OTORRINO - SEMINAR 13 — CERVICAL LYMPH NODES AND CUP SYNDROME

[PRACTICE] — Anatomical cervical lymph node levels Which cervical lymph node level corresponds to the posterior triangle of the neck? A. Level I B. Level III C. Level V D. Level VI.

[PRACTICE] — Sublevels Ia, Ib, IIa and IIb Which anatomical structure is particularly important when distinguishing cervical lymph node levels IIa and IIb? A. Hypoglossal nerve (CN XII) B. Spinal accessory nerve (CN XI) C. Facial artery D. Thyroid cartilage.

[PRACTICE] — Level VII and expanded radiotherapy atlas In the expanded radiotherapy classification, what does level VIIa correspond to? A. Retropharyngeal lymph nodes B. Parotid lymph nodes C. Submental lymph nodes D. Occipital lymph nodes.

[PRACTICE] — Anatomical level versus oncological N category A metastatic cervical lymph node is located in level II. Which statement is CORRECT? A. Level II automatically means N2 disease. B. Every level II node represents distant metastasis. C. Anatomical nodal level and oncological N category are different concepts. D. Level II nodes cannot contain malignant cells.

[PRACTICE] — Regional drainage and potential primary sites Which combination correctly describes typical cervical lymphatic drainage patterns? A. Oral cavity → levels I–III; oropharynx → II–IV; nasopharynx → retropharyngeal and upper cervical nodes B. Oral cavity → level VI exclusively; nasopharynx → inguinal nodes C. Thyroid → level V exclusively; oropharynx → level Ia exclusively D. Every head and neck primary drains to exactly the same nodal levels.

[PRACTICE] — Adult cystic neck mass A 49-year-old patient presents with a painless cystic level II neck mass that has persisted for several weeks. Which diagnosis must be excluded before assuming a benign branchial cleft cyst? A. Otosclerosis B. HPV-associated cervical metastatic squamous cell carcinoma C. Reinke oedema D. Benign positional vertigo.

[RECONSTRUCTED] — Infectious cervical lymphadenopathy Which condition is NOT a bacterial cause of cervical lymphadenopathy? A. Infectious mononucleosis B. Cervical tuberculous lymphadenitis (scrofula) C. Cat-scratch disease D. Pyogenic bacterial cervical lymphadenitis.

[PRACTICE] — Imaging a suspicious cervical lymph node Which statement correctly matches imaging modalities with their roles in evaluating cervical lymphadenopathy? A. Ultrasound assesses superficial nodes and guides FNA; contrast CT maps nodal disease; MRI characterizes selected deep tissues; PET-CT helps locate occult primary and distant disease. B. Audiometry is the gold standard for cervical nodal staging. C. MRI has no role in evaluating tongue-base or skull-base disease. D. PET-CT replaces histological diagnosis in every case.

[PRACTICE] — First-line tissue sampling What is commonly the preferred initial tissue-sampling approach for an accessible suspicious cervical lymph node? A. Routine open excisional biopsy before imaging B. Ultrasound-guided fine-needle aspiration C. No sampling when the mass is cystic D. Empirical antibiotics indefinitely.

[PRACTICE] — N staging and extranodal extension Which statement about head and neck regional lymph node staging is CORRECT? A. The N classification is identical for all cancers. B. Level II automatically corresponds to N2. C. N staging depends on the primary tumor, relevant biological markers, nodal findings and extranodal extension. D. Clinical and pathological N staging always provide identical information.

[RECONSTRUCTED] — Elective neck dissection What does elective neck dissection mean? A. Surgical treatment of distant metastatic disease B. Neck dissection performed only when positive nodes are palpable C. Removal of the larynx D. Neck treatment in a clinically N0 patient with a significant risk of occult metastases.

[RECONSTRUCTED] — Classical radical neck dissection Which structures are removed during classical radical neck dissection (Crile operation)? A. Cervical levels I–V, spinal accessory nerve, internal jugular vein and sternocleidomastoid muscle B. Levels II–IV only, preserving all non-lymphatic structures C. Central level VI nodes and thyroid gland exclusively D. Parotid gland with facial nerve exclusively.

[PRACTICE] — Modified radical neck dissection types I–III Which statement correctly describes type III modified radical neck dissection? A. It preserves only CN XI. B. It preserves CN XI and the internal jugular vein but sacrifices SCM. C. It preserves CN XI, internal jugular vein and SCM while removing levels I–V. D. It preserves no non-lymphatic structures.

[PRACTICE] — Selective and extended radical neck dissection Which operation is a typical elective selective neck dissection for appropriately selected oral cavity SCC? A. Selective neck dissection levels I–III B. Selective neck dissection level V only C. Removal of central level VI only D. Removal of retropharyngeal nodes exclusively.

