Head and neck tumors, salivary and endocrine surgery
Head and neck oncology questions test staging logic, anatomic boundaries, and treatment sequencing. Know the AJCC TNM principles: T reflects primary tumor size and invasion, N reflects nodal burden (number, size, laterality, extracapsular extension), and M reflects distant disease. Understand that HPV-positive oropharyngeal squamous cell carcinoma has a distinct, more favorable staging system and prognosis than HPV-negative disease.
Master the nodal levels (I-VI) and their drainage patterns: level I submental/submandibular (oral cavity), level II-III upper/mid jugular (oropharynx, larynx, hypopharynx), level IV lower jugular (thyroid, hypopharynx), level V posterior triangle (nasopharynx, skin), level VI anterior compartment (thyroid, larynx). Know that extracapsular extension worsens prognosis and can influence adjuvant chemoradiation decisions within the actual tumor and patient framework.
Understand the treatment paradigm: early-stage disease often single-modality (surgery or radiation); advanced disease often combined surgery plus adjuvant radiation/chemotherapy. Recognize the role of sentinel node biopsy in early oral cavity cancer and the importance of margin status and perineural/lymphovascular invasion in adjuvant decisions.
Traps: staging a neck node without examining the primary site; forgetting that distant metastasis changes intent; and missing second primary tumors in smokers. Also know that salvage surgery is an option for recurrent disease after radiation.
Rule of thumb: "Stage the primary and the neck together; treatment intent follows M status."
Worked example: A patient with a T2N1 oral tongue cancer and a positive margin after resection should be considered for adjuvant radiation with or without chemotherapy, given the high-risk feature.
Thyroid, parathyroid and surgical risk
Thyroid questions test nodule evaluation, cancer staging, and surgical complications. Know that ultrasound is the first imaging study for thyroid nodules and that fine-needle aspiration is guided by ultrasound features (size, microcalcifications, irregular margins, hypoechogenicity). Understand the Bethesda system for cytology and that papillary thyroid carcinoma is the most common thyroid cancer, spreading via lymphatics; follicular carcinoma spreads hematogenously; medullary carcinoma arises from parafollicular C cells and is associated with MEN2 and elevated calcitonin.
Know the complications of thyroidectomy: recurrent laryngeal nerve injury (hoarseness), external branch of superior laryngeal nerve injury (voice pitch), hypocalcemia from parathyroid injury, and hematoma causing airway compromise. Postoperative hypocalcemia is managed with calcium and vitamin D; check calcium and PTH.
For parathyroid disease, understand primary hyperparathyroidism (elevated calcium, elevated or inappropriately normal PTH), most often from a single adenoma, and that sestamibi scanning and ultrasound localize before focused parathyroidectomy. Secondary hyperparathyroidism occurs in renal failure.
Traps: missing medullary carcinoma (check calcitonin, screen for MEN2); attributing postoperative stridor to edema when a neck hematoma is the cause; and forgetting that follicular lesions often require diagnostic lobectomy because FNA cannot distinguish adenoma from carcinoma.
Rule of thumb: "Papillary spreads to nodes, follicular spreads to bone and lung, medullary disease warrants assessment of hereditary risk rather than an assumption that every case is inherited."
Worked example: An appropriately confirmed medullary-thyroid-carcinoma diagnosis prompts the relevant oncological and germline RET assessment. An isolated elevated calcitonin value does not by itself establish the whole operative plan.
Staging must use the specified primary site, edition and pathological or clinical framework. HPV-associated oropharyngeal disease does not use every nodal rule of HPV-negative mucosal disease. A surface tumor size alone can be insufficient when depth of invasion contributes to the category. A positive margin or extranodal extension changes risk, but an advanced T category does not automatically prescribe the same postoperative chemotherapy for every patient.