The document discusses key factors that indicate advanced stage head and neck squamous cell carcinoma: 1. Involvement of the pterygoid muscles or pterygopalatine fossa with cranial neuropathy. 2. Gross extension to the skull base through erosion of bones or widening of foramina. 3. Direct extension to the nasopharynx, Eustachian tube, or lateral nasopharyngeal walls. 4. Invasion of the carotid artery. 5. Direct extension to the neck, mediastinum, prevertebral fascia or cervical vertebrae. 6. Presence of subdermal metastases.

1. Moeez Fatima

7.  Involvement of the pterygoid muscles, particularly when associated
with severe trismus or pterygopalatine fossa involvement with cranial
neuropathy.
 Gross extension of the tumor to the skull base (eg, erosion of the
pterygoid plates or sphenoid bone, widening of the foramen ovale)
 Direct extension to the superior nasopharynx or deep extension into
the Eustachian tube and lateral nasopharyngeal walls
 Invasion (encasement) of the common or internal carotid artery.
 Direct extension of neck disease.
 Direct extension to mediastinal structures, prevertebral fascia, or
cervical vertebra.
 Presence of subdermal metastases.

8. Scenario 1
 56 year old male, denies any co-morbids,
complains of swelling in the right cheek.
Examination reveals 4cm size of ulcer involving
buccal mucosa. Patient has palpable lymphnode
on the right side of neck, measuring 2cm. No
metastatic work-up has been done till now.
 TNM??
 Specific tumour Management?
 Safe margins of excision?
 Clear / Close / involved margins?

10. Scenario 3
 35 years old female presented with ulcer on the mucosal
surface of right cheek. Dimensions: 1.5x1cm in size, depth:
2mm. No lymph node palpable or vidsualized on Ct scan.
Metastatic workup is un remarkable.You classify this tumor
as (T1N0M0). Patient does not agree fore surgical removal
of ulcer despite all counselling sessions.
 How will you proceed?

13. Scenario 4
78 years old male, K/C of
Hypertension, Diabetes,
Ischemic heart disease,
is brought to your
outpatient department
with a massive sweling
on right side of lip.
Biopsy proven squamous
cell carcinoma.Tumour
has metastasized to
lungs. Patient has PS 3.
T4bN3M1.
How will you proceed?

15. DEFINITVE RADIOTHERAPY: T1,T2, N0
ADJUVANT RADIOTHERPAY: T1-2N0 (with positive L.N)T3N0,T1-3N1-N3,
T4aAny N
PALLIATIVE RADIOTHERAPY: Advanced cancers.
REIRRADIATION: Tumour recurrence

16.  Involved surgical margin.
Or any 4 of the following
Excision margins less than 5mm
Stage t3/t4
Perineural /Vascular invasion
Poor differentiation
Primary oral cavity
Multicenter primary
> 4 nodes positive
Soft tissue invasion
Dysplasia or CIS at the resection margin

17. Definitive RT
High risk: 66-70 Gy, daily Mon-fri in 6-7weeks
Low risk: 44-63 Gy
Post-operative: Approx. 6weeks of surgery
High risk: 60-66 Gy, daily Mon-Fri in 6-6.5weeks
Low risk: 44-50 Gy

19. Scenario 5
 32 years old male, shopkeeper by profession
denies any co-morbids, addicted to paan and
guttka, came with complain of swelling in the
left cheek for 3 months. (biopsy proven
squamous cell carcinoma)Tumor size is 4x3
cm. Depth of tumor is 4mm. No lymph nodes
palpable.
 Will you do an elective neck disection?

20.  Same individual , but assume Depth of tumor
is 2mm.
 Which type of neck disection is done in END?
 What are the lymph node levels in SND of
oral cancers ?

21. Scenario 7
 45 years old male has squamous cell
carcinoma of right side of cheek.Tumor size
is 3x3 cm involving mucosa. Depth of tumor is
2mm. Patient has lymph node palpable on
the left side of neck.
 Will you do an elective neck disection?
 If no then defend yourself, if yes then what
type?

22. Done for risk of occult metastasis
N0: Selective neck dissection
 Oral cavity at least levels I-III
 Oropharynx at least levels II-IV
 Hypopharynx at least levels II-IV and levelVI when appropriate
 Larynx at least levels II-IV and levelVI when appropriate
N1-N2a-c: Selective or comprehensive neck
dissection
N3: Comprehensive neck dissection

23.  N0
Depth greater than 4 mm  strongly considered
if RT is not already planned.
Depth less than 2 mm  elective dissection is
only indicated in highly selective situations.
For a depth of 2–4 mm, clinical judgment.
Recent RCT  elective neck dissection in
patients with oral cavity cancers >3 mm

24. Scenario 9
 55 years old smoker comes into you outpatient
department with complaints of newly onset
hoarness of voice. He is known case of
squamous cell carcinoma of oral cavity.Tumor
was resected 2 years back. Current work-up
revealed recurrence of tumor, and plan of re-
resection was made. Per-operatively you
observe tumor invadingVagus nerve.
How will you proceed?

26.  Incisonal Biopsy: The tissue is taken only to establish a diagnosis and
perhaps to perform special tests that help determine what therapy would be appropriate
(eg. Receptor status) and grade.
 EXCISONAL/ RESECTIONAL BIOPSY:
 Diagnosis
 Grading
 Gross examination
 Marking discription
 Microscopic features
 Invasion
 TNM class
 Receptor status
 Margins (mucosal, cutaneous)

28.  Preferred approach is cisplatin with
radiotherapy

30. Past paper scenarios.