a biopsy, often with a fine needle aspiration.
For further assessment of palate salivary cancers, both CT and MRI are typically employed to assess for bone erosion and perineural invasion, respectively.
Due to the close association of the mucosa of the hard palate and the underlying bone, infrastructure maxillectomy is often required.
When considering a patient for an infrastructure maxillectomy, it is essential to consider the expected defect and discuss options for rehabilitation. If the use of a maxillary obturator is considered, a preoperative evaluation by a maxillofacial prosthodontist is crucial to get a surgical obturator created.
To successfully retain an obturator, it is necessary to have adequate dentition to stabilize the prosthesis. Retention of the ipsilateral canine tooth typically allows for excellent obturator stability.
In patients where a maxillary obturator is not appropriate or desired, more definitive reconstruction with a regional or free flap is needed.
Multiple Choice Questions
1 In managing a 52‐year‐old female patient with a cT1N0M0 SCC of the right lateral tongue, you offer a right partial glossectomy. Final pathology demonstrates invasive SCC with maximal dimension of 1.5 cm and 6 mm depth of invasion. What would be the most appropriate next step in management of this patient?Close observation of the neck with clinical exam and ultrasound every 3 months.A right‐sided supraomohyoid neck dissection.A right‐sided radical neck dissection.A bilateral supraomohyoid neck dissection.Answer: b. This patient has a pT2 lesion. With a depth of invasion greater than 3 mm, level I evidence shows improved disease control and overall survival when an ipsilateral supraomohyoid neck dissection is performed. Since they are cN0, a radical neck dissection would not be appropriate. Moreover, since it is a lateral tongue cancer, it would not be necessary to do a bilateral dissection.
2 In a patient who undergoes a left partial glossectomy and left neck dissection, final pathology shows a 3.2 cm primary lesion with 12 mm depth of invasion. There was 1 out of 37 lymph nodes positive in the neck dissection (2.2 cm maximal dimension and no ECS). What is the pathologic stage of this patient's cancer?pT2N1M0, stage III.pT3N1M0, stage III.pT3N1M0, stage IVa.pT4aN1M0, stage IVa.Answer: b. Due to the depth of invasion being greater than 10 mm but the overall lesion size being less than 4 cm, this would be a T3 tumor. T3N1M0 carries a group stage of III.
3 A 67‐year‐old male presents for evaluation of persistent pain in the left jaw following a tooth extraction. On exam he is found to have granular tissue emanating from the extraction site of his second left mandibular molar. He expresses progressive left lip, chin, and tongue numbness. Biopsy is consistent with SCC. Which of the following would not be an appropriate next step in the evaluation of this patient?A neck MRI with and without gadolinium.A neck CT with IV contrast.A neck ultrasound.A PET/CT from the skull base to midthighs.Answer: c. In this patient, there seems to be significant tumor extension beyond what is identifiable clinically. A CT of the neck will provide good detail of the bone involvement, but an MRI will also be needed as the tongue numbness suggests there may be perineural invasion tracking proximally on V3. A PET/CT is also helpful in completing the staging for this patient. A neck ultrasound, while it may be helpful in looking for cervical lymphadenopathy, would not be able to assess the mandible and would be redundant if other studies were ordered.
4 The lingual nerve runs in what relationship with the pterygoid muscles?It runs medial to both muscles.It runs between the medial and lateral pterygoid muscles.It runs lateral to both the medial and lateral pterygoid muscles.It has a variable relationship with the two muscles.Answer: b. This is an important landmark on tumor resections with extension into the infratemporal fossa. The lingual nerve can also be traced proximally to identify foramen ovale.
5 Retention of which tooth on a right posterior maxillectomy will have the biggest impact on whether or not they can be rehabilitated with an obturator?Tooth #4.Tooth #5.Tooth #6.Tooth #7.Answer: c. Retention of the ipsilateral canine tooth for posterior infrastructure maxillectomies has been shown to significantly reduce the fulcrum effect and improve obturator retention.
6 A 76‐year‐old male patient presents with a T4aN1M0 SCC of the left ventral tongue and floor of mouth with involvement of the left mandible body. On history, the patient has a history of lower extremity claudication with walking of 1.5 blocks. It is anticipated that resection will require a left hemiglossectomy and a segmental mandible resection of 9 cm. What would be the most appropriate donor site for reconstruction in this patient?Left scapula osseocutaneous flap.Right fibula osseocutaneous flap.Left radial forearm osseocutaneous flap.Anterolateral thigh musculocutaneous free flap.Answer: a. This patient has a segmental mandibulectomy defect and a considerable soft tissue defect as well. Due to the soft tissue requirements as well as the lower extremity claudication, a fibula free flap would not be ideal. The radial forearm free flap with bone is a reasonable option, but the concern here is an inadequate amount of soft tissue. Scapular or parascapular free flap can be harvested with a large amount of soft tissue with adequate bone to reconstruct up to 14 cm of bone. The subscapular system tends to be less impacted by atherosclerosis than flaps from the extremity.
7 Which of the following is true:Tumors in the upper lip and commissure have a higher incidence of lymph node metastases at the time of diagnosis.Tumors of the lower lip have a higher rate of lymph node metastasis than those of the upper lip and commissure.Tumors of the local commissure have the highest rate of lymph node metastasis of all lip cancers.All locations of lip cancer result in the same rate of lymph node metastasis.Answer: a. Due to extensive lymphatic drainage from the upper lip and commissure, tumors of these subsites have a higher incidence of lymph node metastases at the time of diagnosis.
8 You evaluate a patient with a 1.5 cm, thin‐appearing SCC of the left lower lip. His clinical exam and recent CT imaging do not demonstrate any enlarged adenopathy. How would you counsel the patient regarding the efficacy of surgery versus primary radiotherapy as definitive treatment for his tumor?Primary surgical resection offers a higher chance of local control and overall survival.Primary surgical resection offers a higher chance of local control but equivalent overall survival.Primary surgical resection offers equivalent local control and overall survival.Primary surgical resection offers inferior local control and overall survival.Answer: c (see de Visscher et al. 1999). A retrospective study of 99 patients treated with definitive radiotherapy versus surgery for stage I lower lip cancers found that rates of survival and disease control were equivalent between treatment groups. Tumor size was independently associated with poorer outcomes.
9 The above patient elects for primary surgical resection, and the final pathology demonstrates a 1.7 cm SCC with a 6 mm depth of invasion and positive perineural invasion. How would you stage the patient, and what additional treatment would you offer, if any?T1N0: elective neck dissection, no adjuvant RT if cN0.T1N0: adjuvant RT only.T2N0: observation only.T2N0: adjuvant RT only.Answer: d. This patient's tumor should be staged according to the AJCC oral cavity staging criteria. With a depth of invasion >5 mm, this tumor therefore meets the criteria for a T2N0. Perineural invasion has been described as a strong predictor of locoregional failure for lip cancers and is considered an indication for adjuvant RT. Management of this patient with adjuvant RT only would therefore be appropriate. Elective ND followed by potential avoidance of RT if cN0 could be considered. However, the patient would be at increased risk of local failure.
10 Which of the following is true regarding minor salivary gland cancer tumors?More common in advanced age.Are more common in women.Cervical lymph node metastases are common.The most common site is the oropharynx.Answer: b. The most common site for minor salivary gland cancer is the oral cavity, accounting for 68% of cancers, followed by the oropharynx in 21%, sinonasal tract in 8%, and larynx/trachea in 3%. A particularly common location is the junction between the hard and the soft palate due to the high concentration of minor salivary
