Head and Neck Oncology: Staging, Neck Levels, and Treatment Sequence
Scope
Head and neck surgery and oncology tests TNM staging, neck dissection levels, oral cavity and laryngeal cancer, salivary and thyroid tumors, and multidisciplinary sequencing. The exam emphasizes what to do first and which findings change prognosis.
Core rules
- Squamous cell carcinoma workup: history, physical examination including neck palpation, endoscopic biopsy, contrast CT or MRI, and PET-CT for advanced disease. Discuss in a multidisciplinary tumor board.
- Oral cavity cancer is treated surgically first, with neck dissection for clinically positive nodes or depth of invasion. Adjuvant radiotherapy is added for close margins, perineural invasion, or extranodal extension.
- Early glottic cancer can be treated with radiotherapy or transoral laser surgery; advanced laryngeal cancer often requires total laryngectomy and adjuvant therapy.
- HPV-positive oropharyngeal carcinoma has separate staging and a better prognosis, but it is still treated with curative intent.
- Neck levels: level I submental and submandibular, levels II to IV jugular chain, level V posterior triangle. Oral cavity drains to levels I to III.
- Thyroid: papillary carcinoma spreads via lymphatics; medullary carcinoma is monitored with calcitonin; anaplastic carcinoma is rapidly aggressive.
- Parotid tumors require facial nerve preservation; FNA guides surgery.
Worked example
A 60-year-old smoker has a 2-cm ulcer on the lateral tongue and a fixed level IB node. Biopsy shows squamous cell carcinoma. Imaging stages the neck, and treatment is wide local excision with neck dissection. Adjuvant radiotherapy is indicated for extranodal extension or close margins.
Traps
Assuming a neck mass is benign; omitting neck palpation; applying HPV-negative staging to HPV-positive cancer; ignoring level VII in thyroid disease; and biopsying a parotid mass without planning facial nerve preservation.