[PRACTICE] — Postoperative complications and pathological reporting Which combination correctly describes complications and important pathological reporting after neck dissection? A. CN XI injury may cause shoulder dysfunction; lower left-neck surgery may cause chyle leak; pathology should document nodal levels, metastatic nodes and extranodal extension. B. CN XI injury causes only hearing loss; chyle leak cannot occur in neck surgery. C. The pathology report only needs the patient's age. D. Extranodal extension is irrelevant after neck dissection.

[PRACTICE] — Occult metastasis in clinically node-negative disease A 58-year-old patient has resectable lateral oral tongue SCC with no clinically or radiologically detected cervical lymph node metastases. Which statement is CORRECT? A. cN0 completely excludes microscopic metastases. B. The decision about elective neck treatment should consider occult metastatic risk, including tumor depth of invasion. C. Every cN0 patient requires classical radical neck dissection. D. Nodal level and N category mean the same thing.

[RECONSTRUCTED] — Definition of cervical CUP What is CUP syndrome in head and neck oncology? A. A benign congenital neck cyst B. Cervical metastatic carcinoma with an unidentified primary tumor C. Acute cervical lymphadenitis D. A primary vocal-fold polyp.

[RECONSTRUCTED] — Initial approach to suspected CUP Which is the most appropriate initial approach to a patient with suspected cervical CUP? A. Perform a bone PET scan without tissue diagnosis. B. Establish the histological nature of the node, then perform directed examination, imaging and relevant immunohistochemical/viral testing. C. Perform tonsillectomy immediately in every patient without confirming malignancy. D. Perform only random biopsies of normal tonsillar mucosa.

[PRACTICE] — HPV-associated cervical metastatic SCC HPV-positive metastatic cervical SCC particularly suggests an occult primary in the: A. Oropharynx B. External auditory canal C. Submandibular duct D. Mastoid antrum.

[PRACTICE] — p16 immunohistochemistry Which statement about p16 immunohistochemistry in cervical CUP is CORRECT? A. p16 positivity always proves HPV-driven carcinoma. B. p16 is a surrogate marker, but HPV-specific testing may be necessary to establish the viral association. C. p16 is unrelated to HPV-associated tumors. D. p16 measures lymph node diameter.

[PRACTICE] — EBV and the nasopharynx Which viral association particularly suggests an occult nasopharyngeal primary in cervical metastatic carcinoma? A. Rotavirus B. Rhinovirus C. Epstein–Barr virus D. Influenza B virus.

[PRACTICE] — Complete clinical examination in CUP Which combination is appropriate in the systematic search for a primary tumor in cervical SCCUP? A. Inspection of the palatine tonsils, tongue base, nasopharynx, hypopharynx, larynx, facial skin and scalp B. Examination of the affected cervical node alone C. Tympanometry without head and neck examination D. Immediate diagnosis of tonsillar carcinoma without inspection or biopsy.

[RECONSTRUCTED] — FDG PET-CT and occult primary detection Which imaging technique may help identify an occult primary tumor in cervical SCCUP after appropriate initial assessment? A. FDG PET-CT B. Pure-tone audiometry C. Tympanometry D. Spirometry.

[PRACTICE] — Directed biopsies versus random biopsies Which approach is preferred during examination under anaesthesia (EUA) for cervical SCCUP? A. Routine random biopsies of all normal mucosal surfaces B. Examination of suspected primary sites with biopsies directed toward visible or radiologically suspicious abnormalities C. Avoid inspection of the oropharynx D. Perform biopsy only after definitive chemoradiotherapy.

[RECONSTRUCTED] — Diagnostic value of palatine tonsillectomy Why may palatine tonsillectomy be useful in cervical SCC of unknown primary? A. It always proves a nasopharyngeal origin. B. It can identify an occult oropharyngeal primary hidden within tonsillar tissue. C. It eliminates all risk of cervical recurrence. D. It replaces histopathological evaluation.

[PRACTICE] — Lingual tonsil and tongue-base mucosectomy A patient has confirmed HPV-associated cervical metastatic SCC, but clinical assessment, imaging and palatine tonsil evaluation have not identified the primary. Which additional investigation may be appropriate? A. Lingual tonsil evaluation or tongue-base mucosectomy B. Routine tympanoplasty C. Mastoidectomy without ear disease D. Submandibular duct exploration alone.

PRACTICE] — Limitations of negative PET-CT Does a negative FDG PET-CT completely exclude an occult palatine or lingual tonsil carcinoma? A. Yes, in all cases. B. Yes, if the cervical node is cystic. C. No, small tumors within tonsillar lymphoid tissue may remain undetected. D. Yes, if the cervical node contains SCC.

