomized trials demonstrated that oral tyrosine kinase inhibitors (TKI) of EGFR such as erlotinib and monoclonal antibody inhibitors of EGFR such as cetuximab resulted in similar tumor control.

B. Activating EGFR mutations are frequent in HNSCC.

C. The EGFR inhibitor cetuximab improved overall survival when added to definitive radiation therapy or to palliative platin-based chemotherapy in HNSCC.

D. High EGFR expression is associated with sensitivity to radiation therapy.

Question 13.3 Which of the following are risk factors for HNSCC?

A. Tobacco use

B. Alcohol use

C. Fanconi anemia

D. All of the above

Question 13.4 Which of the following characteristics are typical features of human papilloma virus (HPV)-related HNSCC?

A. Most patients have limited or no smoking history and most have primary tumors that involve the oropharynx (base of tongue or palatine tonsils).

B. Survival outcomes are substantially better than in patients with smoking-associated HNSCC.

C. The role of the HPV in subsites other than the oropharynx is not clear.

D. All of the above.

Question 13.5 A 56-year-old man presented to his primary care physician with a 3-month history of right ear pain and two masses on the right side of his neck. On examination, he was found to have a 3-cm right palatine tonsil mass and two enlarged lymph nodes under the upper part of the right sternocleidomastoid muscle. One lymph node was 2 cm, and the other was 1 cm in diameter. A fine-needle aspiration (FNA) of one of the neck lymph nodes was performed and it was consistent with p16+ SCC. Neck and chest computed tomography (CT) showed no additional lymphadenopathy or distant metastasis. What is the stage of his disease?

A. Stage II

B. Stage III

C. Stage IVA

D. Stage IVC

Question 13.6 Which of the following statements is TRUE?

A. Radical neck dissections should be performed for the management of all locally advanced HNSCC.

B. Complications from neck dissections may include hematoma, seroma, lymphedema, wound infections and dehiscence, carotid artery exposure and rupture, and damage to the VII, X, XI, and XII cranial nerves.

C. In a surgically treated tumor without radiographic evidence of lymph node metastasis, an elective neck dissection should be performed if the risk of occult metastasis to the neck nodes is greater than 50%.

D. For patients who have had a neck dissection for HNSCC, there is no benefit from postoperative adjuvant radiation therapy.

Question 13.7 Which of the following statements is TRUE?

A. The combination of cisplatin and 5FU improves overall survival in comparison to single-agent methotrexate in patients with metastatic HNSCC.

B. Cetuximab has no activity in metastatic or recurrent HNSCC.

C. The combination of cisplatin and 5FU results in a higher tumor response rate than single-agent methotrexate in patients with metastatic HNSCC.

D. Higher chemotherapy doses improve overall survival.

Question 13.8 A 66-year-old man presented to his otolaryngologist with a 4-cm left floor of mouth SCC. A 3-cm left neck node was felt on examination. CT of the neck also showed that the primary tumor invaded into the mandible. There was no evidence of distant metastasis on CT of the chest. What is the most appropriate initial therapy for this patient?

A. Surgery

B. Radiation therapy

C. Concurrent chemotherapy and radiation therapy

D. Chemotherapy

Question 13.9 A 54-year-old woman recently underwent resection of a SCC of the supraglottis with bilateral neck dissections. The pathology showed a T2 lesion completely excised to negative margins but lymphovascular and perineural invasion were present. Two of the 28 lymph nodes contained SCC with extracapsular extension on the right. What is the most appropriate adjuvant therapy for this patient?

A. Observation

B. Radiation alone.

C. Concurrent chemotherapy and radiation therapy.

D. Chemotherapy alone.

Question 13.10 What is the benefit of cetuximab in patients with HNSCC?

A. Concurrent cetuximab and radiation therapy resulted in improved overall survival compared to radiation therapy alone in stage I to IV disease.

B. Cetuximab is equally effective as cisplatin when given concurrently with radiation therapy.

C. Addition of cetuximab to concurrent cisplatin and radiation therapy improved overall survival and reduced relapse risk.

D. Concurrent cetuximab and radiation therapy resulted in improved overall survival compared to radiation therapy alone in nonmetastatic stage III to IV HNSCC.

Question 13.11 Which of the following statements about the treatment of laryngeal SCC is TRUE?

A. Radiation therapy alone resulted in worse overall survival compared with concurrent chemotherapy and radiation therapy in patients with locally advanced laryngeal SCC.

B. Concurrent chemotherapy and radiation therapy resulted in better local tumor control and laryngeal preservation rate than radiation therapy alone for locally advanced SCC of the larynx.

C. A total laryngectomy is required for the treatment of locally advanced SCC of the larynx.

D. Large-volume laryngeal SCC is defined as tumor that extends more than 1 cm onto the base of tongue and/or extension through the thyroid cartilage into adjacent soft tissue and is best treated with nonsurgical therapy.

Question 13.12 True or False: There is an overall survival benefit with adjuvant chemotherapy given after resection of a SCC of the larynx.

