Devita, Hellman, and Rosenberg's Cancer

LWBK1006-17 LWW-Govindan-Review December 7, 2011 21:14

200 DeVita, Hellman, and Rosenberg’s CANCER: Principles and Practice of Oncology Review

Answer 17.5. The answer is C.

The patient has a tonsil mass that is between 2 and 4 cm. This makes his

primary tumor T2. He has multiple ipsilateral regional lymph nodes with

the largest lymph node being smaller than 6 cm, which is N2b disease.

His tumor shows no evidence of distant metastasis. The patient’s disease

is T2N2bM0, which is stage IVA.

Answer 17.6. The answer is B.

Control of neck disease is very important in the management of SCCHN.

Both surgery and radiation can be used. When a tumor is treated surgi-

cally, a neck dissection is recommended even in a clinically negative neck

if the risk of occult metastasis exceeds 10% to 15%. Modified neck dissec-

tions that can preserve structures such as cranial nerve XI, internal jugular

vein, and sternocleidomastoid can often be performed without compro-

mise of disease control. Patients with positive neck lymph nodes clearly

have a benefit from postoperative radiation if multiple lymph nodes

are involved or N3 disease and sometimes chemoradiation depending

on the pathologic findings. Complications from neck dissections include

hematoma; seroma; lymphedema; wound infections and dehiscence; dam-

age to the VII, X, XI, and XII cranial nerves; carotid exposure; and carotid

rupture.

Answer 17.7. The answer is C.

The treatment of metastatic squamous cell cancer is challenging. Many

cytotoxic chemotherapeutic agents including cisplatin, carboplatin, 5FU,

taxanes, ifosfamide, and methotrexate have activity against metastatic

SCCHN. Combinations of conventional cytotoxic chemotherapy and

higher doses of chemotherapy have a higher response rate but have not

shown a clear survival benefit over single agent cytotoxic chemotherapy.

The anti-EGFR antibody cetuximab has shown significant activity against

SCCHN. Recently in the EXTREME trial, the addition of cetuximab to

conventional cytotoxic chemotherapy showed a survival benefit.

Answer 17.8. The answer is A.

This patient has a stage IVA (T4aN1M0) squamous cell cancer of the

oral cavity. The therapy that is most effective in this situation is surgery.

Radiation and chemoradiation as primary therapy will be of little util-

ity here, particularly with invasion of the mandible. He will most likely

require radiation or chemoradiation after surgery depending on the

findings.

Answer 17.9. The answer is C.

After gross tumor resection, adjuvant therapy with radiation or chemora-

diation is recommended for locally advanced SCCHN. The decision on

what adjuvant therapy is to be recommended is based on operative find-

ings. Major risk factors for local recurrence are positive margins or lymph

node disease with extracapsular extension. Minor risk factors include