[PRACTICE] — Complete SCCUP diagnostic algorithm Which sequence best reflects the systematic diagnostic algorithm for cervical SCC of unknown primary? A. Immediate chemoradiotherapy → diagnosis of histology → imaging several months later B. Confirmation of metastatic SCC → HPV/EBV assessment → clinical/endoscopic examination and imaging → directed biopsies and selected tonsillar procedures → site-specific or CUP treatment plan C. Random tonsil biopsy only → no staging → discharge D. Diagnose all cervical metastases as HPV-positive oropharyngeal SCC without testing.

[PRACTICE] — Correct staging framework for CUP Which statement about staging cervical CUP is CORRECT? A. Every CUP case uses an identical N1–N3 staging system. B. HPV-associated, EBV-associated, non-viral and non-mucosal malignancies may require different staging frameworks. C. Tumor biology and primary-site origin are irrelevant to staging. D. Cervical CUP cannot be staged unless the primary tumor is visible.

[PRACTICE] — Risk-adapted treatment by nodal burden Which statement correctly describes treatment selection for cervical SCCUP? A. Every patient requires identical surgery and radiation fields. B. Treatment should be individualized according to nodal burden, unilateral/bilateral distribution, extranodal extension and patient characteristics. C. HPV positivity means treatment can always be omitted. D. A large bilateral nodal mass is best treated by observation alone.

[PRACTICE] — Neck dissection alone In which patient may neck dissection alone be sufficient for cervical SCCUP? A. Selected patient with a single involved node, no ENE, adequate surgery and complete diagnostic workup B. Every patient with multiple bilateral bulky metastatic nodes C. Every patient with pathological ENE D. Every patient with distant metastases.

[PRACTICE] — Extranodal extension and cisplatin Which pathological finding particularly supports postoperative radiotherapy with concurrent cisplatin in a suitable patient with cervical SCCUP? A. Single involved node without adverse features B. Pathological extranodal extension C. Normal reactive lymph nodes D. Benign epidermal inclusion cyst.

[PRACTICE] — Radiotherapy target volumes Which statement correctly describes modern radiotherapy planning for cervical SCCUP according to the lecture? A. Every patient must receive irradiation of all head and neck mucosal surfaces at identical doses. B. Radiation fields should be adapted to nodal distribution, HPV/EBV status, possible mucosal primary sites and organs at risk. C. Cervical lymph nodes are excluded from radiotherapy planning. D. Preserving salivary and swallowing structures is irrelevant.

[PRACTICE] — Indications and suitability for cisplatin Which statement about concurrent cisplatin-based chemoradiotherapy in cervical SCCUP is CORRECT? A. Every HPV-positive patient should automatically receive reduced treatment intensity. B. Cisplatin suitability depends on performance status, renal function, baseline hearing and comorbidities. C. Concurrent cisplatin is always contraindicated in node-positive disease. D. Renal function and hearing are irrelevant to cisplatin treatment.

[PRACTICE] — PET-CT response interval When is FDG PET-CT generally performed to assess response after definitive chemoradiotherapy for cervical SCCUP? A. Immediately after the first radiotherapy fraction B. Within 24 hours of treatment completion C. Approximately 12 weeks or later D. Only after five years.

[PRACTICE] — Cystic neck mass with non-diagnostic aspirate A 49-year-old patient has a cystic level II neck mass. Initial FNA produces fluid but no diagnostic cellular material, and no mucosal primary is visible on examination. What is the safest next step? A. Diagnose a benign branchial cleft cyst immediately. B. Repeatedly prescribe antibiotics without further investigations. C. Investigate possible cystic cervical metastasis and obtain an adequate tissue diagnosis. D. Discharge without follow-up.

[PRACTICE] — Errors in cervical CUP investigation Which of the following represents an important error in the diagnostic management of cervical CUP? A. Confirming tissue histology before applying a disease-specific diagnostic algorithm B. Performing targeted biopsies of suspicious mucosal lesions C. Assuming isolated p16 positivity always proves HPV-driven oropharyngeal CUP D. Using nodal distribution and viral markers to direct the search.

[PRACTICE] — Complete integrated cervical lymph node and CUP question Which combination of statements correctly summarizes the principal concepts of Seminar 13? I. Cervical nodal level describes anatomical location, whereas N category describes oncological stage. II. Classical radical neck dissection removes levels I–V together with CN XI, IJV and SCM. III. HPV-positive cervical SCC suggests a possible occult oropharyngeal primary, while EBV-associated carcinoma suggests a nasopharyngeal origin. IV. Pathological extranodal extension may support postoperative radiotherapy with concurrent cisplatin. V. A complete response after chemoradiotherapy does not automatically require planned neck dissection. A. I, II and III only B. II, III and V only C. I, III, IV and V only D. All five statements.