A. True

B. False

Question 13.13 Which of the following statements are TRUE? (Select two correct responses)

A. The three subtypes of nasopharyngeal carcinoma are World Health Organization (WHO) type I keratinizing SCC; WHO type II nonkeratinizing SCC; and WHO type III undifferentiated carcinoma or lymphoepithelioma. Type III nasopharyngeal SCC is due to EBV infection and has a much better prognosis than Type I nasopharyngeal SCC.

B. Nasopharyngeal carcinoma is usually treated with chemotherapy and radiation.

C. Common presenting symptoms of nasopharyngeal carcinomas include hoarseness, painful lower neck mass, and weight loss.

D. The majority of nasopharyngeal carcinomas present with distant metastatic disease.

Question 13.14 A 56-year-old woman presented to her primary care physician with left-sided facial swelling and facial drooping. The patient had weakness of the lower portion of her face and a palpable left parotid mass. A biopsy was performed and showed high-grade mucoepidermoid carcinoma. There were no palpable neck lymph nodes. What is the best treatment for this patient?

A. Radiation alone

B. Concurrent chemotherapy and radiation therapy

C. Surgery alone

D. Surgery followed by adjuvant radiation therapy

Question 13.15 Which of the following statements is TRUE about locally advanced HNSCC? (Select two correct responses)

A. The most common long-term complication of radiation therapy is xerostomia.

B. Once the patient is able to receive nutrition via a G-tube, there is no benefit from having the patient continue to swallow during radiation therapy.

C. Intensity-modulated radiation therapy (IMRT) decreases the risk of xerostomia.

D. The severity of the acute side effects of radiation therapy is similar when chemotherapy is given concurrently.

Question 13.16 Which of the following statements are TRUE regarding second primary cancers in patients with HNSCC?

A. Patients with HPV-related oropharyngeal SCC have a similar risk of second primary cancers as do patients with smoking-induced HNSCC.

B. Patients with resected HNSCC who quit smoking have a lower risk of second primary cancers than those who continue to smoke.

C. Treatment with α-tocopherol decreases the incidence of second primary cancers.

D. Treatment with isotretinoin decreases the incidence of second primary cancers.

Question 13.17 Which of the following statements regarding induction chemotherapy in the treatment of HNSCC is TRUE?

A. Treatment with concurrent chemotherapy and radiation therapy resulted in improved overall survival compared to induction chemotherapy followed by radiation therapy for locally advanced laryngeal SCC.

B. Addition of docetaxel to cisplatin and 5FU was associated with similar overall survival when compared to cisplatin and 5FU in patients with locally advanced HNSCC subsequently treated with radiation therapy alone or concurrent carboplatin and radiation therapy.

C. Induction chemotherapy may facilitate organ preservation in patients with locally advanced laryngeal or hypopharyngeal SCC.

D. Induction chemotherapy followed by concurrent cisplatin and radiation therapy results in improved overall survival compared to concurrent cisplatin and radiation therapy.

Question 13.18 A 35-year-old nonsmoking female with a history of chronic oral lichen planus presented with a painful right oral tongue lesion measuring 2.5 cm. Biopsy revealed well-differentiated SCC. Ultrasound revealed that the oral tongue lesion was 0.6 cm thick. CT showed no abnormal neck nodes. The lesion was widely excised and a right selective neck dissection (SND) was performed. Pathology revealed a 2.6 cm SCC, negative surgical margins, no perineural or lymphovascular invasion, and all 15 lymph nodes without SCC. The pathologic stage was II (T2N0M0). The most appropriate next therapy is:

A. Postoperative adjuvant radiation therapy.

B. Postoperative adjuvant concurrent chemotherapy and radiation therapy.

C. Close monitoring.

D. Left selective neck dissection.

Question 13.19 A 58-year-old male with stage IVA SCC of the larynx was treated with concurrent chemotherapy and radiation therapy 12 months ago. On routine surveillance CT, multiple new bilateral pulmonary nodules were noted. A biopsy of one of the pulmonary nodules showed SCC consistent with metastases from the laryngeal cancer. The patient has an ECOG performance status of 0 and has no serious comorbidities. What is the most effective treatment for this patient’s cancer?

A. Weekly administration of cetuximab

B. Weekly paclitaxel

C. Carboplatin, docetaxel, and cetuximab with peg-filgrastim

D. Carboplatin, 5FU, and cetuximab

Question 13.20 A 65-year-old male presented with a large hard palate mass. Biopsy showed a salivary ductal adenocarcinoma. The mass was completely excised and pathology revealed a 4 cm tumor with positive surgical margins. Postoperative adjuvant radiation therapy was given. Nine months later, a surveillance CT showed several pulmonary nodules. A biopsy of one of the pulmonary nodules showed metastatic salivary ductal adenocarcinoma. The patient was referred to medical oncology for management. The most appropriate next step in the management of this patient is:

A. Weekly cetuximab.

B. Platin, 5FU, and cetuximab.

C. Taxane.

D. Perform immunohistochemistry stain for the androgen receptor.

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